Therapists and counselors of all types at least occasionally encounter clients seeking help with “sexual issues.” Typically, these clients are worried about too much sex, not enough sex, no sex, bad sex, strange sex, addictive sex, consequential sex, and other kinds. Sometimes these concerns are the clients’ primary presenting issue, but more often—usually due to shame, embarrassment, and/or fear of rejection—sexual concerns are discovered in the background, only coming to light when exploring concurrent problems with self-esteem, relationships, mood disorders, substance abuse, and unresolved trauma.
Knowing this, it can be useful to incorporate a few basic sex-related questions into an initial phone inquiry or clients’ first therapy sessions. Nonthreatening queries include:
- Do you have any concerns about your current or past sexual behaviors?
- Has anyone close to you ever expressed concern about your sexual behaviors?
- Is there anything about your sexual life that feels shameful to you or that you try to keep secret?
Just as initial assessments typically involve questions about clients’ life history related to eating, exercise, education, social life, family life, goals, health, recreation, and other important areas, the questions above should also be asked, thereby ensuring that primary issues aren’t inadvertently overlooked. By simply posing these and similar queries and nonjudgmentally following up on any pertinent responses, therapists are giving their clients “permission” to talk about sex, letting them know that it is okay (i.e., safe) to discuss their sexual concerns openly in treatment.
If and when adult sexual issues do surface, it is useful for therapists to ask themselves the following questions before proceeding:
- Is this a primary therapeutic issue that I need to address directly?
- Do I need to address this concern immediately? (Think about client safety and, when relevant, partner safety.)
- Is this a secondary concern that can be explored later, after other, more pressing issues are under control?
- How, if at all, does this issue relate to and/or affect the current overall treatment plan?
- Is what I’m hearing pathological from a clinical perspective, or simply troubling to the client (most often due to moral, cultural, and/or religious values)?
- If this issue requires direct intervention and treatment (either right away or later), do I have the skill-set and experience needed for effective treatment?
- Is this disclosure merely an attempt by the client to be seductive with me? (Hint: How did I feel when hearing it?)
- Do I know how to deal with a sexually seductive client? In other words, do I know how to intervene upon and manage erotic transference?
- How comfortable am I with the potentially explicit questions I may need to ask in order to fully assess, diagnose, and treat this concern?
- How do I feel about what I’ve just heard (countertransference), and will my values, beliefs, and feelings influence how I deal with it?
Unfortunately, few therapists have received extensive training in the assessment and treatment of sexual disorders. Beyond basic licensure-required education related to HIV/AIDS and specific populations, what most of us have learned about sex from a clinical perspective depends almost completely on self-education and professional experience. To at least partially fill the knowledge and experience gaps that many therapists have, I have provided herein a brief overview of the sexual concerns most often encountered in clinical settings, along with diagnostic criteria and suggested treatment protocols.
Emma, age thirty-nine, has been married for seventeen years. In counseling, she says she recently borrowed her husband’s phone and noticed an app labeled AM. She says, “I wasn’t snooping, and I honestly didn’t think my husband could possibly be cheating on me, but my curiosity got the better of me and I opened the app. I was shocked to see the app was Ashley Madison, and that he had all sorts of texts and sexts with other women. When I confronted him, he said he’s never seen any of them in person so it’s not really cheating. But that’s not how it feels to me. I’m hurt, I’m angry, and most of all I’m uncertain about where this leaves us as a couple.”
From a clinical perspective, infidelity is not inherently pathological, though it can become so if it takes on a life of its own and spirals out of control, as occurs in cases of sexual addiction or if it causes problems with clients’ life functioning and/or mood. Typically, the therapeutic approach taken when dealing with marital infidelity depends on whether you are treating the cheating partner or the cheated-on partner.
Treating the Unfaithful
With a cheating partner, directive forms of therapy are typically the most useful, especially if clients wish to stop what they have been doing. For instance, you might implement a behavioral contract in which clients agree to abstain from further infidelity, while also seeking to understand the meaning of the infidelity. For instance, are these individuals unhappy in their relationship? Do they have an issue with sexual compulsivity? Do they have deeper underlying psychological issues that cause them to behave in this way? However, if you are working with people who are unremorseful about their behavior, do not think it is hurtful (or don’t care that it is hurtful), and don’t wish to stop, then there is not much that you can do.
