Tài liệu Handbook of Clinical Sexuality for Mental Health Professionals docx

Handbook of Clinical Sexuality for Mental Health
Professionals
HANDBOOK OF CLINICAL
SEXUALITY FOR MENTAL
HEALTH PROFESSIONALS
Stephen B.Levine, MD
Editor
Candace B.Risen, LISW
Stanley E.Althof, PhD
Associate Editors
Brunner-Routledge
New York • Hove
Published in 2003 by
Brunner-Routledge
29 West 35th Street
New York, NY 10001
www.brunner-routledge.com
Published in Great Britain by
Brunner-Routledge
27 Church Road
Hove, East Sussex
BN3 2FA
www.brunner-routledge.co.uk
Copyright © 2003 by Taylor & Francis Books, Inc.
Copyright © for Chapter 10, Facilitating Orgasmic Responsiveness,
belongs to the author of that chapter, Carol Rinkleib Ellison, Ph.D.
Brunner-Routledge is an imprint of the Taylor & Francis Group.
This edition published in the Taylor & Francis e-Library, 2005.
“To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of
thousands of eBooks please go to www.eBookstore.tandf.co.uk.”

All rights reserved. No part of this book may be reprinted or reproduced or utilized
in any form or by any electronic, mechanical, or other means, now known or
hereafter invented, including photocopying and recording, or in any information
storage or retrieval system, without permission in writing from the publisher.
Library of Congress Cataloging-in-Publication Data
Handbook of clinical sexuality for mental health professionals/Stephen
B.Levine, editor; Candace B.Risen, Stanley E.Althof, associate editors.
p. cm.
Includes bibliographical references and index.
ISBN 1-58391-331-9 (hbk.)
ISBN 0-203-49032-0 Master e-book ISBN
ISBN 0-203-59350-2 (Adobe eReader Format)
1. Sexual disorders—Handbooks, manuals, etc. I. Levine, Stephen B., 1942–
II. Risen, Candace B. III. Althof, Stanley E., 1948–
RC556 .H353 2003
616.85′83–dc21
2002152844
Contents
About the Editors vii
Contributors viii
Preface
Stephen B.Levine, MD; Candace B.Risen, LISW; Stanley E.Althof, PhD
x
Part 1 Adult Intimacy: Hopes and Disappointments 1
Chapter 1 Listening to Sexual Stories
Candace B.Risen, LISW
3
Chapter 2 What Patients Mean by Love, Intimacy, and Sexual Desire
Stephen B.Levine, MD
19

Chapter 3 Life Processes That Restructure Relationships
David E.Scharff, MD
35
Chapter 4 Infidelity
Stephen B.Levine, MD
55
Chapter 5 Dealing With the Unhappy Marriage
Lynda Dykes Talmadge, PhD, and William C.Talmadge, PhD
73
Part 2 Women’s Sexual Issues 91
Chapter 6 When Do We Say a Woman’s Sexuality Is Dysfunctional?
Sharon G.Nathan, PhD, MPH
93
Chapter 7 Women’s Difficulties with Low Sexual Desire and Sexual
Avoidance
Rosemary Basson, MD
109
Chapter 8 Painful Genital Sexual Activity
Sophie Bergeron, PhD; Marta Meana, PhD; Yitzchak M.Binik, PhD;
and Samir Khalifé, MD
131
Chapter 9 The Sexual Aversions
Sheryl A.Kingsberg, MD, and Jeffrey W.Janata, PhD
153
Chapter 10 Facilitating Orgasmic Responsiveness
Carol Rinkleib Ellison, PhD
167
Chapter 11 The Sexual Impact of Menopause
Lorraine L.Dennerstein, AO, MBBS, PhD, DPM, FRANZCP
187

Part 3 Men’s Sexual Issues 199
Chapter 12 Young Men Who Avoid Sex
Derek C.Polonsky, MD
201
Chapter 13 Psychogenic Impotence in Relatively Young Men
Peter Fagan, PhD
217
Chapter 14 Erectile Dysfunction in Middle-Aged and Older Men
Raymond C.Rosen, PhD
237
Chapter 15 Rapid Ejaculation
Marcel D.Waldinger, MD, PhD
257
Part 4 Sexual Identity Struggles 275
Chapter 16 Male and Female Homosexuality in Heterosexual Life
Richard C.Friedman, MD, and Jennifer I.Downey, MD
277
Chapter 17 Understanding Transgendered Phenomena
Friedemann Pfäfflin, MD
291
Chapter 18 Men Who Are Not in Control of Their Sexual Behavior
Al Cooper, PhD, and I.David Marcus, PhD
311
Chapter 19 The Paraphilic World
J.Paul Fedoroff, MD
333
Part 5 Basic Yet Transcendent Matters 357
Chapter 20 Therapeutic Weaving: The Integration of Treatment Techniques
Stanley E.Althof, PhD
359

