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Gender and Sexuality: Shame and Safety in the Psychiatric Encounter 

Gender and Sexuality: Shame and Safety in the Psychiatric Encounter
Chapter:
Gender and Sexuality: Shame and Safety in the Psychiatric Encounter
Author(s):

Andrew Cruz

, Julianne Torrence

, and Christopher M. Palmer

DOI:
10.1093/med/9780190849986.003.0010
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date: 20 May 2019

Guilt—a feeling of violating one’s ethical or cultural standards—is an emotion that serves a purpose. It causes us pause and prompts us to ask ourselves, “Is this a good decision?” It is a potentially powerful filter through which we can reflect upon decisions made to determine if the result is worth the cost. Guilt is intended to be not a burden that must be carried at all times, but rather a guidepost to help us chose our behaviors.

Shame, however, is a belief system: “I do bad things; therefore I am bad. I failed at this, so I am a failure.” But who determines what is bad? Society, certainly. But what other factors contribute to a person’s belief about what is inherently good or bad? Upbringing, culture, religion, education, geography, even biology shape our personalities and how we react and respond to our worlds. How do we, as clinicians, navigate this minefield of complexity?

Shame is often an inherent aspect in the very decision for someone to seek psychiatric or psychological treatment.1,2 To reach a level of mental suffering that requires the help of another is often humiliating. Many loved ones and friends will offer advice such as “Just get over it,” “Stop worrying so much,” and “Snap out of it,” implying that this type of suffering should be easy to overcome. Such advice further implies that those who can’t manage these symptoms on their own are somehow stupid or weak. That intrinsic shame does not even factor in those feelings that emerge from the issue for which the patient is seeking treatment in the first place. Depression, anxiety, grief, relationship challenges, historical diagnoses, and difficulties successfully navigating through each day are, by their very nature, issues that can trigger shame. But what about issues that are already labeled as shameful? Discussing sexuality and behaviors that may feel taboo or deviant likely adds to an already shaming experience and can make therapy torturous for some patients.

However, the psychiatric encounter, with its intrinsic personal questions and emotional complexity, presents a unique opportunity to safely broach and explore diverse aspects of our patients’ worlds, including taboo or deviant topics such as sexuality. As clinicians, we learn early in our training to meet the patient where they are, to find a way to connect. But what do you do when someone presents in your office with a situation with which you have no experience? Or no knowledge? Or have strong beliefs about? Or are uncomfortable with? What about when the patient is from, or embedded in, a culture with which you are either unfamiliar or have your own history? If we are already working to incorporate into our new doctor–patient relationship an understanding of our patient’s possible shame or hesitancy to come to therapy, how do we simultaneously adjust our belief systems, our values, and our own shame to meet the patient where they are, particularly with such potentially volatile and difficult topics?

Most people have strong feelings and beliefs about sexuality and sexual behaviors, often accompanied by judgments of right or wrong. These feelings arise from entrenched values and mores in our society and are well described in the clinical literature.3,4 To be a truly effective clinician, therefore, we must first be clearly and specifically aware of our own morals, values, beliefs, prejudices, biases, likes, dislikes, triggers, and influences around many situations and circumstances, including those involving sexuality. This is not always easy, but taking an honest and comprehensive self-assessment is the least we can do for our patients. Sound supervision around this exploration is a cornerstone to true self-awareness.

Sexuality and sexual behaviors are normal, healthy parts of human development and life. They can, at times, also be signs and symptoms of psychopathology. Distinguishing what constitutes normal, healthy sexual expression from psychopathology can be clinically challenging, and, unfortunately, there is little science to guide clinicians. As such, clinicians often must rely on what they themselves know and believe to determine which sexual behaviors may be symptomatic of a psychiatric illness and which are nonnormative but healthy consensual acts. Familiarity, therefore, with a wide range of sexual behaviors, beliefs, practices, cultures, and resources is paramount. Some sexual behaviors may indicate stand-alone psychiatric diagnoses. Many are, or can be, symptoms of a more complex psychiatric picture. Still others are “just sex,” as we will explore in our cases. In addition, it is not unusual for these scenarios to overlap and change meaning with time and circumstance. The more informed a clinician is around topics of sexuality, the better he or she can distinguish what constitutes pathological versus nonpathological sexual behaviors. Several of these concepts are summarized in Table 10.2 and will be explored in more detail throughout the chapter.

Table 10.2 Prevalence and Diversity of Female and Male Sexual Fantasies in the General Population

Women’s Sexual Fantasies

% Women

Men’s Sexual Fantasies

% Men

I like to feel romantic emotions during a sexual relationship.

99.2

I like to feel romantic emotions during a sexual relationship.

88.3

I have fantasized about having sex in an unusual place (e.g., in the office; public toilets).

81.7

I have fantasized about having sex with two women.

84.5

I have fantasized about having sex with someone that I know who is not my spouse [ . . . ].

66.3

I have fantasized about having sex in an unusual place (e.g., in the office; public toilets).

82.3

I have fantasized about being dominated sexually.

64.6

I have fantasized about having anal sex.

64.2

I have fantasized about making love openly in a public place.

57.3

I have fantasized about watching someone undress without him or her knowing.

63.4

I have fantasized about having sex with more than three people, both men and women.

56.5

I have fantasized about dominating someone sexually.

59.6

I have fantasized about being tied up by someone in order to obtain sexual pleasure.

52.1

I have fantasized about being dominated sexually.

