Tag Archives: Sexual Wellness

Talking about menopause

By Laurie Meyers January 7, 2019

Sleepless nights. Sudden temperature spikes and night sweats. Fluctuating moods. Brain fog. Sudden hair loss (head). Sudden hair growth (face). Dry skin, leaky bladder, pain during intercourse.

This litany of symptoms may sound like the signs of a mysterious and slightly terrifying disease, but they’re actually all possible side effects of a normal, natural life transition: menopause.

Menopause is an inevitable part of life for women — or, more precisely, people with ovaries — but chances are, many clients who show up to counseling know little about it. “The Change,” as it is sometimes called, isn’t taught in sex education classes and is rarely brought up by doctors. Even friends don’t always tell other friends about it. Unprepared for this disruption that usually coincides with a life stage already known as a major time of transition, clients may turn to counselors for help navigating this natural biological process.

Understanding the process

Therein lies the first lesson: Menopause is part of a process. Menopause refers to a specific point 12 months after a person’s last menstrual cycle. Perimenopause, which can begin up to 10 years before menopause, is the transitional time during which most menopausal symptoms occur. Perimenopause usually begins in a person’s 40s but can start as early as a person’s mid- to late 30s.

“During these years, most women will notice early menopausal symptoms such as hot flushes, night sweats, sleep disturbance, heart palpitations, poor memory and concentration, vaginal dryness and … depression,” says American Counseling Association member Laura Choate, a licensed professional counselor (LPC) who has written extensively about issues that affect women and girls.

According to the National Institutes of Health, other perimenopausal symptoms include irregular menstrual periods, incontinence, general moodiness and loss of sex drive. Some people also experience aches and pains and weight gain, particularly in the abdominal area, although experts are unsure whether these effects are tied directly to perimenopause or are instead caused by aging.

LPC Stacey Greer, whose practice specialties include assisting clients with issues related to perimenopause/menopause, says that many clients show up to her office because they’ve been feeling “off” or “not like themselves.” Some of these clients may even have received a perimenopause diagnosis, but most still are unaware of the symptoms and don’t understand the process, she says.

Both Greer and Choate believe that knowing what to expect in perimenopause can in itself ease some of the discomfort of the transition. Choate notes that for those who are unaware of the signs of perimenopause, many of the symptoms can be alarming. Some clients’ symptoms may be mild, but for others, they are severe and can significantly interfere with clients’ functioning and quality of life, Choate says. She adds that symptoms usually peak about a year before the last menstrual period and begin to ease significantly in the second year of postmenopause.

Is it hot in here?

Knowing what to expect from perimenopause is all well and good, but in this case, forewarned doesn’t mean forearmed. Clients still have to live through the symptoms.

Counselors can help with that. Greer says that charting is an excellent tool. She gives clients a chart listing perimenopausal symptoms and asks them to note all the ones that they experience over the course of a month. This allows her to identify and focus on a client’s specific problems.

Hot flashes, night sweats and trouble sleeping are some of the most common complaints. Choate says research has shown that cognitive behavior therapy (CBT) can help with hot flashes and night sweats. She recommends the techniques contained in Managing Hot Flushes With Group Cognitive Behavioral Therapy: An Evidence-Based Treatment Manual for Health Professionals by Myra Hunter and Melanie Smith. The book highlights the importance of identifying and reframing thoughts that occur during a hot flash.

When hit with a hot flash, instead of thinking, “Not other one!” or “I am going to pass out” or “This will never end,” clients can tell themselves, “It will pass” or “Menopause is a normal part of life” or “The flashes will gradually go away over time,” Choate explains.

“In addition to changing self-talk, it is helpful to have an attitude of calm acceptance, mindfully accepting the hot flash instead of trying to push it away or become upset by it,” she says. “There is evidence that mindful acceptance and allowing the flash to ‘fall over you’ helps women cope more effectively. Also, using paced breathing to elicit the relaxation response helps women cope as they focus on their slowed breathing instead of the discomfort that accompanies a hot flash.”

Many people also experience problems sleeping during perimenopause. According to the National Sleep Foundation (NSF), this is not only because of nighttime hot flashes but because of decreasing levels of progesterone, which promotes sleep. The NSF recommends the following for menopause-related sleep problems:

  • Stay cool. Keep a bowl of ice water and a washcloth near the bed for quick cool-offs when awakened by a hot flash. Also maintain a cool, comfortable bedroom temperature (ideally between 60 and 67 degrees), and keep the room well ventilated.
  • Choose the right bedding. Skip thick, heavy comforters and fleece sheets and go for bedding made from lighter materials, such as breathable and fast-drying cotton. This prevents overheating.
  • Eat soy. Eating soy products such as tofu, soy milk and soybeans may help combat dropping estrogen levels. Soy products contain phytoestrogens, which have weak, estrogen-like effects that may ease hot flashes.
  • Consider a natural remedy. Natural hot-flash helpers include botanicals such as evening primrose and black cohosh. Make sure that clients consult a physician before taking these or any other supplements because they are not regulated and may interfere with other medications.
  • Try acupuncture. This ancient Chinese remedy uses tiny needles to unblock energy points in the body and may help balance hormone levels to ease hot flashes and trigger the release of more endorphins to offset mood swings.
  • Balance hormones. Clients should consult a physician for sleep problems that last for more than a few weeks. A physician might recommend hormone replacement therapy (HRT), which helps stabilize decreasing hormone levels and lessen the severity of hot flashes. Other medication options such as low-dose antidepressants and even some blood pressure drugs have also been shown to alleviate menopausal symptoms.

Good sleep hygiene habits are also important. The NSF recommends the following:

  • Get earplugs or a sound conditioner to maintain a quiet environment. Extraneous noise in the bedroom can disrupt sleep.
  • Keep overhead lights and lamps in the home dim (or turn off as many as possible) in the 30 to 60 minutes before going to bed.
  • Position the alarm clock so that it’s difficult to see from bed. Watching the seconds and minutes of a clock tick on and on while trying to fall asleep can increase stress levels, making it harder to get back to sleep when awakened.
  • Keep a consistent sleep schedule. Going to bed and waking up at the same time every day — even on the weekends — reinforces the natural sleep-wake cycle in the body.
  • Develop a bedtime routine. Running through the same set of habits at night helps the body recognize that it is time to unwind.
  • Stay away from stimulants such as nicotine and caffeine at night. Avoid drinking tea or coffee, eating chocolate or using anything containing tobacco or nicotine for four to six hours before bedtime. Alcohol can also disrupt sleep, so avoid more than a single glass of liquor, beer or wine in the evening.
  • Get regular exercise, but not too close to bedtime.

Greer also recommends relaxation techniques. She works with clients to help them focus on the things they can control and let go of the things they cannot control.

Many people find significant relief from hot flashes, sleep problems and mood disturbances by taking HRT or antidepressants, but clients often need help sorting through their options, Greer says. It’s not uncommon for clients to come to counseling with a whole sheaf of information from their OB-GYN, much of which can be difficult to understand. Greer helps clients navigate the material and identify any follow-up questions they have for their physicians. “This can help them feel more empowered and have a voice in their treatment,” she says.

“Speaking to a trusted medical and mental health professional is important at this time,” says Joanna Ford, an LPC whose practice specialties include assisting clients with issues related to menopause and perimenopause. If her clients don’t already have a physician, she suggests that they ask family members and friends or even consult social media for recommendations. In fact, some of Ford’s clients have created circles on social media that offer recommendations on physicians and treating menstrual issues.

Depression risk

Choate, who is currently writing a book on depression in women across the life span, says that depression is a common perimenopausal symptom. “There is an increase in depressive symptoms, first-time episodes of major depressive disorder (MDD) and … risk of recurrence of MDD in women who have a history of MDD,” she says. “Symptoms of depression occur at a 40 percent greater rate [among perimenopausal women] than in the general population, and the prevalence of depression increases 2-14 times in women during perimenopause versus the premenopausal years.”

Interestingly, perimenopausal depression presents slightly differently than depression as defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. In perimenopausal depression, clients are more likely to be irritable or hostile, have mood lability or anhedonia, and have a less depressed mood than is commonly seen in MDD, Choate explains. “Therefore, without a predominantly depressed mood, depression during the transition can be overlooked or misdiagnosed,” she says.

“Counselors can help women focus on self-compassion and self-care during this time, as studies show that there is an increase in negative life events for midlife women compared to other times in their lives,” Choate continues. “This could include children leaving home, caring for aging parents, the death of parents, personal illness, divorce or separation, [and] loss of social or financial support. With the increase in stressful life events, paired with the biological changes of perimenopause, women are more likely to experience distress.”