Chapter 21 Recognizing and Reversing Sexual Side Effects of Medications
R.Taylor Segraves, MD, PhD
379
Chapter 22 Sexual Potentials and Limitations Imposed by Illness
William L.Maurice, MD, FRCPC
393
Chapter 23 Understanding and Managing Professional-Client Boundaries
S.Michael Plant, PhD
407
Chapter 24 Sexual Trauma
Barry W.McCarthy, PhD
425
v
Chapter 25 The Effects of Drug Abuse on Sexual Functioning
Tiffany Cummins, MD, and Sheldon I.Miller, MD
443
Author Index 457
Subject Index 465
vi
About the Editors
Stanley E.Althof, PhD (Co-editor) is Professor of Psychology in the Department of
Urology at Case Western Reserve University School of Medicine in Cleveland, Ohio and
is Co-director at the Center for Marital and Sexual Health in Beachwood, Ohio
Stephen B.Levine, MD (Editor) is Clinical Professor of Psychiatry at Case Western
Reserve University School of Medicine in Cleveland and is Co-director at the Center for
Marital and Sexual Health in Beachwood, Ohio
Candace B.Risen, LISW (Co-editor) Assistant Clinical Professor of Social Work in
the Department of Psychiatry at Case Western Reserve University and is Co-director at
the Center for Marital and Sexual Health in Beachwood, Ohio
Contributors

Rosemary Basson, MD, MRCP is a Clinical Professor of Psychiatry and Obstetrics/
Gynecology at the University of British Columbia in Vancouver, Canada
Sophie Bergeron, PhD is Assistant Professor in the Department of Sexology,
Université du Québec à Montréal in Montréal, Québec and Clinical Psychologist at the
Sex and Couple Therapy Service at McGill University Health Centre (Royal Victoria
Hospital)
Yitzchak M.Binik, PhD is Professor of Psychology at McGill University and Sex and
Couple Therapy Service at McGill University Health Centre (Royal Victoria Hospital) in
Montréal, Québec, Canada
Al Cooper, PhD is the Clinical Director of the San Jose Marital and Sexuality Centre
in Santa Clara, Associate Professor (Research) at the Pacific Graduate School of
Professional Psychology, and Training Coordinator for Counseling and Psychological
Services at Vaden Student Health, Stanford University in Palo Alto, California
Tiffany Cummins, MD just completed her residency at the Department of
Psychiatry at Northwestern University in Chicago, Illinois
Lorraine L.Dennerstein, AO, MBBS, PhD, DPM, FRANCZ directs the Office for
Gender and Health and is Professor in the Department of Psychiatry at the University of
Melbourne at Royal Melbourne Hospital in Australia
Jennifer I.Downey, MD is Clinical Professor of Psychiatry at Columbia University
College of Physicians & Surgeons in New York
Carol Rinkleib Ellison, PhD is a psychologist in private practice in Oakland,
California and an Assistant Clinical Professor in the Department of Psychiatry at
University of California at San Francisco
Peter Pagan, PhD is Associate Professor of Medical Psychology in the Department of
Psychiatry and Behavioral Sciences at The Johns Hopkins University School of Medicine
and head of the Sexual Behaviors Consultation Unit in Lutherville, Maryland
J.Paul Federoff, MD is Co-Director of the Sexual Behaviors Clinic and Research
Unit Director of the Institute of Mental Health Research at the Royal Ottawa Hospital at
the University of Ottawa in Ontario Canada
Richard C.Friedman, MD is Clinical Professor of Psychiatry at Columbia University

College of Physicians and Surgeons in New York
Jeffrey W.Janata, PhD is Assistant Professor in the Department of Psychiatry and
Director of the Behavioral Medicine Program and University Pain Center at Case Western
Reserve University School of Medicine in Cleveland, Ohio
Samir Khalifé, MD is a gynecologist at the Departments of Obstetrics and
Gynecology At McGill University and Jewish General Hospital in Montréal, Québec, Canada
Sheryl A.Kingsberg, PhD is Assistant Professor the Department of Reproductive
Biology at Case Western Reserve University School of Medicine in Cleveland, Ohio
I.David Marcus, PhD is a psychologist at the San Jose Marital and Sexuality Center
in Santa Clara, California
William L.Maurice, MD is an Associate Professor in the Department of Psychiatry of
the University of British Columbia in Vancouver, Canada
Barry W.McCarthy, PhD is a psychologist in private practice and Professor in the
Department of Psychology at American University in Washington, DC
Marta Meana, PhD is Associate Professor in the Department of Psychology at the
University of Nevada at Las Vegas, Nevada
Sheldon I.Miller, MD is Professor of Psychiatry at Northwestern University School
of Medicine in Chicago, Illinois
Sharon G.Nathan, MPH, PhD, is a psychologist in private practice in New York
Friedemann Pfäfflin, MD is psychiatrist and head of the Department of Forensic
Medicine in the University of Ulm in Germany
S.Michael Plaut, PhD is Assistant Dean for Student Affairs and Associate Professor of
Psychiatry at the University of Maryland School of Medicine in Baltimore, Maryland
Derek C.Polonsky, MD is a psychiatrist in private practice in Brookline,
Massachusetts and is Clinical Instructor in Psychiatry at Harvard Medical School
Raymond C.Rosen, PhD is Professor in the Department of Psychiatry at the Robert
Wood Johnson Medical School in Piscataway, New Jersey
David E.Scharff, MD is Co-Director, International Institute of Object Relations
Therapy in Chevy Chase Maryland and Clinical Professor of Psychiatry, Georgetown
University and the Uniformed Services University of the Health Sciences in Washington,

