Section 3: Clarifying Personal Values

Many sex educators have said that probably the most difficult aspect of their preparation in becoming sex educators was not a lack of accurate knowledge about sex and sexuality, but their own struggle in developing a healthy attitude toward themselves and their own sexuality. Most clinicians did not grow up in open environments that facilitated becoming comfortable with themselves in the area of sexuality.

Explorations about sexuality will necessarily involve explorations about values. For clinicians who wish to provide successful corrective experiences to their clients, it will be essential to be skilled in clarifying and maintaining awareness of values around sexuality – both the client's values and one's own values.

The following exercise will serve to help the clinician focus on some of the value complexities that can arise in the process of assessing sexual concerns with clients.

Before starting the didactic portion of this course:

Number a separate sheet of paper from 1-21 or print this list of value statements.

First, take some time to reflect briefly on each statement. Without analyzing and soul searching, write down A for Agree and D for Disagree for each statement.

Next, go back to each statement and reflect on what the statement means to you in terms of your life, the way you were raised, the messages you have held on to, and any other information that informs your values and beliefs.

1. I believe sex is for fun.
2. I have sexual fantasies at times.
3. I approve of masturbation for myself.
4. I believe that small children of any age should be allowed to masturbate.
5. I approve (or approved) of premarital intercourse for myself.
6. I would approve of premarital intercourse for my 16 year-old son.
7. I would approve of premarital intercourse for my 16 year-old daughter.
8. For me, oral-genital sex is an acceptable alternative to intercourse.
9. For me, mutual stimulation to orgasm is an acceptable alternative to intercourse.
10. I believe that a good sexual relationship is the most important factor in a marriage.
11. For me, love is necessary in order to have good sex.
12. While in a committed relationship, I have found myself sexually attracted to someone else.
13. I believe that by far the best kind of sex is spontaneous and unplanned.
14. I believe that homosexuals should not work with young children.
15. For me, casual sex (such as a one-night stand) can be exciting, fulfilling, and practiced with little guilt.
16. When it comes to sex, there is a great difference between what I do and what I would like to do.
17. Masturbation is an acceptable way of relieving sexual tensions, even if a person is in a committed relationship.
18. I believe AIDS is a punishment for immoral behavior.
19. I feel comfortable discussing sexual issues with my partner.
20. I have had difficulty reconciling my religious beliefs with my sexual behaviors.
21. At times in my life, I have had sexual concerns.

Now, go back through the list and reflect on your answers in a deeper, thoughtful way and see what reactions are evoked. Are there some that are easy to answer? Others that are more difficult? Some that evoke anger? Guilt? Shame? Excitement? Frustration? Anxiety? Sadness? Happiness? Other feelings?

Finally, respond to the following question and sentence completion statements.

1. To whom would YOU go with a sexual concern?
2. My greatest difficulty in dealing with sexual concerns of clients is_____________
3. My greatest asset in dealing with sexual concerns of clients is ____________.

One of the challenges of doing sexual counseling/therapy is to work within the patient’s system of values and beliefs. When the patient comes from a similar background to the clinician, this is frequently easier for the clinician. When the patient comes from a background that is radically different from that of the clinician, this can be a much greater challenge.

A prerequisite for being able to handle this challenge is to have the capacity to understand one's own values and control one's own emotional responses – so that the focus of attention can remain on the client's values and concerns, instead of what is difficult or confusing for the clinician.

This presentation of material will work at three levels that have been described in the literature. First, clinicians who work with clients from different cultural backgrounds are supposed to be culturally aware. (Sue and Sue, 1999) This is to say that – at the very least – clinicians should be aware of their own cultural background - and aware of how the socialization from that background has created certain assumptions and biases that shape how they see and interact with the world.

These assumptions and biases – left unattended – can create blinders on the eyes of the clinician when working with clients from different cultures. This is because these items are often embedded in value systems that are so familiar and comfortable for the clinician that they are almost invisible. These biases can cause the clinician to shape the therapeutic experience in ways that affirm and make comfortable the values of the clinician, while denying and discounting the experience and cultural material of the client.

Cultural awareness requires that the clinician remove his or her blinders and strive to become comfortable working with the cultural differences that exist between the client and clinician (Sue and Sue, 1999). The cognitive parts of this involve keeping one's thinking and perception flexible and remaining open to seeing and understanding different world views.

The emotional part of this may at times be even more difficult than the cognitive part. The emotional part requires the laying aside of any hidden or buried cultural biases and tolerating the discomfort of having one's own deeply held personal – and/or professional - values challenged by someone who may partially or wholly disagree with and reject those values.