Treating the Betrayed
When dealing with the cheated-on partner, things can get complicated, as many betrayed spouses are deeply traumatized by their experience. In fact, research shows that betrayed spouses often experience acute stress symptoms characteristic of posttraumatic stress disorder (PTSD), such as hypervigilance, reactivity, sleep disorders, and mood instability (Steffens & Rennie, 2006). For these individuals it is usually the betrayal of relationship trust rather than any specific sexual act that causes the most pain. Exacerbating matters is the fact that many betrayed partners have had their accurate version reality denied, perhaps for years, by an unfaithful spouse who insists that he or she is not cheating, that he or she is not being distant or indifferent, and that the concerned partner is just being paranoid, mistrustful, and unfair. In this way betrayed spouses are often made to feel as if they are the problem, as if their emotional instability is the issue.
Typically, betrayed spouses are angry not only with the cheater but with themselves. In treatment they need, at the very least, the following: validation for their feelings; direction, education and support for moving forward; empathy for the pain they’re experiencing; and help processing the shame/rage of being cheated on. Additionally, they may require guidance with day-to-day issues such as managing anger, setting appropriate boundaries, approaching and dealing with potential health care issues (including STDs), and help with curtailing their ever-present desire to question the betrayer in endless detail about his or her sexual past and present.
Generally, these cases are most like crisis management in the early stages—a concept that should guide you toward helping clients with both self-care and finding productive ways to vent strong feelings. Treatment is most often undertaken using a combination of traditional talk therapy and more directive modalities, mixed and matched as necessary depending on the needs of clients at any given time. Note that it is rarely (if ever) helpful to ask betrayed partners early-on about why they didn’t know what was happening, as they are probably already blaming themselves on some level for what has occurred. It is also not helpful in the early stages to explore a betrayed spouse’s childhood or relationship history. Instead, what these men and women need most, like anyone in the midst of a crisis, is solid support, education, and direction. Later, once the crisis stage is past, underlying systemic issues can be addressed with whatever modality seems appropriate.
John and Mary, both fifty-three and married for twenty-six years, enter therapy because their sex life has become unsatisfying. They say that for the first twenty years of their marriage they had “a normal amount of sex,” but in recent years both the quantity and quality of their sexual interactions has waned. John describes having trouble achieving and maintaining erections, while Mary complains about difficulty lubricating and relaxing. Both state that they are happy in their marriage, except for their sexual difficulties. Both would like to have sex more often, and to enjoy it the way they used to.
Sexual dysfunction is extensively addressed in the DSM-5 (APA, 2013). Issues covered include delayed ejaculation, erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder, genito-pelvic pain/penetration disorder, male hypoactive sexual desire disorder, premature ejaculation, substance/medication-induced sexual dysfunction, and more. Clients who present with any form of sexual dysfunction should always be referred to an appropriate medical professional before psychotherapeutic treatment is engaged in earnest, as the issue is often more physical than psychological. Much of the time, erectile dysfunction, genito-pelvic pain/penetration disorder, and related issues can be addressed with medication and/or lubricant, and by helping clients adapt emotionally to the age-related changes that naturally affect sexual functioning and desire.
If you lack formal training in sexology and run into cases where sexual dysfunction is found to be more of a psychological than a medical issue, clients are best referred to a sexology specialist. Referral resources are listed at the end of this article.
Andrew, age fifty-one and married for thirty-two years, enters therapy because his wife has threatened to leave him. He says he has been using online porn for over ten years. For the past two to three years he’s been locking himself in his office for several hours every night, looking at and masturbating to porn. He says that he no longer has sex with his wife, and that he prefers “porn-sex” to the real thing. He has promised his wife on numerous occasions that he will stop using porn, but inside he knows he is lying. During his assessment, he alternately displays remorse about hurting his wife and defiance about his “right” to look at pornography.
Sexual addiction is a dysfunctional preoccupation with sexual urges, fantasies, and behaviors. To qualify as sexually addicted, clients’ compulsive behaviors must continue for a period of at least six months, despite the following:
- Attempts made to self-correct the problematic sexual behavior
- Promises made to self and/or others to change the sexual behavior
- Significant, directly-related negative life consequences such as relationship/family instability, emotional turmoil, health problems, trouble at work or in school, health and legal issues, loss of interest in hobbies and other enjoyable activities, and others.