DC
R.Taylor Segraves, MD, PhD is Chairman at the Department of Psychiatry at
MetroHealth Center and is Professor at Case Western Reserve University School of
Medicine in Cleveland, Ohio
Lynda Dykes Talmadge, PhD is in private psychology practice in Atlanta, Georgia
William C.Talmadge, PhD is in private psychology practice in Atlanta, Georgia
Marcel D.Waldinger, MD, PhD is a psychiatrist in the Department of Psychiatry
and Neurosexology at Leyenburg Hospital in The Hague and is in the Department of
Psychopharmacology at Utrecht University in The Hague, The Netherlands
ix
Preface
Each mental health professional’s life offers a personal opportunity to diminish the sense of
bafflement about how health, suffering, and recovery processes work. Over decades of
work in a mental health field, many of us develop the sense that we better understand
some aspects of psychology and psychopathology. Those who devote themselves to one
subject in a scholarly research fashion seem to have a slightly greater potential to remove
some of the mystery for themselves and others in a particular subject area. But when it
comes to the rest of our vast areas of responsibility, we are far from expert; we remain only
relatively informed.
The authors of this handbook devoted their careers to unraveling human sexuality’s
knots. Their inclusion in this book is a testimony to their previous successes in helping
others to understand sexual suffering and its treatment. Because one of the responsibilities
of scholars is to pass on their knowledge to the next generation, in the largest sense,
passing the torch is the overarching purpose of this book.
We humans are emotionally, cognitively, behaviorally, and sexually changeable
creatures. We react, adapt, and evolve. When our personal evolution occurs along
expected lines, others label us mature or normal. When it does not, our unique
developmental pathways are described as evidence of our immaturity or psychopathology.
Sometimes we are more colloquially described as “having problems.”
Sexual life, being an integral part of nonsexual life processes, is dynamic and

evolutionary. I think about it as having three broad categories of potential difficulties:
disorders, problems, and worries. The disorders are those difficulties that are officially
recognized by the DSM-IV-TR—for example, Hypoactive Sexual Desire Disorder, Gender
Identity Disorder, and Sexual Pain Disorder. Many common forms of suffering that afflict
groups of people, however, are not found in our official nosology and attract little
research. I call these problems. Here are just two examples: continuing uncertainty
about one’s orientation and recurrent paralyzing resentment over having to accommodate
a partner’s sexual needs. Problems are frequent sources of suffering in large definable
groups of the population—for example, bisexual youth and not-so-happily married
menopausal women. Then there are sexual worries. Sexual worries detract from the
pleasure of living. They abound among people of all ages. Here are five examples: Will I
be adequate during my first intercourse? Will my new partner like my not-so-perfect
body? Does my diminishing interest in sex mean that I no longer love my partner? How
long will I be able to maintain potency with my young wife? Will I be able to sustain love
for my partner? Worries are the concerns that are inherent in the experience of being
human.
Sexual disorders, sexual problems, and sexual worries insinuate themselves into the
therapy sessions even when therapists do not directly inquire about the patient’s sexuality.
This is simply because sexuality is integral to personal psychology and because the
prevalence of difficulties involving sexual identity and sexual function is so high.
Unlike the frequency of sexual problems and worries, the prevalence of sexual
disorders has been carefully studied. Their prevalence is so high, however, that most
professionals are shocked when confronted with the evidence. The 1994 National Health
and Social Life Survey, which obtained the most representative sample of 18- to 59-year-old
Americans ever interviewed, confirmed the findings of many less methodologically
sophisticated works. In this study, younger women and older men bore the highest
prevalence. Overall, however, 35% of the entire sample acknowledged being sexually
problematic in the previous 12 months.
1
There are compelling reasons to think that the

prevalence is even higher among those who seek help for mental
2
or physical conditions.
3
Although people in some countries have unique sexual difficulties,
4
numerous studies have
demonstrated that the population in the United States is not uniquely sexually
problematic.
5,6
To make this point about prevalence and, therefore, the relevance of this book even
stronger, I’d like you to consider with me a retrospective study from Brazil. The authors
compared the frequencies of sexual dysfunction among untreated patients with social
phobia to those with panic disorder.
7
The mean age of both groups was mid–30s. The
major discovery was that Sexual Aversion, a severe DSM-IV diagnosis previously thought
to be relatively rare, was extremely common in men (36%) and women (50%) with panic
disorder, but absent in those with social phobia (0%). The sexual lives of those with social
phobia were limited in other ways.
I find this information ironic in several ways. This finding probably would not have
shocked therapists who were trained a generation or two ago because it was then widely
assumed that an important relationship existed between problematic sexual development
and anxiety symptoms.
8
Modern therapists, however, tend to be disinterested in sexuality
and so are likely not to respond to these patients’ sexual problems. Adding insult to
injury, the modern treatment of anxiety disorders routinely employs medications with a
high likelihood of dampening sexual drive, arousability, and orgasmic expression.
For most of the 20th century, sexuality was seen as a vital component of personality

