‘iflflfifi .

98 c Handbook ofLGBT-Affirmative Couple and FamilyTherapy

GOYUDB-II. sex How (2006). Sanfte Couples: gay and lesbian Couples am teach heterasexuals how t0 improve relattonshzps. Retrleved from http://www.gottman.com/49850/Gay--Lesbian-Researchhtm] Gottman, 1., Levenson, R. W., Gross, I., Frederickson, B. L.‚ McCoy‚ Y.‚ Rosenthal, L.‚ Yoshimoto, D 7 (2003). Correlates of and lesbian gay Couples’ relationship satisfaction and relationship dissolution.i Sex With Journal ofHor/nosexuality, 45(1), 23-43. Therapy Lesbian Couples Hertlern, K.M.‚ Weeks, G.R.‚ 8( Gambescia, N. (Eds). (2009). Systemic sex therapy. NewYork, NY: Hertleln. K. G. 8: Routledge. MARLA COBIN and MICHELE ANGELLO M.‚ Weeks, R., Sendak, S.K. (2009). A clinicianä guide t0 systemic sex therapy. New York, NY: Routledge. Iasenza, S. Some (2005). unconscious sources of low sexual desire in gay male and heterosexual peer mar- riages. Contemporary Sexuality, 39(7)‚ 3-7. S.A. Kingsberg, (2006). Talcing a sexual history. Obstetrics Gynecolagy Clinics ofNorth America. 33, 535-547. S. Lerblum, (Ed.). (2006). Principles and practice ofsex therapy (4th ed.). New York, NY: Guilford P['e3s_ 8: Le|blurn‚_S., Rosen, R. (Eds).). (2000). Principles und practfce ofsex therapy (3rd ed.). New York, NY: Gmlford Press. Sex between women has a precarious place in history. Even today, there are plenty of “experts” L.‚ 8: who deem that sexbetween women is unnatural.It is notdifficult to find reorien- Long, Burnevtt, I. A.‚ ihomas, R. V. (2006). Sexuality counseling: An integrative approach. New York, therapists doing NY: Memll. tation therapy. Wornen in same-sex relationships need therapy as much as anyone else. Whereas LoP1ccolo‚ I.,8€l-Ieiman, I.R.(1978). Sexual assessment andhistory interview. In I.LoPiccolo 8:L.LoPiccolo it can be difficult to find a therapist who is well versed in working with lesbians, it is even more (Eds), Handbook ofsex therapy (pp. 110-123). New York, NY: Plenum Press. to find a who is at with lesbian more E- 8KVan challenging therapist adept working Couples. Significantly 043111901311: l—‚ Lankveld, I.I.(2004). Hypoactive sexual desire disorder: An underestimated condi- U011 diflicult than this is finding a therapist who i5 trained, experienced, and competent to d0 sex m men. B]UInternational, 95, 291-296. doi:10.1111/j.l464-4l0X.2005.05285.x Purcell, D. with lesbian it is for this reason that there is a of W, Wolitski, R-1., HOfE C-C. P3130115, I.T.‚ Woods, W.1., 8: HaIkitis‚ P.N. (2005). Preclictors of therapy Couples. Perhaps paucity ernpirical the use of viagra, testosterone, and antidepressants among HIV-seropositive gay and bisexual men. research and little written about sex therapy with lesbian Couples. lt is time for this area of the AIDS, 19(Suppl. l), 57-66. sexuality therapy field to develop so that women in same-sex relationships having sexual dif- Rxtter, K.‚ & A. Terndrup, (2002). Handbook ofafiirmative psychotherapy with lesbian: andgay men. New ficulties can more find the that need and deserve. York, NY: Gwlford Press. easily help they The dearth of reliable information with this community makes it arduous for nascent thera- ifistrada, D. L.‚ 8: G. (2008). Sexual orientation and counselor Rl-lftefärä»e lfefguson, Piggs, competency: to in this area. far‚ the pioneer in this field is Margaret Nichols, lmpact of traunng on enhanclng awareness, knowledge, and skills. Journal ofLGBT lssues in pists develop competency By Caunselmg 2, 209-225. who has been writing about the subject since the 1980s. In 1987, the book Lesbian Psychologies: D. E.‚ 8€Schafft". S. was SChafE. I. (1987). Qbject relarionsfamib/ therapy. Linham,MD: Iason Aronson, Inc. Exploration: and Challenges, edited by the Boston Lesbian Psychologies Collective, pub- L. (2002). Shaplro. .8:R055. Applrcatlons ofnarrative theory and therapy to the practiceof family medicine. lished. Two of this groundbreaking book's chapters were written byNichols (198721, 198713). Her Pamrljz Medrcme. 34(2), 96-100. to G. chapter, “Lesbian Sexuality: lssues and Developing Theory,” highlights what she found be Tunnel], (2006). An aflirmational approach to treating gay male Couples. Group, 30(2), 133-152, common sexual problems among lesbian Couples. Morerecently, Leiblum(2007) wrote the Chap- ter “Therapy With Sexual Minorities" for the popular sex therapy book she edited, Principles and PracticeofSex Therapy. MarnyHall (1998,2004) has written several articles andbook Chap- ters about lesbian bed death and developed a four-stage modelfor working with lesbian Couples. There are several others who have written works that include information on this subject. Many ofthese authors are cited throughout this chapter anddeserve credit for contributing t0 this area ofliterature that is so lacking. It should be noted that in this chapter weuse the Word lesbian when, in fact, weacknowledge that many Couples made up of two women d0 not identify as such. Often women in same-sex relationships identify as bisexual, queer, or otherwise. As therapists, we ask Clients how they identify both as individuals and as a couple in order to ensure that we utilize appropriate lan- guage throughout the therapeutic relationship.

