Talking About Sex. Learning Objectives. Learning Objectives. Assessing Preparation for talking about sex

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1 1 Talking About Sex Douglas Braun-Harvey, MFT,CST, CSTS The Harvey Institute 2 Learning Objectives Discuss current international conceptualizations of sexual health Define and summarize six fundamental principles of sexual health Measure current level of therapist comfort and willingness to engage in sexual health conversations Identify common therapist barriers to sexual health conversations Learning Objectives 3 Explain essential elements of effective psychotherapeutic sexual health conversations. Identify skills that increase confidence and willingness to engage in sexual health discussions in individual, couples, family and group psychotherapy. Choose sexual health conversation skills relevant to therapy for individual, couples and groups as well as intern training and ongoing clinical supervision. Formulate client development of a personal vision of their sexual health. 4 4 Assessing Preparation for talking about sex

2 5 What are the components of a sexual health conversation? Suspending Judgment about client sexual behavior 7 Suspending Judgment 8

3 9 World Health Organization Health Dimensions Spiritual Mental Physical Sexual 9 10 Inextricable element of human health 10 Sexual and Reproductive Health Problems Account for 18% of the total global burden of disease % of the Total Global Burden of Disease Among Reproductive Aged Women is from Sexual and Reproductive Health Problems

4 13 World Health Organization (2006) What is Sexual Health? 13 Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. 14 Sexual health requires a positive and respectful approach to sexuality and sexual relationships,the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. World Health Organization(2006) Not just the absence of disease Human sexuality is a positive part of being human Possibility of having pleasurable sexual experiences Safe Protects sexual rights declaration_of_sexual_rights_sep03_2014.pdf

5 17 Positive Sexual Rights Lifespan right to sexual pleasure and eroticism Right to sexual and gender expression Right to physical and emotional intimacy Right to engage in chosen sexual behavior 18 Negative Sexual Rights Freedom from sexual violence Freedom from STI's and unwanted pregnancy Freedom from exploitive sexual practices Freedom from sexual oppression and discrimination Freedom from fear, shame, and guilt related to sexual expression 19 mmmmmmm 20 Where do sexual health conversations happen? 20

6 21 Sexual Health Conversations Happen: Anytime At the last minute Anywhere At work With yourself conversation 22 Knowing one's own relationship with Sexual How Did Sexual Health in Drug and Alcohol Treatment Come Knowing One's Own Relationship with Sexual Health 24 What are professional barriers to sexual health conversation in psychotherapy?

7 25 26 Therapist Verbal and Non-Verbal Avoidant Patterns in Discussing Sexuality 27 The Six S's: 1. Silence 2. Silliness 3. Shame 4. Shyness 5. Suppression 6. Superstition 28 The Six S's: 1. Silence Retreat from interaction is preferable to risking an intervention Awkwardness Defensiveness Conflict with client

8 29 The Six S's: 1. Silence Competing priorities between personal honesty, privacy, secrecy, and self disclosure decorum. 30 The Six S's: 2. Silliness Humor, innuendo, smirks, smiles, and laughter to avoid straight forward sex talk. Models silliness as primary entree into sex talk. The Six S's: 3. Shame Facial expression, action, or inaction can communicate shame. Therapist may think that the client needs to sense disapproval to discourage the client form engaging in a specific sexual activity The Six S's: 3. Shame Client unexpected discussion about sex may activate therapist disgust, anger, contempt, or rage What outlets are useful for therapists having these feelings?

9 33 The Six S's: 3. Shame Reappraisal may be especially effective in regulating verbal distress when exposed to disgusting cues in the environment. Olatunji, B. O., Berg, H. E., & Zhao, Z. (2015). Emotion regulation of fear and disgust: differential effects of reappraisal and suppression. Cognition and Emotion, The Six S's: 3. Shame Supervision, sexuality training, and sex education is vital for processing feelings in a useful manner to decrease being bothered as much the next time. 35 The Six S's: 4. Shyness Blush, shake, begin shallow breathing, feel speechless or hesitate to say or do anything The Six S's: 4. Shyness When visible to client clinical focus may move from client's sexual concern and shift to counselors feelings Can discourage client from continuing to explore sexual matters 36

