©iStockphoto.com/Thomas_EyeDesign Delving into Desire DISCREPANCY or DISORDER? Adam A. Neal, M.A., AMFT/APCC
hen our work with partnered clients is focused on issues of sexual Wdesire, whether therapy is individual or conjoint, our ability to consider The articles printed under the heading “Professional factors of diversity and communication can profoundly impact our support Exchange” represent the of individual sexual healing and partner intimacy. Sexual authenticity and views and opinions of the connection are essential ingredients for both quality of life and the ability writers and do not necessarily reflect the attitudes or to sustain a healthy relationship, yet these topics are often vulnerable to opinions of the California generalization based on assumptions of what healthy sex should look like. Association of Marriage and Family Therapists. Professional Exchanae Exchange Professional Professional 12 The Therapist | July/August 2019 | www.camft.org professional exchange “
For clients who seem to be experiencing “clinically significant distress” (American Of course, the idea of initiating sex at all Psychiatric Association [APA], 2013, pp. can transport partners subconsciously back to 433, 440) in relation to sexual desire, it is important to assess whether the crux of the longstanding attachment wounds. distress seems to be intrapsychic in nature or relational. Facilitating a safe environment that honors the sensitivity of such issues can be a “ a client’s gender, sexuality, or relationship an anxious-avoidant attachment style may complex undertaking once the therapist takes configuration. When beginning work influence a partner not to make overt sexual into account potential differences in cultural related to sexual issues with any partnered initiations, as doing so leaves them vulnerable background, sexuality, gender expression, and client, the more clarifying the questions we to rejection and abandonment. This would relationship configuration. The following ask, the greater the trust we forge. Gently certainly be confusing for a partner with a discussion and related research are meant to asking, “Is your relationship monogamous, secure attachment style who likely expects reflect this diverse intersectionality, and the nonmonogamous, or polyamorous?” sexual initiation from a partner to be clear and pronouns “they” and “them” will be used in indicates both an honoring of nontraditional direct. Honoring the possibility of what might both singular and plural contexts to maintain relationships and an awareness of diversity. In be termed initiation discrepancy with clients gender universality. this way, we not only support such possibilities, and perhaps facilitating a dialogue or exercise we also offer clients productive modeling of around it may be an unexpected boon for Initiation the open, transparent sexual discussion that partners whose struggle appears to be linked to Clients facing issues of sexual interest in may be absent from their relationship. this first phase of sexual interaction. relationship may introduce them to us in numerous ways: With any relationship configuration in the Progression therapy space, we can always begin in the here- Tracking sexual communication this way “I can’t tell. Is it that they’re not into me, or that and-now when addressing desire discrepancy. echoes the well-known progression of sexual they’re not into it?” We may ask, using a Gottman-style (2015) response identified by pioneers Masters and approach, “Can you have a conversation with Johnson (as cited in Ogden, 2018) in which “Every time I try to initiate sex, they shut me each other now in which you discuss your excitement leads to a plateau that eventually down—and I don’t know even know if they’re next sexual experience together?” Then, in causes orgasm, which is followed by the aware of it.” medias res, we can track the partners’ respective body’s resolution of the sexual experience. The communication styles, note who initiates what, nonlinear model of sexual response formulated “I really only think about having sex when they and even bring awareness to warning signs by Basson (2000) examines more deeply the bring it up. Is there something wrong with me?” of destructive patterns, such as those defined concept of plateau by naming factors such by Gottman’s Four Horsemen metaphor as intimacy and desire as contributors to “There never seems to be a ‘right’ time for them for relationship dissatisfaction: criticism, excitement and by reinforcing the unnecessary to have sex with me. But then I’ll overhear them defensiveness, contempt, and stonewalling inclusion of orgasm as a requisite for any masturbating when they think I’m asleep. It’s like (Gottman & Silver, 2015). If the here-and- satisfying sexual experience. a constant rejection.” now feels particularly tense, or the partners Partners who successfully send and receive seem uncomfortable with such an enactment, each other’s signals of excitement can When it comes to an imbalance in sexual encouraging them to share a narrative about mutually agree to engage in some form of interest between partners, how can we navigate their last sexual exchange (physical or verbal) sexual activity. If the challenge is consistent the inevitable labyrinth of needs, desires, may be a helpful way to unpack their current miscommunication around initiation, there insecurities, deep wounds, and even deeper sexual pattern, from initiation to resolution. are methods of concretizing the exchange to symbols operating in clients? When might build such mutuality. Buehler (2017) notes the conversation start to move from desire It may become clear in