But all hope is not lost, Choate says. “I think it is helpful to be aware of studies that indicate that while women do experience a decrease in their mental health during these years, recent longitudinal studies show that depressive symptoms decrease as women age out of the perimenopausal years and enter their late 50s, 60s and 70s,” she says. “It is helpful to view this time as a window of vulnerability that does dissipate as women age and as they learn to view mid- to later life as a time of renewal and vitality.”

Sense of self and sexuality

It is not uncommon to feel grief about the menopausal transition. Greer says that some of her clients describe feeling “old” and struggle with their identity as women. “I try to help them work through the grieving process and work toward an acceptance of what is happening to their body,” she says. “It [the transition] does not change who they are, just how they see themselves.”

It isn’t difficult to understand why perimenopausal women feel old. As Choate notes, in Western cultures, youth is viewed as highly desirable, particularly for women, who continually receive the message that signs of aging should be avoided and obscured as much — and as long — as possible.

“The anti-aging industry is designed to perpetuate the myth of eternal beauty — that women can and should maintain a youthful, thin appearance regardless of their age,” Choate says. “The myth implies that women should exert the energy needed to conceal signs of aging, and if they don’t, then they are to blame.”

Women are socialized to prevent or repair skin changes such as wrinkling, sagging and age spots, all of which are natural signs of the aging process. Thinning and graying hair and weight gain are other results of aging that are considered undesirable, Choate notes.

Women “are taught that as they lose their youth, they will also lose their physical beauty, their sexual appeal, their fertility and their overall use to society,” she says. “In contrast, in cultures in which older age is revered, women report fewer symptoms during the menopausal transition. Cross-cultural studies show us that when older women are valued for their wisdom and contributions, they have more positive expectations about aging and menopause, and they also experience few menopausal symptoms. The message from these cross-cultural studies is that when women welcome aging as a natural process, not a disease, and accept naturally occurring changes to their weight, shape and appearance, they are less likely to experience negative symptoms associated with menopause.”

Women may know all of this intellectually, but the societal message is hard to ignore: Youth = beauty = power. Even women who habitually kept these weapons sheathed may feel the shift as they enter the perimenopausal transition.

“Body issues are important to address during this transition time,” emphasizes Ford, a member of ACA. “Aging is part of every life. The culture that we are surrounded by may impact our image of ourselves and our self-value. If we can increase our awareness about how we speak to ourselves about our bodies, it is possible we can accept the changes instead of fighting them.

“People may feel invisible before entering perimenopause, and it can increase feelings of depression and isolation. It is imperative to find a support system that encourages an individual’s values based on a variety of things, such as personal interests, skills, spiritual or religious beliefs, occupation, artistic or creative pursuits or any topic people can connect through.”

Body image issues can become part and parcel of the sexual changes that accompany perimenopause. “Menopause is reached upon the cessation of a woman’s menstrual cycles for 12 consecutive months. This means that menopause culminates in the loss of fertility,” Choate says. “For many women, this is a difficult role transition, particularly if they have based their identity upon a youthful appearance, which is often associated with fertility. For other women, the end of the childbearing years is a welcome change, as they become free from monthly menstrual cycles and also gain freedom from the need for birth control and other pregnancy concerns. They may experience negative biological sexual changes but may be more motivated to seek treatment for these changes as they begin to explore their sexuality apart from its association with childbearing.”

“Women often report a decrease in libido during this time,” Choate continues. “Some of this is due to physical factors — pain during intercourse, vaginal dryness — and some is due to psychological factors, including poor body image, beliefs and expectations about aging and sexuality, stress, fatigue from night sweats, and sleep disruption.”

Estrogen replacement therapies can help with many of the physical factors, but addressing the psychological factors is equally important.

“CBT is also helpful in examining a woman’s expectations for menopause, aging and her sexuality now that her sexuality is no longer linked to fertility and youth,” Choate says. “She might need to change her beliefs about women and aging, viewing menopause as a natural process that occurs to all women but does not indicate a disease, nor does it necessitate a view of herself as an aging, asexual woman. She might benefit from discussing her concerns with her partner to clear up any miscommunication about her partner’s expectations or attitudes toward the changes that are occurring in her body.”

It is essential — but sometimes difficult — to talk about those negative biological sexual changes, Ford notes. “Testosterone and estrogen levels are decreasing at this time and can lead to a change in libido or discomfort during intercourse,” she explains. “I do think people have to ‘re-envision’ their sexuality because hormonal changes are always happening.”

Of course, sex does not mean just intercourse, Ford continues. Embracing different ways of sexual expression can be helpful if intercourse becomes painful. People for whom intercourse is painful may also want to consult their physicians about lubrication or hormonal therapies, she says, adding that she recommends clients read The V Book: A Doctor’s Guide to Complete Vulvovaginal Health by Elizabeth G. Stewart and Paula Spencer.

Ultimately, counselors can help clients see not just the losses associated with menopause but also the opportunities.

“Now that you are entering a new life stage, what new opportunities do you want to seek out for yourself?” Choate asks. “What can you explore and enjoy during this next life phase? Research shows that while women do experience increased unhappiness during their early 50s, longitudinal studies show that they are happier than ever in their mid-50s and into their 70s and benefit from decreased caregiving and work responsibilities in their later years.”

Greer reassures clients that even though the menopausal process may sometimes seem as if it will go on forever, the stage is temporary. “There is life after menopause,” she emphasizes.

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Addicted to sex?

By Amanda L. Giordano and Craig S. Cashwell August 7, 2018

Sex and sexuality are necessary, healthy and, arguably, sacred aspects of the human experience. What happens, though, when sex is used not to enhance intimacy and connection with others but, rather, becomes out of control? What happens when a person describes a clear set of personal values around sexual behavior yet consistently crosses his or her own boundaries and compromises personal sexual values? What happens when a person continues a pattern of sexual behavior despite detrimental consequences? Can a person be addicted to sex?

Although most forms of sexual expression are healthy, the sex addiction model posits that some individuals may develop compulsive, dependent relationships with sex. Critics of the sex addiction model suggest that the addiction label pathologizes nonnormative sexual behaviors (e.g., fetish, kink), yet true proponents of the model do not claim to define morally appropriate forms or frequencies of sexual acts. The focus, rather, is on one’s relationship with sex.

Just because a sexual behavior violates an individual’s personal values, religious or spiritual beliefs, or societal norms does not make it an addiction. Instead, sex addiction has specific defining characteristics:

  • Loss of control
  • Continued engagement despite negative consequences
  • Mental preoccupation or cravings

Thus, rather than being sex-negative, advocates of the sex addiction model work to identify those who are unable to control their sexual behavior, are experiencing distressing outcomes and are mentally preoccupied or craving sex. Once sex addiction is determined, individuals then can get the treatment and support they need to establish healthy sexuality. 

A topic for debate

The notion that sex can be addictive still is debated among mental health professionals. Instead of addiction, alternative explanations for problematic sexual behaviors include impulse-control issues, obsessive-compulsive disorder, neuroticism, learned behavior, a form of sensation seeking, internalized sex-negative messages or manifestations of a mental health issue such as bipolar disorder.

The addiction model, however, purports that the primary issue is an out-of-control relationship with sex resulting from changes in chemical messengers in the brain. Specifically, naturally reinforced behaviors, such as eating and sex, are linked to the release of neurotransmitters (i.e., dopamine) related to pleasure and reinforcement. A naturally rewarding behavior such as sex can become a supernormal stimulus leading to dysregulation in the dopaminergic system. The resulting neuroadaptations affect reward, memory, attention and motivation. Thus, from an addiction model perspective, sex can hijack the natural functioning of the reward pathway in some individuals, leading to addictive behavior.

The sex addiction model contends that in addition to being positively reinforcing through the release of dopamine and other neurotransmitters, sex can be negatively reinforcing. Over time, sex can become addictive when it is used as the primary or, sometimes, sole method of regulating undesirable emotions. In other words, sexual behavior can be negatively reinforcing when it functions as an avoidance strategy and is used to escape emotional pain. In a negative feedback loop, however, the individual often feels shame as a result of his or her out-of-control sexual behavior. Paradoxically, this shame may become part of the undesirable emotions that the person then strives to regulate through sexual acts. From an attachment perspective, it is likely that these individuals never learned to coregulate emotionally and, instead, try to autoregulate emotions.

Scholars who primarily emphasize the negative reinforcement of sexual behavior often argue for terminology other than sex addiction, such as compulsive behavior or hypersexuality. However, the fact that sex provides both negative reinforcement (i.e., escape) and positive reinforcement (i.e., pleasure) seems to give credence to the addiction model.

