Our profession has come a long way since the time when homosexuality was considered a mental disorder. So far, in fact, that our code of ethics specifically requires that we deal with gays and lesbians in the same way that we deal with their heterosexual cousins. This extends to all issues, from parenting to power struggles, fear of death, and sex.

So MFTs have a pretty good record on sexual diversity these days, right? Well, as long as we simply mean sexual orientation, that’s true. But if “diversity” refers to the whole range of sexual interests, desires, and experiences of our client population, there is more to be done. Way more.

When it comes to sexuality, as in the rest of our practice, we may be called upon to support patients in behavior that can be healthy for them, while lying outside of our own expertise or approval. Doing so may require us to get more information; it certainly requires that we find ways to suspend our discomfort, disapproval, or—dare we admit it—prejudices.

Here, then, are some areas in which we need to be sensitive to and supportive of sexual diversity. Although this is just a handful of the many sexual issues we might want to notice, it’s a good starting point, because these represent such a large percentage of everyone’s practice.

Inevitably, by the way, any generalization about “therapists” will have its limits. As the commercials say, your mileage may vary. So don’t discount the entire discussion that follows if one of its assertions about what “therapists” do or believe doesn’t seem completely accurate, or true for you.

Non-monogamy
MFTs are in the relationship business. These days, we know that relationships come in all shapes and sizes, such as blended families, gay couples, nursing home romances, and “friends with benefits.”

One area in which some of us are not entirely up-to-date or comfortable is in the arena of monogamy (sexual exclusivity) and nonmonogamy.

I’m not talking about “affairs”—clandestine arrangements in which one partner is breaking her/his contract of exclusivity by having sex with someone else. Although some situations are ethically complex or ambiguous, most therapists agree that breaking an important promise is generally a bad idea. (Interestingly, in a huge number of long-term couples at least one partner does break their vow of monogamy; our profession could be a lot more curious about this.)

Rather, I’m talking about consensual nonmonogamy, which itself comes in a variety of forms.

There’s “don’t ask, don’t tell,” in which each partner does what he/she wants sexually (typically while out of town), with the understanding that he/she will shield his/her partner from any knowledge of what goes on. This understanding sometimes develops in relationships in which one partner travels a lot, or when people want to stay together but can’t find common sexual interests.

There’s the “friend of the family,” an individual who has sex with one member of the couple and is known to the other—in fact, is considered part of the couple’s inner circle. Obviously, people have to deal with issues like jealousy and time allocation. This “friend of the family” works best when the couple’s relationship is strong, and all three people have a good sense of self. This arrangement is common among military couples, gay male couples, and relationships in which one person is disabled.

Some couples participate in “the lifestyle,” also called “swinging.” They go to parties with other swinging couples, perhaps make it a point to meet new sexual friends on vacation, maybe belong to one of the hundreds of swingers’ clubs across the country. Swingers typically have good sex with their mate, and obviously have worked out certain issues regarding jealousy. Swingers (there are several million in the U.S.) tend to be over 35, college-educated, and include all body types, from absolutely ordinary-looking to seriously buff.

Regardless of venue or style, when we hear about couples who have chosen non-monogamy, what do we think? Too often we make assumptions about commitment (they aren’t good at it), intimacy (afraid of it), or even diagnose (narcissistic, low self-esteem, in denial, unwilling to grow up, etc.).

We often do the same thing when we see a non-committed couple in which one person is ready to settle down and the other isn’t. Whether the people are 25, 45, or 65, don’t we tend to pathologize the one who doesn’t want to settle down? Don’t we assume that the ultimate goal of all romantic relationships is sexual exclusivity?

Why do we think this way? It’s not that monogamy has such a good track record here in the United States. In most long-term sexually exclusive relationships, both the frequency and quality of sex over time declines dramatically. We may tell ourselves that it is inevitable, but almost no one wants this outcome. Certainly, few people begin a marriage saying, “of course, the sex will decline over time, but we don’t care.”

So there’s no reason to assume that longterm sexual exclusivity is in any way superior to another arrangement. I’m not aware of any data that shows that people who live non-monogamously are any less grown-up than people who live monogamously. Our profession’s belief that monogamy is the gold standard of sexual relationships is simply a value that we have absorbed from the culture around us.

Alternative Sexual Expression
For most of modern Western history, being sexually “normal” has been considered very important. “Abnormal” sexuality has even been criminalized. For example, not only has “sodomy” been illegal in many countries, it has been defined as any sexual activity other than penis-vagina intercourse—including oral sex. This was true in the U.S. until just five years ago.

Fortunately, most therapists now accept the “normality” of a wide range of sexual activity— oral sex, anal sex, hand jobs, playful games, and a toy or two, such as a vibrator or blindfold.

On the other hand, many therapists are still reinforcing the ideal of “normal sex,” as if there is some objective standard, free of cultural influences. If you travel enough outside the U.S., or if you know a little about history or anthropology, the idea of “normal sex” quickly seems foolish or at least ill-advised. Our ideas, for example, that pathologize group masturbation or child-child or adult-teen sex appear quite naïve in much of Europe; our acceptance of cunnilingus, on the other hand, appears quite disgusting in much of the Middle East. Our determination to shield children from seeing nude bodies or hearing adults make love would be considered bizarre in 18th Century America and Europe.

