Things I Learned Reading "Case Studies in Sex Therapy" (So Far)

Freud argued that everything is about sex. Most people think Freud is out-of-date. And yet, it's pretty obvious that everything really is about sex. The easiest way to prove it is to point at the Internet and say the word "porn". Or watch an episode of one of the stupidest and most popular TV shows on the planet, Baywatch.

I happen to think Freud was on to something. If the sex drive moves us through the world, knowing the secrets of sexuality is like knowing magic. That's why I love reading about sexual deviance, fetishes, and other sex oddities.

Recently, I bought the book Case Studies in Sex Therapy (1995), edited by Raymond C. Rosen and Sandra R. Leiblum. It's a collection of chapters written by multiple authors, with three main sections:

1. Sexual Desire Disorders

2. Sexual Performance Problems

3. Sexual Addiction and Compulsion

I'm about two-thirds of the way through the book, but I can't wait -- I have to tell you some of the things I've learned.

* * *

A big part of sexual performance anxiety can be the feeling of obligation. "You made me feel good, so I must immediately reciprocate by making you feel good."

This caused the writer, Bernard Apfelbaum, to suggest renaming performance anxiety as "response anxiety." He argues that the sexual revolution created "a virtual epidemic of response anxiety. It is now as if being good in bed is what sex is all about."

Many men and women pride themselves on being "great lovers" in the sense that they make their partner feel good. When it comes to lying back and feeling pleasure themselves, they become anxious and self-conscious. This way of thinking can result in problems. Say Bill perceives himself as a "great lover" in the above sense -- he can dish it out, but he can't take it. He might blame any sexual difficulties on his partner, Jenna.

"I know I'm great in bed -- so all of our problems must be her fault."

But Bill is wrong. His very unwillingness to experience pleasure himself messes with the sex. For example, say Jenna comes up with a sexual adventure that requires Bill to be passive. He'll panic, the sex will fail, and Bill will blame it on her.

It's strange to think of it this way, but sex can be used to AVOID intimacy. If Bill is in charge, insisting Jenna always be passive, Bill never finds himself in a position of weakness. He never has to let his guard down. His focus is entirely on getting her off. This kind of sexuality prevents intimacy.

One of the key exercises used in sex therapy is sensate focusing. Each person takes turns lying down, letting their partner touch them all over. This typically starts as touching of non-sexual body parts -- no breasts, no genitals. Later exercises include the naughty bits, and the passive partner can indicate what they like and what they don't like.

Some find the artificiality of sensate focus exercises as quite off-putting. Where's the spontaneity? Where's the freedom to express yourself?

But the idea is that the forced passivity simultaneously removes any "response anxiety" while forcing someone like Bill to confront his need to be in control. Bill has to lie there and take it, while Jenna touches him all over. This can lead Bill to understand the roles he has been imposing on both himself and Jenna. Not only can this empower Jenna -- granting her more control of sex -- but it can also lead to greater intimacy.

* * *

Baby boomer lesbian couples often have lots of sex at the beginning of their relationship, and then very little sex as years go by -- less sex than gay male or heterosexual couples. Writer Margaret Nichols says the term colloquially used to describe this is lesbian bed death. (That also happens to be the name of a punk band.)

The studies that examine this specifically focus on the 1980s. I suspect, therefore, that lesbian bed death applies mostly to baby boomers. Modern, Gen X lesbians seem to be a lot more sexually open. All the same, lesbian bed death is so common, many different sexologists and lesbian theorists have tried to explain it:

- Cuddling and closeness is enough intimacy for lesbian couples. Who needs sex?

- Some lesbian couples get so close that their identities blur into one. Nichols says this is usually referred to as "fusion or merging". Where does one woman end and the other woman begin? Nichols writes, "within the context of already excessive closeness, the act of sex, characterized by even greater union, may be too threatening".

- Women of the baby boomer generation were taught that men pursue the sex, not women. Put two women together into a couple, and you double the sexual repression.

-Women are more likely to be abused or raped, so a couple made of two women is more likely to involve those sorts of issues, and therefore have less sex.

- Maybe the sexuality of baby boomer lesbians doesn't necessarily involve a lot of orgasms and sex. So what? Who are we to say that it's not "correct" or "normal"? Isn't that the patriarchal way of judging sexuality? How do you count the number of sex acts, anyway? If we were studying heterosexuality, and only counted the sex acts where the woman achieved orgasm, wouldn't the frequency of sex acts drop dramatically too? No one is even sure what sexuality is for, beyond procreation. We're in no position to judge the lesbians.