Social lssues Lesbians remaina marginalized group, facing continual ridicule, judgment, and sometimes vio- lence. Homophobia and heterosexism continue t0 permeate society. Green (2004) outlines four challenges that may lead t0 problems between Same-Sex Couples. They are societal homophobia and heterosexism, the “lack of [a] normative and legal template for same-sex couplehood," lower levels of family and social Support, and the possibility ofboth partners conforming to “tradi- tional gender roles” (Green, 2004, p. xv). It is imperative to acknowledge both vulnerability and resiliency within the couple. Many women in relationsllips with women have bccn cut ollfrom thcir family oforigin bccause ofthc

99 c 101 u - _ Sex Therapy With Lesbian Couples I00 Handbook of LGBT_Atfirmatlve Couple and Famlly Therapy

' ' ' ' desire than one’s to acce theu’ * -- than one's with orgasm, experiencing greater familys unwillingness pt onentanon. This concePt 0 f bexng d’lsowned can mmally lower desire partner, Problems with lead t0 . . ' ' and about sex. Far fewer lesbians reported problems an "n5 against the workr, dYnamlc m which the couP1ePartner‘s lnsu1ate the1r relanon.- partner,difficulty lubricating, anxiety . ' lesbians lubricate more and but fectlon w1th_ - - as well as The reason for this may be that 3111p den), anything per e h th . mmdset evolves lubrication reaching orgasm. avoid into a more than do heterosexual women,or it may be that lesbians realistic view, and the couple Parltläer: caelll‘ encounEventurllyer 1 cuultopla:ty ac nowledging that and have less painful penetration v . to withlubrication difficulties and d0 not empha- they have differencesa a8 d0 anCou 1 .If th - andthus d0 nothave cope unacknowledged’ this dis- vaginal penetration more than d0 connect can lead to fusion ' The data did show that lesbians achieve orgasm reliably betweell 21S couplfesfvfielfefltryefltcfisY e remallnCoup e partners mi ht ex size nonclitoral orgasms. . . ‘ g permnce emotlonal ‘ ‘ sexual relationships (Nichols 8cSchernoff, 2007). dwtance from each other=unresolved cOHfhct’ some t e of d f“flctlon w1th 011e or women involved in heterosexual ‘ ‘ yp 75 This term - . ‘ ' what in the 1980s was coined lesbian bed death. both Partners‚or triangulatmnm WhlCh a th1rd party is involved In order t0 obv1ate blame {mm Many authors have talked about the in literature about lesbian relationships of sex being frequent dur- couple (Green=BetünSei’: 3FZacks, 1996). On the contrarY,the same authors refers to a common theme _ acknowledged-- . off More recently, this concept has been that this Concept Offusion amon actuall be c0'151‘der‘!d the first few and then tapering significantly. glesb1an. . Couples may y aposltlve attnbute ing years The because Ofthe cou . ' ' ' of the research spawning the term questioned. concept man}, ples exhlbued mtense closeness that manifested m mnmacy’ mutual criticized and the empirical validity “ that mainstream defines sex as including and ‘ The authors went on to s criticized for several reasons. The first is theory engagement, empowerment a)’, Our findings indicate thatl esb‘m“ is sexual are - - . . a of Many lesbian Couples have more frequent Couples exceptionally close and more t‘ fi d w1th the1r relatlonshlps than gay male and genital contact with goal reaching orgasm. include contact and/er than do some heterosexual heterosexual l not orgasm coupless, (Grünet a1‘ 1996l PS2; contact that may simply genital -- . . for mainstream theory as heterosexist is that it asserts Blumsteinand Schwartz (1983 as a contrib„ couples. The second reason criticizing indicator of sexual health (Goldstein et al., 2007; Nichols 8:Schernoff, utingfach” in the highdissolutign 1122:5261:letslln;ilajcllcefaftliffilllllllllllfitloflhofs 1P. not ertmfixrriageseory for the dissolu. that frequency ofsex is an ' that it is much mmof that Nichols “ v the heteronormative undertones of this term-namely, relationship (198%JSuggested 1s that womeI1 Couple prematurely, which 2007). Finally, beyond or low leads t0 „later _„ “ ' with women to have issues with sexual infrequency a famn offof I for women g sexual deslre (p. 101) She says that On ly fall‘Ing m love produces more common partnered sexual ' ' levels. desire’sowefall in love aE3111. w1th a new partnera and the limerance ofth‘1s new relatlon-- clesire-it is on many „ . problematic 30-40% of revives our Sexual“ ' ' ' is a common of women in general, with possibly ship flagging y (Nichols, 19S7b=p. 107) She suggestst hat 1t1s Important for Low sexual desire complaint _ —. deem this as is a source of debate (Basson, lesbian Cou [es t0 d _ __developed (Nlcholsl 1987m women reporting low desire. When to dysfunction . or low of sex dis— Becauselzhere iselalrflällhergllä er“lhliädlflreklsm to w1th _ "Ihere are several possible reasons for the sexual repression frequency I? lBSblaIl Couples 2007). One is that ’ ‘ - to lesbian seeking sex therapy. ___==______.__.__1(See Chapter 3’ this volume)» bis we WäHE:giäwtbtedm o moregznerallt tlgerapy lrrlPact played by lesbians that often contribute Couples’ _ be less to sex. Lesbians have been oppressmn on lesbian Couples. It is importantto mention‚howeexragrl‚tlualtnslttnllfi?1ssues asIof soclnlaltalo- because of socialization, women may likely actively request ‘ omop “ ” ’ ' “ certain, constricting and bia' heterosexism’ intemalized homo _ out‚ and ender-role socialized as heterosexual women and have likely adopted possibly Phübla. Commg g soclallzatlon may More lt afi-ect 1ssuesaround Sex and _ . _ ' ' is and (Nichols, I987b). recently, SexualitY,1n addmon t0 general relationshiplssues, forlesblan coue conflicting, views about what appropriate acceptable . ‚ in heterosexual relationships, women in lesbian rela- ples (Connonyn 2004) Thema aremyrlad other 1ssues that ma also coI1t f1‘bUte t0 was asserted that compared with women - . 7 the reasons that that lesbian lesbian Seek sex . ' ' to have sex because their partner wants it, implying Couples theraPY, lncludmg race=classv bisexuality‚ and tionships are less likely solely gender Identlty. want to have sex (Goldstein et al.