Of course, you don’t have to leave home (or this century) to realize you’re surrounded by an enormous range of sexual behaviors right in your own community. Whether you know it or not, here are some of the sexual practices in which your patients variously indulge:

• Pre-marital sex
• Extra-marital sex
• Pornography
• Romance novels
• Internet sexuality
• B/D-S/M
• Non-monogamy
• Playing out fantasies
• Piercings of genitalia or nipples
• Anal sex
• Blood play
• Electrical play
• Commercial sex
• Adult entertainment
• Sex toys
• Sex games
• Sex clubs
• Erotic asphyxiation
• Cross-dressing
• Voyeurism
• Exhibitionism
• Bisexual play
• Risk-taking
• Threesomes
• Fetishes or paraphilias
• "Friends with benefits”
• Anonymous sex

No MFT is expected to be an expert on all forms of sexual expression. Clinically, sex is like work, parenting, and religion: we aren’t expected to know the details of all occupations, every parenting philosophy, or all religious beliefs. We are, however, expected to be able to learn about a patient’s experience and understand his/her perspectives on it. Most of us would agree that it’s poor clinical practice to assume that being a Baptist is “wrong,” or that a patient who is a forest ranger is wasting her time. We need a similar non-pathology approach to our patients’ sexual practices.

S/M (Sadomasochism)
A term that’s far more descriptive than “S/ M” is “erotic powerplay:” the conscious playing with power dynamics in erotic relationships. Millions upon millions of Americans engage in various forms of this activity. Many don’t even have a special name; they call it “fun and games” or “making love.” For every person who visits a dungeon on Saturday night, there are thousands who play the “hey, don’t go thinking you’re gonna get some of this sugar tonight (wink, wink)!” For many couples, that’s code for “let’s play the spanking game,” or “mm, I’d love to have my hair pulled during sex exactly the right amount.”

The popular stereotype of S/M is that it involves a lot of heavy equipment and physical pain. Uninformed non-participants don’t realize that S/M is far more psychological than physical, and that it isn’t usually a grim business in some dark basement (although, for example, having one’s nipples or butt seriously squeezed when already excited can be highly arousing for some).

Keep in mind that eroticism, being rooted in primary process, is a set of primitive urges. Healthy eroticism includes both the desire to dominate and the desire to submit. S/M games can be a healthy way for some to explore and express those desires.

If S/M is primarily psychological, what’s it all about? Participants typically say it’s about trust, connection, sharing, and intimacy. Studies show (and the connoisseur literature encourages and illustrates this) that S/M players have a higherthan- average level of communication about sex, boundaries, pleasure, and their bodies. The expectation of communication and mutual education is something that non-S/Mers could really benefit from.

“Bottoms” say they enjoy, among other things: Knowing their limits will be respected; The thrill of pushing themselves knowing that someone is caring for their safety and comfort; Relinquishing control and responsibility within a safe space; and Having the chance to explore the pleasures of submission.

“Tops” talk about:
The pleasure of taking care of someone having an intense experience; Feeling grateful to have someone’s trust and body in their hands; and The meditation of following a bottom’s breathing and subtle movements.

Some therapists assume that people involved in S/M must be re-enacting childhood abuse or exploitation. There is simply no meaningful data to support this presumption. On the contrary, the studies that have been done on non-clinical populations show that S/M participants are no more likely to have been sexually exploited than non-S/M participants. The fact that so many clinicians continue to assume this link (“why else would anyone want to be spanked?”) is a sad commentary on our profession’s instinctive pathologizing of non-normative sexual expression.

Of course there are unhealthy people doing unhealthy things with S/M. Of course, the same is true with even the most “vanilla” kind of sex.

And by the way, more men want to be “bottoms” than women. The stereotype that S/M is mostly men whipping women is simply inaccurate. Interesting.

Pornography
Fifty million Americans look at pornography each month. That’s almost a quarter of the adult population.

This is no marginal or accidental diversion for a few lonely or angry people. Involving some $10 billion annually, Americans spent more money on pornography last year than on all the tickets for professional football, basketball, and baseball combined. Porn is mainstream entertainment.

There’s no lack of mythology or feelings about pornography. It’s impossible to pick up a magazine or turn on Fox News without hearing about a sex fiend busted with porn on his computer. It’s apparently impossible for a wide range of “decency” leaders to talk about American culture or behavior without telling some outlandish lie about porn leading to divorce, crime, and suicide.

Perhaps worst of all, politicians and the media are allowed to use the expression “porn and child porn” as if it had any meaning at all— when in real life, the two have virtually nothing in common. One is legal; the other isn’t. Audiences for the two simply do not overlap. When dealing with patients involved with porn (either their own viewing or their mates’), therapists need to decide if they want to operate from mythology and emotion (judgment, fear, resentment). Alternately, therapists can work from the same place of helpfulness, compassion, open-mindedness, and curiosity from which they handle other content areas all week. This requires the therapist to know some facts and to adopt a position of neutrality.

