Clinical reviews editorial: discovering connections

We have all been there – reading through multiple content tables, scanning abstracts… looking for a semi-quick answer to the question, “Is this article going to give me a good suggestion for helping with my clients’ concerns?” As sexologists, it is always a bit of a battle to bridge the gap between research and practice. This is true for many disciplines, but in the field of sex we often find ourselves mixing the two and yet not distinctly identifying how a research outcome can be applied in “real life,” nor how a clinical application can be applied to (or from) the next big break through. While a brief editorial is not able to cover or explain all of the applications – a summary of sorts may be beneficial, especially if it attempts to bridge a connection.

In this issue of Sexual and Relationship Therapy, there is a wide range of articles spanning topics such as menopause, desire and functioning, teaching sex therapy, transgender relationships, sex workers, and assessments. There are qualitative, quantitative, and even mixed methods studies represented – all providing incredible insight. As I reviewed the articles in this issue, I saw a very general overlap related to permission-based work in sexual and relationship therapy, which will be the theme of this first Clinical Reviews Editorial.

Permission-based therapy and interventions is nothing new, but the way in which it is being adapted to today’s clientele is under development (Belous et al., 2019a). Historically, permission was utilized in sex therapy to free clients from the burden of social oppression by providing the “okay” to engage in sexual experiences that they were interested in – we know this as the first stage/step of the PLISSIT [permission, limited information, specific suggestions, and intensive therapy] model developed by Jack Anon in 1976. This original model was expanded in 2007 by Taylor and Davis to incorporate an extended version of permission throughout the model – giving permission (and getting it) at each step. This type of work, where a client’s autonomy and ability to retain their own power of choice, is incredibly important to ensuring positive outcomes and effective treatment. Permission work includes honoring the client’s ability to choose what to disclose, at what pace, and ensuring continued consent in the conversation and therapy process. It is actually a quite simple task and is directly related to enthusiastic consent in sexual activity practices (Coy et al., 2016). Throughout, and often, the therapist should gain the permission, check in with the client that the topic is still okay and that they are willing to continue, and that everything is going in a direction in which they are comfortable. If the client is not comfortable or unwilling to continue – their wishes should be honored, and a pause is placed on the therapy topic until the client is comfortable again (during this pause, it would be appropriate to check in with the client, talk about the discomfort, and determine safe paths forward).

In this issue, Curtis et al. (2019), highlight this process in their phenomenological study on sex worker’s lives, and the impact that their profession has on relationships (and in the therapy room). Specifically, the authors recommend that clinicians should focus on more collaborative approaches to treatment. Ideally, they state, therapists would have genuine curiosity, respect, and a humanistic approach when it comes to providing treatment; highlighting the need for clients to be empowered through a non-pathologizing stance. Utilizing a permission-based lens through which to work with clients can increase client abilities, trust in the therapist, as well as allowing the client to become more vulnerable and willing to engage in the therapy process. Additionally, they specifically call out a need for therapists to ask about permission in the homelives of sex workers – what boundaries are in place around work/life balance and what should be shared or kept apart from partners (something that needs to be agreed upon by both). This overlaps with the other two areas that were major themes – communication and genuineness – but is an important construct in achieving client and personal power and autonomy while maintaining respect.

Curtis, et al.’s article spoke about the way in which we perceive actions and professions, and further brought that into how, as therapists, we can be significantly influenced by our own biases and reactions. Kato’s (2019) work related to infidelity perceptions in Japanese heterosexual relationships overlaps with this idea, and is also included in this issue, in that they studied the imagined response to different types of infidelities. They found that women responded with more jealousy when an imagined emotional affair had occurred, whereas men had higher jealousy when an imagined physical relationship occurred. Additionally, they found that reported attractiveness of the supposed or imagined partner had no effect on overall jealousy ratings. This information can be helpful in understanding the reactions that partners may have when perceived jealousy over external relationships exist. While their findings adhere to a stricter cisgender guideline of interpretation and gender schemas in place, it would be helpful to know how cisgender persons who are in monogamous relationships react, or the amount of effort that they invest into these difficulties. Permission-based work can be helpful here in validating the lived experiences and emotional reality of each person and working toward helping the clients understand the other.