53.3

I have fantasized about dominating someone sexually.

46.7

I have fantasized about tying someone up in order to obtain sexual pleasure.

48.4

I have fantasized about tying someone up in order to obtain sexual pleasure.

41.7

I have fantasized about being tied up by someone in order to obtain sexual pleasure.

46.2

I have fantasized that my partner ejaculates on me.

41.3

I have fantasized about having sex with two men.

45.2

I have fantasized about having homosexual (or gay) sex.

36.9

I have fantasized about spanking or whipping someone to obtain sexual pleasure.

43.5

I have fantasized about being spanked or whipped to obtain sexual pleasure.

36.3

I have fantasized about being forced to have sex.

30.7

I have fantasized about being forced to have sex.

28.9

I have fantasized about being spanked or whipped to obtain sexual pleasure.

28.5

I have fantasized about having sex with a fetish or non-sexual object.

26.3

I have fantasized about having sex with a fetish or non-sexual object.

27.8

I have fantasized about spanking or whipping someone to obtain sexual pleasure.

23.8

I have fantasized about forcing someone to have sex.

22

I have fantasized about forcing someone to have sex.

10.8

I have fantasized about my sexual partner urinating on me.

10

Joyal CC, Cossette A, Lapierre V. What exactly is an unusual sexual fantasy? J Sex Med. 2015;12(2):328–340

Exploring issues of sexuality in the context of the psychiatric relationship will expose biases on the part of both the provider and the patient; acknowledging these biases can enhance open and honest communication between the parties. An informed understanding of both the provider’s and the patient’s ideas about sexuality can be the key to providing truly compassionate and competent mental health care. To illustrate the varied and complicated spectrum of human sexual behavior, we will present four clinical cases with subsequent discussion. As the cases evolve throughout the chapter, make note of the feelings, thoughts, hypotheses, diagnoses, reactions, and responses you experience, as well as how those emotions and beliefs influence your potential treatment decisions.

Resources are available to clinicians as they begin to develop their own acceptable level of comfort and style. For instance, the Centers for Disease Control and Prevention offer clear guidelines and prompts for how to comfortably incorporate a thorough sexual history into a clinical interview5 (Table 10.1). In addition, new techniques for proclivity-specific interviewing frameworks are being explored and vetted.6,7 Although such guidelines are helpful as a baseline, clinicians will develop their own style and methods for discussing sex in clinical relationships, which must include creating a safe environment, using nonpejorative language, avoiding judgment, using open-ended questions, and being overall culturally sensitive and aware.

Table 10.1 Taking a Sexual History

Statement/Question

Follow-up

I am going to ask you a few questions about your sexual health and sexual practices. I understand that these questions are very personal, but they are important for your health. Just so you know, I ask these questions to all my adult patients regardless of age, gender, sexual orientation, or marital status.

Are you currently sexually active?

If no, ask, “Have you ever been sexually active?”

In recent months, how many sex partners have you had?

If the answer is more than zero, ask, “Are you sex partners men, women, or both?”

I’m going to be more explicit here about the kind of sex you’ve had over the last 12 months to better understand if you are at risk for STDs.

What kind of sexual contact do you have or have you had? Genital (penis in the vagina)? Anal (penis in the anus)? Oral (mouth on penis, vagina, or anus)?

Do you and your partner(s) use any protection against STDs?

If not, could you tell me the reason?

If so, what kind of protection do you use? How often do you use this protection?

What other things about your sexual health and sexual practices should we discuss to help ensure your good health?

What other concerns or question regarding your sexual health or sexual practices would you like to discuss?

Adapted from Centers for Disease Control and Prevention. A Guide to Taking a Sexual History. CDC publication 99-8445 (pamphlet).

Case 1

A 45-year-old male presents to a mental health clinic. When asked about what brought him in for evaluation, he says, “My depression.” He elaborates that he has felt down most of his life but his hopelessness has increased during the past six months after an extramarital affair. He now finds it difficult to get out of bed in the morning, has stopped going to the gym, and is having difficulty attending his children’s sporting events. He fears that he will lose his job because it has become increasingly difficult to handle the same workload that was manageable before. His wife has been supportive, but the patient does not feel worthy of her support; even more, he feels guilty for her support after his affair. The patient becomes tearful; he begrudgingly confesses that his affair was with a man. He has been attracted to men since his teenage years but has never had a relationship or sex with a male before this affair. “I’m desperate. I hate what I am and what I have done. Help me.”

The patient described in this case discloses an extramarital affair in addition to presenting with symptomatology of major depression. The clinician’s treatment of the patient will be preceded and influenced by a personal judgment made as the patient shares his situation. The clinician’s reaction to infidelity likely depends on several factors: the clinician’s personal experiences with infidelity, comfort with discussing sexuality, familiarity dealing with similar situations, and the amiability of the patient, among others. Many clinicians would assume that because this man is married to a woman and has children, he is heterosexual. When it is revealed that he is having an affair with a man, one can imagine that clinicians’ reactions would be quite varied. Some may feel a sense of sadness for him—perhaps societal, religious, and cultural pressure forced him into a life that was no longer sustainable? Some may feel anger—with a family and wife at home, this patient’s actions were selfish and irresponsible. Some, lacking experience with sexual minorities, may feel befuddled—a heterosexual man cannot have sex with another man without substances or an underlying pathology playing a role. Then there is, of course, the question of how the clinician would react if the gender of the patient’s lover were changed. In a world free of biases, the reaction would ideally be the same regardless of the gender or sexual orientation of the patient. While that may seem impossible in the silent bias-riddled thoughts of the clinician, the way the clinician outwardly empathizes, advises, and treats all patients should be equal regardless of the sexuality dynamic. Undoubtedly, the ability of a clinician to treat patients from sexual minorities and majorities equally depends on his or her familiarity with the topic.