hearing each partner that a common therapist suggestion is for discrepancy to sexual-desire disorder? share such a narrative that there are differences partners to schedule a specific time for sex, in the ways partners are attempting to initiate explaining that despite the initial aversion to First and foremost, it is imperative to sex. If one partner expects a verbal sexual non-spontaneous sex that most clients express, consider our own biases and to monitor initiation and the other assumes there must be this can be an effective way to ensure mutual our countertransference regarding the open a physical sexual initiation, simply giving voice commitment to the exchange, lessen the discussion of sexual material. Unfortunately, to this disparity will present an opportunity pressure on one partner to initiate, and build therapist discomfort and insensitivity tend to for the partners to begin initiating in clearer interest and possibly even excitement around go hand-in-hand, since shirking sexual material ways. Of course, the idea of initiating sex at all the anticipation of the planned event. This out of shyness or disapproval can often lead can transport partners subconsciously back to scheduling activity is designed to embody to making uninformed assumptions about longstanding attachment wounds. For example, mutual excitement, desire, and arousal through
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verbal communication. It is as if we are inviting the discrepancy in a symbolic way; for a developed challenge. This may relate to clients to get excited together and allow this example, inviting the lower-interest partner Gottman and Silver’s (2015) idea of solvable mutual excitement to spark the sexual exchange to consider expressing more public affection versus perpetual problems, which places to come. Partners who build awareness of each or acting more demonstratively can be a way focus on the partnership’s relationship to other’s preferred approach to intimacy through to mediate the lesser desire for direct sexual the challenge rather than on the individual such communication can better navigate the contact. Perhaps a higher-interest partner partners’ relationships to the challenge. If the path toward orgasm, or perhaps forge a mutual who is consistently feeling rejected can begin desire discrepancy is an original challenge, path that diverts from orgasm to uncharted to recognize the physical ways their mate the implication is that the partners are aware territories of sexual experience. shows affection for them, which can lessen the of the issue as a foundational part of their intensity of the emotional impact when sexual ongoing work together; in systemic terms, Sexual History contact does not meet their expectations. homeostasis has been established around the A primary historical question to ask may be, issue. If it is a developed challenge, the issue “Which partner first named this discrepancy?” To further delve into this idea of “low interest,” becomes positive feedback that has disrupted If the decidedly “higher interest” partner it is essential to uncover what exactly the other homeostasis. This factors into how the partners initiated, how was this expressed to the “lower partner or partners are not interested in. As the perceive the issue within the context of the interest” partner? Conversely, if the “lower late, great Dr. Gina Ogden (2018) explains, relationship. Ultimately, this begs the question: interest” partner expressed the imbalance “[I]t may be breakthrough information for is desire discrepancy within this partnership a first, what was that communication like? The [clients] to hear from you that intercourse is relational issue or an individual one? manner in which the disparate level of desire not the only sexual activity on the planet” (p. has been communicated will offer essential 49). In considering a holistic approach to sex Clinical Assessment information to us about how this system that does not presume intercourse + orgasm = As clinicians, our assessment of an individual manages intimacy and expresses sexual needs. satisfaction and in which intercourse is simply diagnosis of sexual desire disorder or sexual one of myriad iterations of sexual expression, is interest/arousal disorder must first account Also, if the communication around this it that this identified patient has low interest, for the possibility of desire discrepancy, issue has been conflictual, there is already or is it that their preferred mode of engaging which implicates the partners’ relationship an established “history of the symptom” to and enacting their sexual needs has been left before the individual’s supposed dysfunction. be noted. Symbolically, is a higher-interest out of the equation? Often, clients will conclude that they must partner interpreting a partner’s lower interest have a sexual desire disorder because they as a personal affront, or is there a foundation Chronological Factors recognize that their partner’s sexual interest of awareness around their differing levels of When working with desire discrepancy, there or drive far exceeds their own, or because sexual desire? Does a lower-interest partner feel are some basic variables to be considered, such their partner has continually criticized or pressured or unable to please their mate and as age, sex, and relationship length. Gray, shamed them for lacking sexual interest. so stay avoidant of sexual exchange for fear of Garcia, and Gesselman (2019) conducted Rather than simply allow one partner (or disappointing their partner or feeling crowded? a study of sexual interest using a sample of more, for polyamorous