Although controversy remains, the mental health field is steadily embracing the notion that behaviors can become addictive. For example, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) included the diagnosis for gambling disorder in a chapter titled “Substance Use and Addictive Disorders.” In addition, internet gaming disorder and nonsuicidal self-injury (which some conceptualize as a behavioral addiction) were included in Section III as conditions in need of further study.

A diagnosis of hypersexual disorder was considered for the DSM-5 but ultimately was not included. The American Society of Addiction Medicine, however, revised its official definition of addiction to include both chemicals and naturally reinforcing behaviors. Furthermore, within the World Health Organization, the Working Group on Obsessive-Compulsive and Related Disorders for the 11th version of the International Classification of Diseases has recommended a diagnosis of compulsive sexual behavior. The organization determined the need for additional research to classify sexual behavior as addictive but clearly recognizes that out-of-control sexual behavior is a public health issue.

In addition, the recent surge of public concern related to pornography use and related erectile dysfunction among relatively young men (as evidenced by high traffic on websites dedicated to helping individuals “reboot” or discontinue use of pornography) has contributed to the influx of neuroimaging studies exploring addiction to pornography. Researchers have confirmed that the same regions of the brain activated by drug stimuli also are activated by online sexual stimuli and that addictive sexual behavior may be associated with decreased gray matter and diminished connectivity in the brain.

Types of sex addiction

Scholars conceptualize two types of sex addiction. The profile for the classic type includes early attachment wounds, family-of-origin issues and trauma histories, culminating in insecure attachment strategies in adulthood. Research shows a clear link between problematic sexual behavior and insecure attachment styles, and the majority of individuals in treatment for sex addiction have experienced trauma. For individuals with classic sex addiction, their sexual behavior may have been a primary means to fulfill attachment needs or escape emotional pain. Over time, however, the behavior became compulsive and out of control as the natural longing for sex became a need and then an addiction. 

Recently, a second contemporary type of sex addiction has been identified among individuals without the classic profile of trauma or attachment wounds. Instead, the contemporary type emerges as a result of chronic, excessive exposure to sexual stimuli, especially in the form of pornography or cybersex, made more readily available when the internet became ubiquitous. Sex researcher Alvin Cooper referred to cybersex as a triple-A engine, offering affordability, anonymity and accessibility to users.

Online sexual images and videos are pervasive, and current estimates suggest that the average age of first exposure to pornography is 11. This initial exposure is often accidental on the part of the child, with pornography sites known to purchase domain names of commonly misspelled children’s websites (referred to as cybersquatting). Over time, however, pornography becomes a supernormal stimulus reshaping the brain by repetitive experiences of pleasure associated with online sexual images. The brain responds to this hyperactivity in the reward pathway by decreasing natural dopamine production and receptors. Consequently, with decreased natural dopamine production, those with sex addiction may feel mildly depressed at baseline, inducing cravings for sexual behavior to alleviate the negative mood. Thus, whether classic or contemporary, sex addiction leads to changes in brain circuitry, which, in turn, perpetuates the addictive cycle.

The nature of sex addiction

Among individuals for whom sex has become addictive, the condition is all-consuming. When those with sex addiction are not engaging in sexual behaviors (acting out), they likely are thinking about them (fantasy and mental preoccupation), getting ready for them (preparation and ritualization) or recovering from the consequences (physically and emotionally).

Sensitization caused by neuroadaptations may lead individuals to seek novel or more intense sexual stimuli to achieve the desired effect (otherwise known as tolerance). For example, an individual may shift from nonviolent to violent pornography or change from streaming cybersex to partnered anonymous sex. Those with sex addiction begin to live a double life as they hide their out-of-control sexual behaviors from others, withdraw and isolate. Furthermore, many people with sex addiction lose sexual interest in their romantic partners and experience sexual dysfunction because of classic conditioning in which arousal is paired with alternative stimuli such as a computer. The addiction affects the individual physically, psychologically, spiritually, relationally and emotionally. Although sex addiction begins to control these individuals’ lives, they often are reluctant to tell anyone about their experience because of intense feelings of shame and self-loathing.

Addictive sexual behavior can manifest in a variety of ways, from compulsive masturbation, anonymous sex and prostitution to compulsive sexual relationships, voyeurism or rape. Indeed, some sexual acting-out behaviors can cross the legal line and fall into the realm of sexual offenses, but the majority of those with sex addiction do not offend; rather, they engage in legal forms of compulsive sexual behavior.

Sex offenders generally have distinct profiles from sex-addicted nonoffenders. Specifically, sex offenders are more impulsive; engage in more intrusive behaviors; respond to offenses with hatred, anger and entitlement; and have low remorse. This profile differs from the progressive trajectory of sex addiction that tends to include more frequent, yet less intrusive, acting out; triggers shame, despair and powerlessness; and is met with high remorse. When sexual acting-out behaviors cross the line of legal offense, those who are sexually addicted are legally responsible for the consequences of their actions despite having an addiction (much like someone with alcohol addiction who injures another person while driving under the influence).

Although individuals with addiction are not responsible for “giving themselves” sex addiction, they are responsible for their recovery through seeking help and working a treatment program. Increasing public awareness about sex addiction can help promote early access to professional treatment, with the hope being that this step will aid in avoiding decades of negative consequences both for individuals with sex addiction and for others who may be affected.

Clinical considerations

Given that sex addiction can include myriad sexual behaviors, it is important for clinicians to assess and screen appropriately. Most sex addiction emerges in late adolescence and young adulthood, so school counselors and community clinicians working with young clients can provide early intervention by regularly screening for sex addiction. Counselors are encouraged to broach the subject of sex in counseling and explore clients’ relationships with their sexual activities, such as masturbating, sexting, hooking up, using pornography, engaging in cybersex, using sexual apps and engaging in compulsive sexual relationships.

Despite the fact that sex addiction emerges early, most individuals do not seek professional treatment until later in life as a result of experiencing often extreme negative consequences (i.e., “hitting rock bottom”). Accordingly, all clinicians should be screening for a loss of control over sexual behaviors, continued engagement in sexual behaviors despite negative consequences, and mental preoccupation or cravings. Along with informal screening and exploration, many formal assessments for sexual compulsivity and addiction exist, including the Sexual Addiction Screening Test, the Sexual Compulsivity Scale and the Sexual Dependency Inventory. The use of these instruments can help clinicians better understand their clients and coconstruct appropriate treatment goals.

Once counselors identify the presence of sex addiction, they have many tools and treatment programs to assist in helping clients reach long-term recovery. Unlike recovery from chemical addictions, the goal of sex addiction treatment is not abstinence from all sexual acts, but rather the development of healthy sexuality. It is the compulsive, detrimental sexual behavior that counselors and clients work to eradicate.

To help clarify recovery from sex addiction, many clinicians and 12-step recovery programs (such as Sex Addicts Anonymous) use the three-circles activity. With a sponsor or counselor, those with sex addiction draw three concentric circles. In the innermost circle, the client lists all unhealthy sexual behaviors that have led to negative consequences and over which the individual has lost control. These are the behaviors from which the client is choosing to abstain.

In the middle circle, the client lists behaviors that may lead to sexual acting out. Identifying middle-circle behaviors is important from a neurological perspective. The amygdala is responsible for emotional memory; thus, it remembers stimuli associated with the experience of pleasure. After years of sex addiction, individuals likely have associated specific locations, sounds, sights, smells and actions with sexual pleasure. The middle circle, therefore, includes any stimuli, such as excessive fantasizing, cruising or sexually objectifying others, that may trigger the amygdala and lead to sexual craving.

Finally, the client uses the outermost circle to identify healthy behaviors that will support the individual’s recovery. These behaviors might include participating in 12-step groups, engaging in counseling, fostering spiritual practices, exercising, eating healthy, keeping home and work spaces nonchaotic, spending time doing recreational activities and increasing healthy social support.

Many counseling approaches and interventions, including cognitive-behavioral approaches, psychodynamic approaches, acceptance and commitment therapy, motivational interviewing, art therapy, group counseling, couple and family counseling, and even psychopharmacology, are appropriate for work with sex addiction. It is important to note that recovery from sex addiction often spans years rather than months. Clients, family members and partners may erroneously believe that recovery occurs within a matter of weeks and can become disheartened when initial attempts to change behavior are unsuccessful. Providing psychoeducation about the neurobiology of sex addiction can offer a more accurate perspective and create realistic expectations. Clients can find hope in the fact that, in time, the brain can heal and resolve dysregulation in the reward circuitry. This healing process takes time, however, and the completion of specific tasks such as those outlined in Patrick Carnes’ 30 tasks of recovery.