In your clinical practice, you will undoubtedly encounter some of the 3.5% of Americans who identify as lesbian, gay, or bisexual, in addition to the 0.3% who identify as transgender.8 Sexual minorities experience increased rates of substance abuse, sexually transmitted infections, anxiety, and depression compared to the general population.9 These amplified risks must be understood as a consequence of the increased bullying, isolation, shame, and guilt these patients experience and not as a direct biological consequence of their sexual orientation. These increased risks are also important clinically because of their potentially lethal implications. Risk factors for suicide, including mood and anxiety disorders, are increased in sexual minority populations.10 Furthermore, meta-analyses have revealed a twofold excess of suicide attempts in LGBT populations.11 Of note, even within the sexual minority communities that have an overall elevated risk of suicide, the transgender community has much higher risks. Their mental health risks, often described academically as the same, do, in fact, differ from their homosexual counterparts.

Even the astute clinician is easily tempted to focus on this patient’s underlying mood disorder without truly addressing his underlying struggle with his sexuality. Omitting the patient’s struggle with sexuality is a mistake. Sexual minority patients often perceive health care environments as inhospitable.8 Their perception is shaped by the fact that they have spent their lives, closeted or not, in a largely heteronormative climate. Becoming accustomed to waiting rooms with male-female relationships depicted in posters and interview questions aimed at heterosexual relationships and sex have made an entire generation of sexual minority patients feel “less than.” Health care institutions, hoping to address an obvious and troublesome health disparity, have instituted a variety of diversity training programs.12 However, growing evidence shows that diversity training does not sufficiently address the problem.12

Compounding this problematic clinical scenario is the simple fact that clinicians feel uncomfortable speaking to their patients about sex.13 As health care providers, we find it difficult to speak about subjects that we have been raised to find taboo or off limits. Yet, sexuality is a common thread that runs through all humans, has vital clinical implications, and influences human behavior in such an immense way that it cannot be ignored. As we explore ways in which that information can be pertinent to the clinical encounter, the most obvious but easily, and often purposefully, forgotten missing piece is obtaining the sexual history. Clinicians must ask patients in an open and nonjudgmental way about sexual behaviors and sexuality, particularly in the mental health field. Clinicians must not become voyeurs with their questions, but must use the sexual history to make the correct diagnosis and to provide proper treatment.

Furthermore, the sexual history can elucidate areas of sensitivity that can build rapport and enhance the clinician–patient relationship.14 Learning to speak comfortably with our patients, including using preferred nomenclature and language, has a positive impact on the clinical relationship.15 An example is the correct use of pronouns when working with transgender patients, as this is a basic and essential foundation of understanding between the clinician and the patient. It tells patients that they are not “others” and that the words they use to identify themselves mean enough that the clinician cares to ask about them and use them properly. Countless other situations exist in the realm of information obtained from the sexual history. Patients are often more open than clinicians may think, and only by encountering these situations and exploring them with patients can the clinician reach a place of comfort for both patient and clinician.

In the case of this patient, who presents with an episode of major depression in the setting of a same-sex affair, it is important for his treatment to delineate how his symptoms relate to his underlying mood disorder and how they similarly or differently relate to the underlying struggle with sexuality. Guilt can be a cardinal symptom of depression, though in the case of patients struggling with their sexuality, guilt and its appropriateness can be difficult to distinguish. As sexual minorities become increasingly accepted in the 21st century, it can be difficult to remember that not long ago they were ostracized, pathologized, and discriminated against. The patient’s guilt or concrete feeling—that he has performed or indeed IS an offense—could be the result of a lifetime of repressed sexuality in a world that was vastly different in his formative years. Thinking about how depression often cognitively highlights negative thoughts, feelings, and emotions in patients can be helpful. The guilt this patient feels is likely multifactorial and related to a chronic feeling that is exacerbated by his current depression. These two manifestations of guilt are intimately connected and must both be addressed.

Deciding clinically how to advise the patient to proceed in this situation is controversial and will differ on a patient-by-patient basis. The patient’s sexuality is still somewhat of a mystery, to the clinician and perhaps even to the patient. The framework that people are always “becoming,”16 regardless of sexuality, can be helpful for clinicians and patients. In this case, there is no urgency to identify a sexual orientation for the patient; the focus instead must be on crisis control and stabilization. The multitude of worries the patient almost certainly has—Should he tell his wife? What is his sexuality? What will his kids think?—will be addressed over time; for now, talking through and processing his experience is the priority. The clinician must set aside preconceived notions of sexuality and, in each encounter with the patient, empathize with and learn from the patient’s story. It can be helpful to step back from the certainty of clear answers and explore the similarities to all patients—each patient is looking for answers and seeking help from you.

Case 2

A 47-year-old gay man with a history of alcohol use disorder who meets criteria for major depression presents for psychiatric care. When the clinician inquires about potentially risky behaviors, he reports that he has been “meeting up” with and having sex with different men several times a week. When asked how he meets these men, he reports using “hookup” apps on a daily basis. He reports around 700 lifetime partners. When asked if alcohol is involved, he reports that it is only involved rarely and this behavior is “normal.”