‚ 2007). women are more empowered and say n0 ifthey d0 not Reasons for Treatment discussed in Nichols’s early work, is that Another possible reason for lesbian Couples’ low desire, - in the relationship a contributing Hall (2004) discussed the idea of have maneuver. On one side, often, sex and love are fused for women, making problems ‘Eo that some believe that, often, sexual contact lesbians are faced with a Societyaifiarlälicc}; tfläät leslblän egupleseven experts,» invalidate their factor to low sexual desire. Nichols (l987b) explains decrease as women become “overinvolved” or “fused.” relationships and deem the“ sexual encounters Äzriltulrll uaäs: On other side, there creates fusion and that sex and desire be that, based on one ofwomen having a his- is research that lesbians have s sex lves. Yet issue in decreased desire may quarter asserting frequent passiozafhe Irnumorei.ccorEinemg to Hall (2004): another as it is this Confusion Ofien leads t0 a disfllusion ' ' this statistic affect lesbian Couples more than other Couples, ofthe sexual relationship’ W1'thfrequency slgnlficantly tory of sexual assault, may ' - . women has had a traumatic sexual experience. Internalized declining after the first few years. Couples are then faced w1th emotxonal 1ssues- that come w1th more likely that one or both of the cites. Women who have not completely desire discrepancy (Hall, 2004). is another issue that Nichols (1987b) . homophobia because of heteronormative ideas lovflgdeslireboror es ian Couples seekin s th one their sexual orientation may feel sexually inhibited has been written accepted ” about for 3 decades’ isgt11::Offl: fggnligon sex“shoul consist of. neafly. fzeffaiflggsi sexua1ssues,‘esiretgatiscrepancYhatween ofwhat “suffer _ ‘ ' a notion lesbian relationships partners (NIChOlS’ 1987b-’NIChOlS 8:Schernoffr 2007 NlChOlS Nichols also talks about “fusion” or “merging,” many l asserts that mt he last 2 decades‚ contact the communit She that some individuals believe that sexual lesbian y has become more sexual (Nichols» 2005). In her more recent work, from” (Nichols, 1987b, p. 107). explains Nichols a vafiet that sex and desire decrease as women become “overinvolved” explores y of more current reasons that lesbian Coup1es Seek Sex therapy‘ These creates fusion and consequently include ' ' - nonmonoganfl)’=identitYISSUES, COmmg-out problems’bisexu31Y=33l't dOmasochlsmsex- 01' “fused” (Nichols, l987b). - - . between lesbian partners is the other ualfrin e ‘s s‘ Along with low sexual desire, sexual desire discrepancy ‘ . 8( Schernofl’, 2007). Blumstein 1 e rese r t - been made. most common reason for seeking sex therapy as a couple (Nichols Recently, less sex than do male or het- an Internet was am ductEadCthEPCO 81:11???' and Schwartz found that lesbians have significantly gay study 31:35: e130‘assttlrgptlonslhaveproblems of lesbians and (1983) 50% of other women. The results h d th “ . f Sv-exua Low desire is a common complaint for Couples, with approximately stgnlficantly fewer sexual Problems erosexual couples. 8: man hetemsexuar 13:13] urith this as the presenting issue for sex therapy (Segraves Wmnen”s( Oh Etc’c ‚geäclrted- r, l3. 395). women, lhc most „m. hctcroscxuul Couples presenting mon Anaong problems, beginning with the“ m6“ frequent. Were lack of mterest in sex and/or having Segraves, 1991). I02 n Handbook ofLGBTvAflirmative and Couple FamilyTherapy Sex Therapy With Lesbian Couples o 103

Manywomen are seen in sex for such therapy sexual painissues as vaginismus and dyspareu- lesbians, tend to talk about their sexuality in a political context has nia. to Nichols and Schernoff _ . . ‘ ' According (2007), such Conditions are seen a torm ot At the same time, becaus;s ouselxiualifyassumebeetlgläsäfl in sex rarely among lesbians as oppression (l987b‚ p. 108). therapy. The reason for this not be that fewer ' therapists n0. may lesbians have’ vulvar or vaginal pain but Chems l alitarianism in their relationships or that all Clients are feminists. Most of the that if they do‚ it is easier, in lesbian sexual relationships, to avoid penetrative sex and sirnply €21“ egn lesbian cou les has been on white, upper-middle-Class, educated lesbians who focus on other aspects of sex that are This pleasurable. Complaint could also be in part attribut- resear?come onefominist erspelztive (Ritter 8: Terndrup, 2002). Therapists must be careful not to able to the fact that manyheterosexual assume couples that penetrative sexwill bea part oftheir generaliomallidetoize beCulljturally sensitive when workingwithlesbians across race‚ dass, education sexual experience, whereas for lesbians this is not always the Case. level, and so on. Female orgasrnic disorder was . - ' . . formerly Categorized in the DSM-IV-TR as inhibited female As Nichols states in her early work‚ belleve, an t t b orgasm. When a woman is a ancl experiencing persistent or recurrent delay in, or absence of, „active and directivä (1987a‚ 245). A we oegsifltlalt ‘Q1323:is trlllietiitfälfllgviträ this can be an issue that orgasm, p. significant part erapy g i: brings the Couple in for therapy. Wehave found this and often include homework the _ needs t0 1 of an Complaint to beless nature may assignments. Therefore, thefaPlst P 3V issue with women in relationship with other women. We that ‚ ‚ . . .— suspect perhaps the assump- an active role in engaging with and guiding the couple by offering"'htdtt'stoinsig an s ra egie tion in many heterosexual that U relationships penile-vaginal penetration is ultimately help improve their sexual functioning. It is also important for therapists for both is satisfying . . ‘ ' partners perhaps more women rrien _ - » why partneredwith present with this concern. selves lesbians to be positive role rnodels for lesblan “MP195: dlsPselx37m8 59x P05i ivearitttheärg;a l u Aversion to oral sex is a common cornplaint among lesbians, sometimes with both partners (Nichols, 1987a). and sometimes with one of the . . . ' partners disliking cunnilingus. It is only a problem when the Of course, not all therapists providing sex therapy for lesbian couples are 1esbians_ n Couple partners believe that not in oral participating sex as part of their sexual activity will women’for that matter. There is thus importantinformation heterosexual andother non10i’eslivelan- diminish their experience. Some women ‚ . - - ' ' believe that oral sex is an importantpart oflesbian sex, K t,2008.Itis not whereas others see it as unpleasant and unimportant. Sometimes the aversion is on a physical adequate t° be g“ friendly lf bemg so that t e t level, whereas other times it is on an emotional level Imphel (Loulan‚ 1984;Ritter 8:Terndrup, 2002). Clinicians should be aware ofthe stages of coming out as erljptlsr sexualjzllid ofsPecific Chal- that some face: for reluctance to ngnlnic 212.0 l ffecüon for each Othef Role offlierapist lenges Couples exainple, . 