Additionally, sex addiction may not be the only concern addressed in treatment. Given the common mechanisms underlying addiction, it is not surprising that coaddictions to gambling, food, gaming, the internet or substances often exist among those with sex addiction. Furthermore, research supports the prevalence of comorbid mental health problems, including bipolar disorder, major depressive disorder and attention-deficit/hyperactivity disorder, among those with sex addiction. Finally, a trauma-informed perspective may be necessary to help clients resolve trauma to improve emotion regulation.

Clinicians should take an integrated approach to address all addictive and mental health concerns in treatment. Integrated care may be more complex than addressing one concern at a time, but diverse treatment teams, supplemental or adjunct resources, and holistic recovery plans can best help clients reach long-term health and wholeness.

Advocating for clients

One of the most necessary forms of advocacy for this population is increased awareness related to sex addiction. During the Masters Tournament in 2010, roughly six months after the story broke concerning Tiger Woods’ sexual behavior and treatment for sex addiction, someone flew a plane over the Augusta National Golf Club with a banner reading, “Sex addict? Yeah. Right. Sure. Me too.”

It is inappropriate for anyone outside of Woods’ personal and professional circle to try to determine a clinical diagnosis for his case, but the plane and banner reflect a popular public sentiment: Sex addiction is not real. Advocates can work to increase public knowledge relating to sex addiction and dispense critical research about the condition.

Additionally, mental health professionals can take several practical steps to advocate for clients who are sexually addicted. Currently, many counseling centers do not include information about sex addiction on their websites or relevant items on their intake forms. This lack of acknowledgment may inadvertently communicate to clients that sex addiction is not an appropriate topic for counseling. Thus, one of the simplest forms of advocacy is to include the experience of compulsive sexual behavior on websites, advertisements and client intake forms.

Another important advocacy effort is to acknowledge that individuals of all genders can have sex addiction. Specifically, when community groups, media spokespeople or well-meaning educators leave women out of the conversation about addiction to sex or pornography, they add a layer of stigma for these individuals. Although prevalence rates may differ among genders (about 1 in 7 of those with sex addiction are women), it does not discount the salience of sex addiction among female populations.

Finally, the most recent standards of the Council for Accreditation of Counseling and Related Educational Programs require educators to teach students about theory and etiology of addictive behaviors. Therefore, counselor training programs can advocate for future clients by infusing relevant, up-to-date information regarding sex (and other behavioral) addictions in the counseling curriculum.

Conclusion

Much work is needed to decrease the stigma and shame associated with sex addiction. Although stigma exists with any addiction, it seems particularly poignant with regard to compulsive sexual behavior. In the cycle of sex addiction, shame serves as both a precursor and a consequence of sexual acting out. Raising public awareness regarding the nature of sex addiction can help combat this shame.

Rather than conceptualizing compulsive sexuality as a moral failing, the addiction model provides a framework to empower clients to manage their condition while offering effective tools for recovery. Controversy may always exist regarding the conceptualization of sex addiction, but it is imperative to continue the conversation, increase empirical evidence and engage in advocacy efforts to serve and support this population.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Amanda L. Giordano is an assistant professor at the University of Georgia. A licensed professional counselor, she specializes in addictions counseling and multiculturalism. Giordano serves on the executive board for the Association for Spiritual, Ethical and Religious Values in Counseling and the editorial review boards for the Journal of Addictions & Offender Counseling and Counseling and Values. Contact her at amandaleegiordano@gmail.com.

Craig S. Cashwell, a professor in the Department of Counseling and Educational Development at the University of North Carolina at Greensboro, is an American Counseling Association fellow. Additionally, he maintains a part-time private practice focusing on couple counseling and addictions counseling. He serves as editor-in-chief of Counseling and Values.

 

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

It’s not about ‘clean’: Dismantling the language of HIV stigma

By J. Richelle Joe and Sarah B. Parkin June 5, 2018

Words matter. The language we use when discussing sensitive, controversial or stigmatized topics reflects and shapes our attitudes and beliefs about those topics. Such is the case with HIV and AIDS. Since being widely identified in the 1980s, HIV and AIDS have been perceived negatively by the general public, resulting in the pervasive use of language that characterizes those living with the virus or the disease as undesirable and even dangerous.

The counseling context is not immune to such damaging language, and it is reasonable to infer that words have a powerful influence on mental health and counseling outcomes for people living with HIV. Counselors must beware of the power of language; outdated information about HIV and AIDS can intersect with the inadvertent use of stigmatizing language and undermine the ethical principles of nonmaleficence and beneficence that form the foundation of our profession. We also have a responsibility to actively oppose HIV- and AIDS-related bias and stigma by educating ourselves about HIV and AIDS and changing the language we use when discussing them.

Let’s start by offering a quick guide to HIV and AIDS terminology:

  • HIV: Human immunodeficiency virus; people can be diagnosed with HIV and not have an AIDS diagnosis
  • AIDS: Acquired immunodeficiency syndrome; caused by HIV
  • CD4 cells: Cells that are a part of the body’s immune system; also known as T cells
  • Viral load: The amount of HIV particles in the body
  • Opportunistic infections: Illnesses, including certain types of cancer, that occur more often when someone has a weakened immune system
  • ART: Antiretroviral therapy, a common treatment for HIV
  • PrEP: Pre-exposure prophylaxis, daily medication that can reduce one’s risk of contracting HIV
  • PEP: Post-exposure prophylaxis; prescribed use of ART within 72 hours of a possible exposure to HIV
  • Viral suppression: When the amount of HIV particles in an individual’s system decreases to the point that the virus is not detectable by current tests; occurs when an individual is adherent to treatment; also known as having an undetectable viral load

The changing face of HIV and AIDS

In the United States, AIDS was originally called GRID (gay-related immune deficiency), and the illness was most commonly associated with gay white males. Although the name of the illness changed as it became apparent that minority sexual orientation was not a determinant of HIV transmission, AIDS continued to be viewed as a “gay disease,” with multiple layers of associated stigma.

Although the stigma remains, the demographics of individuals living with HIV have shifted and increasingly include women and individuals of color. According to the Centers for Disease Control and Prevention (CDC), women account for approximately 20 percent of new HIV diagnoses, and among African American women, the estimated lifetime risk of an HIV diagnosis is 1 in 54 (compared with 1 in 941 for white women). African American and Latinx communities are disproportionately affected by HIV and AIDS. This is largely as a result of social determinants of health such as access to accurate information, preventive methods and health care, which are influenced by geographic location, cultural and social beliefs, socioeconomics, and stigma about sex and sexuality.

As the demographics related to HIV and AIDS have changed since the 1980s, so has the scientific knowledge, leading to key advancements in HIV prevention, diagnosis and treatment. Today, people with HIV can live long, healthy lives, provided that they adhere to treatment and monitor other aspects of their health.

Unfortunately, much of what is commonly known about HIV and AIDS is outdated and inaccurate. For instance, recent surveys conducted by the Kaiser Family Foundation indicated that some Americans still believe that HIV can be transmitted via mosquito bites, shared eating utensils and toilet seats. Many Americans also instinctively associate HIV with death, despite critical advancements in HIV care.

HIV is not a death sentence. For individuals living with HIV, the key to their health is the strength of their immune systems as measured by their CD4 cell count and viral load. Ideally, the goal for people living with HIV is to have a high CD4 cell count and a low viral load. Fortunately, as a result of significant medical advances over the past few decades, individuals with HIV who are consistent in their adherence to ART can have a viral load that is undetectable. Studies have shown, and the CDC has affirmed, that individual with undetectable viral loads have almost zero chance of transmitting HIV to another person even if other protective measures are not present. Never before in the history of HIV and AIDS has there been such hope for HIV prevention generally and people living with HIV specifically.

Unfortunately, not all individuals living with HIV access care and have an undetectable viral load. According to the CDC, approximately 1.1 million Americans are currently living with HIV, with 85 percent of these individuals aware of their HIV status. However, only 62 percent of Americans living with HIV are engaged in care, and only 49 percent of individuals living with HIV have an undetectable viral load. Multiple factors, including public health policies and social determinants of health, contribute to these statistics.

Unaddressed mental health needs might also be at work. People living with HIV may experience adjustment difficulties, depression, anxiety and trauma — all of which can affect an individual’s willingness and ability to seek medical care and remain adherent to treatment. In the past, HIV care focused primarily on the medical needs of people living with HIV. Today, there is growing awareness of the need to address the psychological and emotional aspects of HIV and AIDS because those factors may affect overall wellness.

The power of language

Despite the hope that science has given us with respect to HIV prevention and treatment and the increased awareness of the need for mental health support for people living with HIV, the language frequently used to describe HIV and AIDS continues to bolster the stigma associated with the illness.

