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Home , Sex therapy

Sex therapy It’s more than just being comfortable talking about sex

Interviews with four sex therapists: Dr. Daniele Doucet, Dr. David McKenzie, Dr. Teesha Morgan, and Dr. Pega Ren

by Carolyn Camilleri

et’s say a woman tells actually dealing with something such and sustain it. Treatments you she has low or as , and this woman needs for behavioural issues start with what the quality of her specific guidance to heal, such as seeing Morgan calls “homework assignments.” has diminished. As her a pelvic-floor therapist,” says Morgan. Once biological and behavioural aspects counsellor, you start to ask Pain during intercourse is just one have been addressed, she assesses for Lquestions and learn she has pain during common issue Morgan sees in her office. psychological concerns, such as anxiety intercourse. The next step illustrates a “With women, it’s predominantly and depression. key distinction between couple therapy low libido or pain during intercourse or “There are three things to look and sex therapy. a difference in a couple’s sex drive,” says at: biological, behavioural, and Dr. Teesha Morgan would ask, where Morgan. “With couples, much of the psychological. If you’re missing one of is the pain located? What kind of pain time, it’s quantity and quality of sex — those three categories, you’re dropping is it? How often is it occurring? In her either one or both has become an issue, the ball on the whole thing,” says mind, Morgan would be assessing for and they want to communicate around Morgan. “You can’t just look at one vaginismus, , vulvodynia, their sex life in a more effective way.” and hope that you’ve found it, because clitodynia — medical terms to describe With men, the predominant oftentimes, one is causing the other.” problem is , which different types of vaginal pain under the Her holistic approach comes from broad category of Genital Pelvic Pain Morgan calls an umbrella term for a very specific training in . Disorder — and then she would provide multitude of issues. When a client specific suggestions to treat it. presents with erectile dysfunction, More than a definition “We can talk with a woman and Morgan starts by referring him to, at problem empathize, but if you’re just tackling the bare minimum, a GP to check The term “sex therapy” is not protected it from an anxiety perspective or a testosterone, prostate, diabetes, blood nor are there official requirements for relationship perspective, a safety or pressure, and other possible causes that using it. Technically, anyone could say communication perspective — and those may be biological. She then addresses they are a sex therapist, even without all might be important factors of what behavioural aspects by assessing the training. “Sexologist” is another is going on — you may be missing a client’s tendencies and term that can be misused. Dr. David key component or diagnosis, that we’re their effect on his ability to get an McKenzie offers clear definitions.

Learn more about our experts and what they do

Dr. Daniele Doucet (Nee Duplassie): Dr. David McKenzie: Dr. Teesha Morgan: Dr. Pega Ren: www.shanti-centre.com/danielle-duplassie/ www.davidmckenzie.ca www.teeshamorgan.com www.smartsextalk.com

14 INSIGHTS magazine INSIGHTS magazine 15 “There are three things to look at: biological, behavioural, and psychological. If you’re missing one of those three categories, you’re dropping the ball on the whole thing.”