Unfortunately, the DSM-5 does not directly address sexual addiction, making it difficult to identify and treat, and to seek insurance reimbursement for clients. Nevertheless, sexual addiction clearly exists. Furthermore, it is undoubtedly on the rise, thanks to the current tech-connect boom, which has greatly increased the average person’s ability to affordably and anonymously access an almost endless supply of highly stimulating sexual content and partners.
Typically, sexual addiction treatment incorporates strategies that have proven effective in the treatment of substance abuse and eating disorders: behavioral contracting, cognitive behavioral therapy (CBT) and group therapy coupled with Twelve Step, faith-based or other sexual recovery support groups. One primary difference between the treatment of sexual addiction and the treatment of substance use disorders lies in the definition of sobriety. Whereas complete abstinence is the goal in drug and alcohol treatment, sexual sobriety is more like sobriety for a binge eater, where problematic food-related behaviors need to be identified and eliminated, but not eating itself. As such, sex addicts work to carefully define and eliminate the sexual behaviors that are causing problems. After doing so, they typically commit, in writing, to engage only in nonproblematic sexual activities, and even then to do so only moderately and appropriately.
If you are struggling to determine if clients are sexually addicted, an excellent screening test can be found on the Sexual Recovery Institute’s website (“Self test,” 2016), or you can use the SAST-R (Carnes, 2007). No matter what, when evaluating for sexual addiction and related problems, it is wise to consult with a specialist. Certified sex addiction therapists (CSATs) can be found through numerous professional organizations, several of which are listed at the end of this article.
The DSM-5 addresses sexual offending obliquely in the material covering paraphilias, most notably in the sections discussing exhibitionism, voyeurism, frotteurism, pedophilia, and sexual sadism (APA, 2013). It is important to note that while the legal definition of sexual offending varies from jurisdiction to jurisdiction, the clinical definition—nonconsensual sexual activity—is a constant. For the most part sexual activity is considered nonconsensual (the clinical definition of sexual offending) if one or more of the following takes place:
- The activity is forced
- The other person is incapacitated and can’t consent, such as drugged, drunk or passed out.
- The other person is mentally unable to consent to the activity, such as developmentally disabled or psychologically disturbed.
- The other person is too young to consent
- The other person is subjected to a sexual experience that he or she did not invite or agree to, such as exhibitionism, voyeurism, frotteurism or up-skirting
Unless working with offenders is a focus area and you have had direct training and supervision, the best course of action when faced with sexual offenders is referring them to a specialist. Regardless of whether you decide to take or refer sexually offending clients, you need to keep in mind your legal reporting requirements.
Edward, age twenty-seven, enters therapy stating that he is filled with anxiety and dread about his future. Reluctantly, he admits that even though he’s been seriously dating a woman from his church, he’s also been viewing and masturbating to gay porn and occasionally visiting the local adult bookstore, where he has on several occasions performed oral sex on other men. After careful questioning, it is clear that Edward’s presenting concern—and the underlying cause of his anxiety—is that he fears his attraction to men, wants it to go away, and doesn’t want to be gay. Basically, he feels that homosexuality is immoral, and he is certain that everyone important to him—his family, his church, his girlfriend, and even his friends—will reject him if he continues to explore and pursue these “unacceptable” behaviors.
The plain truth is that you can’t change a person’s sexual orientation, no matter how ego-dystonic those feelings and related behaviors might be. Simply put, a gay man is attracted to other men whether he likes it or not, a lesbian woman is attracted to other women whether she likes it or not, and bisexual men and women are attracted to both genders whether they like it or not. And no amount or type of therapy is going to change this.
Interestingly, there are certain therapists (and clergy) who say they can “cure” homosexuality through “reparative therapy,” also known as gay conversion therapy, even though heaps of scientific research and decades of clinical experience say otherwise. Disturbingly, their misguided attempts at reparative therapy are often harmful, creating even deeper ego dystonia. Recognizing this, both the American Psychiatric Association (2011) and the American Psychological Association (2009) have issued strongly worded public policy statements condemning the practice, and last year both California and New Jersey passed laws banning the use of reparative therapy on minors.