development, mental health, and mental distress. During the last 25 years, the extent of
sexual problems has been even better defined, and their negative consequences have been
better appreciated. Mental health professionals’ interest in these matters has been
thwarted by new biological paradigms for understanding the causes and treatments of
mental conditions, the emphasis on short-term psychotherapy, the constriction of
insurance support for nonpharmacological interventions, the political conservatism of
government funding sources, and the policy to consider sexual problems inconsequential.
xi
As a result of these five forces, the average well-trained mental health professional has
had limited educational exposure to clinical sexuality. This professional is
neither comfortable dealing with sexual problems, skillful in asking the relevant
questions, nor able to efficiently provide a relevant focused treatment. It does not matter
much if the professional’s training has been in psychiatric residencies, psychology
internships, counseling internships, marriage and family therapy training programs, or social
work agency placements. Knowledgeable teachers are in short supply. The same paucity of
supervised experiences focusing on sexual disorders, problems, and worries applies to all
groups.
In my community, Cleveland, Ohio, there happens to be a relatively large number of
highly qualified sexuality specialists. Most moderate to large urban communities,
however, have no specialists who deal with the entire spectrum of male and female
dysfunctions, sexual compulsivities, paraphilias, gender-identity disorders, and marital-
relationship problems. Although many communities have therapists who deal with one
part of this spectrum, the entire range of problems exists in every community.
A remarkable bit of progress occurred in the treatment of erectile dysfunction in 1998.
Since then, primary care physicians, cardiologists, and urologists have been effectively
prescribing a phosphodiesterase-5 inhibitor for millions of men. But despite the evidence
of the drug’s safety and efficacy, at least half of the men do not refill their prescriptions.
There is good reason to believe that this drop-out rate is due to psychological/
interpersonal factors, rather than to the lack of the drug’s ability to generate erections. This
fact alone has created another reason for mental health professionals to become interested

in clinical sexuality. Most physicians who prescribe the sildenafil are not equipped to deal
with the psychological issues that are embedded in the apparent failures. The
nonresponders to initial treatment need access to us. But mental health professionals need
to be better educated in sexual subjects. So there are three reasons for developing this
handbook: (1) to pass the torch of knowledge to another generation; (2) to better equip
mental health professionals to respond to sexual disorders, problems, and worries as these
appear in their current practice settings; and (3) to help patients take advantage of
emerging advances in medication treatment by helping them to master their psychological
obstacles to sexual expression.
Stephen B.Levine, MD
YOU CAN DO THIS!
We use this exhortative heading for a reason. “You Can Do This!” is our way of saying
that the handbook provides coaching, encouragement, and optimism and aims to inspire
others to turn their interests to clinical sexuality. Mental health professionals can learn to
competently address their patients’ sexual worries, problems, and disorders.
xii
How We Created the Handbook
Once the editors decided to say yes to the publisher’s invitation to develop a handbook, we
set our sights on creating a unique book. We imagined it as a trustworthy, informative,
informal, supportive, and highly valued volume that would encourage and enable mental
health professionals to work effectively with patients who have sexual concerns. To attain
this lofty goal, we knew that the book would have to be a departure from the usual
excellent book on clinical sexuality.
We created the handbook through seven steps.
The first step we took was to define the intended audience. We quickly realized,
having valued teaching so highly during our careers, that this audience was mental health
professionals with little formal clinical training in sexuality. Although we thought some
readers might be trainees in various educational programs, we envisioned that most of the
readers would be fully trained, competent professionals. We thought that experienced
clinicians would have already had many clients who alluded to their sexual concerns and

might have already perceived how their sexual problems may have contributed to their
presenting depression, substance abuse, or anxiety states. We wanted to help general
mental health professionals think about sex in a way that diminished their personal
discomfort, increased their clinical confidence, piqued their interest in understanding
sexual life better, and increased their effectiveness. We wanted professionals to stop
avoiding their clients’ sexual problems. We also clarified that we were not trying to
create a book that would update sexual experts. We were writing for those who knew that
they needed to learn both basic background material and basic practical interventions.
The second step was to realize that because we were writing an educational text, our
authors would have to be excellent teachers. Excellence as a researcher or a clinician
would not be compelling reason to put a person on the author list.
The third step was to define our strategy for making the handbook unique. We decided
it would be through our instructions to the authors about how to compose their chapters.
We gave them ten instructions:
1. Use the first person voice—use “I” as the subject of some sentences.
2. Imagine when writing that you are talking privately to the reader in a supervisory
session.
3. Reveal something personal about your relationship to your subject—how you
became interested in the subject, how it changed your life, how your understanding
of the subject evolved over the years.
4. Imagine that you are guiding your readers through their first cases with the disorder
you are discussing. Do not share everything that you know about the subject! Try not
to exceed your imagined readers’ interest in the topic.
5. Keep your tone encouraging about not abandoning the therapeutic inquiry, even if
readers are uncertain what to do next.
xiii
6. Discuss your personal reactions to patient care as a model for the appearance of
countertransference. Illustrate how a therapist might use his or her private responses
to better understand the patient.
7. Either tell numerous short patient stories or provide one case in depth. Do not write