about that, guilty even,” says McKenzie. do so,” says Dr. Daniele Doucet, adding “Someone would come to me regarding that most training opportunities are in issues around human sexuality, and the U.S. I could be sympathetic, I could give To date, regulating bodies in Canada suggestions, but I didn’t have any haven’t made training in human training as to how to treat it, where sexuality mandatory. If it were, Doucet to go, what to do. In my own training, believes more graduate programs would which was extensive, I never got any offer it. It’s an issue in the medical kind of training in sexuality.” community, too. Ren facilitates a four- “ is simply the study of The issue goes deeper than not hour workshop for graduating medical human sexuality, and sex therapy having training. McKenzie points out doctors called Sex Therapy for Non Sex requires a counselling background,” that many counsellors don’t even Therapists. She may be the only person says McKenzie. “Sex therapy has a ask about sexual issues. “They’re who talks to them about sex. much broader perspective that takes uncomfortable. They’re not in touch “All I have time to say is, ‘These into account the dynamics of couple with their own sexuality, or they’re just are the things that can change; these relationships, of how to treat sexual very nervous, because they don’t know are the things that can’t change, and problems, how to diagnose them, how to handle it.” you need to know what’s on each of whereas a sexologist is somebody who Dr. Pega Ren agrees. those lists, because your first job is do could be studying the history of kink. “ and family counsellors all no harm,’” says Ren. “And very well- That doesn’t make them a therapist.” deal with sexual issues,” says Ren. “And intentioned people do harm. They meet Nor does training as a couple I think most never mention it, don’t issues with their own prejudices, their counsellor make one a sex therapist. know how to ask the questions, don’t own ignorance, and do their very best “Relationship counselling has a lot to know how to respond when questions to be helpful without the knowledge or do with communication concerns, but are asked of them, don’t know how training to handle it effectively.” that is just a piece of what sex therapy to incorporate sex therapy. And it Ethics are the root of the problem. is,” says Morgan. “Sex therapy is a makes sense to me that that is the “We’re not supposed to engage in specialization like trauma or addiction.” case, because most psychologists have therapeutic activities that are beyond McKenzie, who has been a sex between six and 10 hours of training in our competence,” says Doucet. “But therapist for the last 13 years of his sexuality. And many counsellors don’t people assume that if they took a basic 43-year counselling career, began his have any training in sexuality at all.” course in human sexuality or if they career as an Anglican minister trained in The lack of training comes from a took a marriage and family course and pastoral counselling. A couple asked him lack of training opportunities. read a book on human sexuality, that for help with premature . “As it is now, there are no graduate it makes them qualified to do therapy “Medical doctors just have one programs requiring training in related to sex, and it’s dangerous.” solution: take Paxil and that should human sexuality; however, there are help, but it doesn’t always, and I didn’t people who hang up their shingles as good intentions gone wrong know who to refer to. I certainly didn’t relationship therapists and talk about Ren says her clients contact her about know about it myself, and I felt sad sex but don’t have adequate training to a wide range of concerns, including

16 INSIGHTS magazine relationship issues, unmet expectations, that may be very different from the The major problem of bias disappointment with trying to follow next person who presents us with the When McKenzie started studying the cultural script, erectile dysfunction, same symptom,” says Ren. “We need sexology and sex therapy, many of his body issues, painful intercourse, more than empathy.” assumptions were challenged. infertility, and GAS: guilt, anxiety, and Above all, sex therapists need to “For instance, being an Anglican shame. Much of it starts with a lack of listen without judgment. pastor, I was under the assumption adequate and accurate . “People hold enormous shame about that the only sex that counted, the “People don’t understand how their what they do sexually and can take it sex that was good and healthy, all had bodies work. And they don’t understand nowhere, because we, as a culture, hold to be within a committed or loving when their bodies don’t work the way negative judgment about sexuality,” says relationship,” says McKenzie. “That’s they expect them to and whether Ren. “We slut-shame women. We make absolute balderdash.” that’s a problem with their body or men feel guilty for being aggressive and Nor does love and commitment the expectation,” says Ren. “And there make them feel guilty for being sissies, always connect to sex. Once McKenzie are very few avenues for them to get so they can’t win. And being able to say started in sex therapy, he found he accurate, non-judgmental information.” to someone, ‘I am a sex therapist so you had some couples coming to him who Sex therapists have comprehensive can tell me anything,’ means that for had very successful , who knowledge of sexuality in all its forms, many, many people, the sex therapist is communicated and loved each other but behaviours, and lifestyles, and an arsenal the first person they speak to.” weren’t having sex. of solutions to issues that may arise. While all counsellors are trained to “There’s a myth out there that the “We have to have the answers before be sensitive to bias, sex therapy may sex life is the barometer of the rest of we start giving them. We have to know uncover bias you didn’t know you had, the relationship,” he says. “Well, that’s what works and what is appropriate for despite your experiences professionally not always true, though it certainly can the person sitting in front of us. And and personally. point to difficulties in the relationship.”

The PLISSIT Model

Jack Annon’s PLISSIT model is one of the most favoured approaches to sex therapy. It’s an acronym for the series of steps a sex therapist can take to address a wide range of issues. P for permission, LI for limited information, SS for specific suggestions, and IT for intensive therapy.