“Hookup” apps have become increasingly popular in the last decade.17 They represent a novel and, in some ways, revolutionary approach to looking for sex. These are mobile phone apps in which people of all gender and sexual identities can meet each other for everything from small talk, to dates, to sexual encounters, to full-fledged relationships. The apps are structured so that people can scroll through a hundred other people in a matter of minutes. Interestingly, people often reveal personal characteristics about themselves that, in the past, would gradually be revealed after numerous dates. It is not uncommon, for instance, for people in the public forum of the app to write about their sexual preferences, substance use habits, occupations, religious affiliations, hopes, and dreams. In a world that has become increasingly driven by instant gratification, the implications of these apps are enormous.

This case presents numerous challenges. This patient meets criteria for a mood disorder that must be addressed, but the context in which that disorder presents is equally important. Understanding the importance of hetero- and homonormative behaviors as they apply to pathology and diagnosis is challenging and often results in many assumptions and biases by clinicians.6,18,19,20 The first concern, from a clinical perspective, is always safety. The patient has a history of a substance use disorder; screening for current pathology in that regard is part of a well-developed clinical interview that assesses for safety. What must also be taken into consideration is that substance use discrepancies between sexual minorities and their heterosexual counterparts are profound. In a large systematic review, the odds of recent and lifetime illicit substance abuse were over three times higher for sexual minority youth relative to heterosexuals.21 Also of note, among sexual minority populations substance use starts at earlier ages than among their heterosexual counterparts. There is also a gender difference, with substance use being higher in men.22 The reasons for these discrepancies are not entirely clear, but are most likely multifactorial.22 The increased substance use may represent a combination of increased availability of substances, an attempt to cope with stressors and fear, and a mechanism for finding a community. When asking a patient with a history of substance use about current use, the clinician must be thoughtful to ensure that he or she is not missing a potential contributing factor to the patient’s depression and behavior. This patient’s current depression and increased sexual behavior are clinical clues—much as an uncontrolled glucose would be in a previously controlled diabetic—that either the disease itself has progressed or that there are disease-modifying behaviors contributing to this change. A comprehensive substance use screening will help to determine which of the aforementioned is primarily contributing to this patient’s presentation.

An equally important aspect of this patient’s presentation that must be addressed is his sexual behavior. It is important to understand that clinicians who treat sexual minority patients can have significantly different sexual orientations, gender identities, religious affiliations, and cultural backgrounds from the patients who seek their guidance. For those not familiar with sexual minority culture, particularly gay culture, hearing a patient tell you that he has had 700 lifetime partners can be shocking. Patients are intensely aware and observant of how clinicians react to such disclosures. A balanced, controlled, nonjudgmental reaction is what they hope for and what clinicians, despite their own background, must convey.

Hypersexuality is a minefield of potential incorrect diagnoses if the clinician is not careful.23 As one of the few times that clinicians ask about sex is during psychiatric review of symptoms when concerned for mania, a clinician could attribute this patient’s hypersexuality to part of a bipolar spectrum disorder. A thorough review of systems will help determine if the patient does, in fact, show signs of bipolar affective disorder. Another clinician may attribute this patient’s hypersexuality to borderline personality disorder, noting that many with this diagnosis use sexual behavior to help fill a void or escape from chronic feelings of emptiness or identity confusion.24

One disorder that did not make the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5)25 is hypersexual disorder.26 This disorder roughly constitutes a set of symptoms colloquially known as “sex addiction.” Questions about the impact that the patient’s sexual behavior is having on his life will help determine if this is, in fact, an addiction. This patient’s apparent lack of concern by referring to his behavior as “normal” argues against the diagnosis of hypersexual disorder. Sex is also a common strategy for distraction from or numbing of depression, anxiety, and other mood symptoms.27,28

Men who have sex with men do have a higher prevalence of lifetime sex partners. The patient is a gay male. The homosexual culture has a different mindset about casual sex; hence, he may see his sexual encounters as a normal and enjoyable part of life.29 In this context, the patient’s answer that this behavior is “normal” could be as equally valid an explanation as the aforementioned diagnoses. Promiscuity does not, in and of itself, necessarily imply pathology. Regardless of its etiology, initially the patient must be assessed as with any other patient. A normal part of any clinical encounter is counseling about risky behaviors in a nonjudgmental and evidence-based way. There are very real risks to having a large number of sexual partners. Among men who have sex with men, there has been an upward trend in condom-less anal sex with both casual partners and main partners, as well as condom-less anal sex with partners of unknown or discordant HIV status; there is some evidence attributing this to viewing pornography containing condom-less sex.30 The availability of preexposure prophylaxis (PrEP) will likely reduce these risks in the future, but access is not yet widely available, and knowledge of the treatment is limited. The clinician must ask the patient about sexual practices, condom use, and HIV status of his partners. These questions and the clinical advice that follows should be similar to the questions and advice with which you would counsel any sexually active patient.

Herein lies one of the most important aspects of caring for sexual minority patients: They are minority in some ways but, like all patients, they are of course human as well. Their care has differences, yes—but it must be fundamentally the same as the care offered to all patients—humane.