Whereas phrases such as “clean bill of health” are benign with respect to other illnesses, when used in connection with HIV and AIDS, they can have a much different connotation. For instance, use of the word “clean” to describe someone who does not have an HIV diagnosis can send the message that those who are HIV positive are somehow unclean and dirty, or even impure and sinful. But HIV is not about clean. Not having an HIV diagnosis is not a determinant of cleanliness or good moral character. Equally, having an HIV diagnosis has nothing to do with being dirty or having loose morals.

Similarly, referring to HIV “infections” rather than HIV diagnoses or transmissions conjures thoughts of contamination, impurity and even death. Simply put, the dichotomy of “clean” versus “infected” breeds stigma, negativity and hopelessness. These negative connotations make getting tested, disclosing one’s HIV status, discussing methods of protection, and accessing and staying in care more difficult.

When counselors inadvertently use stigmatizing language in reference to HIV and AIDS, they risk harming clients by perpetuating stigma and reinforcing barriers to both physical and mental health care. By reducing stigma through intentional language choices, counselors can better help individuals explore their options for entering care or identify potential barriers that may prevent them from staying in care in the future. Additionally, helping clients identify protective factors such as support systems, positive coping strategies and individual strengths can be beneficial to their growth and development.

Regardless of HIV status, and in the name of balance, it is also important for counselors to inquire about aspects of their clients’ sexual wellness when the topic arises. As previously mentioned, with clients who are living with HIV, counselors can discuss getting and staying in care. With clients who are not living with HIV, counselors can use psychoeducation to identify appropriate prevention methods, including PrEP, PEP and proper condom use.

 

 

Say this, not that

Recognizing the negative impact that stigmatizing language has on individuals is only the first step toward defusing the taboo of HIV and AIDS. The next step is to identify specific stigmatizing phrases and replace them with appropriate alternatives.

On a foundational level, counselors can make an easy change in their communication about HIV and AIDS simply by using person-first language. Saying “person living with HIV” rather than “AIDS patient” does several things. First, it builds the therapeutic relationship and helps to externalize the diagnosis rather than fusing it with the client’s identity. Second, person-first language decreases stigma by emphasizing the possibility of living, and living well, with HIV.

The use of “person living with HIV” rather than “AIDS patient” also reflects a more accurate understanding of the illness and its progression. Often, HIV and AIDS are used interchangeably, despite an important medical distinction between the two. For counselors, it is essential to accurately differentiate between an HIV diagnosis and an AIDS diagnosis.

An HIV diagnosis follows a reactive test for the HIV virus; however, a diagnosis of AIDS is given by a physician only if an individual’s CD4 cell count is below 200 or if the individual develops certain opportunistic infections. Given that effective treatment is available for individuals who have been diagnosed with HIV, it is likely that someone who is adherent to treatment will never receive an AIDS diagnosis. By ignoring the difference between these two diagnoses, a counselor might appear to be invalidating, deterministic and incompetent to a client who is living with HIV.

Additionally, the phrase “full-blown AIDS” needs to be retired from our collective vocabulary. This phrase — which bolsters fear, reinforces HIV stigma and conjures thoughts of death — is wholly inaccurate and is no longer used among medical professionals. Along the same lines, stating that someone “died from AIDS” is also unproductive and inaccurate. If HIV progresses to the point that an AIDS diagnosis is given, an individual is vulnerable to opportunistic infections, which could be fatal. Hence, an individual might die from an opportunistic infection or an AIDS-related illness but not from AIDS itself.

Accuracy in our language when discussing this particular illness is critical. Errors in our word choices can communicate misinformation and harm clients, adding to the barriers that often prevent clients with HIV from seeking medical and mental health care services.

Conclusion

Understandably, discussing HIV and AIDS can be awkward or uncomfortable for some individuals, including counselors. However, equipped with the right language, counselors can engage their clients in vital conversations about their sexual and mental health. By discussing HIV transmission rather than infection, we can destigmatize the illness and the conversation. We can disrupt the pervasive narrative that equates HIV and AIDS with death, uncleanliness and immorality. And most important, we can be bridges rather than barriers so that people living with HIV will feel encouraged and empowered to access care and live well.

 

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J. Richelle Joe is an assistant professor of counselor education at the University of Central Florida. Her work focuses on HIV prevention and culturally and ethically sound services for people affected by HIV or AIDS. Contact her at jacqueline.joe@ucf.edu.

Sarah B. Parkin is a master’s student in clinical mental health counseling at the University of Central Florida. Her research interests focus on intersectionality and marginalized communities.

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Behind closed doors

By Zachary David Bloom May 7, 2018

Few topics are more controversial or downright uncomfortable to talk about than sex and sexuality. It seems we could examine any period of time in human history and find a number of social values and ideas related to sexual behavior, all of which might be discussed with some nuanced language or slang of the time. More often than not, we would find some positive messages about sex but also a fair share of messages that promote — intentionally or not — feelings of guilt and shame. Even with the timeless double binds that accompany messages around sex and sexuality, it is important to recognize that sex remains an important part of our storied history. After all, without sex, we wouldn’t even be here to have this conversation.

When we talk about sex, we are talking about something loaded with assumptions and values. Sex does not exist in a vacuum; rather, it is woven into our personal identities. It is with that idea that I want to encourage sensitivity and tolerance for a topic that has been dressed up and dressed down: pornography.

Sex and pornography in the 21st century

When considering key markers of sex and sexuality that exemplify the zeitgeist of today’s technological era, one might think of pornography, an industry that pulls in billions of dollars each year. Access to pornography has only increased with widespread use of the internet and the diverse number of gadgets available to connect to it. As such, it makes sense that counselors report working with more and more clients who have issues related to their pornography use.

Researchers have attempted to establish correlations between pornography use and a number of other issues of clinical concern (e.g., depression, anxiety), but it has been difficult to draw any definitive conclusions. However, we do know that clients are presenting to counseling for issues in their romantic relationships related to pornography use (e.g., fighting about how much or how often it should be viewed, if at all), for issues that mirror symptoms of addiction related to their pornography use and for a variety of other issues that can be traced back to their pornography use.

Some of the more nuanced issues related to pornography use include clients reporting decreased sexual satisfaction in their primary relationship or even an inability to perform sexually because of a desensitization to sexual stimuli. Some clients report experiencing anxiety and distress about expectations — either self-imposed or solicited by a partner — to replicate acts depicted in pornography that contrast with the client’s value system. Similarly, some clients report experiencing distress connected to feelings of inadequacy that result from comparing themselves with the actors and actresses in the pornography industry.

This is not an exhaustive list, but I believe it speaks to what has been identified in the counseling literature and what counselors have anecdotally reported seeing in their practices, which parallels what I have seen in my own clinical practice. It is also worth noting that clients are more likely to come to counseling with presenting issues that appear not to connect to their pornography use. Most often, this is because the presenting issue simply has no connection to their pornography use. Other times, it is because clients have not yet gained awareness of how their presenting issue relates to their pornography use or, commonly, do not yet feel safe enough in the therapeutic relationship to talk about their pornography use. Yet the question remains: Why are clients now coming to counseling for issues related to pornography?

Accessing pornography

Imagine a child on a school playground in Anywhere, America, playing with their friends when they hear a sexual word or phrase that they’ve never heard before. Maybe they don’t even know that the word has anything to do with sex or sexuality. Now imagine that the child is too embarrassed to ask their friends about it, so the child either types the word into an internet browser on their smartphone or waits until they get home to Google it. In a matter of seconds, the child is confronted with definitions that might go beyond their scope of understanding or is seeing a sexual act, either via high-definition images or video.

Although this example doesn’t fit as well for older age groups, it is representative of how the cultural narrative around pornography has changed from previous decades. You can imagine that the same child in the 1970s or 1980s would not have had easy access to that kind of content. Instead, the child would have needed to ask a friend or relative to explain the concept or term. Even if this person felt uncomfortable with the question or was not the ideal person to ask, there still would have been a connection between the two people. In other words, the child would not have been left to wrestle with this concept in isolation.

In previous decades, if minors wanted to access pornography, they had to find it, borrow it or steal it. Adults needed to show an ID to purchase it. Today, the only thing required to access pornography is a technological device. Even devices with software blocking services work inconsistently at best. Consequently, we are simultaneously more connected and more isolated than we have ever been in human history.

When we think about the dynamic and contrasting messages that society promotes about sex and sexuality and place that in conjunction with sexuality being tied into a person’s identity and valuation of themselves and others, it makes sense that we are seeing an increase in problems related to client pornography use.