The human and personal components of being a clinician can be sorely tested by this. The clinician's core defining values may be the central reason why he or she entered the mental health field in the first place. It may be for religious or spiritual reasons, or it may be for deeply held personal values and beliefs. However it is based, this set of core defining values often serves a very important centering function in the emotional life of the clinician, in addition to bringing comfort, certainty, and meaning to the work that he or she does.

For this reason, having one's most important values questioned or rejected can be a very disturbing or unsettling emotional experience. It can provoke powerful countertransference feelings and inclinations to translate those feelings into actions. This is a real risk or danger in cross-cultural work. With emotionally laden arenas such as sexuality, the ability to maintain a sufficient degree of cultural neutrality can be even more difficult.

However, one of the ethical sacrifices that is required of those who choose this profession is the willingness to engage in these difficult questions - without running away too easily and too quickly towards that which is more personally comfortable. One cannot practice ethically without being able and willing to tolerate a certain amount of the discomfort that comes with sitting with cultural differences.

The final piece of being culturally aware is to know one's limitations when working with clients from different backgrounds Sue and Sue, 1999). This falls under the category of operating within one's area of competence. When clinicians are not able to remove their own blinders or handle the emotional challenges of working with clients with different world views, the culturally aware clinician is at least able to know this about himself or herself, and know when to refer the client to another clinician who may be better able to respond to the cultural needs of the client.

The second level of cultural competence involves being culturally knowledgeable (Sue and Sue, 1999). This requires that the clinician possess a significant degree of understanding concerning the cultural elements of the client that are relevant to the definition of problems and solutions. This includes knowing the role - in relation to the dominant culture - of the minority group of which the client is a member.

(Not to state the obvious, but this also requires that the clinician has a quite clear picture of the landscape of the dominant culture, what its biases are, what its assumptions are, what the weaknesses, flaws, and internal contradictions in its perceptions and values are, etc.)

The culturally knowledgeable clinician should also have a solid background in the relevant practice literature concerning practice with non-dominant cultural groups, and also understand the institutional and cultural barriers that impede minority groups from using mental health services (Sue and Sue, 1999).

Finally, the third and highest level of cultural competence is being culturally skilled (Sue and Sue, 1999). This requires that the clinician possess a wide range of skills to use in interventions with clients from different cultural backgrounds, including fluency with verbal and non-verbal modes of communication that are well-received and understood by the clients within their own cultural experience (Sue and Sue, 1999).

This level of cultural competence also requires that the clinician be able – and willing – to intercede on the behalf of the client when the client's cultural components are "right" and the dominant culture's cultural components are "wrong" (Sue and Sue, 1999). When the dominant culture's values are "dysfunctional" for the client from a different cultural background, the clinician must not be blinded by his or her own biases, and unwilling or unable to grasp this.

Let us take as examples the following situations. 1) A woman who has grown up with the belief that touching herself is bad might have difficulty with a program that encourages her to become orgasmic with self-stimulation before she incorporates a partner; 2) People who believe they must be highly skilled in certain behaviors and responses in order to be a “real” man or a “real” woman are programmed for performance anxiety.

Example: A couple in their 30s came to a therapist complaining of the woman’s difficulty experiencing orgasm. What surfaced were their beliefs that 1) a man should be able to give a woman an orgasm, 2) the orgasm should come only from intercourse and the husband’s thrusting, and 3) real women have orgasms with just intercourse, and no other forms of genital touching should be necessary. The woman was in fact able to have an orgasm with intercourse, but this was taking 45 minutes to one hour of thrusting. The husband’s comment was, “I’m tired.” As a result of the pressure to perform that he was feeling with each sexual encounter, he was actually beginning to lose his desire.

Negative sexual experiences repeated over time will eventually begin to impact desire. The man who has the belief that he has to “give” his partner an orgasm, the young mother who, despite her fatigue and frequent irritation with her spouse, continues to have obligatory sex, the man who frequently experiences erectile difficulty, and the woman who experiences pain with each act of intercourse may be headed down the road to low or no desire.

Working with Sexual Minority Clients

As a healthcare professional, another important aspect of addressing sexuality concerns has to do with answering for yourself questions such as, “What types of clients am I comfortable with/willing and able to provide services for?” “Are there practices I can’t condone/accept or that make me too uncomfortable to be effective in a therapeutic role?” “How much do I know or need to know about nontraditional practices, relationships, lifestyles?”

There are a number of groups of clients whose sexual practices may be unfamiliar and uncomfortable for clinicians when viewed from the standpoint of the clinician’s own internalized values about what is “acceptable” in a person’s sexual life. These may include what are referred to as Sexual Minority Clients: Gay, Lesbian, Bi-sexual and Transgendered clients, as well as clients who engage in Polyamory (various ways of having more than one intimate relationship at a time with the knowledge and consent of everyone involved), and other non-traditional sexual practices.