Permission Limited Specific Suggestions Intensive Counsellors who are Information At this stage, a counsellor would Therapy 1 comfortable with 2A counsellor who 3 need to have good training in 4 The final steps sexuality and gender give is quite knowledgeable in sexuality to go beyond empathy and require an experienced sex the client “permission” to human sexuality can offer offer guidance that does no harm. therapist. However, Ren express issues that may accurate factual information Morgan says it may be tempting says fewer clients need be attached to shame or that puts the issue into to assume the sexuality-based sex therapy at this stage. be difficult to talk about perspective and makes the problem is a symptom of something More often, the issues or process. The counsellor client feel more comfortable: psychological, when it may be the are due to the client being accepts the person and the statistics on erectile root cause. Ren uses the example of frightened, ashamed, or issue without judgment. dysfunction or on how helping a client manage masturbation uninformed, and once they For example, a client may difficult it is for a woman behaviour so it doesn’t, for example, have that resolved, they say they believe they are to reach , how become a threat to his employment, are finished sex therapy. masturbating too much. common a behaviour is in which could solve the problem and “Then they can go back The counsellor gives different populations or how end the need for therapy. In other to their marriage and permission by responding a behaviour is harmless. For situations, specific suggestions could family counsellors, and with “I’m glad you told example, “Perhaps you would lead to treatments and continued do the rest of the life me that” and then “What feel better knowing that therapy. It takes training to know stuff because they’ve got makes you think it’s too there are no harmful effects what to offer in the way of specific the sex piece finished,” often?” of masturbation.” suggestions for a wide range of issues. says Ren.

INSIGHTS magazine 17 One of his sub-studies was swinging, are all sorts of sexual proclivities and enough good, valuable work for marriage open, and alternate relationships. kinks,” he says. and family counsellors to do without “Many people think that people who Sex therapists take SAR repeatedly; feeling they have to do it all.” have alternate sexual lifestyles are going in Doucet’s case, three times a year for How to be truly helpful to come apart, and they don’t, and that three years. “We did a lot of process- “Not all counsellors are couple was a real shock to me,” McKenzie says. oriented talking about our reactions counsellors,” says McKenzie. “But Further studies included kinks, BDSM, — our judgments, our biases, our anybody doing couple counselling who’s and sadomasochism. “It was a real eye- discomfort — and examined that in not asking about the sex life should not opener, but it doesn’t mean the person’s extreme depth, so we could see the ways be doing couple counselling, period.” sick because they practise it.” sex-negative culture had influenced us,” For counsellors without adequate Doucet says sex negativity is so says Doucet. sexuality training, McKenzie’s answer is normalized that people think it’s Part of SAR’s effectiveness is that it clear: “As soon as the issue of sexuality normal. “Through a sexological lens, is done in a group setting with specially we see that sexual preferences are as diverse as food preferences. We don’t pathologize people who like liver, “When you live in a society that even though a small portion of the has these ideas that certain sexual population likes liver. When you live activities are good and normal and in a society that has these ideas that certain ones are terrible, immoral, certain sexual activities are good and and abnormal, it creates a perspective that normal and certain ones are terrible, permeates all of us at a societal level.” immoral, and abnormal, it creates a perspective that permeates all of us at a societal level.” trained facilitators. Doucet says even is raised in the relationship as a problem, Religion has long played a role in sexuality students and counsellors find they need to refer out.” pathologizing sexuality. McKenzie has it challenging, but it is critical to get While there are many clear been a guest lecturer on the subject of past bias to address even basic sexuality distinctions between couple counselling sex, religion, and culture at the UBC issues with clients. and sex therapy, there are some areas of School of Medicine, SFU, Trinity “How comfortable do therapists feel overlap with respect to intimacy. Western, UVic, and University of about asking clients about masturbation “Marriage and family counsellors can Northern B.C. in an attempt to educate practices?” says Doucet. “Most are very work with couples on communication professionals on the sexual assumptions uncomfortable, but it is so important and empathize with regard to problems and negativity based in religion. to someone’s sense of self as a sexual with intimacy, especially if some Another pathologizing influence: person. You need to ask about a client’s of the major issues are ‘We’re not DSM IV. The DSM V has been comfort level around sexual pleasure and communicating. I don’t know when updated to recognize that unique sexual being comfortable in their bodies and my partner’s in the mood. My partner preferences in and of themselves are not with their body parts.” doesn’t know when I am, and my pathologies, says Doucet, adding, “In my Unprepared counsellors can leave partner doesn’t know what kind of training, I learned how much bias I had clients feeling distressed. touch I like,’” says Morgan, but cautions, based on sex-negative attitudes within “I’ve had many clients tell me they “Even within that realm, understanding our society. I didn’t realize I had them.” didn’t feel comfortable talking about sex things like a person’s sexual schema is The process of undoing bias and sexuality with their counsellors,” important and is more into the sex- begins with SAR — Sexual Attitude says Doucet. “They couldn’t have those therapy realm. You might be helping Reassessment. McKenzie describes it as important conversations.” with the communication but not a blunt, in-your-face experience viewing Ren also talks about remedial work as understanding that the main reason they erotic material. “It’s desensitization that a result of others’ good intentions. aren’t connecting is because there’s a gets a person used to the idea that there “It’s unnecessary,” says Ren. “There’s differentiation in their schemas.”

