LGBT Treatment Suggestions

I have a plan to watch the psychotherapy video shown in class week again and again, it was that good!  Why?  Because one psychotherapist noted that LGBT clients seek out therapy more than heterosexuals and because 95% of therapists will have at least one LGBT client.

Several elements to the videos were helpful.  First, it is important to understand the concept of internalized homophobia and the continuum from awareness about one's orientation leading to integration.  This continuum has four general categories.

1. Integration = sexual orientation is fully realized

2. Acceptance = some acceptance of sexual orientation

3. Awareness = some awareness of sexual orientation

4. Little or no awareness of sexual orientation

To help LGBT clients, it is vital to understand where the client is on the continuum.  When the gay client  is fully integrated in his identity, then a treatment plan can be developed as usual because their orientation is not causing them distress. However, the LGBT client with little or no awareness about their orientation, their distress may be complicated or generated in a small degree by their lack of awareness. The video provides a great example of helping a client move along the continuum towards integration.  The therapist finds just the right balance between being directive and empathetic. 

The video was equally helpful in demonstrating the coming out process. The therapist uses the continuum to show how the client has changed so wouldn't it make sense for family members to change just as he did?  This is a excellent example of hypothesis testing, a great therapeutic concept for all types of sexual orientation.

Another important point made is that societal stigma should not be overpathologized or underdiagnosed when dealing with LGBT clients.  This is equally important when treating same-sex couples who may differ in where they are in the coming out process.

This blog is just some of the highlights from the video, it was that jam-packed with helpful information.  With the news of another tragic transexual suicide this week, this information takes an even more importance.

 Mr. Grey and Ms. Steele, did you know there's more variations?

With the major motion picture release of Fifty Shades of Grey, millions of Americans now know about BDSM, one of 500 paraphilias. Count me as one of those who really did not know much about BDSM. Thanks to a great presentation by Lauren, Victoria and Emily, I now know about the other 499.  Could I have gone the rest of my life without knowing about Emetophilia?   Yes!   But thankfully, because of this knowledge, if I ever were to have a client who finds vomit arousing, I could possibly refrain from looking shocked and dismayed and treat the client with the respect that they deserve.

What a daunting project to tackle but with humor and clear organization, this team did a great treatment video and wikipage.  The cartoons provided comic relief and helped me not to"yuck someone's yum."  Focusing on the big eight paraphilias and providing the DSM 5 definitions gave this topic much needed structure.  I especially enjoyed the italicized summaries of the research reports.  Kudos on the treatment video, especially to Victoria as Shawn who kept calling his partner, "Court", short for Courtney which is such an accurate depiction!

A race car analogy is useful to describe where I was before this presentation.  I was going about 25 miles per hour.  But this project got me going 25 to 100 mph.  Talk about acceleration!  But instead of crashing into a client with an unexpected paraphilia, this presentation will keep me on track to treat everyone with dignity and acceptance.

Sex and Medical Conditions

Since this topic was my group's presentation, I am more than a little familiar with the material.  But what I think is an overriding theme is people in these situations (cardiac challenges, spinal cord injuries and intellectual disabilities) and people, even without these challenges, all could be helped by sex education.  Imagine a sex ed class where the myth of asexuality is shattered once and for all?

A recent article in the New York Times highlighted a sex education program started by Julie Metzger. Like a stand-up comedienne, she presents anatomy to intercourse topics to an audience of mothers and daughters or fathers and sons.   Participating teen ask questions about sex by writing them on index cards which she reads and answers accurately but humorously. Metzger says this helps parents hear what teens are wondering about and opens the door for parents and kids to talk regularly about sex. Metzger, a nurse, was motivated to start this program because she noticed that kids either learn about sex in dry health classes for 10 weeks or maybe a 10 minute conversation with a parent.  Why not get parent and kid together and make it fun?

Make no mistake, teens attending Metzger's classes do not want to go initially. But in the end,  everyone gives the program high ratings.  The article describes Metzger's attempts to reach out to more culturally diverse demographics. Others wonder how transgendered teens could benefit from this program.  Here's my question: does Metzger include questions about sex and disabilities? One can only hope. In the meantime, she deserves credit and accolades for tackling sex education with humor and creativity.

