These guidelines are for the support and guidance of Psychotherapists and Psychotherapeutic Counsellors who may encounter clients with issues and concerns relating to gender and sexuality in the course of their work.
Training in Psychotherapy and Psychotherapeutic Counselling may not routinely address gender and sexuality issues, so they may be overlooked in the work with clients. These Guidelines aim to encourage the development of interest and knowledge in this field, to raise awareness of obstacles for the therapist in addressing these issues with clients, and to give suggestions of possible referral routes where that seems appropriate. Equally we would encourage therapists from any modality to expand their knowledge, skills and professional development by seeking out psychosexual and relationship therapy workshops or short courses. The COSRT website provides all the current information of their approved workshops on the home page. www.cosrt.org.uk.
Raising Awareness of Personal Attitudes
One of the major obstacles to addressing gender and sexuality with clients lies in the conscious and unconscious resistance within the therapist. Personal attitudes, opinion, and judgements may contribute to discomfort in addressing the field at all. Investigating and exploring these aspects of the therapist might be an important part of opening up the topic for further learning. Personal therapy, development groups, sexuality awareness groups might be indicated to help with this and increase the therapist’s understanding of the importance of raising awareness of their own attitudes, prejudices and discomforts, and understand how their own psychosocial and psychosexual histories impact on their relationships generally, but particularly with clients.
According to the World Health Organisation’s current working definition, 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. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as 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.” (WHO, 2006a)
Commendable though this statement is, it does not have a realistic understanding of the lives of many people outside a western centric perspective. It describes a sexual Utopia where the sexual and general rights of lesbian, bisexual, gay, queer, and trans / gender variant communities, as much as those of heterosexual men, women and children, from all ethnicities, cultures and religions are considered and respected. In reality the influence of sexual, cultural and religious, socio-economic and ethnic mores in each country and its culture are the basis of what creates “a state of physical, emotional, mental and social well-being in relation to sexuality”, or the opposite, a picture of intolerance which may lead to a person’s persecution, abuse and even death.
In addition gender and socio-economic inequality and other factors such as cultural practices, can lead to compromises in safer sex and /or contraception, the shame and stigma of STI’s and HIV, the economic hardship of over large and often under-fed families, as well as maternal deaths from lack of medical facilities.
Ways in which Gender and Sexuality Issues may present
Clients rarely open these topics in therapy directly; they test the field with the therapist in order to decide if this is a safe place to talk about it or not. If the therapist cannot read the cues, or is uncomfortable talking about gender and sexuality and so does not raise the matter, it is often assumed by the client that it cannot be included, may even be forbidden, perhaps thus creating or confirming beliefs about their desires and sense of sexual and/or gendered self being wrong. It is the responsibility of the therapist to develop more consciousness of sexuality and gender, and to feel comfortable to – albeit very tentatively – introduce these issues if the client cannot.
Clues that there may be an issue lie in the body language and posture, the account of current intimate events or life history, or indeed the avoidance of so doing, the presentation of childhood trauma, the levels of shame and anxiety, and the hesitation in what and how is presented. There may be difficulty in addressing life cycle transitions, where emotional development may appear to present at a much younger stage of development than chronologically appropriate. The importance of psychosomatic symptoms such as minor physical ailments may also signify that there is an underlying gender and sexuality concern.
Clients bring a range of issues including childhood trauma, neglect or abuse. Any traumatic event may interrupt the development of healthy sexuality, leaving the individual with a sense of alienation, of feeling different to their peers, being earlier or later in developing sexually, perhaps feeling as though their childhood was stolen or they are like a child among adults, or experiencing guilt as though this was their fault, even having a ‘spoiled identity’ (Goffman,1964).
Some seeking psychotherapeutic help come from ethnic minority backgrounds or other countries where they experienced traumatic events to their family, and survived individual or cultural factors such as war, re-location, and bereavements; they may have sexual sequelae in addition to their other emotional and psychological suffering. In working with any clients it is important for the therapist to make sensitive enquiry as to the existence of any such feelings around their gender and sexuality, and if this transpires to be the case, then in the same way that a therapist without specific trauma training might look for an EMDR specialist, so the non-psychosexually trained therapist may need to consider if this work falls ethically in their range of skills and training, or if they need to seek specialist supervision, possibly even refer the client on. We would always encourage a therapist to seek specialist supervision, unless it is evidently ethically and professionally inappropriate to continue the work, in order to avoid disturbing the therapeutic alliance, particularly with clients whose previous relationships have involved the breaking of trust and betrayal perhaps leading to an expectation of abuse and/or rejection and disappointment.