a conceptual paper without clinical illustrations.
8. Annotate at least half of your bibliography. Your reference list is not there primarily
to demonstrate your scholarship; it is there to guide the interested supervisee.
9. Be realistic about the reality of life processes and the limitations of professional
interventions. Although we want the readers to be encouraged to learn more, we do
not want to mislead them into thinking that experts in the field can completely solve
people’s sexual difficulties.
10. Be cognizant when writing that you are trying to prepare your reader to skillfully and
comfortably approach the patient, to gain confidence in his or her capacity to help,
and to rediscover the inherent fascination of sexual life.
The fourth step was the definition of relevant sexual topics. We did not want to deal with
uncommon problems—for example, there was not going to be a chapter devoted to
females who want to live as men, to female impersonators, or to serial sex murderers.
This book was to help with common problems, ordinary ones, the ones that are often lurking
behind other psychiatric complaints. This task was relatively easy.
The fifth task was slightly more difficult: to decide what basic information was
necessary as background preparation for dealing with the common sexual problems. After
this, we set about matching authors to the intended topics.
The sixth step was really fun. We had been told that it was often difficult to get people
to write for edited texts and that it might take 6 months or more to complete the author
list. The vast majority of our esteemed colleagues who were asked said yes immediately
and thought that the idea for the book was terrific. A few needed several weeks to agree.
Four pled exhaustion and wished us luck.
The final step—the seventh—involved the review of the manuscripts. It was during
this 5–month process that we, the editors, more fully realized what modern clinical
sexology is. While reading these 25 chapters, we realized that as a group we vary
considerably in our emphasis on evidence-based, clinically-based, or theory-based ideas. All
of us authors, however, speak of having been enriched as we struggled to better
understand and assist people with various sexual difficulties. All of us have seen
considerable progress in our professional lifetimes with our specialty issues. Some of the

chapters are stories of triumphs (treatment of rapid ejaculation, erectile dysfunction,
female orgasmic difficulties), others of disorders still awaiting the significant breakthrough
(female genital pain, sexual compulsivity, sexual side effects of SSRIs). A number of authors
address essential human processes that are part of life (boundaries and their violations,
menopausal changes, love), whereas others are coaching their readers about how to think
of their roles and attitudes (sexual history taking, diagnosis of women’s dysfunction,
transgenderism). Some chapters focus on grave difficulties (aversion, sexual avoidance,
xiv
sexual victimization) and yet others on hidden private struggles that tend to remain
unseen by those around them (homoeroticism in heterosexuals, paraphilias, unhappy
marriages). All in all, we find the field of clinical sexuality fascinating and hope that our
readers will rediscover what they used to know: sex is very interesting!
We designed this handbook with the idea that the vast majority of readers will look at
only the few chapters that are relevant to their current clinical needs at one sitting. Those
who are taking a course in clinical sexuality and reading the entire handbook, however,
will quickly discover some redundancy. In editing, we objected to any redundancy within
a chapter; we were reassured by it in the book as a whole. This was because it meant to us
that teachers of various backgrounds focusing on different subjects shared certain
convictions about the importance of careful assessment, how to conduct therapy, the
limitations of medications, the possibility of being helpful despite not being expert, and so
forth.
We are deeply indebted to the authors of the handbook for their years of devotion to
their subjects that enabled them to write such stellar educational pieces. As editors, we
considered it a privilege to have been immersed in their thinking. We hope that our
readers feel the same way.
Stephen B.Levine, MD
Candace B.Risen, LISW
Stanley E.Althof, PhD
NOTES
1. Laumann, E.O., & Michael, R.T. (Eds.). (2001). Sex, Love, and Health in America: Private

Choices, and Public Policies. Chicago: University of Chicago Press.
2. Kockott, G., & Pfeiffer, W. (1996). Sexual disorders in nonacute psychiatric patients.
Comprehensive Psychiatry, 37(1), 56–61.
3. Dunn, K.M., Croft, P.R., & Hackett, G.I. (1999). Association of sexual problems with
social, psychological, and physical problems in men and women: A cross sectional
population survey. Journal of Epidemiology and Community Health, 53, 144–148. Another
demonstration that the chronically mentally ill have a high prevalence of sexual dysfunction,
some of which is medication-induced, some of which is illness-induced, and some of which is
simply part of the difficulties of living.
4. El-Defrawi, L.G., Dandash, K.F., Refaat, A.H., & Eyada, M. (2001). Female genital
mutilation and its psychosocial impact. Journal of Sex & Marital Therapy, 27, 465–473.
5. Dennerstein, L. (2000). Menopause and sexuality. In Jane M. Ussher (Ed.), Women’s Health:
Contemporary International Perspectives (pp. 190–196). Leicester: British Psychological Society
Books.
6. Madu, S.N., & Peltzer, K. (2001). Prevalence and patterns of child sexual abuse and victim–
perpetrator relationship among secondary school students in the northern province (South
Africa). Archives of Sexual Behavior, 30(3), 311–321. Childhood sexual abuse is a major
concern everywhere. Though in the United States, its prevalence varies widely from one
economic group to another, this variation is not likely to be unique to the United States.
xv
7. Figueira, I., Possidente, E., Marques, C., & Hayes, K. (2001). Sexual dysfunction: A
neglected complication of panic disorder and social phobia. Archives of Sexual Behavior, 30(4),
369– 378. Although this is only a retrospective study that awaits confirmation, those highly
interested in anxiety disorders will profit from the implications of their data.
8. Freud, S. (1905). Three Essays on the Theory of Sexuality in the Complete Psychological Works of
Sigmund Freud, Volume VII (p. 149). London: Hogarth. This is an interesting read even today,
almost a century after it was written. Freud organized information about sexual life in a new
language, which reflected a wonderful grasp of the range of sexualities in the population and
what might account for the numerous variations that he categorized.
xvi