Reflections on FOD

My heart went to the couples who suffer so much when dealing with vaginismus. I am so glad for this presentation because sadly before this, I potentially would have been one of those who would give the terrible advice: "Have a glass of wine and forget about it."

Because of this presentation, I now know there are sex therapists and even clinics that help women train their vaginas not to have "panic attacks." What I found interesting is this condition is a great illustration regarding the female desire, arousal, orgasm process because of the complex interplay of biopsychosocial factors.  So with vaginimus, the desire is there, the arousal may or may not be there but physically the walls tighten to prevent penetration. Possibly this physical reaction may be rooted in some part in anxiety.   It's easy to imagine the shame and guilt that would prevent a couple from seeking help.

All this complex interplay involved in female orgasm process is an argument against the female version of Viagra. So one pill is going to help?  Sorry drug companies, this presentation in HDF 505 shows Pfizer and the like should look elsewhere to make a profit.

SIAD Wikipage Reflection

Brittany, Sara and Chrissy's presentation and wikipage about arousal disorders for women and men deserve a huge round of applause. Clinicians can use this page as a resource when faced with cases involving these disorders which are among the most commonly seen.  What I appreciate is the SIAD wikipage's organization, depth of information, thorough research references sprinkled with cartoons and videos. The following examines each of these elements.

The wikipage's organization is key because otherwise the page just turns into a list or mishmash of information.  I am happy that this group went first because these framework will be imitated but it just makes an overwhelming amount of information accessible. Each disorder starts with the DSM-V Diagnostic Criteria except in the case of SIAD. Because of the concerns about change made in DSM of adding HSDD plus FSAD to form SIAD, the group listed the advantages and disadvantages to the definition change.  This organization clarified a confusing topic for me. After the DSM definition, each disorder's prevalence, predictors, assessment approaches and treatment options are outlined followed by research references. Having the assessment inventories accessible within the page is giant help!

One only has to look at the length of this wikipage to see that each disorder is thoroughly presented. There are multiple helpful charts.  I found the SIDI-F Table 1 about Components of a Comprehensive Sexual, Medical, Psychosocial History especially helpful because it's quick way to see topics included in  a comprehensive sexual health interview.

The number of references went beyond the assignment's requirements.  But I also found helpful that each element was clearly referenced so if I wanted to look up the Pursuing Pleasure CBT treatment program for example, it is easy to do.  I thought the table from Trudel et al. (2001) regarding women's thoughts regarding sex was fascinating and a potential resource for CBT treatment.

The bottom line is this wikipage covers intimate topics that represent a lot of pain and suffering often done silently by millions of men and women.  Add in clinical research that isn't known to be an "easy read" creates a recipe for weariness.  However, this team brilliantly added in cartoons and videos that literally provide comic relief.  I especially enjoyed the Couples in Therapy in Movies clip.

So Brittany, Sara and Chrissy, congratulations on a great presentation and wikipage!  You have set the bar very high!

Joan Collins says the secret to staying young is sex, sex, sex

Way before Real Housewives of Beverly Hills and Desperate Housewives, Americans were obsessed with Dynasty, a prime time soap opera that was a huge hit in the 1980s.   Joan Collins played the conniving ex-wife of a rich oil baron. Now 80 years old and recently knighted by Queen Elizabeth, Joan is opening a one-woman show about her life with Percy Gibson, her fifth husband as director. 

Joan does not believe in botox or plastic surgery but says her secret to staying young is "sex, sex, sex." She credits the success of her 12 year marriage to Gibson who is 32 years younger than Joan to their abundant sex life. She said in a recent interview when asked about their age difference,"If he dies, he dies."

Given how common Female Sexual Interest/Arousal Disorder (SIAD) is, wonder if sex's anti-aging benefit could be added to a sex therapist's list of psychoeducation to help improve a woman's psychological situation?

http://i.telegraph.co.uk/multimedia/archive/02516/Joan_Percy_2516164a.gif

 In the meantime, how refreshing it is to hear an 80 year old enjoying abundant sex?  Maybe Joan is helping to deconstruct the stereotype that old people have diminished to nonexistent sex lives.