Sex and gender
Therapists as much as any other person are often confused between the terms, ‘sex’ and ‘gender’; possibly the easiest way to think of them are embodied and non-embodied respectively. Sex may be seen as referring to the biological genitalia and reproductive organs including sex chromosomes and hormones. One view is that gender is a psychosocial construct not located in the body, a virtual reality in that it is created by the societal mores and expectations of the culture in which a person lives. Generally talk about traditional family values could be translated as being patriarchal, where gender defines your role, your power, and life style based on your biological sex. In non-western countries this can appear more overt but exists in folk memory in many countries nearer home. This rigid binary division could be described as static, where unless there is a sudden seismic shift in economics e.g. necessitating women to leave the home to work, or collective outlook – such as educating girls as well as boys, or national disaster such as war – there may not be any change in gender expectations in many generations. This was seen in Italy after WW2, and Spain and Portugal after the eras of Franco and Salazar; “All sorts of movements appeared: women’s movements, gay liberation movements, ecology movements. A mood spread of challenging everything, of wanting to know about and discuss everything that was banned under the old regime” (www.themilitant.com/2005/6919/691950.htm) However in the UK there is still inequality in pay between men and women, women do more housework and childcare, and marriage and having a family is still the norm for the majority of people, so ‘traditional’ or gendered values are still in place albeit watered down, covertly present as normalised and masking the lack of parity for many women.
While definitions of male and female are based on the presumed but physiologically inaccurate binary of physiological and biological sex, what each person considers masculine and feminine in areas such as clothes, interests, employment, interpersonal relationships, proper and improper behaviour are consciously and unconsciously ‘gendered’ firstly by the individual, secondly their family and those people closest around them, thirdly the society in which they live. We internalise the values we grow up amongst, and even if as adults we subsequently reject them, they usually remain like the underlying melody in a fugue, returning in different keys as a reminder.
Cisgender is a term used to describe someone whose gender identity corresponds with the sex they were assigned at birth. Transgender, as an umbrella term, covers a much wider spectrum of gender variance but basically can be defined as people who experience a difference between their gender identity and their assigned biological sex, but this should not be considered in pathological terms as a disorder unless it is causing distress to the individual.
Not all trans identifying people experience body dysphoria. Advances in transgender rights, which allow a person to live in their gender identity without psychiatric diagnosis or receiving medical intervention, have increased the number of trans people who choose to socially transition, which is to assert one’s identity legally, in relationships with others and in one’s social and public role. Some, but by no means all, transgender people wish to transition through hormones and possibly medical intervention to take on the physical characteristics of the preferred gender. The term “transsexual” is regarded by many to be continuing an oppressive narrative wherein gender variance was only thought to be “real” if the person submitted to medical interventions. Therefore, it is not an appropriate term to use unless you are asked specifically by a person who identifies themselves as transsexual to use that term in relationship to that specific person’s identity.
Gender variance, Non-Binary or gender nonconforming is a wide spectrum and should not necessarily be thought of as a continuation or replica of the cisgender binary division, while ‘fluid sexuality’ allows partner choice to be equally as varied. It must equally be remembered that some people prefer the term ‘non-trans’ in the belief that it allows sexuality definitions such as lesbian , bisexual, gay, queer, polyamorous, asexual and pansexual to have recognition of their sexual validity without the gender expectations or binary division of cisgender or of monosexual identities. This extends into the understanding of bisexuality as attraction to people of the same sex as oneself and to people of other sex to oneself, and not the commonly mistaken definition of “attracted to men and women” which makes the same error of perceiving gender as binary.