clients) to conclude more than 1,500 singles and concluded that that the other partner is “disordered” because Partner Physicality while 33 percent of self-identified men over sexual activity has always been lacking or Getting a sense of the partnership’s physicality 70 years of age reported sexual activity at least has apparently dwindled to an unacceptable is also a beneficial exploration, as the focus can once a year, only 15 percent of self-identified level, we work with the partnership (whether be broader and less directly sexual in nature. women over 70 reported this. Therefore, if individually or conjointly) in all its complexity What is the physical connection between the we are working with an older partnership, to uncover potential variables. Sometimes partners outside the home? Are the partners this evidence of inherent desire discrepancy partners will assure us that they are indeed the publicly affectionate (“PDA”-friendly) or more between the sexes can offer validation to “problem” and that this has been a prevalent reserved? Do the partners act demonstratively clients and support understanding of it as a issue throughout their life. In these cases, it toward each other in physical ways—touching, potentially less “individual” issue, i.e. “There’s becomes imperative to consider whether hugging, or kissing—without any immediate obviously something wrong with her” or individual therapy might be a more productive expectation of sex? “He wants more sex than people our age are mode than conjoint since a partner is openly supposed to have.” expressing what may be considered a clinically While direct sexual activity (i.e. genital- significant impairment in functioning. focused) tends to take center stage in An equally important piece of foundational most sexual conversations, it is of utmost information is the duration of the relationship. At the outset of partner therapy, it is important importance to approach the sex life of any If the partners have been in relationship to discern the extent to which the identified partnership in a holistic manner. Rather than for a short while, perhaps less than a “low interest” patient agrees with their partner’s decide that the “problem” is a lack of sexual year, desire discrepancy will be an original (or partners’) assessment. However, even if the gratification, we can consider addressing challenge within the relationship rather than designated IP is in full agreement, it is worth
14 The Therapist | July/August 2019 | www.camft.org professional exchange noting external circumstances and other factors this disparity, it becomes arguable that as a result of their lack of sexual interest the clients may not have considered. Is the erectile dysfunction, a common challenge or inability to become sexually activated IP’s lack of sexual interest related to a major for older men, may be a stronger sexual psychologically. That said, the very idea of a life change, such as a new baby or a recently deterrent than an analogous condition for “desire disorder” carries an arguable implication diagnosed illness, or is it linked to a stressful older women such as vulvovaginal dryness. of socially constructed judgment by suggesting work situation or physical injury? Is there an Men who are unable to become erect even that someone can be, in essence, clinically indirect physiological component, such as a when neurologically aroused, known as symptomatic for lacking desire that they change in medication regimen or a shift in diet? nonconcordant arousal (Nagoski, 2018), may believe others would consider “appropriate” or Or perhaps, in working with this absence of feel shame and frustration, and be less apt even “necessary.” For example, to those in the desire or interest, we begin to uncover a long- to engage in extragenital sexual activity than asexual community, for whom sexual activity latent trauma, a highly charged secret, a distorted women experiencing the same phenomenon is not a focus in or out of relationship, the body image (e.g. dysmorphia, body-focused (i.e. mentally aroused but not experiencing very existence of “desire disorder” may feel malingering, etc.), or any one of a multitude of physically observable sexual arousal). While offensive or, at the very least, unjustified. complex, potentially intersecting issues. women can apply lubricant to mitigate nonconcordant arousal, men suffering from For males, the disorder is called Male While low sexual interest has traditionally ED are more restricted in their available here- Hypoactive Sexual Desire Disorder (APA, 2013, (and unjustly) been relegated to female and-now resources. p. 440), which highlights the absence of sex- partners, men can certainly be less sexually related thoughts and sex-seeking urges. For focused than their partners, whether those When consulting the DSM-V (APA, 2013), females, the disorder is now named Female partners are female, male, or intersex. Gray we learn that there is still a rather perplexing Sexual Interest/Arousal Disorder (APA, 2013, et al. (2019) discovered in their research that distinction made between male and female p. 433) seemingly to emphasize a general sexual satisfaction appeared to increase for sexual desire disorders. Ultimately, these disinterest in sex or inability to feel sexual or women as they got older while the opposite diagnoses are meant to reflect an individual’s become sexually activated altogether. Why was true for aging men. In accounting for report of significant distress or impairment the subtle semantic divide between the sexes? savings.Sun-kissed CAMFT members could save even more with a special discount on car insurance.
