Abstract
Sexual
dysfunction affects the majority of couples at least once during their sexual
lifetime, yet many seem too embarrassed to seek counseling for such issues.
Individuals who are within the sexual minority population are less likely to
seek mental health services, for a myriad of reasons. The following paper will
address the case study of two lesbians, Sara and Amy, examining their chief
complaint of Sara’s lack of sexual interest, as well as the possible
contributing factors that may be present in their relationship. Finally, an
application of a biopsychosocial counseling approach will be applied, with some
suggested steps Sara and Amy can take to rekindle their sex life.
Working with couples through
relationship issues can often be an uncomfortable situation for the clients, as
they are sharing their most intimate details with a relative stranger. Providing
a welcoming atmosphere is essential to allow the clients to feel more at ease,
which may bring about a relaxed communication style that can help clients and
counselors work together in addressing the presenting issues.
For the purpose of the current counseling
plan, the relationship between Sara and Amy will be examined. The women, both
in their 30s, are experiencing a variety of stressors in their relationship,
some of which stem from their cultural backgrounds and also their current
economic status. Additionally, the challenges faced by sexual minorities are
accompanied by the fact that the two women are also from different racial
backgrounds, which may contribute to their current relationship turmoil.
The counseling plan and evaluation
of the couple will include both individual assessments, as well as collective,
since they are in a relationship which they desire to preserve. While Sara was
the initial client suggesting the need for counseling in the relationship, and
as such will be the primary client addressed in the counseling plan, Amy’s
attitude towards obtaining counseling services is important to examine, as it
may provide insight into the dynamics of the relationship.
Assessment of
Sexual Issues
Sexual issues in relationships
happen for a myriad of reasons, and while usually portrayed as a heterosexual
problem in the media, it also affects gay and lesbian relationships. While the
issues may differ, as erectile dysfunction does not apply to Sara and Amy’s
relationship, they do face some rather common sexual issues. Lack of sexual
desire is one of the most common sexual dysfunctions reported in lesbian
couples, which has spurred the development of the term “Lesbian Bed Death” to
refer to the decrease in sexual activity (Hacioglu, Cosut, & Yildirim,
2011). While limited information is available regarding lesbian specific sexual
disorders, a decrease in sexual desire, combined with external stressors and
hormonal changes can contribute to a decrease in overall sexual activity
(Hacioglu, Cosut, & Yildirim, 2011).
Female
Sexual Disorders in Lesbian Relationships
Much
of the previous research that has sought to discover the unique aspects of the
female
sexual disorders that may occur, have centered around primarily women in
heterosexual relationships. The Masters and Johnson (1966) model of the sexual
response cycle offered a good starting point and was effective in addressing
the sexual disorders present in individuals, but the four stage model proposed
by Masters and Johnson (1966) does not appear to be applicable in lesbian
relationships. Research findings suggest that there is a larger difference
between the techniques and disorders that occur in heterosexual women and
lesbians, than between heterosexual and gay men (Tiefer, 1995).
Instead of the four stage model
proposed by Masters and Johnson (1966), which includes the excitement, plateau,
orgasmic, and resolution phases (with the latter added by Helen Kaplan in 1979),
a more applicable model to consult would be the nonlinear sexual response cycle
developed by Joanne Loulan in the 1980s. Loulan suggested that the female
sexual response cycle should start with “willingness,” instead of excitement,
and end with “pleasure,” instead of orgasm (Loulan, 1984).
Considered to be feminist in approach,
Loulan’s theory suggests that sexual desire can be influenced by “unexpressed
feeling towards one’s partner” (Loulan, 1984). The desire that appears to be
lacking between Sara and Amy could be contributed to the underlying issues
present in their relationship. Additionally, a more recent theory posited by Rosemary
Basson (2007) has expanded upon Loulan’s theory to address low sexual desire
within lesbian couples.
The
Basson model is more holistic in examining the possible causes of sexual
dysfunction, which encompasses emotional intimacy, sexual stimuli, and
relationship satisfaction (Basson, 2007). Within lesbian couples, the drive and
motivation for sexual activities stem from a desire for intimacy (Basson,
2007), instead of lust as seen in the more traditional models of sexual
response. If one of the women in a lesbian relationship loses sexual desire, in
the present case that would be Sara, Basson suggests that the woman who still
maintains a high sexual desire for their partner, which would be Amy, a feeling
of rejection can be experienced (Bigner & Wetchler, 2012) , and is
consistent with Sara’s presenting information provided. Additional research has
supported the dysfunction finding regarding the inequality in sexual desire is
a more common occurrence in lesbian relationships as compared to heterosexual
women (Nichols, 2005).