Part One
ADULT INTIMACY: HOPES AND
DISAPPOINTMENTS
2
Chapter One
Listening to Sexual Stories
Candace B.Risen, LISW
INTRODUCTION
When I began listening to sexual stories, I was 27 years old, married, and returning to
clinical practice after a 10-month maternity hiatus. Prior to the birth of my child, I had
been a social worker for 4 years, most of which were spent in an inpatient psychiatric
unit. I heard that a psychiatrist, wishing to launch a new subspecialty clinic devoted to
sexual issues, was looking for an intake coordinator. It was not exactly what I had in
mind, but I needed a job. In that new role I had to screen referrals, ascertain the nature of
the sexual complaint, present the intake to the clinic staff for assignment, and see some of
the cases myself. I had to talk about sex! I had to know about sex. How was I going to do
that? My frame of reference was limited to my own personal life experiences. I had strongly
internalized the cultural expectation that I was a “good girl”—that is, I could not be that
worldly! My mother echoed my concerns when, upon learning of my new position, she
asked, “But how do you know so much about sex that you can help people?…No, no, don’t
answer that question…. I don’t want to know!”
Thus began the next 27 years—a journey of personal growth and discovery, and ever-
increasing confidence and competence in helping people tell their sexual stories. Over time,
I learned to listen without anxiety, to ask pointed questions without fear of reprisal, and
to articulate sexual issues in a manner that was extraordinarily helpful to many of my
patients. Book knowledge certainly helped me along the way, but I learned far more from
the patients themselves. I have spent thousands of hours hearing about a wider range of
sexual experiences, feelings, thoughts, and struggles than I could have ever imagined. I am
indebted to those countless patients who taught me through their sexual stories. In this
chapter I will share what I believe are the key obstacles to overcome and the necessary

skills to acquire in order to develop professional sexual comfort and expertise.
Why Do I Need to Learn This?
Everyone has sexual thoughts, feelings, and experiences that are integral to their sense of
who they are and how they relate to the world. Sexual problems often manifest and mask
themselves in the major symptoms that bring patients to treatment; depression, anxiety,
failure to achieve, low self-esteem, and the inability to engage in intimate relationships.
Yet patients are shy about revealing their sexual concerns. It feels so private, so awkward,
so potentially embarrassing that many are reduced to paralyzing inarticulateness. They
dread being asked, but they long to be asked. They know for sure that they need to be
asked if it is ever to come out. Too often, therapists find themselves reluctant to initiate
an inquiry. They rationalize, “If my patient doesn’t bring up sex, it must not be an issue
and I should not be asking about it.” At best, this can lead to a missed opportunity to be
helpful; at worst, it can lead to the wrong therapy plan.
Why Don’t I Want To?
This is often the fundamental question behind “Why do I need to?” The reasons for not
wanting to are many.
1. I’m not used to talking about sex…my discomfort and awkwardness will be obvious.
2. I don’t exactly know why I am asking or what I want to know.
3. I won’t know how to respond to what I hear back.
4. I may be unfamiliar with, not understand, or neither be familiar with nor understand
something my patient tells me.
5. I may offend or embarrass my patient.
6. I may be perceived as nosy or provocative.
7. I won’t know how to treat any problem I hear.
8. I’ll be too embarrassed to consult with my colleagues.
The anxiety and discomfort underlying these reasons can be overcome with the courage to
try something new. Most of us can recall having some of these concerns about a wide
range of issues when we first began our clinical careers. Questions about what to ask, how,
when, and why were the ongoing central focus of our learning. patience, persistence, and
a sense of humor helped to get us through the processes of gaining experience. Over

time, increasing comfort and expanding knowledge made the job that much easier.
The concerns about being perceived as nosy or intrusive or about offending or
embarrassing our patients may be more specific to sexual topics. Although patients may
initially react as though you have intruded into territory too personal to be shared, they
are usually settled by a simple explanation as to the relevance of the question.
THERAPIST: “You’ve told me a lot about your ambivalence about marrying Joe…your
concerns about his lack of ambition and his relationship to his family. You
haven’t mentioned anything about your sexual life together. Can you tell
me about that?”
JILL: “Well, uh…it’s okay, I guess.” (Squirms in her seat.) “What do you want to
know?”
4 HANDBOOK OF CLINICAL SEXUALITY FOR MENTAL HEALTH PROFESSIONALS
THERAPIST: “Sexual intimacy is often a vital part of a relationship…. It can really
enhance it or can be problematic. How have you felt about your sexual
relationship with Joe?”
JILL: “Well, sometimes it feels like he lacks ambition in bed, too…. He doesn’t
seem to be interested that often…we are so busy during the week; I can
understand…but it seems he would rather spend Sunday afternoon visiting
his family than being, you know, intimate with me.”
THERAPIST: “How do you feel about that?”
JILL: “Well, I haven’t told anyone…. It’s embarrassing to admit that we’re not
even married yet and already Joe seems disinterested…. Isn’t it supposed to
take several years before that happens? It makes me feel like he isn’t
attracted to me, like I’m too fat or not sexy enough.”
Jill is a little taken aback by the initial question. She doesn’t know how to respond because
she is not used to articulating aspects of her sexual life. A simple statement by her
therapist about sexual intimacy helps Jill to get started.
Sometimes, however, it is the therapist, not the patient, who feels weird or
embarrassed by the exploration of sexual material. This is particularly true when the topic
is something the therapist has never experienced (“My ignorance will show.”), can’t