10 37 The Six S's: 5. Suppression Excluding sex talk, sexual thoughts, sexual memories, sexual behavior or sexual desires from therapy. 37 What notions might a therapist be operating under that would suppress sexuality discussions? 38 The Six S's: 5. Suppression Counselor anxiety. Collude with client motivation that avoids risk of therapist judgment. No clear invitation to counteract suppression. The Six S's: 6. Superstition Most of our understanding of human sexuality has been developed in the last 40 years Superstition reigns when data and facts are not available View sexuality in simplistic terms The Six S's: 6. Superstition An essential and specific way in which to function/behave sexually Close mindedness to overtures to collaborative discourse

11 41 Readiness 42 Exists along a continuum from not at all ready or perhaps even opposed to various degrees of uncertainty to the other end of the spectrum: ready, willing, and open to change Write down the sexual topic or issue you feel most confident about discussing with your clients

12 45 Write down the sexual topic or issue that comes up in your work and you do not feel confident about discussing with your clients 46 Ambivalence Unsure about interest, confidence, and readiness to address client sexual activity, worries or problems 47 Addressing sexuality with clients? What are your mental attitudes and emotions about sex? 48 Family Therapist Comfort With and Willingness To Discuss Client Sexuality Harris, S. M., & Hays, K. W. (2008). Family therapist comfort with and willingness to discuss client sexuality. Journal of marital and family therapy, 34(2),

13 49 "Most health professionals, regardless of discipline, lack sufficient preparation to be considered competent in addressing sexual concerns" (Harris & Hays, 2008, p. 240) "Mental health professionals need to maintain an accurate knowledge base about human sexuality" (Harris & Hays, 2008, p. 240) 50 Therapist anxiety and reactivity when combined with client anxiety and reactivity to discussing sexuality contribute to an anxious-avoidant pattern in response to sexual health issues in therapy. Clients need a non-anxious/non-avoidant informed therapist to initiate sexual health assessment and clinical treatment interventions. Harris, S. M., & Hays, K. W. (2008). Family therapist comfort with and willingness to discuss client sexuality. Journal of marital and family therapy, 34(2), Providers protect the therapeutic space for client curiosity and honest self-reflection when they avoid prematurely endorsing client or their own diagnostic conclusions. Maintaining a nonjudgmental stance is difficult when faced with sociocultural forces or client distress. Braun-Harvey, D. (2015). Treating out of control sexual behavior: rethinking sex addiction. Springer Publishing Company. 52 Principles

14 Protected from STI s, Shared HIV Values and Pleasure unplanned Honest pregnancy Nonexploitive 53 Comfort Consent Sexual Health Consent Consent and a Cup of Tea 56 "if you give a woman, or a man for that matter, without his or her knowledge, a drug, and then have sex with that person without consent, that's rape. And I think this country, any civilized country, should have no tolerance for rape."

15 57 57 Nonexploitive 58 Psychological Exploitation Conceal aggressive intentions and behaviors. Know the psychological vulnerabilities of the the other person to determine which tactics are likely to be the most effective. Have a sufficient level of ruthlessness to have no qualms about causing harm to the person if necessary. Simon, G. K., & Foley, K. (2011). In sheep's clothing. Tantor Media, Incorporated. 59 Honesty What sexuality questions or issues might it be difficult to be honest about?

16 61 61 Shared Values Societal values on sexuality? 62 Public Health Concern Private Family Matter Normal Developmental Process Moral Problem Ethical Problem What clinical issues are common within psychotherapy that may be values conflicts related to sexual health fundamentals?