Stress and Sexual Dysfunction
Same-sex relationships often incur
additional stress on top of the common daily events that may arise. While the
economic downsizing may not discriminate depending on sexual orientation, the
changes in employment experienced by Sara may have increased her current level
of stress that was attributed to being part of a sexual minority relationship.
Studies have suggested that one of the biggest differences between the
experience of stress found within same-sex and heterosexual couples is that
same-sex couples may find themselves in a community that may marginalize their
relationship (Mohr & Daly, 2008).
Complicating
matters is that stress can come from both internal and external factors, which
have been linked to a diminished psychosocial functioning within same-sex
couples (Mohr & Daly, 2008). External stressors can include discrimination,
prejudice, violence, and hate crimes, while internal factors can stem from
internalized homophobia, concealing of their sexual identity within their
social circle, and fear of rejection from society (Derlega et al., 2011). Amy
and Sara are may also be experiencing an additional stressor due to their
interracial status, and are considered to be susceptible to experiencing
multiple marginalized relational identities (Rostosky, Riggle, Savage, Roberts,
& Singletary, 2008). The compounding stress may be a contributing factor to
Sara’s report of “sex being one of the last things she wants to do when she
comes home.” Conflict and difficulties communicating have also been cited as a
significant cause of decreased sexual desire, which also leads back to the role
stress plays in sexual dysfunction. Additional contributing factors associated
with stress and its effect on a relationship includes fatigue, personal values,
and even religious beliefs (Shifren, Monz, Russo, Segreti, & Johannes, 2008),
which appear to be present in Sara’s life.
While
the prevalence of sexual dysfunctions related to stress peak in middle-aged
women (Shifren, Monz, Russo, Segreti, & Johannes, 2008), which neither Sara
nor Amy have reached at the current point, the role of stress should not be
ignored when examining the underlying causes for a decrease in sexual interest.
When evaluating for the presence of stress in Sara’s life, it would be
important to also screen for depression, as about 40% of individuals with a
sexual disorder, such as loss of sexual desire, have concurrent depression
(Rosen et al., 2009).
The Influence of
Attachment Styles in a Relationship
When examining the behavior of both
Sara and Amy, they each exhibit unique attitudes in how they relate to one
another. One such explanation for the differences may lie in the different
attachment styles each one possesses. While the majority of research into the
different attachment styles have been based on heterosexual relationships,
emerging studies have focused on the differences in attachment styles within
lesbian, gay, and bisexual populations. Same-sex relationships that fall within
the secure attachment realm, are characterized by an ability to effectively
handle negative emotions and to seek help from outside sources when necessary
(Wang, Schale, & Broz, 2010), which appear to be two attributes missing
from Sara and Amy’s relationship.
Anxious Attachment Style
An
anxious attachment style is usually hall-marked by a tendency to desire more
intimacy than they receive, fear being abandoned by their partners, and not
being loved in the manner that they desire (Horne & Biss, 2009). Such
traits can be seen in the behaviors exhibited by Amy (feeling of rejection,
frustration, wants more sex). Amy’s anger and feeling of rejection could also
stem from another attribution associated with an anxious attachment style,
namely being excessively reliant on the other individual to meet their needs,
and when those needs are not met, a high level of emotional reactivity may be
present (Derlega et al., 2011), which could explain Amy’s violent verbal
escalations. A lower sense of self-worth and self-confidence may also be
present in individuals with an anxious attachment style (Wang, Schale, &
Broz, 2010), which may contribute to Amy’s report of sadness regarding being
the one that usually has to initiate sex.
Avoidant Attachment Style
Contrasting
the anxious attachment style is the avoidant attachment style, which is
characterized by a feeling of being uncomfortable being close to others, find
trust difficult to establish in others, and become nervous when others become
too close (Simpson, 1990). Sara may fall within the avoidant attachment style,
since she has stated that she refrains from displaying affection with Amy outside
of the bedroom because she is scared of it leading to sex. Avoidant individuals
also typically express extreme levels of emotional and behavioral withdrawal
(Simpson, 1990), which could explain Sara’s role in the couple’s arguments, as
she typically avoids confronting Amy, preferring to revisit the topic at a
later time. Keeping physical and emotional distance when the couple experiences
relationship turmoil is also indicative of an avoidant attachment (Derlega et
al., 2011). Additionally, individuals with an avoidant attachment style are
also more likely to engage in sexual behaviors to fulfill relationship
obligations (Wang, Schale, & Broz, 2010), instead of pursuing sexual
relations based on desire. However, Sara’s behavior could also be attributed to
shyness, rather than an avoidant attachment style, which also includes social
avoidance despite the desire for close relationships (Scholz, 2009). Further
investigation would be necessary to discern which would be most applicable to
Sara’s case.