Three of the articles in this issue also focus on what I like to call “Aging Sexual Beings” (ASB). There is ample evidence that as people age, their desire for sex does not decrease – only their ability to function shifts and changes and so they begin to feel less confident or capable in sexuality activities. Unfortunately, this often results in fewer and less frequent satisfying sexual encounters. Menopause has a profound effect on a person’s overall functioning. In this issue, Bülbül et al. (2020) share that the more somatic difficulties a woman has, the lower they will rate the quality of their sex life, which in turn effects their overall marital satisfaction. Similarly, the work of Nazarpour et al. (2019), also in this issue, shows that the specific medical conditions of cardiovascular disorders, diabetes, and musculoskeletal disorders also have a negative impact on sexual functioning in post-menopausal women. In general, these two articles directly connected with sexual functioning in post-menopausal women, highlight the need for continued collaboration between medical professionals and mental health providers. It is important to remember that the field of sex therapy was founded on extensive collaboration between professions, and as (generally so) systemic thinkers, careful consideration of the whole context of a person’s life (e.g. biology, psychology, cultural background, etc.) is vital to any forward progress.

Also in this issue, Ayalon et al. (2019) report findings of how in heterosexual relationships with ASB’s male achievement of normed sexual activities (e.g. penile penetration into a vagina) or the ability to be orgasmic had a profound impact on sexual satisfaction in the relationship. In this article, the authors highlight a macroaggression within many societies around the world related to sexual expression – that (male) orgasms are the point of sexual activity, and if you cannot put a penis into a vagina than it is not “quality” sex. Sex therapists know these things not to be true, but our clients often come in demoralized when not able to engage in these activities – especially if they have been able to engage in them before. This can lead to shame and anxiety spirals, which exacerbates any sexual difficulty that may exist. Permission-based, open-ended, and consistent confirmation-based questions normalize the discomfort in disclosing difficulties, while also providing the space necessary to hold control and feel power of choice in one’s life – something clients may feel they have lost.

Articles in this issue by Belous et al. (2019b) as well as Krasnow and Maglio (2019) highlight the importance of sex positivity and deconstructing barriers to communication by focusing on non-pathologizing and opening brave spaces for sharing and exploring to create healthier sexual schemas. Genuineness through the use of humor and humility are examples of how to implement and create these spaces. Additionally, Krasnow and Maglio highlight elements to incorporate or learn more about for treatment that may be beneficial for clients who are presenting with female sexual desire concerns, specifically: positive psychology, interpersonal insight, and asking/focusing on getting to know the whole person – including the sociocultural, economic, and political context of their lives. Brown (2019), also in this issue, encourages and provides a framework for a fuller assessment in the areas of love, intimacy, sex, and power to help increase personal and relational sex positivity. This framework can also be utilized as an intervention in session to create the insight necessary to decrease sexual difficulties.

At the core of permission-based work is respect. Respect for the individual and couple or family system, respect in the profession to want to make it better through improving outcomes, and respect for yourself as a clinician as well. Genuineness and authenticity are traits of respect and transcend the therapy session to create systemic ripples of change. This is especially true when a person’s social location and identities place them at increased risk for oppression and overt discrimination. Transgender persons in the United States (US) and many other places on the globe, continually face open and blatant discrimination in their everyday lives. Fuller and Riggs (2019), also in this issue, report that gender related discrimination can potentially be mitigated by strong support systems with significant others, and/or even through the bond between having a pet living in the home. This information can be used in treatment to help provide insight into the importance connections play in a person’s mental health and wellbeing.

In summation, this issue provides articles that suggest many interventions that could be helpful, as well as provides new information from studies that can help to enhance your practice (such as the way in which Francis et al. (2019) outline their study in program evaluation to measure efficacy for sexual dysfunction, which is also included in this issue). The difficult part is, and will always be, having the imagination and creativity to see how results from a study can be applied in practice, and seeing how one therapist’s suggestions for treatment can be applied in the way through your way of treating clients. This is the joy of being a scholar and a practitioner. I do hope you found this editorial interesting and helpful.

Christopher K. Belous
Associate Editor, Clinical Reviews
Purdue University Northwest, Hammond, IN, USA
[email protected]