18 INSIGHTS magazine McKenzie believes strongly that, as “We need training so counsellors can hear Dr. Rosemary Basson of UBC’s Sexual their clients ask about something Clinic once stated, “Sex never without feeling they have to solve it but stands alone. It is always connected to being able to respond without bias.” other issues.” Doucet says counsellors who are “That is why family of origin is vital. interested in human sexuality can seek out We replicate our family-of-origin issues training opportunities, such as courses and in our primary relationship and that has conferences. “Consult with experts who profound impact on our sex lives,” he do have training. Learn how to integrate says. “Most of our sexual issues have both questions about sex and sexuality in intrapersonal and interpersonal roots, intakes. Get supervision. All the things and if these are not thoroughly explored, we would say therapists should be doing the sex therapist is only doing band-aid when they’re practising in an area they’re work.” unfamiliar with.” Like any area of counselling, Morgan Couple Morgan, who is a co-founder of says, it’s important to be aware of Counselling the Westland Academy of Clinical Sex the limits of your own training and Homework Therapy, suggests the PLISS aspects of experience and refer out when progress David McKenzie often gets the PLISSIT approach to sex therapy (see seems stalled. calls from counsellors page 17) are a good areas for counsellors looking for input on their “We get to a point where we realize, clients’ sexual problems. to research, become knowledgeable ‘Wow, I’m sinking,’ and ‘I’m out of my The first thing he asks on, and possibly incorporate into their realm of expertise here,’” says Morgan, counsellors for is the practices. It’s not a quick tool, but rather a clients’ sexual history (he adding that she may refer once biological uses an eight-page form). framework, and learning how to apply the and behavioural concerns have been “You cannot begin to PLISSIT model for each sexuality-based addressed — for example, if the client has evaluate a couple until dynamic requires training and supervision. you’ve taken the sex severe issues with anxiety or trauma. history, relationship history And Ren suggests putting together For Doucet, it is a question of training of both of them.” your list of experts. “Counsellors need to to avoid compartmentalized therapy. He then asks about the have the pelvic floor specialist on speed clients’ family of origin and “Ultimately, I think anybody doing depression inventory. dial and the sex therapist on speed dial, relationship therapy needs to have some “Their relationship is just like they need the social worker and driven by that family of type of training in human sexuality, the person who knows how to get Mom origin, and depression is because our sexualities are an integral part one of the leading causes into the nursing home without an eight- of our everyday existence,” says Doucet. of sexual shutdown in both year wait list and someone who knows men and women, especially “We don’t wake up in the morning and men,” he says. something about autism.” say, ‘Oh, you know what? I’m queer, “Without that “All of us need the community of but I’m going to put that in a box today information, which tells therapeutic interveners to do our jobs you about attachment and and go live my life and then come home relationship styles, it’s a well. We can’t all know it all,” says Ren. and put on my queerness again — or case of the blind leading “Sex therapists know the sex part, and we my sexual attractions or my sexual the blind. You need to know it well, because we have doctorates get at the root of why the preferences.’ Hopefully, humans aren’t couple is together.” in it. We don’t dabble in sex. We come compartmentalized in that way.” “That kind of work has to to it with a great deal of expertise and be done in the first session, The training isn’t to turn every knowledge and not a whit of judgment.” ■ and usually by the end relationship counsellor into a sex of the first session, I can therapist: it is to help counsellors manage pretty well diagnose what the issues are and show Find information on sex therapy discussions with their clients. them a plan for treatment,” resources, training, and professional “We need counsellors to be trained says McKenzie. associations at the BCACC blog at www. in hearing clients ask for help,” says Ren. bc-counsellors.org.

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