1eISP because there is a risk of being physically 01' in egffabein disenfranchised Many lesbians have, bythe time enter a attacked, they therapisfs office, alreacly had negative,pathologiz- because one’s partner is not eligible for domestic partnerIclngfiltssliäene s. o b8unirglformed 1Sa form ing experiences with doctors and mental ' health professionals. Therefore, it is critical that the Of d'ce b omission” (Kort. 2008). stance of the not be ' therapist judgmental or Lesbians seek for t0 is normal for for pathologizing. couples sex therapy also irlrliportant therapists not make assumptions about what any many ofthe same reasons that male and ‚ . - ' ’ ' gay Couples heterosexual couples do. So, sometimes particular Couple. Asking questions and learning about each Client s ideas about hat means sexual orientation is largely irrelevant. A difference does sex exists, however, in that in order for and how sex should happen are critical. Ritter and Terndrup (2002) the point therapy to be Comfortable for the Clients and effective, the . ' ' that therapist must be “perceived as queer Clients should be assured that there is no one way 01' a W3)’ mäke Criltical en a e in friendly" (Nichols 8: Schernoif, 2007, Not ‘ght p. 388). rnaking heterosexist assumptions and using sex. Sexual activity should not be based on heterosexist norms fordkäliaigfflfviegel:an Y Y frfmgone gender-neutral language are but Critical simple ways to let the Clients know that the therapist couple to another (Ritter 8: Terndrup, 2002). has every intention of being respectful. Another issue for therapists to be mindful of is that often‚ lesbians, liketheir male did not Assessment gay Counterparts, have normative adolescent experiences around sexuality and may continue to deal with such issues l as seCreCy, shame, and poor self- An importantassessment tool, particularlywhen working with a detailed sex _ worth (Nichols 8: Schernofl”, 2007). It is Critical for couples, ‘is history. therapists to leave behind any preconceived This assessment activity is done when meeting with each partner notions about what is normalwhen about sex. indn/idually. talking Iudgment must not come into the therapy has been that bythe time mostCouples enlist the Support ofa sex they Oiläeixptfffäeflxfäe oflice (Nichols 8: Schernofl‘, 2007). Lesbians are therapist, already stigmatized, so it is essential that they oftentimes hopeless. Reviewingtheir sex history can feel overwhelming to themfeef1 es; 51ed are oifered a safe, supportive space for sex couples’ therapy. with an appropriate amount of clinical savvy and respect for what the as a w11110:0 e, a wen Coming in for sex can make couple a:. therapy anyone apprehensive, and certainly corning in with a as each individual, is experiencing. We find it helpful to significant other to discuss the sex Iife within can ‘integrate aseriesvof nonthreatening your relationship be even more anxiety pro- questions regarding the presenting problem(s) by engaging in a fluid therapeutic con- voking. It should be noted that for some Same-sex Couples, the additional fear that the therapist versation” (Iasenza, 2004,couple;sp. 18 . will in some way (whether or have a . overtly not) moral judgment about the relationship or at It is suggested that the clinician maintain the Standard sex format least perpetuate heteronormative is ‚history expectations something the therapist should be willing t0 Inore broad systemic approach in gathering information. For clmicians unfamiharalsohtafel: gently Confront from the first Session. We have several iivit bookshelves in our offices, and we both dard sex history taking, we recommend that Wincze and aS a 5311s are intentional about books about sexual Carey (2001) [_Jrm_1er‚ keeping orientation, gender identity, and kink as vis— of the should be done 06086611 session in order ible on the shelves as those about portion therapeutic relationship during tlae indiviiiua general therapeutic issues. We also each make visible some t0 allow for the amount of comfort for the Client. in rnind 1e kind of “safe greatest space” sign as a Clear indicator that we not are to Keepmg ‚that most welcome only open discussing but also presenting for therapy have had very few to discuss their sex peOtIJh Conversation about these very important and sometimes opportunities openly often vulnerable questions that therapist should begin with the most nonthreatenmg information, as demog‘hisäory, ä go unsaid because the Clients are Concerned about the such‘ *_1P therapisfs reaction or moral judg- further inquiry into what brings the Client For ‘Csbant ment. Nichols points out that it is critical that when intotherapy. female with discussing sexuality, therapists working regularity ofmenses and last gynecological appointment should Client:. ilglfäätlonseflsgglhere lesbian couples be “mindful of the political bedISCIIISSC implications” because women. and specifically’ notable medical concerns as endometriosis, wc request that the Client sign a re1ease soatrh at xx‚e 104 u Handbook of LGBT-Affirmative Couple and Family Therapy Sex Therapy With Lesbian Couples c 105 can speak to the appropriate physician to gather more information. We ask each Client to talk to relationship and issues between (Iasenza‚ 2004). “Attention to the a bit about what she considers the ideal outcome sexuality couples ways that to be, as well as when the presenting issue various levels create was first systemic heip or maintain problems” enables the therapist to “rapidly and experienced (to assess for lifelong versus acquired as well as versus situ— generalized efliciently help a couple make positive shifts that might not be possible” if the were t0 ational types). We are interested in from each member of the how therapist hearing couple this concern only focus on “the problem” (Iasenza‚2004, 19). is the else that presenting p. impacting relationship. Something we find helpful in the sex history portion of our interview is to hear about the overt as well as covert messages regarding sex that the Feminist Approach Client received as a child. We conclude each sex history by asking if there is anything that We choose to use a feminist and find it we t0 ask or approach particularly useful with lesbian couples. A forgot anything the Client would like to clarify. When about Chi1dhood‚ feminist talking approach is one that recognizes gender roles and inequalities; gender race, we agree with Iasensza’s (2004) approach, which includes about script; dialogue gender roles‚ gender class, and cultural differences; and how societal affect between treatment, sexual toward others, inequalities relationships feelings religiosity, race, ethnicity, and class. When disCuss- Issues of are addressed in feminist literature and in addition to partners. power affect couples not only ing adolescence, standard sex history questions, Iasensza expresses interest in but sexual relationally sexually as well (Prouty Lyness 8cLyness, 2007). Feminist therapists can help experiences and coming out experiences. When exploring adulthood, she asks about couples explore how gender-role preferences and differenCes-«including power imbalances coming-out experiences at home and work. When Current sexual exploring experiences and as related to gender role, income, age, and the like—and how race, class, and Cultural dif- functioning, she explores gender identity and sexual orientation, in addition to Standard sex ferences affect a couples intimacy and views of sexuality. It is important not to such history topics. Usinga multicontextual approach in a sex Iasenza ignore taking history, includes Con- differences. Doing so is equivalent