imagine experiencing (“That’s disgusting!”), or has experienced with ambivalence and
conflict (“I don’t think I want to go there!”). The therapist may unwisely avoid the subject
if it threatens to bring up painful memories.
ALAN: “I can’t believe I slept with my roommate’s girlfriend! I mean, I’ve had sort
of a crush on her, but I wasn’t thinking about that when he asked me to
look out for her over the weekend while he was away. We were just
talking, drinking some beer, and having a good time. One thing led to
another. Now she won’t speak to me and my roommate will be back
tomorrow. What can I do?”
THERAPIST: (This is making me very anxious…. I don’t want to remember what I did to
Jim in college…. It was the end of our friendship…. To this day I feel like a
worm about it.) “I’m sure everything will be okay. These things happen.”
Alan is clearly upset by his behavior and wants to talk about it. The situation, however,
reminds his therapist of a similar time in his life. In an effort to ward off his own feelings of
guilt, the therapist cuts off the discussion and falsely reassures Alan that everything will
work out.
The heterosexual therapist may be most reluctant to bring up sexual issues
when dealing with a client of the opposite sex; the homosexual therapist may feel similarly
anxious when dealing with a client of the same sex. The gender of the therapist often
dictates what the particular worry is about; in other words, the male therapist is more
likely to worry about feeling excited if he pursues sexual issues with his client and the
female therapist is more likely to worry about being seen as provocative or inviting of her
client’s sexual interest.
LISTENING TO SEXUAL STORIES 5
Who Should I Be Asking?
Everyone: Unless the chief complaint is so specific and narrow in focus or the time spent
together so short or crisis-oriented, every patient should at least be offered the opportunity
to address sexual concerns. How will we know whether sexuality is of concern unless we
inquire? Because sexuality is a topic that is difficult for patients to bring up, the therapist
must assume responsibility for introducing it as an area of possible relevance. If nothing

else, the inquiry tells the patient, “This is okay to talk about…. I’m interested in hearing
about it if you want to tell me…. I’ll even help you talk about it by taking the lead.”
Including Older Persons: Therapists are often reluctant to inquire about the sexual
feelings and activities of “the elderly” (often defined as anyone as old as or older than
one’s parents!). Our culture emphasizes youth and beauty, and there is a tendency to see
aging people as asexual or, even worse, to make fun of their displays of sexual interest.
Older adults, in turn, may be embarrassed to admit that they still have needs for physical
affection, closeness, intimacy, and sexual gratification. They may be told by their
physicians that they are “lucky to be alive” and shouldn’t fret over sexual concerns.
Even When Your Patient Is the Couple: It is hard to imagine a marital
relationship in which sexuality does not play a role. Yet marriage counselors often refer
patients to sex specialists and tell us, “Mr. and Mrs. X have done terrific work with me in
the past year on their marriage. We were winding down and they brought up a sexual
issue. I’m sending them to you to deal with their sex life.” This process is neither clinically
nor financially efficient and is a result of either the marriage counselor’s discomfort with
the topic of sex or the assumption that sex is not within the range of marital counseling.
When Should I Ask?
Inquiring about sex when someone shows up in a crisis about his dying mother is not
particularly relevant. Early and abrupt questions about sexuality will be off putting unless
the chief complaint is of a sexual nature. On the other hand, putting it off indefinitely or
waiting until the patient brings it up may reinforce the idea that it is a taboo subject. The
situation that offers the most natural segue into the topic is the gathering of psychosocial
and developmental information early on in the assessment phase. As one is inquiring about
childhood and family-of-origin history, significant events, issues, and problems, this can
be a natural lead-in to inquiring about sexual matters.
THERAPIST: “You were telling me about your male friendships growing up…. Do you
remember when you first became aware of sexual feelings?”
JACK: “Do you mean liking girls? I didn’t think much about girls until middle
school…. I had a crush on a girl in seventh grade. Her name was Judy. She
was very popular and hung out with eighth-grade boys. She never knew how