Therapists don’t always do a sufficient job of understanding porn use from the porn user’s perspective. It’s often relevant to inquire about the content: is it cooperative or violent (portrayals of consensual S/M are the first, not the second)? Are the actors smiling, do the characters seem glad to be there, are they responding to each other? Too many therapists assume that if something is “porn,” it’s either violent or ugly.

Further, why does any given patient (or patient’s partner) watch porn? If you talk to people who enjoy pornography, they rarely say “I watch it in order to disrespect women, undermine my relationship, lower my self-esteem, and motivate myself to commit crime.” Rather, most viewers appreciate the portrayal of abundance. In porn there are always enough erections, enough breasts, enough time, enough competence, and enough desire. When we recall how popular movies about rich people were during the Depression, the appeal of porn’s depiction of erotic abundance should be easier to understand.

For better or worse, some porn consumers also enjoy having erotic experiences without feeling performance anxiety or the weight of a partner’s expectations. For those in troubled relationships, a sexual experience without rancor, anxiety, history, or disappointment is not only a pleasure, it’s a relief.

A certain amount of people’s discomfort about pornography is discomfort about masturbation. Let’s face it: most porn is consumed as prelude to, or part of, masturbation. Is that okay?

We see lots of people or couples where one partner is satisfied with masturbation and the other feels sexually deprived. Putting aside the issue of porn—is masturbation an acceptable activity if one’s partner feels sexually deprived? Therapists vary widely on this issue. Therapists have heard plenty from the partners who feel deprived; we would benefit from hearing more from the partners who masturbate rather than having sex with their mates (including, but not limited to, their guilt, shame, and resentment).

I cannot resist the temptation to take a clinical detour here for one moment. Many therapists approach the situation described above by discouraging the so-called “low desire” partner from masturbating. They assume (or hope) that removing this source of gratification will encourage desire for a partner. This clinical strategy hardly ever works. That’s because whatever reasons someone has withdrawn from his/her partner in favor of pornography will not be resolved by simply forgoing masturbation. For these patients, desire for partner sex and desire for masturbation are simply not fungible.

Are you able to treat a patient’s porn use as neutral—like bowling? If a patient bowls every night and leaves her partner alone, we know the problem isn’t bowling—it’s the willingness to abandon a partner. The same is true with pornography. If a patient is pursuing porn while neglecting his/her relationship, we want to know why.

But just as no one would undermine a wonderfully intimate relationship just to go bowl ing, no one would leave a satisfying sexual relationship just to look at pictures or stories. So, rather than blaming the porn, we need to inquire about the relationship and personality dynamics involved. If the therapist has reflexive criticism or judgments about porn, this more sophisticated investigation becomes more difficult or even impossible.

Finally, every therapist needs a healthy model of porn use. All 50,000,000 American consumers can’t be emotionally limited or hostile to women (although of course some surely are). But just as we need a healthy model of civic involvement, sports participation, and parenting (all of which can be used in unhealthy ways), we need a healthy model of porn use. Without it, we are either condemning a percentage of our patients out of hand, or we’re making things up as we go along— which makes us more vulnerable to countertransference, and invites treatment failure.

So What’s the Point?
As therapists, how do we know what we “know?” When it comes to our clinical work around sexuality, most of us have two sources: personal experience, and cultural products like Oprah, USA Today, and Newsweek. These are the same sources of information that our patients rely on. Since our culture is essentially sex-negative, we can expect that what we “learn” from the media about sexuality will be normatively-based and pathology-oriented as well. And when our information about anything comes from the same source as our patients’, it’s much harder for us to notice when their “knowledge” or our “knowledge” is just a bunch of assumptions.

Information, of course, is very important in dealing with subcultures or individuals with which we have little or no personal experience. But accurate information isn’t enough; we have to be genuinely accepting and curious, even while adhering to our own insights about what constitutes emotional health, growth, and satisfaction.

And even that still isn’t enough. We need to feel confident that our standards of emotional health are really about our clients and not about ourselves. When sexuality is involved, virtually all of us have had experiences of disappointment, shame, betrayal, coercion, passion, confusion, and crisis. Some of us are going through those very experiences in sexual situations today.

Professional therapists are committed to handling our own feelings, needs, and histories in ways that don’t limit our ability to help our patients. We are committed to the principle of supporting patients when they make conscious decisions using reasonable criteria to accomplish sensible goals. The actual configurations in one or another patient may look dramatically different from what we might choose. It is our responsibility to approach patients’ sexuality with an encouraging, lifeaffirming attitude—no matter how much work that requires from us.

Former Supreme Court Justice Sandra Day O’Connor recently discussed her marriage in the New York Times. Her long-beloved husband now lives with Alzheimer’s Disease in a facility. He rarely remembers her, and he has become involved with another woman— with O’Connor’s blessing. That’s love. That’s devotion.

It’s not monogamy, although it is fidelity. Can we accept this as a healthy arrangement? If we didn’t know O’Connor, would that make it more difficult? In what ways does our field need to grow in order to keep up with our patients’ complex sexuality?