Reflections on Dr. Laura Berman's Sexual Healing TV show

Dr. Laura Berman is following in Kinsey's footsteps by creating an impressive sex therapy clinic.  This episode documents three couple's journeys from low desire and arousal to much more satisfying sex lives in a week's retreat at the Berman Center.  Dr. Berman's techniques and results are effective but I wonder, if she were to follow-up with these couples in a year, whether their improvements would still be evident.   In the following, each couple's vignette and the positive and negative aspects of the methods employed are examined.

First we meet Tom and Debra who have been married for 16 years and whose sex life has dwindled down to nothing for years.  Debra declares that she would be content never to have sex again.  Tom is understandably hurt by this but his commitment to Debra is evidenced by his patience and caring, supportive attitude throughout the episode.  

Dr. Berman seems to employ a biopsychosocial approach because she has all three women clients get a medical examination.  I can only assume that, for the sake of broadcast time, the men had a medical exam too. As far as the therapy theory model, Dr. Berman seems to use an individual psychotherapy theory because her role as therapist is as an expert giving directives. Dr. Berman also seems to rely heavily on sex toys as the way to heal couple's sexual problems.  This technique's drawback is the novelty can wear off resulting in the toys staying in the dresser drawer. 

My concern is that Tom and Debra were not given the opportunity to explore in conversation during the therapy session their own ideas about what could help their sex life. In other words, I wonder what Tom and Debra might have come up with in a solutions-focused brief therapy session.   Possibly one negative experience with the vibrator could result in Tom and Debra foregoing sex again. Is that possible?  How about this for a scenario?  Tom happily pulls the vibrator out but Debra is so distracted by worries or vaginal dryness, that no matter how long they try, she still doesn't climax.  The Berman clinic is an "artificial" setting, in a way, because there are no screaming children or dishes to be washed or bills to be paid.  So what works there might not work at home.

The next couple, Brandon and Sabrina, were having sex two or three times a day at one point.  But then Sabrina had gastric bypass surgery as a way to lose weight and hold onto Brandon's desire. However, as her weight went down so did her desire so their frequency reduced to twice a week.

Kudos to Dr. Berman for uncovering Sabrina's past sexual abuse but am I the only one who thought the doctor could have been more sympathetic and less in a hurry to restore their frequency rate?   I would like to have spent some time with this couple exploring why Sabrina felt the need to undergo major surgery to hold on to "her man." Why wasn't Brandon asked about his judgement about Sabrina's "too small mouth"?  So because Brandon asked Sabrina to marry him, everything is going to be like a fairy tale? This scenario should spark some feminist outrage.

Then there is Shawn and Kerrie who have a self-described mediocre sex life "like doing the laundry."

I do not understand Dr. Berman's command that Shawn look at his wife's genitals.  Clearly he could use some psychosocial education about vagina elasticity and childbirth instead of this command that he clearly does not want to obey.  One directive that might work is that Kerrie should stop giving Shawn oral sex until he gives her the same. That might help him get over his hesitation.

 What I would like to try the FIRO therapy model with this couple because Shawn indicated that he is not in the mood for sex when the house is messy.

In the FIRO model, Shawn's demand for cleanliness relates to the first level of interaction or inclusion.  Does Shawn view himself as part of the family with Kerrie and their children to participate in cleaning? Once the inclusion question is settled, then this couple can address their "control" differences as seen in their rope climbing exercise and in Shawn withholding oral sex from Kerrie. The FIRO model purports that once the inclusion and control issues are agreed upon, then their intimacy issues will resolve themselves.  I think Shawn and Kerrie have potential to illustrate the FIRO model's effectiveness. 

Of course, it easy to play Monday morning quarterback about this episode of Sexual Healing. Dr. Berman's work clearly had an overall positive impact on all three couples. I just wonder if the positive changes would last in the long-term especially given the universal application and use of sex toys. All the couples deserve recognition for their willingness to invite viewers into the most intimate part of their lives.  I wish them all the best.