When dealing with ego-dystonic sexual orientation, the proper therapeutic approach is helping clients understand and accept what they are feeling and desiring as a natural and healthy part of who they are. For instance, you could help Edward “come out” to his friends and family, and if his friends and family do not accept him as he really is, you can help him process this issue in a healthy way. If you are not trained to do this work or you do not feel comfortable facilitating such a process, it is best to refer such clients to a clinician who might better serve them.
Amy, age thirty-four, enters treatment with severe depression, stating that she thinks she might be a lesbian even though that label doesn’t feel quite right to her. She is in recovery for alcoholism, with nearly three years of sobriety, but she says her life isn’t really getting any better. When pressed, it is clear that her sobriety is solid, her job is going well, and she has a family that loves her and supports her. Eventually, she admits that sometimes she can snap herself out of the doldrums by passing herself off as a young male in public. Over a number of sessions, as Amy becomes more comfortable with therapy and with the topic of gender dysphoria, she admits that she’s always felt like a man trapped in a woman’s body, and that she wants to explore gender reassignment surgery.
Gender dysphoria is evidenced by a significant, longstanding level of discontent with one’s birth sex and/or the gender roles associated with that sex. Gender dysphoria is covered in great detail in the DSM-5 (APA, 2013). The spectrum of gender dysphoria is actually quite wide. For instance, some people feel sexy or more confident when wearing the other gender’s undergarments under their traditional attire, while others feel as if they cannot ever be happy until their physical gender (female in Amy’s case) can be transformed to match their internal identity (male in Amy’s case). This last category is commonly referred to as either transgender or transsexual. Many transgendered people actively seek gender reassignment surgery.
As is the case with sexual orientation, psychological gender is fixed and immutable. In other words, no amount or type of therapy is going to “fix” Amy’s self-identification as male. As such, the job of clinicians dealing with gender dysphoric clients is the same as it is with clients experiencing ego dystonia related to sexual orientation—helping these individuals understand and accept what they are feeling and desiring as a natural and healthy part of who they are. It is important to state that dealing with transgendered clients, especially those who want gender reassignment surgery, is a highly specialized endeavor. If you are not trained for it, you should definitely refer such clients to a specialist.
Sexual Fetishism (Paraphilic Disorders)
Kevin, age twenty-nine, enters therapy stating that for the last several years he has been hiring a dominatrix at least a few times per month, paying her to physically and verbally humiliate him. He says he does not become physically aroused while this is occurring, but after the dominatrix leaves he masturbates furiously. He says that he wants a “regular relationship,” but he also wants to continue with the dominatrix. This juxtaposition is causing him a great deal of stress and anxiety. Essentially, Kevin leads a split life, torn between the “normal” relationship he intellectually desires, and his need/desire for sexual fulfillment through BDSM.
The DSM-5 addresses a variety of fetish-related arousal patterns, officially labeling them “paraphilic disorders” (APA, 2013). These include voyeurism, exhibitionism, frotteurism (touching or rubbing up against someone without their permission), sexual masochism, sexual sadism, bestiality, pedophilia, sexual fetishism, transvestic disorders, and more. In all cases, to qualify as a disorder these conditions must persist for at least six months, and, more importantly, they must be causing significant distress or impairment in social, occupational or other important areas of functioning. It is important to note here that it is not the therapist’s job to pathologize nonharmful, nonoffending fetishes that are not causing distress. If Kevin, for instance, was perfectly okay with his dominatrix sessions and did not feel as if they were interfering with his dating life, and instead was coming to see you related to his desire to change professions, his sexual fetishism would be a clinical nonissue. However, harmful and/or illegal fetishes like pedophilia, bestiality, and the like are a different story entirely, as they may trigger reporting requirements and necessitate a specialist referral.
As is the case with sexual orientation and gender identity, paraphilic disorders are relatively immutable. In other words, no matter how ego-dystonic and regardless of whether they arise from early-life trauma, it is unlikely that any type or amount of therapy will make these sexual interests disappear, though they may be lessened in intensity and/or broadened to incorporate other sexual interests. As such, when these behaviors are among the nonharmful types to self and/or others, the proper course of action is to help clients accept what they are feeling and desiring as a natural and healthy part of who they are, regardless of their current desire to change. If clients wish to incorporate the fetish into their lives more fully, therapeutic help may be needed with spouses/partners to ensure mutual acceptance.
