As with any profession that claims to serve the medical or psychological needs of others, psychotherapists working with issues around sexuality, implicitly, if not explicitly, pledge to “do no harm.” The public places a fundamental trust in our training and knowledge to not lead them down a path toward further suffering, but quite the opposite. In the field of psychotherapy, this is not just a tremendous responsibility but a significant challenge as well.
Part of the challenge and a precondition for providing services that do no harm is to avoid unnecessary judgment. Therapists learn specific techniques to counteract judgmental thinking (e.g. unconditional positive regard and empathic listening) with the goal of accepting our client’s experience without prejudice. However, for those treating issues around sexuality, judgments are almost guaranteed. The majority of therapists are similar to the majority of Americans, in that, although sexuality is thought to be an acceptable form of expression within a committed monogamous relationship, behaviors that fall outside traditional notions of sexuality are often labeled anything from “weird” and “inappropriate” to “deplorable” or “deviantly pathological.”
Yet, who gets to decide which behaviors get included in this list of intolerable sexual expression? Throughout history and across cultures, masturbation, pornography, fetishes, and even women’s sexuality have garnered special attention by self-elected curators of cultural values. Such “act-centered” approaches, ones that focus on specific sexual behaviors, have influenced social norms to the extreme of codifying non-procreative sexual activities as illegal. As morals shift across historical periods and geographical locations, we see the introduction and sometimes re-introduction of sexual behaviors (e.g. viewing pornography) labeled as problematic at best and a public health crisis at worst. It wasn’t that long ago that masturbation was considered more than just an uncomfortable topic of discussion between parents and children but as an actual cause of mental illness.
We know that when clients seek treatment for sex and porn addiction, they are generally looking for someone to help alleviate their shame and suffering, not further it. But, if therapists hold implicit beliefs that certain sexual behaviors are deviant, can they really provide a setting wherein healing can begin, or are they further stigmatizing and potentially traumatizing those who seek just the opposite? One approach that has garnered attention for those who have labeled themselves as sex or porn addicts is espoused by Douglas Braun-Harvey and Michael Vigorito in their 2016 book, “Treating Out of Control Sexual Behavior: Rethinking Sex Addiction.” In their approach, the emphasis on specific sexual behaviors, an act-centered approach, is supplanted by an appeal to universal principles of sexual health, referred to as a principle-centered approach.
The value of utilizing a principle-centered approach is that the therapist’s expression of negative bias towards any specific sexual behaviors is minimized, if not eliminated; the focus of treatment shifts to the underlying factors maintaining the problematic sexual behavior. The client’s overarching treatment goal becomes one of designing and embracing a fulfilling sexual life free from stigma and shame rather than simply tracking an inventory of inappropriate behaviors and their frequency. Sexual behaviors are judged only by whether and how they encroach on any of the universal principles of sexual health. Clients maintain their personal authority over agreed upon principles rather than invoking the idiosyncratic values and morality of any particular therapist.
One obvious criticism of anyone espousing such a principled approach is proving that the principles are, in fact, universal. If clients are to be guided by these principles, then their adoption must resonate deeply with the client’s sense of sexual health. Rather than attempt to argue the universality of each principle, however, the clients decide for themselves. Likewise, rather than try to convince you, the reader, of their applicability, judge for yourself.
Six Principles of Sexual Health
The six universal principles of sexual health are mutual consent, non-exploitation, safe(r) sex, honesty, sharing of values, and seeking mutual pleasure. Let’s take a closer look at each of the six principles.
Consent
Consent is not just a sexual health requirement but also a legal one. Anyone forcing themselves onto another without clear and explicit permission may find themselves in more trouble than simply needing therapy. Sexually healthy interactions require voluntary mutual agreement. This extends beyond needing partners to give consent but also to one’s own ability to provide consent. For example, becoming intoxicated precludes one’s ability to give consent. Thus, the use of drugs and alcohol during sexual encounters may be useful to examine when evaluating sexual behaviors as seemingly out of control.