- Lesbian sexuality, among some baby boomers, is a minefield of politics and judgments, which leads to even greater sexual repression.

To delve more deeply into the last point, Nichols presents a case study. Two women, Mickie and Cheryl, go for sex therapy. Nichols describes meeting the women for the first time:

"Our initial interview was cautious and tentative. Far from treating me with the deferential respect some clients display in facing a 'professional', Cheryl and Mickie interrogated and challenged my credentials -- my credentials as a feminist and activist, that is. I was frank about being bisexual rather than lesbian; my frankness earned me some points that compensated for those I lost through bisexuality. My activist history and obvious familiarity with feminist theory, combined with the recommendation they had received from their couple therapist, whom they trusted, allayed their initial suspicions."

It turns out one of the big issues in Mickie and Cheryl's relationship is that Cheryl's sexual interests are "politically incorrect". Because of this, Mickie looks down on Cheryl's sexuality. Cheryl herself feels obliged to repress her "wrong" sexual desires.

Politically incorrect sex? Yes. Some old school boomer lesbians believe certain types of sexuality are "masculine", patriarchal, controlling, and wrong. On a simple level, any penetrative sex is bad. In a more complicated sense, any power play is improper. No costumes. No bondage. No pain. Anything that puts one woman in a position of authority over the other woman is "patriarchal". (That makes no sense to me at all, but I'm a heterosexual man, and presumably part of the problem.)

Politically correct lesbian sex is almost socialist in nature. No one-sided sexuality is allowed. "Either we both orgasm, or no one orgasms." Both women slowly and simultaneously build pleasure. This sex is mutual, egalitarian, sensual exploration.

At one point in the case study, Mickie refers to Cheryl's interest in non-PC sex (bondage, enemas, and other games) as a "slut mentality".

With these sorts of rules, is it any wonder so many boomer lesbians give up on sex altogether? Talk about pressure. If the personal truly is political, does every orgasm have to be authorized by your local political representative?

Earlier I talked about using sensate focusing exercises to show a controlling sex partner how they are preventing intimacy. That's exactly what happens in this case. When forced to lie down and simply be touched by Cheryl, Mickie realizes how much of her energy is devoted to controlling the sex.

* * *

If a man has his prostate removed because it's cancerous, this can cause erectile dysfunction and incontinence. There are drugs that can be injected directly into the penis to create an erection. (This scares me.) Penis pumps are another alternative. The pump draws blood into the penis, and then a rubber band is placed around the base of the penis to keep the blood in.

(The book was written in 1995, prior to the arrival of Viagra, so they make no mention of it. How quickly things change.)

People have "sex scripts" making up the routine of their sexuality: who initiates, what happens for foreplay, what happens during the big act, what sort of cuddling takes place at the end. When a script gets disrupted (say, by sudden erectile dysfunction) it can cause anxiety, discomfort, and avoiding sex altogether. The couple will need to learn a new script, get comfortable with it, and learn to have a sense of humour about any difficulties that arise.

One chapter discusses how a man's prostate removal caused difficulties. Mr. Smith was particularly concerned and embarrassed by his incontinence. His penis was always dribbling and squirting urine, so he was forced to wear a diaper. The idea of his wife touching his penis and getting urine on her really bothered him.

The sex therapist helped them change their sex script. Sounds simple, but it takes time and effort and patience on the part of everyone. Which leads me to probably my favourite sentence in the book, so far:

"When, at a time of lovemaking, urine squirted in Mrs. Smith's face, this ultimate of embarrassments was dealt with with humor and mutual kindness."

How sweet.

* * *

Sexual abuse during childhood can cause sexual pain in later life. This is kind of obvious, but it can take unusual forms. One case study talks about a woman named Mary who was sexually abused by her father roughly from age 6 to 14. Mary had no pain when she inserted fingers into her vagina. But inserting a penis, or even a dildo shaped like a penis, caused pain -- even though the fingers and the penis were roughly the same size.

The therapist, Julia R. Heiman, describes in detail all the different exercises and approaches she used to try to change Mary's feelings towards sex. One technique that struck me as interesting was trying to change Mary's understanding of what a penis is. From Mary's perspective, all penises were the same -- bad and hurtful. When asked to give the words she associated with "penis", Mary said: "hairy, ugly, disgust, rage, purple, hard, betrayal, invasive, snake, demand, guilt, need, insatiable, hose, alien, fear."

That's a lot for a penis to handle.