Another category of gender variance or nonconformity is that known as inter-sex, which may apply to biological or psychosocial aetiology or both. Due to chromosome abnormalities in utero some babies can be genitally ambiguous at birth such as having a large clitoris and fused labia, or micro penis, or they may also lack defining biological attributes to be accorded a clear definition.These babies are referred to as inter-sex, and while often medically assigned a gender at birth, do not always identify with it when growing up. Some children grow up to accept their non-binary status and have no wish to have medical/hormonal intervention or surgery so then inter-sex can also be used as a term to describe gender nonconformity or variance. However many children are subjected to non-consensual medical and surgical interventions that can create huge problems physically, as well as mentally and emotionally, later in life In 2015 Nils Muižnieks, the Commissioner for Human Rights of the Council of Europe published an important paper called “Human Rights and Intersex People” in which he states: “It is urgent to end unnecessary medical treatment and surgery of intersex individuals without their consent; to respect their right not to undergo sex assignment treatment; to review medical classifications which treat variations in sex characteristics as a pathology; and to ensure intersex persons’ right to self-determination by facilitating their legal recognition in official documents…” This involuntary assignation of gender hopefully will become obsolete with innovations in genetics, and increasing knowledge through education and understanding about inter-sex.
Although Australia is among the countries that have added X to the traditional M and F gender choices in passports and other identification documents, and in 2013 Germany introduced the category of ‘ indeterminate gender’ to the birth certificates of babies with characteristics of both sexes, in the UK there are still legal challenges such as which prison they should be sent to. While gender neutral public lavatories are becoming more common this does not yet permeate every aspect of daily living. It is important therefore to understand that trans and inter-sex has not been fully assimilated or accommodated as a valid human condition in our country, let alone in the world.
While it is important as a therapist to have awareness of what terms such as transgender, gender variant, gender non-conformist and inter-sex mean in the context of peoples’ identity, only if someone is troubled by this should pathology enter the frame. There is however a necessity to understand that the stigma that can be experienced as a result of being ‘different’ may lead to minority stress which is based in societally generated and discriminatory attitudes to the gender variant and gender non-conformist, and may lead to depression and anxiety. Language is always evolving but at present many in the trans community prefer the gender non-defining ‘they’ to ‘he’ or ‘she’. Therapists need to be respectful of such issues and to consider the need to seek specific training in this field before seeing trans or inter-sex clients, although equally to remember that gender variance may not be the reason for a client seeking therapy but problems experienced by all humanity such as bereavement or family problems, work or partner difficulties.
The LBGTQI ( lesbian, bisexual, gay, trans, queer and inter-sex ) communities have reached legal and marital equivalence with those of the heterosexual over the past fifty years in some countries but those which continue to imprison or execute LBGTQI people outnumber countries with equality legislation by 4 to 1. Only 1 in 5 European countries recognise marriage equality, and where this has become available it is still tenuous where the conservative members of government continue to discuss whether this advance should be regressed in order to restore ‘traditional values’. Free and safe movement in the world is still deeply restricted for gender and sexual minorities and the atrocities experienced in other countries should not be regarded as having any less impact on LGBTQI people simply because they are geographically distant. LGBTQI people are also subject can be equally subject to minority stress when sexual and relationship difference from the heterosexual majority is regarded with prejudice – for example by religious parents.
It is important for all therapists, although probably more so for heterosexual therapists, to challenge their own possible biases and check their own belief system, and possibly seek further training; saying ‘I treat everybody the same’ is not a reflective position! Equally important is the fact that the LBGTQI communities are not a homogenous mass; as in the heterosexual world there are many varieties of sexual and relationship preference, so it is important for any therapist to be comfortable with anything the client brings from chemsex to celibacy. However awareness of the possibility of internalised homophobia, biphobia and transphobia is important as there may be psychosexual problems arising from anxiety and stress. As for any client, these can include for males erection and ejaculation/ orgasm difficulties, while women may experience partial or total loss of desire and arousal, leading to problems with intercourse due to this, and ensuing probable lack of orgasm. Exploring these feelings and fears can lead to a reduction in these sexual symptoms, although knowing when to refer to a psychosexual therapist may lead to the optimum sexual outcome. Kink and BDSM
The world of kink and bondage/discipline, dominance/submission and sado/masochism (BDSM) is specialised in a very different way from gender and sexuality, and to be a kink-aware therapist rather than only kink-friendly really needs specialist training. There is a danger in pathologising but equally a need to understand the difference between the consensual boundaries of BDSM and abuse. We have listed recommended reading and training resources at the end of these guidelines.