It is also important for clinicians to be aware of practices called paraphilias. Some of these sexual behaviors are considered non-coercive in nature, and are part of the range of sexual behaviors that may be encountered as adults engage in consensual sex. The non-coercive paraphilias are shown below.

NON-COERCIVE PARAPHILIAS

Fetishism
Sadomasochism
Coprophilia and Urophilia
Transvestism and Crossdressing
Autoerotic Asphyxiophilia

There are also paraphilias that are considered coercive, as they involve behaviors that are non-consensual in nature. These choices of actions may result in legal consequences. They are shown below.

COERCIVE PARAPHILIAS

Exhibitionism (Exposing one’ s self)
Frotteurism (Rubbing up against people)
Scatolophilia (Making obscene phone calls)
Zoophilia (Fantasies of sex with animals)
Necrophilia (Sex with dead bodies)
Voyeurism (Peeping Tom behaviors)
Pedophilia (Sex with young children)

Treatment for paraphilias should probably only be attempted by mental health professionals who possess adequate education and training in this specialty area. The details of what would be involved in such treatment is outside the purview of this course. However, it is important for clinicians to possess at least a basic knowledge of paraphilias, as clients with paraphilias may appear from time to time in your practice.

It is also important to note that the latest edition of the Diagnostic and Statistical Manual, the DSM-5, no longer considers many non-coercive paraphilias to be deviant behaviors. They are now considered to be alternative forms of sexual expression and not requiring treatment unless the client experiences them as ego-dystonic.

For clinicians who would like more extensive presentation of material on these sexual areas, it may be helpful to consider taking yourceus.com’s introductory course: Sex and Sexuality: An Introductory Overview for Mental Health Clinicians, where these are covered in greater detail.

In addition to examining their own competence in handling complex sexual cases, therapists who are considering treating sexual minority patients must also answer the question of whether they really wish to treat such patients. Not all therapists (even those who are themselves sexual minority therapists) are able to overcome their own issues about alternative sexual behaviors and treat patients non-judgmentally. In these instances, patients should be referred (Moser, 1999).

Dr. Charles Moser (1999) has written an excellent article that 1) guides therapists in making the decision about treating sexual minority patients, 2) discusses specific considerations in treating these patients, and 3) provides specifics of interviewing and a glossary of sexual minority terms. The article can be accessed online at http://www.ejhs.org/volume2/Moser/moser1.htm

As a bridge to the next section, which will cover assessment of sexuality and sexual concerns, the interview techniques included in this article are included here. These techniques are very helpful in terms of phrasing questions in non-judgmental and culturally neutral ways, and are applicable to virtually all interview situations.

Interviewing

Better ways of asking questions:

Rather than asking "marital status?"
Ask, "Are you single, married, divorced, separated or partnered?" The next question is, "With whom do you live?"

Rather than "What form of birth control do you use?"
Ask, "Do you use birth control?" If the patient says no, then ask "Do you need birth control?"

Rather than "Do you have any sexual problems?"
Ask, "Do you have any sexual concerns?" There is research showing that this question, however, will not uncover sexual dysfunctions. You have to ask about each specific dysfunction. For example, "Do you have difficulty having an orgasm, getting an erection, maintaining an erection, with pain during sex, lubricating enough or long enough, with the amount of desire you have for sex?"

Rather than "With how many partners did you have sex?"
Ask, "Are you sexually active?" Note: The author has found that this particular question can generate very concrete responses such as, “No, I just lie there,” etc., so please word this question in a different way.

Rather than, "Who beat you up?"
Ask, "How did you get those marks/bruises/welts?"

Rather than, "What is your sexual orientation?"
Ask, "Do you have sex with men, women or both?" (Moser, 1999).


The American Idea of Sex, Medicalization of Sexuality and the New View Campaign

There is one more important area concerned with values and how clinicians approach the topic of sexuality that must be addressed here. Among other trends that have been counterproductive for healthy sexuality, there have been tendencies in the medical community to approach sexual problems as "medical issues", an idea called “medicalization.”

The seeming proliferation of drugs and devices designed to "fix" whatever is "wrong" has led to complaints that sexuality is being “medicalized” and depersonalized and that sexual expression is being reduced to a performance act, often devoid of intimacy. Concerns exist that this may be more attributable to marketing and profit making concerns than with a desire to facilitate a healthy and enjoyable sexual life.

The debate about the medicalization of sexuality becomes further fueled by research findings linking female sexual problems with physical causes. As reported in Science News (June 8, 2005), Connell and a team of researchers at Yale School of Medicine and the Albert Einstein College of Medicine found that female sexual dysfunction (FSD) affected 48.2 percent of women and that these women had decreased sensation in the clitoris, which increased the risk of sexual dysfunction.