If you are not trained to deal with these relatively complex issues, or you feel uncomfortable dealing with them, you should refer your clients to a specialist.
One of the most basic tenets of our profession is that if we feel unsure or insecure regarding clients’ presenting or underlying issues, we should seek consultation from an appropriate specialist. Equally important is the fact that a documented external consultation will nearly always ensure that you have covered your butt should clients later be unhappy with the care you have provided.
If you choose to seek consultation from another clinician regarding sexual concerns, you will most likely be consulting a therapist who is certified and/or trained in one of the following three areas: human sexology, sexual addiction, and/or sexual orientation/gender identity.
Several excellent referral sources are listed here. Many of these organizations also provide trainings and certifications, should you wish to learn more about a specific treatment specialty.
- The American Association of Sexuality Educators, Counselors, and Therapists (AASECT): This organization provides referrals for counselors who can help with nonaddiction, nonoffending sexual issues, along with training and certification.
- The Association for the Treatment of Sexual Abusers (ATSA): ATSA promotes evidence-based strategies for the assessment and treatment of individuals who have sexually abused/offended or are at risk to do so. ATSA provides referrals to qualified therapists.
- The International Institute for Trauma and Addiction Professionals (IITAP): IITAP trains and certifies sex addiction therapists (CSATs). They also provide referrals to qualified therapists.
- LA Gender Center: This facility offers counseling to sexual minorities, especially transgendered people. The center also offers trainings and continuing education.
- Parents and Friends of Lesbians and Gays (PFLAG): PFLAG provides education and support to families and friends of LGBT people.
- RobertWeissMSW.com: This is my personal website, which is filled with information about sexual issues, including sexual addiction, sexual offending, and the ways in which technology and sexuality intersect.
- Safer Society Foundation: The Safer Society Foundation is a dedicated to ending sexual abuse and offending through effective prevention and treatment.
- San Francisco Gay and Lesbian Community Center: This facility offers a wide variety of useful information and social support for gays and lesbians in San Francisco and elsewhere. Most major cities and even many smaller cities have similar community-based support centers.
- The Society for the Advancement of Sexual Health (SASH): SASH is dedicated to sexual health and overcoming problem sexual behaviors, primarily sexual addiction. SASH offers both training and referrals.
- Sex Addicts Anonymous (SAA): This is a Twelve Step support group for sex addicts.
- Sex and Love Addicts Anonymous (SLAA): This is a Twelve Step support group for sex and love addicts.
- Sexaholics Anonymous (SA): This is a Twelve Step support group for sex addicts.
- Sexual Compulsives Anonymous (SCA): This is a Twelve Step support group for sex addicts. SCA is generally regarded as the most gay-friendly sexual recovery support group.
- The Society for the Scientific Study of Sexuality (SSSS): SSSS is dedicated to the study of human sexuality. This is a great organization to contact if you’ve got a client who is ego-dystonic about nonpathological sex-related issues (such as sexual orientation or a nonharming fetish).
- World Professional Association for Transgender Health (WPATH): WPATH is a professional organization dedicated to transgender health.
American Psychiatric Association (APA). (2011). Therapies focused on attempts to change sexual orientation (reparative or conversion therapies): Position statement. Retrieved from http://web.archive.org/web/20110407082738/http://www.psych.org/Departments/EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/200001.aspx
American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
American Psychological Association. (2009). Report of the American Psychological Association task force on appropriate therapeutic responses to sexual orientation. Retrieved from http://www.apa.org/pi/lgbt/resources/therapeutic-response.pdf
Carnes, P. (2007). SAST-R 2.0. Retrieved from http://www.leademcounseling.com/wp-content/uploads/Online-SAST-2.pdf.
“Self tests.” (2016). Retrieved from http://www.sexualrecovery.com/resources/self-tests/.
Steffens, B. A., & Rennie, R. L. (2006). The traumatic nature of disclosure for wives of sexual addicts. Sexual Addiction & Compulsivity, 13(2–3), 247–67.