Female Genital Mutilation (FGM)
According to NHS Choices (http://www.nhs.uk/NHSEngland/AboutNHSservices/sexual-health-services/Pag…) FGM is a large and complex subject which needs addressing in far more detail than is possible here. It is defined by the World Health Organization (WHO) as procedures that include the partial or total removal of the external female genital organs for cultural or other non-therapeutic reasons. There are four main types of FGM as follows:
Type 1 – clitoridectomy – removing part or all of the clitoris.
Type 2 – excision – removing part or all of the clitoris and the inner labia (lips that surround the vagina), with or without removal of the labia majora (larger outer lips).
Type 3 – infibulation – narrowing of the vaginal opening by creating a seal, formed by cutting and repositioning the labia.
Other harmful procedures to the female genitals, which include pricking, piercing, cutting, scraping and burning the area. Despite the very real physical, psychological and emotional damage this causes for many women, FGM remains a very challenging subject involving religion, culture, gender, ethnicity, the law and politics. It will be interesting to see if the young girls from various ethnic backgrounds, who are currently considered at risk of parental consent to illegal FGM by UK authorities, will present with any signs of FGM when they reach marriageable age and become pregnant.
FGM is also known as female circumcision, and due to the very real horror stories of it being frequently performed by medically untrained people, often women known to the girl, without anaesthetic or sterilisation, or proper aftercare, it often obscures the importance of the effects of male circumcision. This may equally be medically dangerous, and as fervently defended by its proponents through all the same issues of religion, culture, gender, ethnicity, the law and politics and result in psychological disturbance as well as lasting psychosexual harm.
Finally there is an irony that while FGM is illegal, cosmetic practices such as labioplasty are not, and have become increasingly sought after by young western women, possibly as an indirect result of online pornography creating body dysmorphia due to partner expectations of how a woman should look.
Disability, whether genetic, through illness or from an accident, may prevent sexual function but not necessarily feelings of desire. It is important for the therapist to appreciate the possible need for intimacy of someone whose disability may create sexual problems along a spectrum from mild arthritis to severe as in paraplegia. Unfortunately all too frequently health professionals overlook, even ignore, the sexual and relationship aspects being part of someone’s care, particularly if the person is middle aged or older. It is the duty of the therapist to be able to explore these aspects of their clients’ lives. Therefore it behoves therapists to learn about the sexual aspects inherent in their client’s condition, or arising from their treatment. Cancer, MS, Parkinson’s disease, heart disease, diabetes are all conditions that most of are familiar with, have known someone to have, yet all have specific symptoms and/or treatments that may create psychosexual difficulties, and by entering fully and holistically into the client’s world a therapist may enable a client to explore and grieve the loss of a functioning sexuality. This may equally allow therapeutically the opportunity for referral to a psychosexual therapist unless some research and /or training has been undertaken, or specialist supervision sought.
Therapists who work with people with learning difficulties may experience the conflicting feelings of their families and carers, as well as their own, towards the client’s sexuality. Often it is left unacknowledged and the client – whose cognitive abilities and understanding might be at a far younger stage than their chronological age – may be treated like a naughty child for masturbating rather than a frustrated sexual and hormonal adult. In turn this may raise conflicting feelings for the therapist possibly triggering off counter-transferential issues around adult autonomy versus childhood dependence. Any assessment or work with people with learning difficulties would of course fall within the remit of the Mental Capacity Act of 2005.
Heal or Cure – Holding the tension
Within psychosexual therapy it may not be possible to offer a natural or medical ‘cure’ for a presenting problem. For example the diabetic who presents with erectile difficulties or failure may never have a spontaneous erection again but will always need medication, or the man whose penis has become unable to penetrate due its curvature from Peyronie’s disease may not benefit from any medical intervention. There may not be a happy sexual ending for the woman who is suffering with extreme effects of birth trauma or cancer treatment. Emotional healing through psychosexual psychotherapy may not only also be required but may offer the only option. Thus sex therapy often works from a two pronged approach looking at both healing and curing. It is ethically right to offer the client with a physical difficulty a medical intervention if there is one, which will, with some immediacy, address the ‘presenting problem’, but staying with the sexual bereavement of a client without further physical or pharmacological input is equally important.