Connell (2005) noted that although epidemiological studies have shown that about 10 million women between the ages of 50 and 74 report sexual complaints, including decreased desire, inability to reach orgasm, and increased pain with intercourse, there has been little research into possible physiologic mechanisms involved in women’s sexual response.

Connell stated, “The sexual response is complex and involves interaction between the nervous system, the vascular system and the musculoskeletal system. Alterations in any of these systems could potentially cause FSD.”

This meta-perspective on sexuality and what constitutes healthy versus dysfunctional sexual functioning has many implications for treatment of clients’ sexual concerns. At the heart of this whole area lies an important values question: how is sexuality to be viewed – as a question of performance or as something more than just performance?

Generally the American idea of sex is a stair step progression to the top step, with intercourse and orgasm as the goal. Indeed, the top step is envisioned to end with the R.T., the Real Thing, which the literature tells us is “multiorgasmic simultaneous orgasm in intercourse for both people.” This is almost always a fantasy, but people aspire to get as close as possible, frequently devaluing and even overlooking pleasurable and enjoyable sexual expression. Often when people are not having intercourse, for whatever reason, they stop touching, sometimes virtually altogether.

Perhaps a better way to view sexual expression is as a circle with many life affirming and relationship enhancing activities possible - the concept of non-goal-directed sex. Health care practitioners can be a very important source of information and support in this area, by challenging the widely held notion that other behaviors “don’t count,” by exploring options for touching and intimate connection, and by supporting expressions of sexuality that are enjoyable and life-affirming. (Original source unknown).

                                                   

The American Idea of Sex                             Non Goal- Directed Sex

One approach that has begun to take shape as a counterpoint to the American Idea of Sex can be found in the New View Campaign.

The New View Campaign

In response to the apparent trend toward looking for physiologic or medical causes of sexual problems and developing devices and substances to enhance performance – particularly female performance - the New View Campaign was formed in 2000. The founders state:

“Our goal is to expose the deceptions and consequences of industry involvement in sex research, professional sex education, and sexual treatments, and to generate conceptual and practical alternatives to the prevailing medical model of sexuality.” (New View Campaign, 2007).

The Campaign does not ignore the physiologic or medical aspects of sexual experience, but it uses no normative list of dysfunctions (of desire, arousal, or orgasm). Instead, it holds that there is no necessary or universal sequence or list of components to a sexual experience, and proposes that the idea of a dysfunction as a deviation from some norm is not useful.

The New View nomenclature considers 4 categories of causes of sexual problems in order of likely prevalence and suggests that interventions be considered in this order as well, ensuring that educational interventions are always considered. These four categories are shown below.

Four Categories of Causes of Sexual Problems

1. Sexual problems due to sociocultural, political, or economic factors
2. Sexual problems due to partner and relationship factors
3. Sexual problems due to psychological factors
4. Sexual problems due to physiological or medical factors

The New View Campaign has a number of resources for professionals, including two Medscape Psychiatry and Mental Health internet programs (Hicks, 2005; Tiefer, 2006).

Confounding viewpoints and information leave clinicians frequently questioning the best course of action to pursue. For example, consensus on such issues as hormone use in women seems to change every few months. In regard to sexual desire in women, much of the research shows that low desire is a contextual matter and rarely a strictly hormonal one. At the same time, there are many situations in which hormonal approaches make sense as part of a comprehensive treatment plan.

As mental health clinicians, we are asked to scrutinize our deeply held personal values in numerous areas of practice, and sexuality will be no exception. Furthermore, we are asked to examine not just our own values for signs and symptoms of perceptual bias, we are also asked to scrutinize the values of the dominant culture as a whole.

While clinicians who are not specialists in sex and sexuality may feel some reticence about choosing sides in this particular debate, there are professional and ethical considerations involved in approaching this issue conscientiously. Given the importance of sexuality in a person’s life, this key value question is one in which clinicians must ultimately engage, no matter the discomfort that is generated.

For health care professionals, the lenses through which one sees the world ought to be inclusive and consider the range of available treatments and the efficacy of each of these for patients/clients. One anonymous clinician sums up the sentiments of many others: “I think it’s egregious how pharmaceuticals are being pushed on younger and younger men, and I think this really promotes performance anxiety in the extreme. On the other hand, the more I study the serotonin/dopamine connection in the brain and its effects on libido, the more I personally wish there was there more integration between medical therapies and sex therapy. A pill should never be taken in lieu of communication, creativity, diet, and health. On the other hand, as someone who suffered from PE, (premature ejaculation), I would have appreciated an integrated approach.”

It is the intention of this course to push for this more integrated approach.

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