Another topic of discussion is the number of partners and the implications of those numbers. While data on dating apps and their effect on sexual behaviors are emerging, there can be little doubt that apps are making an impact on sexual behavior. Men who have sex with men report having, on average, three dating app accounts, opening these apps eight times a day, and spending 1.5 hours on them.31 Given the fast pace of the American worker and the numerous social duties that people have, these statistics are extraordinary. Furthermore, the most-cited reason for having such an app is to facilitate sex. This patient must be interviewed about his motivations for using the app he mentioned and about what he is seeking in his partners. He can be counseled about the health risks, but judgments based on the number of partners may threaten the clinical relationship. While judgmental statements must be avoided, it is worth exploring what the patient believes other people think about his behavior and whether or not that matters to him. Having a conversation, for instance, about how to deal with people who think negatively about his actions will benefit him in the future and help him to think through his responses. The normality of these behaviors is hotly debated, and clinicians will have differing opinions.

What is most important to realize, however, is that there is a novel phenomenon evolving. Sex has become digitized and accelerated, making it more available than ever before. Research will be required about the true effect of smartphone innovations on sexual behavior; for now, however, clinicians and their patients are best served by education in a nonjudgmental interview, as well as exploring the implications of present behaviors on emotions and future goals. It would be important to ask this patient if he does want a long-term relationship eventually, and how his present behaviors would work in that context. What would his future partner’s reaction be? Also, exploring the emotions the patient feels before and after the encounters will be important clinical information. Have there been times when the encounters felt dangerous or did not go according to plan? What were his emotions then? These questions and their answers can serve to elucidate the patient’s diagnosis while simultaneously building a clinical relationship and validating his experience.

Case 3

A concerned mother brings in her 15-year-old son for evaluation. By history, he meets criteria for major depression. As you begin to explore his symptomatology, he endorses extreme guilt around daily masturbation while viewing pornography. He was raised in a religious household and believes that he cannot share his struggle with his parents or friends. His mother is aware of his pornography use and believes that it is the primary reason for the patient’s symptoms.

Sexual behaviors, even those considered normal by the health care community, become complicated in the setting of cultural and religious influences.32,33 In the case of masturbation, there is potential for embarrassment, as well as a general sense of discomfort and lack of knowledge from clinicians, regarding this normal part of sexual development. Masturbatory behavior is a common concern for parents and children and has implications across several clinical fields, particularly mental health. While a wide range of statistics exists, some 90% to 94% of males and 50% to 60% of females report masturbating during their childhood.34 Despite the commonness of the behavior, it is still a difficult subject for patients and clinicians to talk about, even within the confidentiality of the clinical relationship. Clinicians need to explore such issues when presented with cases in which the patient is struggling. Often that requires asking patients directly. Knowledge of the research about pornography and masturbation is essential for the clinician to feel comfortable counseling the distressed patient in this case.

Masturbation, commonly accepted as normal adolescent behavior, can be contrasted with the more controversial and divisive act of viewing pornography. Although they often accompany each other, the mental health literature has not reached as widely an accepted consensus about adolescent pornography usage as it has for masturbation. Studies have shown both negative and positive consequences from viewing internet pornography. Among the potentially damaging consequences are an increased number of partners and substance use at last sexual encounter.35 Concerns about erectile dysfunction, inability to reach orgasm, and other sexual dysfunction associated with porn usage have not been confirmed with evidence in studies and may have been misguided.36,37 More encouraging outcomes have shown that young adults view pornography consumption as helpful by increasing their sexual knowledge and general quality of life.38 It is important to understand though, that in the context of the present case, the benefits and drawbacks of masturbation are of little importance; the adolescent’s guilt and how that is contributing to his mood is the primary concern.

When clinicians encounters a patient, regardless of age, who is struggling with a sexual behavior, their duty, as with any clinical problem, is to assist in healing. Understanding cultural and religious contexts, while simultaneously setting them aside and educating the patient, is an appropriate and beneficial technique. In other words, reassuring the patient about which behaviors are in the realm of “normal” based on statistics and the available literature is the duty of the clinician, not debating religious or cultural norms.

In the case of this patient, speaking with the mother is important to understand where her concerns originate. Her concern may come from seeing the change in mood and personality in her son and, looking for answers, she associates these symptoms with his masturbation and pornography usage. If that is the case, education and reassurance to the mother would prove helpful. A more difficult situation is when the mother’s ideology and personal truth is at odds with clinical truth. In that case, depending on the rigidity of the belief system, educating the parent may not be as beneficial; however, educating the teenager can help him with his self-hate. The importance of reassuring the patient cannot be overstated. Studies have shown that religiosity is a strong predictor of perceived pornography addiction, even when controlling for the actual level of pornography usage.39 This is concerning for several reasons, but most importantly, teenagers could feel distressing guilt and perceive a personal addiction, separate from a clinical measurement of their behavior. In this patient, the overwhelming guilt could have been the catalyst for his current major depressive episode. While medications can be helpful, it is unlikely that his subsequent depression would resolve in the setting of continued inappropriate and misguided guilt. Understanding the inseparable interplay of the sexual behavior and the patient’s underlying mood disorder is the key to addressing his suffering.

Case 4

Mary is a 35-year-old white woman with a history of borderline personality disorder (BPD) referred to therapy by her primary care physician due to difficulties in her marriage.