Discomfort with sexuality

One could make the argument that most clinical issues might increase or decrease along with the availability of and accessibility to: fill in the blank. For example, a couple might argue more when they reach retirement and spend more time together (i.e., an increase of minutes together). The issue of pornography, however, is more dynamic than its presence or absence because it is a piece of the larger puzzle of sexuality. As readers are likely aware, there is often a significant amount of shame and guilt tied to issues of sexuality — for clients and counselors alike.

Sexuality is described as being part of the human experience, and the helping professions’ various accrediting bodies recognize it as such. However, human sexuality is not a standard and mandated part of counselors’ training. In fact, the general sex education that a counselor receives as a child and adolescent in elementary, middle and high school varies in depth and breadth — if it’s covered at all. Consequently, counselors experience a wide spectrum of comfort levels when it comes to discussing issues of sexuality in general. In addition, counselors’ comfort with sexuality influences their propensity to assess and treat clients for sexual issues.

Perhaps because of their lack of formal or meaningful sex education, some people — including counselors — have reported turning to pornography to learn about sexuality. The concern about this is that pornography is not considered to be a realistic portrayal of sex or intimate relationships. Thus, it might lead individuals to form unrealistic expectations about what happens in a sexual encounter and to pursue sexual activities that could interfere with fostering a successful or satisfying sexual experience. At the same time, counselors might be impaired to provide helpful or accurate psychoeducation to their clients related to sexuality if they do not have a more reliable source of information than pornography.

Taking down barriers

The best way to position yourself to meet your clients’ needs when it comes to working with issues of sexuality or pornography is to know yourself. These are controversial topics, and the first step in being available to your clients is to take ownership of your own beliefs, values and attitudes about sex, sexuality and sexual behaviors. As a starting point, ask yourself how comfortable you feel when thinking about working with a client who reports wanting to reduce their pornography use or who says their pornography use is interfering with their romantic relationship. If you notice discomfort or an aversion to working with a client on those issues, it might be a good time to seek consultation or supervision concerning the source of your discomfort.

In my experience with counselors-in-training and counselors I have met at various conferences, the discomfort tends to stem from one of three things:

1) Religious or spiritual values that make it difficult to maintain a stance of unconditional positive regard

2) Previous experiences of trauma that make it difficult to stay present when delving into discussions of sexuality

3) Feelings of incompetence when it comes to forming or maintaining healthy sexual relationships

For issues of personal values and beliefs — whether stemming from religious/spiritual foundations or not — I think it can be beneficial to pursue counseling services to explore those feelings of discomfort. Counseling can be an effective way to question and deconstruct beliefs that might be interfering with the formation or maintenance of a therapeutic relationship with a client who is wrestling with any of these issues. I find it helpful to allow myself to maintain my belief system and simultaneously place brackets on that belief system so that I can join a client or couple without my lens impeding on their experience. Sometimes I find that working with a client or a couple might remind me of an old belief or value that I once held. I can recognize that the belief is no longer serving me and that I am ready to discard it.

As this discussion relates to previous experiences of trauma, we understand that healing is an ongoing process. Sometimes we might believe that we are healed until we are confronted by our own limitations. We then recognize that it is time to delve further into healing from the past so that we can stay in the present. This, of course, extends beyond issues related to sexuality; it applies anywhere in the counseling relationship in which we find ourselves bumping up against our own walls.

As it concerns feelings of incompetence, counselors’ training in treating issues of human sexuality and their general exposure to sex education vary. I suggest that counselors ask themselves three things: What do I know? What do I want to know? Do I feel confident to relay this information?

To address any deficit in knowledge or any identified room to grow or learn more, I recommend that counselors prepare themselves to work with clients by finding educational resources on sex and sexuality. I also encourage counselors to pursue additional training or workshops through their professional memberships and state and regional conferences. Through identifying our areas of discomfort and our learning curve for the future, we prepare ourselves to best meet the needs of our clients. Of course, we need to be aware throughout the entire process of what our limitations are and when it is time to refer out to another helping professional and possibly even to a certified sex therapist.

In addition to preparing ourselves for working with clients through their sexual issues or regarding their pornography use, we need to provide a space for clients to address these issues. Counselors who report working with clients for issues related to their sexuality or pornography use also often report that they did not ask their clients about these issues. I believe that by soliciting that information early in the counseling relationship — through an intake questionnaire or intake interview — we implicitly state to our clients, “I am willing to discuss this issue, and this is something you can talk about here.” Again, because of the amount of guilt and shame our clients can feel around issues of sexuality, it becomes that much more important to ensure that we are maintaining a safe, supportive and confidential professional relationship.

In my clinical practice, my intake questionnaire includes a space for clients to report on areas in which they have concerns (or in which a family member or friend has raised concerns about them). These areas include gaming, eating, gambling, shopping, sexual activity and pornography use. Only rarely do clients circle “yes” to sexual activity or pornography use. More fruitfully, however, when reviewing the intake packet with clients in session, I ask, “Would this be a place where you might feel comfortable enough to talk about any issues related to sexual activity or pornography use if it came up?” Even if clients state that they do not have a problem in those areas, by having that conversation early on, the implicit message I send is that they can address any concerns related to sexuality or pornography should they ever want or need to.

The work

Beyond knowing ourselves and our own limitations — including when to seek counseling ourselves and when to refer out — there are a handful of recommendations for working with clients regarding sexual issues or pornography use. First, it is necessary to co-create a working definition with the client regarding the presenting issue and any important terms being discussed. In the case of pornography, I recommend asking clients how they define what pornography is. Across the counseling literature, definitions of pornography vary, but what is most important is that you and your client are speaking the same language. So, from the client’s perspective, does something qualify as pornography only if explicit sexual acts are involved, or is it anything that includes nudity? Does sexually provocative material count, even if it does not include nudity?

It is necessary to create this shared definition so that you don’t accidentally dismiss a client’s use of “pornography” as not warranting attention when it is something that is causing the client distress. For example, if a client experiences feelings of guilt for viewing images of clothed people in sexually provocative positions, we want to validate the client’s experience of guilt, even if it might not intuitively resonate with the way that we personally define pornography.

In the same vein, we want to ensure we have a shared definition so that we do not miss opportunities to assist our clients in meeting their clinical goals. For example, I once worked with a man who wished to abstain from pornography use and masturbation for religious and spiritual reasons, and he seemed to be making progress. However, I came to realize that although he was abstaining from traditional pornography use and masturbation, he had begun to engage in more frequent promiscuous sexual behavior. After finding out more about his promiscuous behavior, we were better able to define the “spirit” of his counseling goal, which was to gain greater control over his sexual activity — including abstaining from anonymous sex.

Both in co-creating definitions of pornography with our clients and in the clinical work we do with them, it is also necessary that we model appropriate language. There are compelling reasons to believe that pornography use might promote sexist or harmful beliefs about women resulting from how they are portrayed in pornography. As social justice advocates, it is our job as counselors to balance the deconstruction of sexist or misogynistic ideas without alienating our clients by using overly clinical language or shaming them.

In practice, this means finding a way to ask clients to clarify what they mean when they use a certain term. Similarly, when we use a sexual term, we want to make sure we are using language that the client understands that is also as free of negative associations as possible. In my experience working with clients, depending on the length and strength of our therapeutic relationship, I will typically begin by using the client’s language — asking for clarification when I hear a new term with which I am unfamiliar — and gradually introducing more neutral language to replace the previously value-laden language. As I do this, sometimes the client will follow my lead and it becomes a trend that continues until we are using more value-neutral language throughout all of our sessions.

Other times, I might find a way to introduce a moment of psychoeducation in which I clarify my change in language with the client. I then ask the client to try changing their language too as an experiment to see if they notice any differences in the way they are thinking or feeling. Usually, I can find a way to do this that supports the presenting clinical concern. For example, with a client who presents for counseling for symptoms of depression resulting from the termination of a romantic relationship, I might be able to make a connection between “power” in a relationship and the importance of “respect” in a relationship. We can then discuss how altering our language is a concrete step we can take toward facilitating the change of finding more respect and more even distributions of power in a relationship.

Beyond taking general steps to prepare yourself for working with issues related to sexuality and pornography use, it is also important to be able to provide specific psychoeducation to clients regarding their presenting issue. This is not something that is achieved and completed but rather an ongoing component of being a counselor. Sexuality is diverse, and we need to have sound sources of information not only for ourselves but also for our clients.

Typically, I find in my work that a client’s presenting issue includes myths or deficits in knowledge about sex and sexuality. With younger clients, I find that the deficit in knowledge is often related to safe sex practices. Therefore, I recommend familiarizing yourself with books that you can feel comfortable promoting and sharing with your clients, and internet videos or links that are not pornographic in nature that can serve as educational resources.