17 Protected from STI s, Shared HIV Values and Pleasure unplanned Honest pregnancy Nonexploitive 65 Comfort Consent Sexual Health Protected from STI, HIV & Pregnancy PrEP 68 (pre-exposure prophylaxis) refers to an an6retroviral (ARV) drug that can be taken by an HIV nega6ve person before poten6al HIV exposure to reduce risk of HIV infec6on. Prophylaxis is simply taking medica5ons prior to germ or virus exposure to prevent infec5on. Taking Malaria pills before travel is an example. 68

18 69 69 "PrEP is my wake up call to a reality that I need to protect myself and stop pufng my life in others' hands." via Christopher Wilson Rochester, NY Colorado Contraceptive Initiative Teenagers and poor women were offered free contraception options to prevent pregnancy for over one year. 70 The birthrate for teenagers across the state plunged by 40 percent from 2009 to 2013, while teen abortions by 42 percent, according to the Colorado Department of Public Health and Environment

19 Pleasure 74 "Sexual health promotion programs for all groups, including youth and people with disabilities, should embody the reality that sexual pleasure and intimacy are strong motivating factors for sexual behavior and that sexual pleasure contributes to happiness and well-being." Knowledge of the body related to sexual response and sexual pleasure Pleasure Valuing sexual pleasure throughout the lifespan Sexual pleasure balanced with respect for rights of others Engage in sex in a safe and responsible manner Dermer, S., & Bachenberg, M. (2015). The importance of training marital, couple, and family therapists in sexual health. Australian and New Zealand Journal of Family Therapy, 36(4),

20 77 Sexual Health Conversation Sexual Health Language The ability to achieve sexual desire, arousal and orgasm Sexual Functioning 80 The way in which one participates in or engages in a sex act with oneself or another Sexual Behavior

21 81 Individual acts engaged in, including, but not limited to, fantasy, embracing, caressing, masturbation, kissing, oral-genital stimulation, oral-anal stimulation, anal intercourse, and vaginal intercourse Sexual Activities 82 A sequence of physical and emotional changes that occur as a person becomes sexually aroused and participates in sexually stimulating activities Sexual Response 83 Positively valued feelings induced by sexual stimuli Sexual Pleasure 84 A peak of sexual pleasure characterized by a general euphoric sensation and physical or emotional release. Orgasm

22 85 Positive regard for and confidence in the capacity to experience one s sexuality in a satisfying and enjoyable way. Sexual Self-Esteem 86 Sexual Health Conversation Fundamentals How Did Sexual Health in Drug and Alcohol Treatment Come Counterbalance to the commonly focused upon perils of sex How Did Sexual Health in Drug and Alcohol Treatment Come How Did Sexual Health in Drug and Alcohol Treatment Come 88 Affirming Sexual Pleasure

23 89 Credibility established through affirming dangers of sex Sexual health is a balance between pleasure and safety Rewarding experience of sex is How Did Sexual Health pleasure in Drug and Alcohol Treatment Come Sexual pleasure is a positive force in the world 92

24 93 Pleasure is an important motivation for sex Sexual Health is Central to Overall Health How Did Sexual Health in Drug and Alcohol Treatment Come Sexuality affects every aspect of every How Did Sexual Health therapy in Drug and Alcohol Treatment modality Come Not a rare topic for therapy How Did Sexual Health in Drug and Alcohol Treatment Come 96

25 97 Client Behavior Attempt to Address Sexual Worry How Did Sexual Health in Drug and Alcohol Treatment Come Honorable attempt to solve a sexual How Did Sexual Health concern in Drug and Alcohol Treatment Come Focus on Client Motivation How Did Sexual Health in Drug and Alcohol Treatment Come Create an environment for motivating How Did Sexual Health change in Drug and Alcohol Treatment Come 100

26 101 What sexual issues are motivating the person How Did Sexual Health towards in Drug and Alcohol Treatment change? Come Client voices their argument for How Did Sexual change Health (Miller and in Drug Rollick, 2002) and Alcohol Treatment Come 102 Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: preparing people for change New York: Guilford Press Google Scholar. 103 Sexual values, ethics, and boundaries How Did Sexual are Health important in Drug and Alcohol Treatment motivators. Come Focus on incongruence between current behavior and sexual health goals 104

27 105 Place confidence in transformative potential of a clients sexual values Sexual Health Skills for Interns and Supervisees Pronouns Professionalism and loss of personal security 108

28 109 Empathize/ Accept with profound discomfort 109 Talking About Sex 110 Douglas Braun-Harvey, MFT,CST, CSTS The Harvey Institute Thank You for Joining in the Sexual Health Conversation