Self-aware clinicians will pause here to reflect on what feelings, thoughts, and assumptions are provoked from just this piece of the clinical picture. For instance, does Mary’s or the clinician’s race, gender, or socioeconomic status influence assumptions about Mary? What about marital status or sexual orientation? Do clinicians’ family dynamics, culture, or religion impact their thoughts and feelings about marriage, and, therefore, the patient? What about the BPD? A clinician’s biases and experience working with BPD will influence the interaction and influence the framework through which to best explore and understand Mary.

Many clinicians develop strong emotions—negative or positive—when working with BPD patients;40,41,42 a successful clinician will determine how best to manage these intense feelings, while at the same time considering how these intense emotions will influence treatment decisions. Clinically, Mary’s history of BPD will influence the approach that the clinician takes in exploring and understanding her relationships and sexuality. That is not to say that all of Mary’s marital and life issues are a direct product of her BPD; rather, in therapy, those issues need to be viewed within the context of a BPD history and the clinician’s response to it. Astute clinicians will acknowledge that they may have already made assumptions, and possibly judgments, about Mary just from this small amount of information from the referring clinician. Does this self-awareness help or hinder a clinician’s ability to formulate an accurate clinical assessment? To fully assess and address issues within the marriage—the presenting problem here—the clinician must ask about numerous aspects of the relationship and marital life, including the sexual relationship. But will the assumptions and judgments already made about Mary color the exploration of issues around sexuality and sexual behaviors?

The referral goes on to note that Mary has reported a possible history of sexual abuse but has no specific memories of abuse.

This is another issue that can produce strong emotions in clinicians. Many will make assumptions about how this might influence her marriage, sexuality, and her diagnosis of BPD.

When Mary walks into the office, she is casually dressed and well groomed. She seems to have difficulty making and maintaining eye contact, has an almost rigid posture, and holds her hands together on her lap as she takes her seat. The clinician asks Mary what brings her to the office today. Mary is guarded with her answers, offering little or no specific information other than, “I am having trouble communicating in my marriage.” Trying to engage Mary in further conversation, the clinician reviews her history as presented in the referral; Mary confirms with one-word answers, showing no change in affect or body language as she responds. When asked about the possibility of her having been sexually abused, Mary replies, “I think I might have been. I’m not really sure why, but I think I might have been. I am not really sure, though.” Mary never makes eye contact with the clinician as she speaks. Mary’s guarded responses and approach make further exploration difficult. The session comes to an end, and Mary makes another appointment for next week.

Before the next session, a clinician should formulate a plan for working with Mary—how to lessen her guardedness and engage her in difficult conversations about her potential abuse history, as well as her marital issues.

In the second session, recognizing that being in therapy might be difficult and shameful for Mary, the clinician asks Mary what she would like to talk about. Still guarded, Mary slowly reports that she finds she has difficulty making friends and maintaining relationships. She speaks about childhood relationships, as well as her parent and sibling connections. Mary reports that she and her husband have known each other for “a long time” through mutual friends at a club to which they both belong, and that they have been married for 2 years, the longest romantic relationship Mary has ever had.

Curious to see if Mary believes that her BPD plays a role in her history of relationship issues and her current marital stressors, the clinician asks Mary if she has ever considered that. Mary looks a bit amused as she answers, “Um . . . that is what being a borderline is, so, umm, yeah.” Mary then laughs and makes eye contact with the clinician. The clinician is relieved that Mary is more insightful than assumed and that they have finally made a connection, but the session has come to an end. The clinician smiles back and says, “At our next session, we will really get to work to get to the bottom of your relationship issues with your husband.”

When Mary comes for her third session, the clinician is ready with a plan to actively explore her specific marital issues that bring her to treatment, hoping that it will lead to an opportunity to ask about her possible sexual abuse and her current sexual behaviors. As is often the case, the patient shatters the best-laid plans. Mary comes into the session with a sense of determination and says, “I know you want to look at my BPD. And you probably want to have me talk about my sexual abuse, but I came here to talk about communication with my husband!” Mary goes on to tell the clinician that she has been in therapy before and feels that she has already explored and understands those issues. “I have to learn to communicate with my husband better. He asked me to do something, and I did it, and I liked it, but now I feel guilty, and I am scared, and I think he is going to like her more.”

Mary appears and presents very differently today. Is this about her BPD? Did her husband ask her to do something that triggered memories of sexual abuse? Was her initial guarded and flat presentation about depression?

Before the clinician can articulate the next question, Mary says, “Look, I don’t have time to not talk about this, so I am just gonna tell you—my husband and I are in ‘the Lifestyle.’ He is my Dom and I am his submissive. He and I negotiated and agreed to add a play partner to our D/s relationship. We did, and now I am feeling insecure and worried that he will like her better than me. I need help talking to him about this without him thinking I am crazy, or overreacting, or moody, or screwed up. Whatever else is wrong with me, I don’t think that my feelings right now about this are wrong or crazy or unrealistic. I just want somebody who will help me talk about that.” Mary has grown tearful, sitting silently shaking after her confession.