Individuals and couples I have seen in counseling for issues related to sexuality or pornography use tend to have one thing in common: They want to have a fulfilling sex life. Consistent with findings in the counseling literature, I emphasize to my clients that a fulfilling sex life comes from a sexual relationship that is founded on trust and vulnerability. In line with that, for some individuals and for some couples, pornography use can be a barrier toward open, honest and vulnerable sexual expression, especially when their sexuality is framed by messages of expectation. Instead, I promote mindfulness practices, sensate focus activities and building on previous experiences of success. Overall, I find that clients make the most progress when they understand that the sexual fulfillment they are seeking is with their actual partner and not with an imagined conceptualization of their partner or a different and more ideal partner.

As part of counselors’ work of addressing issues of sexuality and pornography use, we need to be prepared for clients to ask us about our own sexual experiences and whether we use pornography. I don’t know how often clients actually raise questions along those lines, but I think that we need to be prepared for such instances. As with most topics, I encourage counselors to explore their own levels of comfort with disclosure and to assess whether their disclosure is for their clients or for themselves. Some disclosures are more or less appropriate with certain clients but not others. However, the entire topic of disclosure becomes especially complicated and potentially harmful when discussing sexuality and pornography. Because of the sensitive nature of the topic, I would encourage you to err on the side of caution when making any disclosures with clients about your own experiences, and I would also encourage you to be prepared with a statement so that you are not caught off guard by a client’s questions.

In the classroom, in session and at various counseling conferences, I have been asked about my personal stance on pornography use. The response that resonates most for me is to remind my clients that what might be right or wrong for me might not be right or wrong for them. In addition, I would not want to influence their choice or decision beyond assisting them in identifying their beliefs about sexuality and helping them to live congruently within their value system.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Zachary David Bloom is an assistant professor at Northeastern Illinois University. He is also a licensed clinical professional counselor and a licensed marriage and family therapist. He specializes in working with couples and with individual clients with trauma. His research interests include the influence of technology on romantic relationships. Contact him at zacharydbloom@gmail.com.

Letters to the editorct@counseling.org

 

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Related reading, from the Counseling Today archives: “Entering the danger zone

The absence of formal and accurate sexual education is a particularly American problem that may find its way into the offices of professional counselors. wp.me/p2BxKN-3JE

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Helping female clients reclaim sexual desire

By Alicia Muñoz October 2, 2017

If you see women in your counseling practice, it will be hard to ignore the issue of female sexual desire in your work together, even if the focus of treatment is something that appears unrelated to sexuality. In fact, a woman’s relationship with her own experience of sexual desire is often inextricably linked to her sense of identity, self-esteem, personal agency, energy levels, self-care habits and interpersonal relationships. Her desire issues and how she feels about them will weave their way, often implicitly, into your sessions.

The more that counselors can increase their awareness of the nuanced issues related to female sexual desire, the easier it will be to create a space in which clients can explore these issues safely and productively. Working with women more explicitly on understanding, experiencing and sustaining sexual desire can empower them to proactively regulate their moods, reduce stress levels and decrease symptoms of anxiety and depression. Furthermore, reconnecting with the motivation to feel sexual desire has the potential to help transition trauma survivors from “survival to revival” (in the words of couples therapist Esther Perel) as they access the enlivening energy of their own erotic life force.

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), female sexual interest/arousal disorder is characterized by a lack of sexual interest or sexual arousal for at least six months. Whether a woman is upset or distressed by her lack of interest or arousal is a crucial criterion for the diagnosis. The disturbance can be moderate, mild or severe, lifelong or acquired, generalized or situational. Furthermore, according to the DSM-5, “Women in relationships of longer duration are more likely to report engaging in sex despite no obvious feelings of sexual desire at the outset of a sexual encounter compared with women in shorter-duration relationships.”

Rosemary Basson, director of the University of British Columbia’s sexual medicine program, has noted that other than in the early stages of a new relationship, women’s arousal doesn’t always follow the traditional model of spontaneous sexual desire. Rather, women’s desire tends to be more responsive, with a deliberate choice to experience sexual stimulation required before an actual experience of arousal.

Estimates on how many women suffer from female sexual interest/arousal disorder vary widely, in part because there is so much complexity, variability and subjectivity to how sexual desire issues and arousal problems are measured and experienced. According to an article by Sharon J. Parish and Steven R. Hahn in the April 2016 issue of Sexual Medicine Reviews, issues with sexual desire or arousal are present in 8.9 percent of women ages 18 to 44, 12.3 percent of women ages 45 to 64 and 7.4 percent of women 65 and older. These percentages translate into a significant portion of the female population. It is hard not to wonder what sociocultural circumstances are contributing to making problems with desire so pervasive and systemic for women.

In Standard E.5.c. of the 2014 ACA Code of Ethics, counselors are reminded to “recognize historical and social prejudices in the misdiagnosis and pathologizing of certain individuals and groups and strive to become aware of and address such biases in themselves or others.” This ethical consideration comes into play when counselors treat women with desire issues.

With the work of Helen Singer Kaplan’s triphasic sexual response cycle and an ever-expanding body of nuanced research on women’s sexuality, studies have come a long way from the male-centric, Freudian view of women’s sexual and psychological functioning and even from Masters and Johnson’s linear model of spontaneous sexual response. Researchers today strive to be more objective and aware of the physiological and psychological reality of women.

Even so, systemic prejudices related to gender and gender identity continue to saturate every area of girls’ and women’s lives, creating unique challenges in female clients in the areas of desire and sex. Fostering the safety and trust necessary to explore your clients’ desire issues can move issues of female sexuality and desire from an implicit undercurrent in your work to an explicit focus of therapy. This can help clients separate the wheat of their erotic potential from the chaff of limiting, destructive or shame-based gender and sexual conditioning.

Take Louisa, a 30-year-old client who has been married for two years. (Note: Louisa isn’t an actual client; however, her situation illustrates common sexual desire issues experienced by clients who seek counseling.) Although Louisa initially seeks treatment for depression and anxiety, a few sessions into treatment she begins referring in passing to life stressors that are “TMI” (too much information). Following these TMI comments, Louisa deflects the conversation to other topics with a shrug and a laugh.

Counselors can be attuned to these “throwaway” comments and to dismissive humor, gently inviting clients to elaborate by expressing interest in the information the client is editing out. When the counselor gently points out Louisa’s “TMI” reference and explores what she thinks might be too much information for the therapist, the issue of Louisa’s sex life begins to surface. Counselors may need to reassure clients who experience shame around sexual desire and sexuality that it can be of great benefit to focus on and explore heretofore off-limit topics and the memories, beliefs, thoughts and feelings connected to those topics.

Interventions

The following interventions may provide springboards for exploring desire issues in counseling sessions with female clients.

1) Provide psychoeducation on the connection between relaxation and sexual arousal, and work with your client to identify ways she can relax. Maureen Ryan, a sexual health coach in Amherst, New York, says, “The first step to a great sexual experience is to relax. Pleasurable touch helps facilitate this process. The body becomes aroused, and then the desire follows. For most women, sexual intimacy precedes desire.”

Explore the thoughts, fears and behavioral patterns that inhibit relaxation. Work on helping your client identify how she might create an external environment that would facilitate her transition into a sexually receptive or erotically engaged state. This might include activities that allow her to feel present or “in the flow” or connect more with pleasurable sensory input (tastes, sounds, smells, visual stimuli, touch).

2) Invite your client to create a body map. Sex therapist Aline Zoldbrod suggests using this technique with couples to facilitate a dialogue about current preferences. However, it can also be used one-on-one with female clients who may struggle with shame issues related to their bodies and their experiences of sexual desire.

Your client draws a body shape, back and front, and then uses red, yellow and green crayons to color the shapes in. Green means “I like to be touched here always,” yellow means “I like to be touched here sometimes,” and red means “I never like to be touched here.” This map can serve as one starting point for a deeper exploration of a client’s relationship to her body and her history with touch.

3) Introduce the “prop” of a velvet vulva into your arsenal of psychoeducational tools and use it to help clients understand the anatomy of the vulva, the clitoris and what movements and sensations typically stimulate arousal. This prop can also be used to instruct women on arousal as counselors model a clear, sex-positive language for expressing needs and preferences to a partner.

4) Introduce your client to the concept of “sexual blueprints.” You may want to provide a client with a handout summarizing sexologist Jaiya’s five erotic blueprints: energetic, sensual, sexual, kinky and shapeshifter. Reading about and discussing these blueprints can reduce shame, normalize a client’s experience of her own sexual predilections and help her consider new possibilities. Jaiya’s website (missjaiya.com) has a quiz to help women and men identify their blueprints.