to workingfrom an ethnocentric, white, heterosexist view versation about “community contact” and “societal influences,” in addition to about questions that not only is limited but also can be damaging. It is also important to that “friends and neighbors (heterosexual/homosexual); involvement in acknowledge religious, educational, and lesbians hold at least a dual status‚ both women government institutions and automatically minority being and sexual self-help groups; political activity (past and present); recreation/ minorities. often also hold other statusesbased on cultural volunteer and They minority Class, race, religion, ethnic- groups; work; any connections to the gay/ lesbian (2004, and the like. In She community" p. ity, addition, there are age discrepancies in lesbian couples more often than 18). also pays cIose attention to “political, social, and economic issues; and etfects ofbiases in heterosexual couples. This discrepancy brings along its own set of power imbalances and based on race, ethnicity, gender, class, sexual orientation, religion, age, disability, and family must not be All these issues are tied into and must not be form” (Iasenza, 2004, ignored. power overlooked in sex p. 18). with lesbian for When with therapy couples, such concerns can clearly affect how couples relate inti- meeting the Couple, it is important to talk about how each partner thinks Culture and and has mately sexually. Feminist couples therapists can help Clients redistribute power, society infiuenced their relationship and sexuality, both individually and as a improve Couple. Communication, build increased affection and intimacy, and “broaden meanings of love” Iasenza (2004) suggests asking such questions as “How do think you growing up and living Lyness 8: 2007). in a and sexist has (Prouty Lyness‚ homophobic society affected your relationship?” (p. 17). We include ques- tions the Clients regarding spiritual beliefs and attempt to investigate the potential Connection Educarion between the presenting concern and Certain faith-based of groups’ disparagement same-sex One of the primary areas of need when doing sex therapy with lesbian is offer- relationships. For some individuals or this Connection couples simply couples, is not an issue they are Con- information. Women who sex with aware ing have women have grown up in a society where hetero- sciously of until given the opportunity to discuss the overt and Covert messages they normative assumptions permeate sex education. Therefore, lesbians feel that their received from such groups. many may sexual behaviors are inadequate or abnormal. Sometimes, simply Clients and validat- Finally,it is CritiCal for to close attention, the sex educating therapists pay during history,to how the cli- ing experiences can be to increase the women’s comfort and confidence in their ent answers their Clients will enough personal questions. Many be inexperienced in talking openly about sexual In our Clinical matters. Some will experiences. practice,wehave found that lesbians often need t0 be reassured that be much more Comfortable than others. Observing these nuances can the give lesbian sexual expression is vastly different from experiences ofheterosexual couples and that it therapist important information (Ritter 8:Terndrup, 2002). can be damaging to compare their experiences or evaluate their experiences against Standards When meeting with the couple partners the must look for the together, therapist levels of based on male sexual desire and experienCe. autonomy as well as fusion. Ritter and (2002) to Terndrup encourage therapists “observe the We have found that many Clients Come into our oflices for sex when, in fact, what distancing stategies used” and find out if the “allows for individual therapy relationship friends and would be more appropriate is education and assistance with the mes- pursuits," aswell as determine “what these outside and ubiquitous Sex-negative purpose allegiances activities serve” for have learned. In these cases it in our both the individual and the sages they (and should be noted that these are the majority couple (p. 351). It is also important for the to learn about Clinical how the therapist practices)‚ we have found it judicious to begin with a four-stage model developed b)’ Couple partners react to Conflict (Ritter 8€Terndrup, 2002). Iack Annon (as Cited in Leiblum 8cSlowinski, 1991). The model goes by the acronym PLISSIT, which stands for Permission (P),Limited Information giving (LI),Specific Suggestions (S5) and Therapeutic Approach Intensive Therapy (IT). The PLISSIT modelis utilized as a filter, beginning with the permission MulticantextualApproach giving and limited information stages in an attempt to free one or both members ofthe couPle We of any anxieties they may have about sexual thoughts, fantasies, desires, or behaviors that are believe that sex therapy with lesbian couples must involve a multicontextual approach in contributing to the presenting issue. If after spending time with these two the order t0 be highly effective. This means that the must view Cornponents-of therapist presenting problems in the PLISSIT model the still find themselves we move onto larger context of and Couple struggling, specific suggesttons. family, community, society‘, appreciating these influences as are Common Lu contribtxting 'll1ere a variety of stiggestions we make,but the most Common i5 sensat- focus täruscnling problems. such systemic influences as homophobia and sexisrn often contribute exercises that concentrate on sensual play that may or rnay not involve genital Contact. There Sex Therapy With Lesbian Couples 107 106 o Handbook of LGBT-Afiirmative Couple and Family Therapy -

tool we with and with In her book on lesbian sex, she outlines has been a great deal written about sensate-focus exercises, but the only educational beginning willingness ending pleasure. exercises for 1984). Basson (2007) developed a more are aware of specific to female couples is the DVDA Lesbian Couples Guide t0 Sexual Pleasure homework couples (Loulan, Rosemary the com- sexual model, that Masters and ]ohnson’s (1966) model and Helen (Schoen, 2006). Finally,after these three interventions have been completed, clinician current response asserting model were too linear and did not to women. When lesbian mences with intensive therapy with the couple. Singer Kaplan’s (1974) apply many aware ofthe afore- come to about low sexual desire or sexual desire discrepancy, Therapists who work with women in relationships with women should be couples therapy complaining the Basson model can be In this model, Basson “incor- mentioned DVDbecause it not only is one of the few that is specific to same-sex couples but also educating the couple about helpful. of emotional sexual stimuli, and relationship satisfaction” includes a “Therapisfs Guide” analogous t0 the section that is