The typical clinician might not know what a D/s relationship is, or what BDSM is, so confusion and insecurity can be common feelings. BDSM is actually a collection of abbreviations that are adopted to best suggest a participant’s preferences. BD describes bondage and discipline; DS represents dominance and submission; SM describes sadism and masochism or slave and master power exchanges.43 Even for those with awareness of this lifestyle, all clinicians must take stock and assess how they feel about someone who engages in such behaviors. Sexual sadism and masochism disorders, along with exhibitionistic disorder and voyeuristic disorder, are all in DSM-5.25 Do these BDSM behaviors automatically equate, then, to pathology? Does BDSM imply active abuse, or can the dynamic and consensual power exchange ever be a healthy one? And what if a BDSM participant has a psychiatric diagnosis such as Mary’s BPD? Does a client’s possible sexual abuse history play a role in her involvement in the practice of BDSM? Should it? Could she be consciously or unconsciously reenacting her possible sexual abuse? If so, is that automatically unhealthy, or could it possibly be part of a healing process? Does it automatically pathologize the practice of BDSM if one or more partners is a victim of domestic or sexual abuse? In this case, should the possibility of sexual abuse even factor into the exploration of the BDSM aspects of Mary’s presenting marital issues? How does a clinician differentiate pathology from potentially healthy thinking and behavior in such a complex clinical presentation?

Although this case study is rich with clinical opportunity, let’s focus on the shame that is inherent in several aspects of Mary’s presentation. Right or wrong, many clinicians have negative perceptions of people with BPD, often using the pejorative term “a borderline,” rather than a person with BPD. With the mere mention of a BPD diagnosis, assumptions are made, and the lens through which a patient is viewed is tinted. Most people with BPD are aware of other’s responses, reactions, and beliefs about them due to this diagnosis.42,44

It is the overlying belief of people who engage in the BDSM lifestyle that most clinicians have negative attitudes toward them, that they lack knowledge of sexual subcultures, and that they are often not adequately aware of their own values and beliefs around these subcultures.20 Furthermore, they are acutely aware that many of the practices in which they engage are diagnosable pathologies in DSM-5.

Imagine, then, the courage it must take for Mary to enter the therapist’s office carrying the shame of a troubled marriage and the baggage of a BPD diagnosis, and wanting to talk about her “deviant” sexual practices that she fears the clinician will not understand or may disapprove of. Whatever beliefs and assumptions the clinician has, appreciating Mary’s bravery in coming to treatment will be an important tool in developing a therapeutic alliance.

To do this, clinicians cannot simply ignore or stop feeling emotions and reactions; in doing so, their response would be disingenuous and therefore unhelpful. Instead, good clinicians must be aware of and acknowledge their emotions and reactions, but also be aware of their own limitations around their knowledge base. It can be helpful to have at least some knowledge of BDSM practices and power exchanges to be able to properly assess and treat people who participate in these activities. Relationship issues that fall into these dynamics, such as ownership, objectification, pick-up play, punishment and reward, service and obedience, the differences between a top and a Dom, as well as a bottom and a submissive, switching (top/bottom), and play partnerships, can all be helpful. Many patients will not be willing to teach the therapist about BDSM for fear of rejection or revulsion.15,20,45

Acknowledging these limitations is important when the clinician’s scope of knowledge and familiarity interfere with the therapeutic connection. Clinicians are human, too, and our emotions, histories, beliefs and values are as real as our patients’. We do no one a service—in fact we do a disservice to patients—if we are unwilling to acknowledge our own limitations. But rather than plowing on with generic treatment planning, good clinicians will try to understand the specific issues and look for resources that are available to learn about and get support on these topics. When this is not possible, or when the clinician’s own beliefs and values prohibit this process, a referral to a colleague who might be a more appropriate fit for the patient may be the best course of action.

In Mary’s case, this assessment needs to be applied to sex—kinky sex in particular. Mary identifies that she is part of the BDSM lifestyle living as a submissive to a Dominant. You may believe that you do not know anyone who engages in these practices, either in your clinical work, as colleagues, as friends, or as neighbors. And yet, research shows that 1% to 25% of the North American population is or has been involved in BDSM activities,46,47 with even higher percentages reporting interest in them. A commonly accepted general belief is that 10% of American adults are involved or interested in BDSM activities.48,49 Pop culture appears to be increasing the acceptance of alternative sexual practices, as evidenced by the dramatic popularity of 50 Shades of Grey and the subsequent increase in sales of men’s restraints and blindfolds.50

If that isn’t enough incentive for clinicians to gain even basic knowledge about alternative sexualities, perhaps the American Psychological Association’s acknowledgment of the burgeoning population of people whose sexual identities, beliefs, and practices vary from the “norm” will. As a result of this acknowledgment, the association altered its definition of sexual orientation in its code of ethics to include a person’s sense of identity based on those attractions, related behaviors, and membership in a community of others who share those attractions. With this new definition, BDSM is considered a sexual minority group; as such, BDSM and other alternative sexual lifestyles are now included in the association’s ethical requirement to obtain adequate training, experience, consultation, and supervision to develop competency in this area.51,52,53

In the context of using this definition of sexual orientation, it is important to note that the DSM-5 and the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)54 billing codes define many of these nonnormative practices as deviant and unusual—fetishism, masochism, sadism, frotteurism, exhibitionism, pedophilia, transvestism, and voyeurism specifically.25 But by whose definition are they deviant or unusual? Clarifying the ambiguity of these labels has clinical, theoretical, practical, and legal ramifications. A literature search of studies that might clarify this ambiguity resulted in the discovery of only 17 studies published between 1995 and 2012, most of which focused on college-age participants and did not include sufficient statistical analysis.55 When left with no clarification on how deviance is assigned to such activities, clinicians are left to make that determination through their own lens of knowledge and beliefs.