5) Explore the meaning of pleasure for your client. What turns her on? What charges her up and connects her to her own sense of flow or aliveness? A counselor can coach a client to say, “I feed my own desire when …” and then complete the sentence with different activities, thoughts and behaviors that enliven her. Encourage your client to begin developing a running list of whatever it is she can proactively do to power herself up, delight herself and revitalize herself.

Also be sure to have an extensive list of your own desire-feeding activities. This will help you menu ideas for your clients.

6) Help clients develop awareness about the sex-negative and body-negative influences that have shaped how they see and experience themselves and their bodies. Encourage them to limit the sex- and body-negative influences in their lives. This may mean avoiding certain magazines, being mindful about television shows and choosing not to watch certain movies or videos. It may mean setting clearer boundaries with select people in their lives.

Also help clients explore ways that they can take in more sex- and body-positive messages, either through reading different magazines, limiting their exposure to narrow standards of beauty, increasing their vigilance of the kinds of advertising or body imagery they expose themselves to, or regularly and intentionally appreciating their own bodies through pleasurable body rituals and experiences.

A shift in attitude

Over time, Louisa begins to understand that the lack of sex in her marriage underlies her anxiety and depressive symptoms. She fears it means that she and her husband are on their way to divorce and that it’s “all her fault.” Here, the counselor helps Louisa increase her awareness of this critical inner voice and develop greater self-compassion.

Louisa’s husband has become more vocal about their sexual problems and grown increasingly more irritable and withdrawn in their day-to-day life. As a result, Louisa is no longer able to continue pretending the problem is just situational, temporary or unimportant.

In therapy, she examines her sexual misconceptions and beliefs and the influence of her family’s cultural and gender-based expectations of her. To her surprise, she realizes she has limited awareness of her actual bodily sensations. She often “lives in her head” and ignores the signals her body sends her. As a result, she has never really tuned in to what she feels leading up a to sexual encounter. Her low sexual desire is just the tip of an iceberg of denial related to sensations and emotions.

Part of Louisa’s work in therapy becomes learning how to “listen” to her body. She practices doing this in session and also sets aside time outside of sessions to sit quietly and observe her own sensory experience.

In the past, when Louisa lost her motivation to have sex with one of her boyfriends and couldn’t recreate the feeling of strong, active arousal with him, she would interpret it as “falling out of love” or the boyfriend “not being right for her.” It wasn’t until Louisa married her husband that she was faced with the stark truth of her own sexual experience: She had a hard time experiencing spontaneous, robust arousal once the novelty of a relationship wore off. Mostly, later in a relationship, she simply responded to her partner’s desire for her.

This insight signaled a shift in Louisa’s attitude toward sex and herself. She started to mourn her lack of erotic engagement with her past partners and current husband and to commit to cultivating a relationship with her own erotic experience. She began recognizing her own inhibitions, her lack of erotic accountability and the expectation she had always carried that her partner should know what pleased her without her assistance, guidance or willingness to explore the ways that their needs and desires met or diverged.

Because Louisa loved her partner and wanted to make their marriage work, she committed to learning how to experience her own desire and arousal more regularly. Her motivation to feel desire for her own pleasure and sense of wholeness shifted her approach to the sexual disconnection in her marriage from that of a burdensome problem to an adventure.

Untapped potential

When it comes to working effectively with female sexuality and desire, remaining neutral about larger cultural biases can stall your work as a counselor. In a culture saturated with narrow and distorted models and templates of beauty, it is nearly impossible for human beings who emerge from their mothers as female babies to grow up free of misconceptions about their core selves, their bodies, their sensuality and their eroticism.

Some women may manage to stay intuitively connected to their erotic core throughout childhood and adolescence despite the social, relational and societal risks involved, perhaps even making it into adulthood relishing the full range of their sexual experiences on their own terms. A great number of women, however, wouldn’t have survived physically, much less psychically, without shutting off their sexual circuit boards.

Usually, this shutdown isn’t a conscious choice. It is something that girls learn to do within the context of their relationships as a way of maintaining caregivers’ and others’ love and approval. Even for girls growing up in progressive, supportive families, fitting in with peer groups or feeling socially rooted can sometimes cost them some important piece of connection to their core sexual selves. Girls may grow up lacking erotically vibrant, powerful female role models. Sometimes their families and circumstances don’t allow them the luxury of maintaining a strong, healthy, intact relationship with their bodies.

When girls suppress aspects of their deepest erotic impulses and experiences, layers of judgment and shame encase not only what and how they feel, but also who they are. Like a seed trapped in amber, a woman’s erotic potential can remain untapped even as she develops and grows in other areas. It waits for the right conditions to emerge.

Counselors can provide those conditions in therapy. Here are some key ways that counselors can help women reclaim their erotic selves.

1) Take continuing education courses on sexuality.

2) Read progressive, inclusive books on women’s sexuality and women’s sexual empowerment, such as Getting the Sex You Want by Tammy Nelson, She Comes First by Ian Kerner, Mating in Captivity by Esther Perel, Woman on Fire by Amy Jo Goddard, Pussy: A Reclamation by Regena Thomashauer, Come as You Are by Emily Nagoski and Women’s Anatomy of Arousal by Sheri Winston.

3) Familiarize yourself with the facts regarding the unique challenges that women continue to face today locally, nationally and globally, particularly as they relate to physical safety, fiscal equality, political representation and reproductive issues and rights.

4) Learn to talk about all of the parts of women’s bodies with ease. Practice with your children, spouses, colleagues and friends. Learn the exact locations of women’s body parts, study how they interact and learn to identify a woman’s body parts by their correct names (e.g., distinguishing between a woman’s visible genitals — her vulva — and the internal, muscular tube that leads from her vaginal opening to her cervix — her vagina). Learn to discuss sex, sexuality and sexual acts correctly and comfortably.

5) When you pick up on a client’s reactivity, defensiveness, shame or self-consciousness related to a sexual topic, bring warmth and compassion to the moment through attuned interventions. For example: “I noticed that you covered your eyes just now as you mentioned having sex with your boyfriend. Can we be curious about what just came up for you?”

It is important to keep in mind that low desire and lack of sexual interest are issues that many women won’t openly admit to, even when these experiences are their daily reality. There is a lot at stake. Just as a man’s sexual identity and sense of competence can get tied up with his ability to pleasure his partner to orgasm or to maintain an erection, a woman’s sense of sexual self-worth can be intricately connected with her ability to both stimulate and quench her partner’s sexual desire.

When the impetus or the drive to engage in sex with her partner or spouse wanes, a woman’s sense of sexual self-confidence can waver. It can feel as if she is failing at an essential aspect of her being: loving and being loved sexually. It can also inspire terror. Will she lose connection to this person she depends on and loves? How will this affect her family relationships? Is this a prelude to something worse? What changes lie around the corner as a result of her inability to match her partner’s sexual needs with her own authentic responses and initiatives?

Counselors are in a privileged and important position with their female clients at this particular historical juncture. Women are feeling pulled to take up leadership positions and exert influence in spheres of power previously dominated by men, from political offices to corporate headquarters to influencing the ecological trajectory of the planet. To experience the fullness of their emotional range, the force of their uniquely feminine values, priorities and principles, and the vitality of their full aliveness, many women need help developing a healthier relationship with their erotic selves. Because many women have adapted and suppressed aspects of themselves to function in a world that prioritizes the more traditionally masculine values of strength, dominance, competition and self-protection, they need to find ways to access the more traditionally feminine priorities of sustainability, vulnerability, connection and empathy to feel truly like themselves again.

Counselors can safely, warmly and sincerely support the exploration of women’s low sexual desire or inhibited arousal by first prioritizing a woman’s desire as an essential energy source in her life. They can help their female clients navigate the unique, nuanced challenges of low desire and the ways it manifests in a woman’s relationship to her own self, her body and those she loves. Once this issue is prioritized in treatment, it can be made explicit and explored. From there, it becomes easier to disentangle the negative beliefs that women harbor about their bodies and themselves from their inalienable, noncontingent worth as women.

Because many women have come to experience their own desire as beyond their control, they may fear that they are the problem — outliers on the graph of normative human sexual desire doomed to disappoint and frustrate the people they love and need most. Helping women take control of their own experience of sexual desire through explicit counseling interventions has the potential to shift clients’ views of what’s possible for them erotically and, in so doing, what’s possible for them as vibrant, entitled human beings with desires that matter. This shift is seismic and can transform all aspects of women’s lives.

 

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Alicia Muñoz is a licensed marriage counselor and desire expert in private practice in Falls Church, Virginia. She is also a speaker, author, blogger and frequent contributor to various print and online publications. Visit marriedtodesire.com for more of her writing on desire, or sign up for her weekly Relational Growth Challenge at aliciamunoz.com.

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