recommended to Clients. It also porates the importance intimacy, models of sexual (Iones, & reaffirms the more circular models. with concepts from the previously mentioned response Kingsberg, sexual-response or desire dis- Whipple, 2005, p. 6). Using this model can help women couples with low desire can teach the that often “the decision to have sex is driven by the Narrative Therapy crepancy. Therapy couple 8: 2007, If a woman is to sex. for women in desire for intimacy, not lust” (Nichols Schernoff, p. 396). receptive We have found narrative therapy to be an effective approach many relationships in this will lead to sexual activity. Activity leads to arousal, which results in desire. A Situation with women who come in for sex therapy. Developed by Michael White and David Epston which both women have lost desire and no one initiates sex is called the Basson-squared effect this that the act as an investigative reporter of (1990), particular approach proposes therapist If one of the women has lost desire, this woman can that in each (Jones, Kingsberg, &Whipple, 2005). only sorts, assisting the Clients in discovering first the themes are ubiquitous person’s who feel shame and worry that without desire sex will not be enjoyable. The woman still has based on social, and cultural contexts in which they have lived. After the Clients life, political, desire feel stories or that have themselves stories or feeling no longer may rejected. recognize feelings they perpetuated, the model can the woman who has lost desire feel validated and can to new narratives. Education about help of benefit them‚ the therapist and couple collaborate forge can the woman help the woman who feels rejected depersonalize the Situation.The therapist help with low desire to herself to become willing to have sexual activity without concern Treatment challenge about lust. The couple should be encouraged not to rerly on spontaneity but, rather, t0 schedule or Lesbian Bcd Death can Decreased Frequency, time for sexual activity. A couple really struggling with low desire on one or both partners have sex has lead the If a couple come in for therapy primarily because the frequency with which they be encouraged to treat these scheduled times as actual dates. Doing so may help couple The significantly declined, it is important that the therapist normalize sexual frequency. couple to be flirtatious and seductive (Nichols 8cSchernofl’, 2007). must must first ask questions about what this decline means to each partner. A thorough investiga- Couples often believe that in order to have a successful sexual encounter, both women must be if one tion into the meaning and hypothesized reasons for sexual frequency decline explored reach orgasm. Therapists can help educate couples t0 change this beliefSystem. Hierefore, that can that it is in order for the therapist and the couple to understand the overall picture. It is important woman has a significantly higher libido than the other woman, they come to see This can be to the therapist not assume that the decline is problematic for the couple. The couple may simply okay to have sexual activity where only one ofthe women reaches orgasm. helpful believe that the decline is a problem because it is a drastic change‚ but sexual infrequency may the woman with lower desire, or anorgasmia, sothat she does not feel pressured t0 reach orgasm of sex in fact be satisfactory to both partners (Hall, 1988). every time the couple has sex. This approach may decrease her avoidance by taking per- more formance anxiety 0E the table. Furthermore, this approach can result in much frequent Low Desire und Desire Discrepancy sexual activity with muchless anxiety (Nichols StSchernoff, 2007). can lesbian increase of desire and As stated earlier, we prefer to view lesbian sexuality from a feminist perspective and recognize Another way in which therapist help couples frequency ofsexual of sex is the their definition of sex. Many couples limit butdo not perpetuate heterosexist assumptionswhen exploring more traditionalviews frequency by helping couple expand what is to oral and manual sex. the couple to such sex toys as Vibra- dysfunction. Sometimes simply talking to Clients about their own assumptions about themselves genital Byintroducing and different of lubrications, the therapist helps the normal can help resolve the sexual couflicts for which they are seeking treatment. tors, dildos, butt plugs, feathers, types t0 t0 sexual connection, not have thought Loulan (1984) believes that the first step in dealing with lack of desire is for the couple partners to find other ways enjoy ways they might make sex more fun and desirable‚ this has been used by Margaret discuss their feelings with each other. Because sexual desire can be “blocked by unrecognized of. A way to help approach diffi- to increase ofsex in lesbian couples (Nichols 8c and unexpressed feelings towards [one’s] partner,” it is important to work through this Nichols in her therapy practice help frequency Loulan culty and rule it out before lookingat other reasons for low desire (Loulan, 1984, p. 93). Schernoff, 2007). low In herbook Ritterand to note the “degree offusion andautonomy” (1984) points out that sometimes simply discussing feelings can unblock desire. Terndrup (2002) encourage therapists well for of and when with couples (p. 351). Lesbian Sex, Loulan (1984) provides lists of questions for the partner with lower desire as and watch "repeated cycles merger Separation" working woman t0 them lesbian be fused in their relationships, they may, over time, find as the partner with greater desire. These questions can be helpful for each help Although couples may early the themselves from each other. in which this as weil ashow conflict understand why they feel the way they do. It can also be helpful for the couple to explore ways to distance Ways happens is can into how the level of fusion in their relationship may affect their questions and subsequent responses together to increase communication and understanding. addressed give insight the 8: In addition, Loulan (1984) points out that differences in dass, race‚ age, size, disability, and sexual relationship (Ritter Terndrup, 2002). like also need to be Because these are often areas of sensitivity, having a skilled, may explored. Oral Sex Aversion culturally sensitive therapist may be helpful in exploring these issues. of oral sex aversion, it is for the therapist t0 In 1984, Loulan expancled Helen Sänger Kaplan’s model, which Loulan believed to be anti- When a couple comes in complaining iinportant Is it societal Is it based on heteronormative ideas lesbian. Loulan (1984) took Kaplan’s three-stage model and expanded it to include six stages‚ discover the source of the aversion. messages? lI l l

108 o Handbook of LGBT-Affirmative and Couple Family Therapy Sex "fherapy With Lesbian Couples o 109