Heiman attempted to teach Mary to differentiate a "good" penis (her husband's penis) from a "bad" penis (her father's raping penis). In doing so, it was hoped that Mary would also learn to differentiate good sexuality from bad sexuality.

Mary was having many bad dreams about snakes, and understood consciously that these snakes were bad penises. The therapist suggested she try to turn this "bad penis" symbol into a "good penis" symbol. Mary couldn't consciously do this. Unconsciously, she had better luck. She had a dream where a snake jumped at her, and turned into a cat which she caught in her arms. This transformation in her dream led to a healthier feeling towards a "good" penis, and she stopped having snake dreams.

Heiman is very big on letting the patient decide what's working and what's not working, and even to suggest approaches themselves. Allowing that sort of freedom seems particularly important when dealing with someone who has suffered through incest. The approach lets them know they're in control.

At one point Heiman suggested Mary buy a penis-shaped dildo. Heiman writes:

"While Mary was reluctant, she did attempt to use the penis both in individual and couple work for about four sessions but decided that she 'hated it', and it only reminded her of her father's penis. Several months later, the penis met its fate by being buried in a Canadian lake, along with several other mementos from Mary's childhood, as part of a small 'cleansing ritual.'"

Mary and her husband Paul performed this ritual as part of Mary's therapy, to help her deal with her incest. They invited friends and Heiman to be there as witnesses.

* * *

Sexuality is awesome, complicated, and still taboo. While we're definitely more open about sex nowadays, most sexologists and sex therapists still get looked at as perverts. I have to admit, that's part of why I enjoy reading about these things. A lot of people want to know about sex, but they're too nervous to explore it. An open interest in sex is seen as suspicious and weird. And if it's weird and makes other people uncomfortable, count me in.

Speaking of sexual repression in modern times, I've been exchanging emails with a fundamentalist Christian in the States who proudly calls himself an ex-masturbator. Let's call him Jacob. (Did you know you can buy an ex-masturbator T-shirt? You can!) I wanted to know more about Jacob's take on things. Chatting with him is very depressing. He quotes bible passages to explain why jerking off is sinful. While Jacob tried to convert me to Christ, I tried to convert him to REALITY. It didn't get me anywhere.

So what if 90% of men and 60% of women masturbate? That just shows you how sinful the world is! Forget those studies that show it's actually medically beneficial for men to wank -- it prevents prostate cancer and keeps your sperm "fresh". (The older the sperm coming out, the less likely they are to fertilize an egg.) Ignore the entire history of masturbation, which shows the original masturbation scare was created to sell questionable "cures". And forget the history of medical devices designed to prevent middle-of-the-night boners. (Picture a condom with a metal spike on the inside, that stabs a dick when it gets hard.)

None of that matters -- BECAUSE THE BIBLE SAYS MASTURBATION IS WRONG.

Well, actually, it doesn't. It says stuff about bad sex, a little bit about spilling your seed, but nothing you can specifically look at and call a boycott on masturbation. It does say that if your brother dies, and you're a single man, you have to marry the widow. (Deuteronomy 25:5) And it says women aren't allowed to speak in church. (Corinthians 14:34) But those are old and out of date and silly.

Meanwhile, Jacob tells me, pleasuring yourself today is just as bad now as it was 2000 years ago.

It's hard to believe this level of sexual repression is taking place on the same continent where the sex research is taking place.

One of the more interesting aspects to sexuality is the weird biases people have, without even knowing it. For example, a lot of people think having sex means strictly inserting a penis into a vagina. If you've done EVERYTHING but that (anal, oral, etc) you're a "virgin". So if a man and a wife get together and masturbate, is it sinful? And is it sex, or is it masturbation? What if they get together and masturbate each other? The man plays with her genitals, and the woman plays with his, simultaneously. Is that sex or masturbation?

I put it to Jacob, and he seemed unable to wrap his mind around it. A young guy, an ex-masturbator, and presumably a virgin, Jacob insisted that sex is when you stick a penis inside a vagina. And why would a man want to masturbate with his wife when they could have sex instead?

For variety. For fun. To explore. To play. To vary the sex script. To discover new levels of intimacy. To grow as human beings. That's why. And shouldn't religion encourage these kinds of things?

Isn't it funny that hard core political lesbian baby boomers and repressed ex-masturbator fundamentalist Christians have so much in common? They've both arbitrarily decided that certain sex acts are "wrong". They both torture themselves. They both mess up their sexuality. And by doing so, they decrease the intimacy and the love they both claim are so important for a healthier and saner world.

And yet these people think of each other as bitter enemies. How awesome is that?