Psychosexual therapy is no longer the behavioural and medical model of the 1960’s but has developed to include components from psychodynamic, cognitive-behavioural and systemic therapy while humanistic integrative/existential approaches may also be integrated if part of a therapist’s training. Therefore it is a multi-faceted model which explores the client’s psyche as much as sets tasks for sexual difficulties, which are often regarded as symptoms of the former rather than discrete entities. History taking – psychosocial and psychosexual – is essential as not only may trauma be part of a client’s difficulties but many people still do not have a real understanding of the physical aspects of their sexual function, nor the effect of anxiety on it. Taking a history may also relieve the natural embarrassment many clients experience when first talking openly about sex and sexual problems. Therefore a reparative, educative and normative approach is intrinsic in psychosexual therapy.
Tasks may be set, masturbatory exercises for erection and ejaculation problems in men or orgasmic difficulties in women, self-exploratory exercises for women with vaginismus, couple exercises starting with communication and leading to non-genital touching for couples with inter-personal dialogic and sexual problems. Reading and exercises to improve communication, empathy and understanding may be suggested and encouraged. Reluctance and non-compliance is as much part of the work as successful completion and outcomes. Length of therapy as in mainstream psychotherapy and psychotherapeutic counselling may depend on whether the client is being seen privately or in an agency or the NHS, but the combination of practical and psychological therapy often results in the physical and hopefully emotional /psychological aspect of a sexual difficulty being resolved in a relatively short number of sessions.
This is a very brief overview at how the issues of sexuality and gender may arise in a challenging way for the therapist. We hope that therapists may consider their own relationship to sexuality and gender both personally and professionally, and that of their clients. Knowing when to seek extra training or specialised supervision and realising when one is outside one’s level of competence is an integral part of being a reflective practitioner, whether this is to do with areas such as addiction, anger management or trauma, and thus similarly with sexuality and gender issues.
Psychosexual therapists equally need to know when to refer on and referrals for medical assessment may include the client’s GP or, depending on the issue, seeking help from a gynaecologist, urologist, neurologist, oncologist or psychiatrist. Therefore it is important for any type of therapist to recognise when there are possibilities to help a client overcome sexual and /or gender issues and to consider if this falls within your area of competence and knowledge. Therapists are as much influenced by cultural and societal sexual mores as anyone else, and if these have not been explored in training, may be blind to the sexual and gendered needs of clients being an integral part of their presenting problems, even if unspoken. Eros is as much part of us as Thanatos but seems at times as big a taboo. Exploring phenomenologically may be helpful for the client to start voicing their lived experience, but needs a therapist to be comfortable with their own sexuality and gender identity. It is too easy to excise parts of the client’s personhood, and not see them in a holistic way, and since the therapist usually holds the superior position in the power hierarchy, thus unwittingly silence the client. This can lead to a client’s needs not being voiced or met in therapy which may last some years without touching on an intrinsic part of their intra-psychic and interpersonal issues. The WHO defines sexuality and gender as being:
“…a central aspect of being human throughout life (that) encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious and spiritual factors.” (WHO, 2006a)
It is therefore a therapeutic duty to acknowledge this integral aspect of humanity, to even celebrate it through respect and recognition that although a client’s experience of sexuality and gender may be very different to our own, it is equally as valid.
Here follows a check list of common sexual difficulties in Appendix 1 and a list of training providers and support groups in Appendix 2.
Sexual Presenting Symptoms
The most recent definitions from the DSM-5 and ICD-10 classifications are listed below for information:
Delayed Ejaculation, Erectile Disorder, Female Orgasmic Disorder, Female Sexual Interest/Arousal Disorder, Genito-Pelvic Pain, Penetration Disorder, Male Hypoactive Sexual Desire Disorder, Other specified Sexual Dysfunction, Premature Early Ejaculation, Unspecified Sexual Dysfunction
Some of the most commonly presented problems and issues are as follows; this list is by no means exhaustive but gives the reader an indication of the type of work undertaken by psychosexual and relationship therapists, and of how therapists from other modalities might wish to inform their own work.