of what sex is? Is it for the individual with the simply unpleasant complaint? Exploringwhat is Margot,who identified as bisexual, shared that this was her first long-term relationship with behind the aversion and the members ofthe helping couple communicate with each other about a woman. She said that she had experienced sexual intimacy with several different women in it may decrease about in or not in act. anxiety engaging engaging the Although there are no college but had, after graduation, found herself sexually attracted exclusively to men. She met studies weare aware ofthat to oralsex aversion with speak specifically regard to lesbian couples, Casey at the gyrn and was surprised to feel both physically and emotionally attracted t0 her. She research with heterosexual that clinieians couples suggests explore issues of physical or sexual said that she found herselfthinking of Casey throughout the day and Iooking forward to the trauma (Wincze 8: 200l). We have found that if the avoidance of oral sex is Carey, something mornings When they both attended the same workout class at the gym. After several long con- attributable to that one or both have sex-negative messages partners incorporated into their versations at breakfast following their workouts‚ Casey asked Margot if she would like to go to sexual scripts, then sensate-focus exercises can be helpful. dinner, and Margot said that she initially froze but said, "I was so into her that I couldn’t say no The had sex on their first date; and when asked she the flemale Orgasmic Disordcr again.” couple why qualified experience by saying that it wasn’t “real sex‚” Margot said because there was no penetration. Also worth Many women have difficulty sex with their This having orgasms during partner, difliculty noting during the individual interviews were answers to the familyuof-origin questions. Margot can often lead to of on the of the woman who does not reach feelings inadequacy part orgasm. had yet to articulate to her family that she and Casey are partnered and share an apartment Similarly, the partners of these women may also feel inadequate, blaming themselves for not She said that she assumes her members rather " together. family know, but she would not dis- able to their being please partner (Loulan, 1984). cuss her relationship openly. Also, Margot is African American and until her relationship with One thing weconsider when a woman with disorder is presents orgasmic whether the prob- Casey was very involvedwith a Christian church. One of the issues that Margot believes further lem is the woman has or one that she something always experienced has acquired. We also isolates her from her family is that her family are not “particularly excited about me dating a explore whether this is an issue the woman has with other or is experienced partners exclusive to white woman.” When she began dating Casey, Margot also felt awkward continuing to attend the current The information the sex relationship. gathered during history interview can give the her place ofworship because it had been made clear to her that Same-Sex relationships were not clinician a deal of into whether there be great insight rnay deeper, unspoken relationship issues accepted. Her family made it clear that people who do not attend church Services are considered that are manifesting sexually. “aspiritual abomination.” When asked what initially attracted her to Casey, Margot responded As with all issues for which individuals and it is couples present, important to rule out bio- immediately, and without hesitation, that she found “Caseys confidence‚ and no-nonsense style factors. Some such consiclerations are logical “disease, injury, or disruption that affects the very intriguing.” or nervous sympathetic parasympathetic Systems” (Wincze 8: Carey, 200l, p. 43). Hormonal k Casey came in the following week for her individual intake. She stated that she came out as a Variation is also to the client’s or something suggest having gynecologist endocrinologist check lesbian when she was 14years old. She had been in several Iong-termrelationships with women. on. Finally, use of medication is another factor that can inhibit some prescription orgasm for She was Caucasian and grew up in what she called a “pretty traditional middle-class house warnen. It is that treatment with SSRIs can commonly acknowledged decrease a woman’s ability with a morn, dad, and a few kids.” She described her family as “more spiritual than religious.” to orgasm (Wincze 8: 2001). Carey, She said that she currently has a private spiritual practice. When asked what attracted her to Case Scenario Margot, she said that she found her “intellectually stimulating as well as really attractive.” Casey said that sexually she enjoyed Margofis freedom early in their relationship, but after a Casey made the initial call for She stated that she and phone therapy. Margot hadbeen together few months felt as though unless she herself initiated sex, their sex life would be nonexistent. for almost 3 years. The concern that the call was that the could to prornpted couple not seem Casey’s family of origin remained accepting and supportive from the moment she came out, find time when each was interested or felt she partner in, had tirne for, sex. Casey reported that 27years ago. both she and were frustrated about “our Margot getting extremely sexless relationship” and When the couple carne back together after the individualsessions, Casey mentioned that she wondered how to it. remedy had read something about female couples having little or no sexual relationship being common When Casey 41) and 32) entered the both nervous (age Margot (age ofiice, appeared slightly and was wondering if this state of aifairs was just something they would “need to learn to live and quiet. The asked what the t0 therapist Margot prompted couple come for therapy, and her with.” It is not unusual for some female couples to self-diagnose lesbian bed death‚ as this condi- response was the same as She stated that their sex life essentially Caseyfs. had been passionate tion has been labeled. The therapist spent time explaining how their Situation might bereframed when they first met and had remained so for the first few but it had since months, then waned asa desire discrepancy and not as a foregone conclusion of two women in partnership with one t0 the point of almost nonexistent. She said that still much being they very enjoyed each other’s another. Both women seemed relieved by this explanation and also appeared anxious to move and were in love company with each other, but both were concerned that they were getting forward with treatment. accustomed to not having sex. It was at this point that the therapist attempted to synthesize the contextual dynamics with It was established by both partners that wanted to be sexual with othef they genuinely each which each member of