Non-exploitation
Exploitation refers to specific situations in which, although consent may be verbalized, given the nature of the relationship between the parties involved, consent is not enough. For example, in some relationship configurations such as adult-child, supervisor-employee, or teacher-student, the differential in power leaves one party vulnerable to the actions of the other. An instructor may lead a student to believe that in order to pass a course they must provide sexual favors. Or, a supervisor may hold out promise of a potential promotion in exchange for a weekend getaway. When evaluating problematic sexual behaviors, the sexual health framework values not just consensual behavior but also the absence of exploitative behavior as well.
Safe(r) Sex
Safe sex, or “safer sex” (because most skin-to-skin sexual activity involves some amount of risk), looks at the measures taken to minimize exposure to sexually transmitted infections and unwanted pregnancy both for oneself as well as one’s partners. Namely, does engaging in the sexual behavior in question occur despite not taking reasonable efforts to ensure safety; e.g. not having conversations about birth control, not wearing condoms, not getting oneself tested after unsafe encounters and continuing to engage in partnered sexual activities. Again, it’s not the sexual behaviors per se that are a problem, it’s when the sexual behavior occurs without concern for safety that is problematic.
Honesty
As a criterion for sexual health, honesty needs little justification. Honesty is necessary to maintain integrity both for one’s sense of personal authenticity as well as one’s interpersonal relationships. But honesty also includes an openness and willingness to acknowledge one’s shortcomings and level of comfort with regards to sexual knowledge and experience. Engaging in activities without a full and honest consideration of the accompanying physical, psychological and interpersonal consequences leaves one and one’s partner vulnerable to unsatisfying if not traumatic outcomes. Honesty is such an integral component of all sexual expression that without it, the other sexual health principles are undermined.
Shared Values
Engaging in healthy sexual activity necessitates an openness to communicate one’s desires, interests, and values around specific sexual behaviors. If one does not partake in this type of discussion, the odds of crossing boundaries or violating relationship agreements are virtually assured. Clearly, if one participates in consensual sexual activity, sharing of interests and values is critical. But, even in relationships with mutual consent, great communication and even great sex, there often exists areas of unchartered sexual discussion. For example, watching internet pornography. For many individuals this private activity is filled with shame that inhibits speaking about it to others, including a partner or spouse. What happens then when masturbating to porn is discovered by one’s partner? Well, it depends. We don’t know for sure because some partners find porn disgusting while others watch porn themselves. Without conversations around specific sexual behaviors, we leave it to chance as to whether we violate a partner’s morals or values. The sexual health principle of shared values encourages partners to engage in specific discussions about sexual activities in order to avoid detrimental relationship consequences. The key is to ensure that discussions focus on the meanings of sexual activities prior to their discovery rather than scrambling to repair a relationship injured by an unknown values discord.
Mutual Pleasure
Another way to assess the relative healthiness of a particular sexual behavior, particularly in a relationship, is to consider whether the physical and psychological needs of all parties are being addressed. For someone with problematic sexual behavior, the emphasis may center more on seeking personal relief rather than seeking mutual pleasure. Feelings of regret after the fact may be common. Even after repeatedly feeling regret and being let down by sexual behavior, some will find themselves seeking the same unsatisfying sexual experiences. If the goal of sexual experience is purely relief, neglected partners may directly challenge the disconnection if not outright selfish attitudes and behaviors. Sexual experiences, apart from efforts at reproduction, are meant to be pleasurable for all parties unless there’s an explicit agreement otherwise. If being intentional about giving and receiving pleasure through sexual activities seems difficult, then it should be no surprise when sexual behavior eventually becomes problematic.
Therapists are human and subject to expressing judgments, often subtly and unconsciously, towards client behavior, especially sexual behavior. One way to eliminate these judgements involves shifting the focus from identifying specific sexual acts as problematic to comparing those acts to universal principles of sexual health. Using the principles of mutual consent, non-exploitation, safe(r) sex, honesty, sharing of values, and seeking mutual pleasure to examine problematic sexual behavior frees the client to explore the underlying meanings of the behavior as well as factors maintaining the behavior, in a therapeutic environment void of further stigma, shame, and possible traumatization.
References
Braun-Harvey, D. and Vigorito, M. (2016). Treating Out of Control Sexual Behavior: Rethinking Sex Addiction. New York, NY: Springer