Dyspareunia – pain upon penetration – male: May create problems for men who have anal intercourse,
An-ejaculation – total absence of ejaculation (global) Delayed ejaculation difficulties – maybe in masturbation and/or exclusive to penetrative/partner sex
Inhibited ejaculation – may not be able to achieve ejaculation (situational)
Premature Early Ejaculation – Ejaculation usually within one minute of stimulation (male)
Retrograde ejaculation – the man experiences orgasm but the seminal fluid pumps backwards into the bladder rather than out through the penis
(formerly known as impotence) men who are unable to achieve or maintain an erection hard enough for penetration, this may be primary or secondary, situational or global
Female orgasmic disorder The inability to achieve orgasm, this may be with partner sex or alone
Genito-Pelvic Pain Disorder/ Penetration Disorder –
Re-defined by the DSM in 2013 this female category covers
Dyspareunia – pain upon penetration making intercourse difficult; it can be either superficial i.e. pain in the vulval area or deep i.e. pain in the pelvic area (female)
Vaginismus – spasm of the vaginal muscles often preventing any penetration. It ranges from women having mild to very severe penetration problems in using a tampon, inserting a finger, undergoing a vaginal examination or having intercourse. It can be primary or early on-set, as in always having had this inability to tolerate penetration, and where the aetiology is often unknown, or secondary or late on-set, where some event has triggered this response, global or situational, which is usually an emotional psychosomatic response.
Vestibulodynia formerly known as vulvar vestibulitis.
Other vulvar conditions such as lichen sclerosis, thrush or interstitial cystitis
ISD (Inhibited or reduced sexual desire) in both men and women. The absence of desire which can be long standing or a relatively new phenomenon
The causes of the above may be either psychological/emotional or physical or both.
Medical Aspects of Sexual Problems
Physical causes may include:
Neurological illness – ie Multiple sclerosis, Parkinson’s disease
Reduced blood flow or occlusive disorder
Side effects of prescribed medication
Spinal cord injury
Neurological illness ie Multiple sclerosis, Parkinson’s disease
Painful scar tissue
Postpartum problems – psychological/emotional and physical
Side effects of prescribed medication
Spinal cord injury
Emotional/psychological causes may include:
Culture / religion
Gender and/or sexuality issues
Inappropriate or absent sex education
Low self esteem
Stress & anxiety which is either work related or home related
Survivors of abuse and neglect
The College for Sexual and Relationship Therapists (COSRT) If seeking specialist supervision/ consultation – COSRT has a register of accredited supervisors Referral for sexual and relationship therapy – COSRT has a register of accredited psychosexual therapists Telephone: 020 8543 2707 http://www.cosrt.org.uk Email: firstname.lastname@example.org
Pink Therapy is the UK’s leading provider of continual professional development, training, clinical supervision and consultation for therapists or trainees who work with, or would like to work with, gender and sexual diversity clients including Kink. Telephone: 020 7836 6647 Email: email@example.com http://www.pinktherapy.com/
Gendered Intelligence work predominantly with the trans community and those who impact on trans lives, offering support, and trans awareness training Telephone: 0207 832 5848 http://genderedintelligence.co.uk
The World Professional Association for Transgender Health (WPATH), formerly known as the Harry Benjamin International Gender Dysphoria Association (HBIGDA), is a non-profit, interdisciplinary professional and educational organization devoted to transgender health. See ‘Standards of Care’ 7thversion http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351&pk_a…
The Beaumont Society is a national self help body run by and for the transgender community who welcome all transgender people and their partners. www.beaumontsociety.org.uk
Oganisation Intersex International http://oiiinternational.com
What You Need to Know about Working with Gender and Sexual Diversities- Pamela Gawler-Wright : Director of Training for BeeLeaf Institute for Contemporary Psychotherapy and a Trainer and Clinical Associate at Pink Therapy. Email: firstname.lastname@example.org