the couple entered the relationship. Casey’s family was supportive and and that they were the passion and closeness that their sexual connection them- missing gave accepting, and she had been out as a selflidentified lesbian for most of her life. With Casey, The couple came in for two sessions and then it was that come together, suggested each person there did not appear t0 be any internal conflict with regard to race, class, or spirituality. Her in on her own. The intention behind this was to establish a sense of connection a9 with them personality was very assertive, and she enjoyed sharing being the initiator of sexual activity. She individuals and also to interview each with to as t0 person regard previous sex histories, as well expected Margot to feel the same. Margot was more reserved‚ however, and did not have explicit gain a greater contextual of each life understanding persorfs experience. including race, claSSw familial Support nfher relationship. She felt from her since her relm hisiüf and estrangerl family oforigin SPiÜtUHÜtl/v y, relationship with lamily of origin, and the experience ofcorning out 35 and also admitted to uncomfortable her about their issue nonheterosexual. tionship feeling confronting family With Casey’s being white. She also was experiencing unspoken discord with her family about l ! |

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I10 o -———vj Handbook of LGBT-Aflirmative and .. Couple Family Therapy Y Sex ‘lherapyWith Lesbian Couples u lll her withdrawal from the church. was Margot comfortable with a bisexual identity;but sexually, multicontexual, feminist approaches, narrative therapy, and a great deal of educational refram- she tended to lean toward more traditionally established gender norms of women being sexu- ingand incorporation ofsensate-focus exercises specific for women. ally passive. Intellectually,she acknowledged that given that Casey was a woman‚she would not be References expected to initiate and that this assumption that women have to be sexually passive was in conflict with her own feminist ideals. R. Sexual Casey expressed initial discomfort with Margofs sharing Basson, (2007). desire/arousal disorders in women. In S.R. Leiblum (Ed.)‚ Princijzles and practice of the expectation of sexual passivity and stated that if Margot expected her to “be the man in ofsex therapy (4th ed., pp. 25-53). New York, NY: Guilford Press. Blumstein, P., 8: P. American the sexual relationship, this isn’t going to work.” Schwanz, (1983). couples: Money,work, and sex. NewYork, NY: Morrovxr. Connolly,C. M. (2004). Clinical issues with same-sex A review ofthe literature. In I. 8: L. Since society indoctrinates a sense of the felt it to couples: I.Bigner I. heteronormativity, therapist important Wetchler (Eds.), Relationship therapy with same—sex couples (pp. 3-41). New York, NY:Haworth Press. explain that even are traditional though many relationships judged by assumptions about Green, R. I.(2004). Forward.In I.I.Eigner 8:I.L.Wetchler (Eds.),Relationshtp therapy with Same-Sex couples gender-role norms, same-sex relationships, as well as many differentrsex relationships do not (pp. xiii-xvii). New York, NY: Haworth Press. always utilize these “rules of conduct.” It is importantto establish a sense of that is not Green, R. I.‚ Bettinger,M., 8cZacks, E. (1996). Are lesbian couples fused and gay male couples disengaged? normalcy In guided byheterosexist assumptions. We agreed to use the notions of and assertive with I.LairdS:R.I.Green (Eds.),Lesbians andgays in couples andfamilies: A handbookfor therapists (pp. passive San regard to the sexual roles. 185430). Francisco, CA: Iossey-Bass. Hall, M. (1988). Sex therapy wvith lesbian couples: A four stage approach. In E. Coleman (Ei), Irttegrated We also discussed the sexual response and used the Loulanand Basson models, which cycle identityfargay men andlesbians: Psychotherapeutic approachesfor emotional well-being (pp. 137-156). more than other rnodels are focused on female sexual response. IIwas suggested that the couple New York, NY: Harrington Park Press. talk openly about cultural differences. Although these are not necessarily issues that would Hall, M. (2004). Resolving the curious paradox of the (a)sexua1lesbian. In I.I.Bigner 8:I.L.Wetchler (Eds.), deter more with same-sex New sexual activity for the couple, the therapist felt it would be myopic to strictly focus Relationship therapy couple: (pp. 75-83). York, NY: HaworthPress. Iasenza, S. (2004). Multicontextual sex with lesbian In S. Green 8: D. on sexuality without considering psychosocial factors that could be t0 the rela- therapy couples. Flernons (Eds.), contributing Quickies: Ihe handbook ofbriefsex therapy (pp. 15-25). NewYork, NY: Norton. tionship. It was also that each write in a with no intention suggested they journal daily of ever Iones, K. P.‚ Kingsberg, 5., 81Whipple, B.(2005). Women’s sexual health in midlife and In Clinical with each other what wrote. It was beyond. sharing they not longbefore Margot and Casey began com- Proceedings. Washington, DC:Association of Reproductive Health Professionals. ing in laughing and happily sharing things they had learned about each other through their Kaplan, H. (1974). The new sex therapy. New York, NY: Brunner/Mazel. conversations. Kort, I.(2008). Gay afirmative therapyfor the straight clinician. New York, NY:WW Norton. Leiblum, S. and As the sessions progressed, the therapist recommended specific sensatofocus exercises. It (Ed.). (2007). Principles practice ofsex therapy (4th ed.). New York, NY: Guilford Press. Loulan, I.(1984). Lesbian sex. San Francisco, CA: Ink. was suggested that they watch A Lesbian Couples Guide to Sexual Pleasure (Schoen‚ Spinsters 2006). Casey Masters, W., 81Iohnson, V.(1966). Humansexual response. London: Churchill. andMargot seemed to enjoythe “homework.” After 12 were approximately weekly sessions, they Nichols,M. (198721). Doing sextherapy with lesbians: Bending a heterosexual paradigm to fit a gay intimate life-style. having frequent sexually experiences. In Boston Lesbian Psychologies Collective (Ed.), Lesbian psychologies: Exploration: 6' challenges (pp. 242-260). Urbana: Board of Trustees of the University of Illinois. Recommended Research Nichols, M. (l987b). Lesbian sexuality: Issues and developing theory. In Boston Lesbian Psychologies Collective (Ed.)‚ Lesbian dr As stated earlier, there is little research in the area of sex with lesbian Most psychologies: Explorations challenges (pp. 97—125). Urbana: Board of therapy couples. Trustees of the University of Illinois. helpful would be more empirical evidence about for the specific therapeutic approaches variety Nichols,M. (2005). Sexual function in lesbians and lesbian relationship. In I. Goldstein, C. Meston,S.Davis, of issues lesbian with in sex couples present therapy. Givingtherapists alarge repertoire of clini- 8