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How do these diagnoses become applicable to relationship, monogamous or polyamorous, Adam A. Neal, M.A., AMFT/ transgender or intersex individuals? with a lower-interest partner, the oft- APCC (Registered Associate quoted platitude, “They’re just not that Marriage & Family Therapist Diversity & Sensitivity into you,” feels far less apropos than it #108784; Registered Associate With the language distinction comes the would in the case of a date-gone-ghost or Professional Clinical inextricable influence of cultural norms. a one-night stand. One essential point of Counselor #5482), has worked in As we move toward greater numbers of entry is the exploration of what type of community-agency and educational settings individuals identifying as transgender, gender sexual exchange this “regular” partner most providing psychotherapy to adolescents and adults. nonconforming, gender queer, androgynous, desires and what potential compromises are Adam completed his master’s in counseling psychology etc., such divided diagnoses become murkier. implicit within it. As discussed by Ogden at Sofia University (f/k/a The Institute of From the DSM-V standpoint, it seems that (2018), intercourse-as-focus has become Transpersonal Psychology) in Palo Alto, CA, and while men are indubitably expected to seek antiquated in the field of sex therapy; in its earned an additional certificate in Creative sex, women’s desires, we are meant to believe, place has risen a holism that characterizes Expression. He now serves as adjunct faculty at Sofia, are still mediated through their overall interest therapeutic “sexploration” as an endlessly teaching courses such as Human Sexuality, Systems or non-interest in sex. The “desire” is inherent complex, moment-to-moment interplay of Theory and Application, Transpersonal Theory and in men, but the “interest” itself is questionable physical, cognitive, emotional, and spiritual Literature, and Critical Thinking and Scholarly for women. meanings. Using her experiential 4D wheel, Writing. Adam has contributed writing to the Ogden invites clients to express their sexual AAMFT-CA newsletter, Psychology Tomorrow To complicate this further, women’s level of yearnings through an all-inclusive format Magazine, TravelLady.com, and AssociatedContent. arousal is factored into their diagnosis, while that honors the deeper meanings present and com. In addition, he has sold writing for greeting for men the arousal component is decidedly connects those meanings to tangible needs cards to American Greetings and has contributed less complex. Is it possible for a man to have occupying aspects of the psyche. A client’s writing for use in statewide standardized tests an arousal disorder in the absence of an erectile surface-level desire to sexually penetrate may through Inksplash, an education publishing company disorder? The neuroscience of arousal, which connect with the spiritual drive to influence based in New York City. Adam served as associate accounts for the complex connections between others. A man’s seeming fixation on sexual editor of Psychology Tomorrow Magazine and sexually encoded stimuli and increased blood cleanliness may bring him to an emotional managing director of the Alternative Therapists flow to parts north of the nether regions, would discovery of his fear of being contaminated. Directory (now the Wellness Providers Network), certainly indicate such (Nagoski, 2018). While A woman’s arousal by a certain cologne both founded by psychotherapist, author, and a self-identified man may meet criteria for may become a trauma narrative of the educator Stanley Siegel. Adam has been the editor of Male Hypoactive Sexual Desire Disorder in day she endured a sexual assault by a man four books, including a compilation of essays by the absence of an erect penis, the qualifying wearing it. By processing our desires in a mental health professionals about sexuality, How Sex marker of male arousal, what if he has no penis more individualized context that brings in Heals, and the latest edition of TOOLBOX at all? Further, would we be expected to note our full range of experience, the prospect of Primer by Dovetail Learning, an education a co-occurring disorder of Gender Dysphoria sexual fulfillment becomes a much grander company based in Sebastopol, CA. He has also served and invalidate a client’s gender identity by undertaking. as editor of several master’s theses and doctoral diagnosing them with the desire disorder of dissertations, mainly in the areas of psychology and their birth sex rather than of their gender? Such Conclusion business administration. Adam is passionate about questions will become the focus of further study When we want “it” and our partner doesn’t, supporting individuals in their growth, especially in as our society continues to expand its perception what is the “it” that we are actually seeking? the areas of sexuality and spirituality. of gender and how it reflects physical anatomy. Is it intercourse, oral sex, digital sex, an intimate kiss, or simply an act of affection References Honoring All Partners or service, such as reaching out for a hug or American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: To return to the possibility that desire folding the laundry? When navigating partner American Psychiatric Association. discrepancy is the issue rather than desire desire, it is easy to become fixated on the Basson, R. (2000). The female sexual response: A different model. disorder, what about our work with the higher- idea of sexual activity, meaning some type of Journal of Sex and Marital Therapy, 26(1), 51-65. Buehler, S. (2017). What every mental health professional needs interest partner(s), the harbinger of the desire genital contact or foreplay. How often do we to know about sex (2nd ed.). New York, NY: Springer Publishing we are meant to consider non-disordered or, at find ourselves merely asking for a few minutes Company, LLC. Gottman, J. M., & Silver, N. (2015). The seven principles for making the very least, less problematic? How do we to physically connect, to ground with our marriage work: A practical guide from the country’s foremost appropriately validate their frustration or sense partner(s), without the implication, “and it relationship expert (2nd ed.). New York, NY: Harmony Books. of undesirability while aiding in their expression must lead to a sexual exchange”? As we move Gray, P. B., Garcia, J. R., & Gesselman, A. N. (2019). Age-related patterns in sexual behavior and attitudes among single U.S. adults: of sex within the context of their relationship? into the future of sexual desire research, a An evolutionary approach. Evolutionary Behavioral Sciences, confluence of exciting and arousing variables 13(2), 111-126. Ogden, G. (2018). Expanding the practice of sex therapy: An If this “regular interest” partner has decided continues to indicate humans’ limitless integrative approach for exploring desire and intimacy (2nd ed.). to forge ahead in a mutually committed potential for sexperience. New York, NY: Routledge.
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