I felt. I was geeky. She wouldn’t have given me the time of day.”
THERAPIST: “How did you handle that at the time?”
JACK: “Not well. I was very self-conscious and it didn’t go away in high school. I
didn’t date although I wanted to. That’s when I found my brother’s
6 HANDBOOK OF CLINICAL SEXUALITY FOR MENTAL HEALTH PROFESSIONALS
magazines under his bed and I started masturbating. I guess most guys do
and it’s not a problem but I got ‘hooked’ on it and I think I still am. I don’t
know if that is related to why I’m here, but it might be.”
Jack’s therapist made a smooth transition from the focus on growing up and friendships to
a question about the emerging awareness of sexual feelings. The transition made sense to
Jack, and he easily picked up on the question. In this case, Jack thinks that the issue of
sexuality may be relevant to his seeking therapy. That isn’t always so. The advantage of
taking a sexual history in the assessment phase, whether or not a sexual problem exists, is
that it gives permission to speak of sexual issues in the future. If, however, one has
forgotten to do this, it won’t hurt to introduce it as a topic at a later date.
How Do I Do This Well?
Using the Right Words: Even when clinicians are convinced of the worthiness of
inquiring about sexual matters and are ready to do so, they often stumble over the
vocabulary. The task of finding the right words and pronouncing them correctly can
intimidate the best of us; we realize that we are far more comfortable reading such words
as “penis, vagina, clitoris, orgasm” than saying them out loud.
Nevertheless, it is up to the clinician to go first—that is, to say the words out loud so
that the patient can follow suit. Sometimes we may use a word that is confusing or foreign
to our patient; sometimes patients will use words we don’t understand. Shortly after I
began this work, a patient told me his chief complaint was “I’ve lost my nature.” I did not
know what a “nature” was, never mind how he could lose one! I was too embarrassed to
ask. I copped out by replying, “Tell me more about losing your nature.” I hoped that the
subsequent discussion would reveal the definition of the word. Even tually, I figured out
that he was using the word to describe his erection. It would have been a lot easier if I had
just inquired, “Tell me what a nature is… I haven’t heard that expression.” Over time one can

build up knowledge of a large repertoire of expressions—some clinical and formal, others
slang and street talk. It helps to gain a working familiarity with both kinds.
Allowing the Story to be Told: Though it helps to have an organized approach to
the questioning, you should not become an interrogator who is wedded to a
predetermined agenda or outline. I have found that the most useful conceptualization for
my talking about sexuality is that of helping people tell their “sexual story.” Sexual stories,
as with any story, have a pattern of flow and a combination of plots and subplots,
characters, and meaning. Some stories unfold chronologically from beginning to end;
others begin at the end and flash backward to illustrate and highlight the significant
determinants to the ending. Either way, the events, characters, and meanings are
eventually interwoven into one or two major themes that constitute “the story.” Whether
or not one begins by asking about current sexual feelings and behaviors and then gathers
history or begins by taking a developmental history depends on two factors:
1. the absence or presence of a current sexual issue that requires direct attention; and
LISTENING TO SEXUAL STORIES 7
2. the client’s comfort with addressing current sexual functioning as opposed to
historical narrative.
Being Flexible: Open-ended questions that encourage clients to tell their sexual stories
using their own language are ideal, but many clients are too inhibited or unsure of what to
say. They require more direction. When your open-ended questions are met with blank
stares, squirming, blushing, or other signs of discomfort, it’s enough to make you regret
ever having broached the topic. But do not give up. Patience and calm encouragement,
along with the guidance of more specific questions, will usually get the ball rolling.
Looking for an aspect of the client’s sexuality that is the least threatening— the easiest to
talk about first—may provide the direction.
THERAPIST: “What is your sexual life like these days?”
JOYCE: “I don’t know what you mean…like, am I seeing anyone?”
THERAPIST: “Sure…we can start there.”
JOYCE: “Well, I’ve been dating this guy, Steven, for 3 months. We have been
sexual…”(long silence).

THERAPIST: “How has that been for you? Are you enjoying the sexual relationship?”
JOYCE: “It’s okay” (silence).
THERAPIST: “Is Steven your first sexual partner?”
JOYCE: “No” (silence).
THERAPIST: “Tell me about the first one.”
JOYCE: “I was 15 and he was a year ahead of me in high school. My parents didn’t
approve of him because he smoked and hung out with a crowd they didn’t
like. But I wasn’t having a good year and he was an escape for me. He had a
car and we would go driving around after school…. I told my mother I had
to stay after school for one thing or another.”
THERAPIST: “What were the circumstances that led up to your being sexual with him?”
JOYCE: “I didn’t really want to, but he did and I didn’t want to lose him. The first
time was in his car…. I didn’t really get anything out of it. We went together
until he graduated and went to work. We were sexual the whole time, but
I never really felt good about it. I didn’t trust him. Later, after he broke up
with me, I heard he had been with others, and I really felt used and angry with
myself…. I think it warped me or something. Sex has never been all that
good. I don’t get much out of it. I think I just do it to stay in a relationship.”
In this case, the therapist helped Joyce by being willing to start with whatever Joyce
brought up, “like, am I seeing anyone?” Even so, Joyce was reticent, and so, rather than push
her beyond a question or two, the therapist switched gears and inquired about her earlier
experiences. Joyce had an easier time responding to this question and was then able to
relax enough to go back to talking about Steven. Had she not seemed more comfortable,
her therapist might have chosen to keep the focus on past experiences and inquire about
Steven at another time.
8 HANDBOOK OF CLINICAL SEXUALITY FOR MENTAL HEALTH PROFESSIONALS