To attempt to clarify this ambiguity, Joyal and colleagues conducted a study to more clearly define which sexual fantasies—the basis for a paraphilic classification—are rare, unusual, common, or typical. Participants rated 55 sexual fantasies derived from established norms and popular internet and pornographic download histories. Two sexual fantasies were labeled rare (2.3% or fewer of the respondents endorsing them), nine were statistically unusual (15.9% or fewer of the respondents endorsing them), and five were identified as typical (84.1% or more of the respondents endorsing them). For the remaining 39 sexual fantasies, 23 were considered common in men and 11 in women. The most notable result in this common category is that both men and women have statistically significant interest in domination and submission fantasies—including being sexually dominated, being tied up for sexual pleasure, being spanked or whipped, and being forced to have sex,55 all of which are included under the BDSM umbrella. As the determination of pathology is defined by unusual or deviant sexual fantasies, care clearly must be taken in assigning pathology when the majority of the 55 identified sexual fantasies have not been statistically identified to be unusual. As for deviance, its association with such sexual fantasies is pejorative in and of itself, and is subjective in nature. Table 10.2 lists several of the notable sexual fantasies from which the participants chose, in descending order of interest for both men and women.

It is encouraging, both for BDSM practitioners seeking treatment and for clinicians who are willing to treat them, that despite the popular opinion that all BDSM practices are stereotypically perceived by both lay and clinical people as “bad,” Kelsey and colleagues showed that the majority of clinicians polled did not universally equate unconventional sexual activities with individual psychopathology or dysfunctional relationships. In their study, 68% of responding clinicians endorsed that people can engage in BDSM without experiencing emotional problems, and 70% of those polled agreed that BDSM activities should not be targeted for reduction in therapy without the patient specifically identifying this as a desired goal for treatment. Furthermore, they conclude that BDSM practices should not be considered as a central therapeutic issue if they are only peripherally related to the client’s presenting concern.20 Wismeijer and van Assen dispelled the notion that engaging in BDSM practices was associated with psychopathology by showing that BDSM practitioners are, as a whole, less neurotic, more extroverted, more open to new experiences, more conscientious, and less sensitive to rejection; and have higher subjective well-being—all suggesting favorable psychological characteristics compared to the control group.56

But what of the reverse situation? Mary came to treatment specifically because of activities within her BDSM dynamic. If BDSM is the client’s primary concern, what is our obligation as therapists to also factor in the client’s history of pathological diagnoses and possible sexual abuse? Are they mutually exclusive or intricately linked? In Mary’s case, the possibilities are endless.

One must explore Mary’s involvement in BDSM to fully understand her current dilemma. An astute clinician will do so in such a way as to simultaneously discern if there is a connection to either her BPD diagnosis or her possible past sexual abuse history. Hypersexuality can certainly be part of a BPD presentation.24 Desperate means to engage in and maintain relationships can also be a piece of that clinical puzzle, with remorse and self-doubt equally so. Are clients with BPD more vulnerable to coercion in an effort to be accepted? Mary’s insecurities about her appeal to her husband can certainly be attributed to her BPD. At the same time, being a submissive in a D/s relationship is also a very vulnerable position; in submission, insecurities can either be heightened or erased, depending on the Dominant and the dynamic. Is the vulnerable nature of being submissive exacerbating Mary’s insecurities that may or may not stem from her BPD? These are all questions that must be explored, carefully, to truly understand Mary’s marital issues.

The potential of past sexual abuse adds another complicated clinical dynamic in this case. Mary is uncertain at best if she is the victim of abuse, but that possibility is very real. Is Mary’s interest in submitting to another a result of, or in protest to, her having been abused? Does giving her consent to be taken sexually somehow reduce or ameliorate her residual feelings of being taken sexually against her will in previous abuse? And if her sexual history plays a role in her becoming involved in BDSM, does that necessitate a pathological context or an empowering one? Is Mary aware of the possible connection?

Richters and colleagues concluded that BDSM practice is a variety of sexual interest that is not, in and of itself, a symptom of sexual abuse or sexual pathology, noting that the prevalence of a sexual abuse history is similar between populations of BDSM practitioners and nonpractitioners.46 However, sexual and domestic abuse histories do exist in the BDSM culture. How a BDSM practitioner reconciles this history to current desires is a complicated and difficult matter. Clinicians who are comfortable with and knowledgeable about sexual subcultures, including BDSM practices, can play an integral role in helping to explore this connection.

But what about Mary?

The best way to comprehensively assess Mary’s situation and the myriad potential interpretations is to talk with her and assess all of these complicated areas and considerations. Tackling difficult topics is best accomplished with open-ended, nonjudgmental questions and responses. Given patients’ reluctance to disclose many aspects of sexual behaviors for fear of rejection or disapproval, clinicians often need to advance these conversations by initiating questions about specific sexual practices, demonstrating awareness of these practices and an openness to hearing honest answers. This can be accomplished only when clinicians increase their knowledge of sexual subcultures, while becoming aware of their own values and beliefs regarding them.

Finally, clinicians must not allow their clinical assessment to be influenced and biased by prejudice and stereotypes. Consistent and thoughtful supervision throughout a clinician’s development and career is an important aspect in accomplishing this goal.

Conclusion

The cases presented in this chapter illustrate some of the challenging and complex ways that sexuality and sexual behaviors can intersect with the psychiatric encounter, influencing diagnostic formulations, treatment, rapport, and the therapeutic relationship. We hope this chapter has provided a framework for approaching and formulating such situations.

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