Religion and
Homosexuality
The religious backgrounds of an
individual have the capacity to influence one’s outlook on both how they view
society’s norms, as well as how they view themselves. Religion often dictates
what is acceptable, and if one’s behavior is to fall outside the boundaries of
normal, there are often consequences associated with violating the rules set
forth, including ostracization and even death, with the latter being associated
with many Muslim nations (Adamczyk & Pitt, 2009). The role of religion in
developing views regarding sexual orientation and gender roles is not to be
dismissed, as previous studies have found that religion is one of the strongest
influences in the United States as it pertains to attitudes towards homosexuality
(Adamczyk & Pitt, 2009).
Effects of Religious Influences
Sara’s childhood, which consisted of
a very conservative and religious nature, has shaped who she is in the current
day. The idea that her personal identification as a lesbian woman contradicts
what she was raised to believe as the role adult women should play. Most
religions categorize same-sex relationships as a sin, unnatural, and impure,
with frequent exposure to religious material being associated with a higher
level of homophobic attitudes (Adamczyk & Pitt, 2009). The inability of
Sara’s parents to recognize her relationship with Amy could lead to further
internal stress, primarily internalized homophobia.
Internalized homophobia is described
as a form of minority stress, which stems from a conflict between the
attraction and desire for same-sex relationships, yet maintain a desire to also
be heterosexual (Frost & Meyer, 2009). In Sara’s case, she identifies as a
lesbian and is in a sexual relationship with Amy, yet may experience a deep
desire to be a heterosexual, as she may be more readily accepted by her family.
The idea that a large part of who Sara is as a person is not accepted by her
family may lead her to experience depressive symptoms and a diminished
relationship quality with her partner (Frost & Meyer, 2009).
Religion also influences the act of
masturbation, which Sara reports as something she does not engage in
practicing, rather preferring sex with her partner Amy instead. While it is
unclear exactly which denomination Sara’s family identifies as, according to
the Catholic religion, masturbation is considered a sin, and that “the
deliberate use of the sexual faculty, for whatever reason, outside of marriage
is essentially contrary to its purpose,” which also applies to self-fulfillment
via masturbatory action (Fisher, 2013).
While Sara may not personally
identify with being necessarily religious, her upbringing, in addition to the
disapproval of her lifestyle by her family, may contribute greatly to her
experience of personal distress. Sara’s low sexual desire, may also contribute
to her sexually related personal distress, which is believed to be intensified
when there is a mismatch in sexual drive with a partner (Rosen et al., 2009). The
inner conflict could also potentially drive a wedge between Sara and Amy, as
their backgrounds and experiences vary greatly. Due to the differences, Amy’s
frustration, while a valid feeling, could stem from her inability to understand
why Sara seems disinterested in sex.
Counseling
Interventions
While the disparities between Sara
and Amy appear to be vast, with appropriate therapeutic intervention methods,
their relationship can become stronger. However, it will take work and active
participation by both partners. While Amy has stated that she believes the
problem lies with Sara, working with the couple together would be beneficial.
Additionally, both clients could potentially benefit from individual counseling
sessions, as they each have their own personal challenges that, when addressed,
can lead to their union growing stronger.
Seeking counseling for individuals
within the gay or lesbian community is often a challenge, as homophobia, both
internal and external, can delay couples from seeking help. The obstacles
same-sex couples encounter when seeking help also includes finding a counselor
who is able to provide effective counseling, paying attention to the unique
issues that may be present in lesbian and gay clients. In a heterocentric
society, individuals within the lesbian and gay community may experience an
increased rate of prejudice and oppression (Palma & Stanley, 2002). Finding
a counselor who possesses both multicultural and sexuality competency would be
essential for Sara and Amy, as being dismissed or judged disapprovingly by a
mental health care worker could lead to further turmoil, both on the individual
and relationship level.
Three main therapeutic goals to
address when working with clients from the lesbian or gay community includes an
examination of intra- and interpersonal relationships, family and social
supports, and societal support systems (Palma & Stanley, 2002).
Establishing a comfortable rapport with clients is essential in allowing full
disclosure of sensitive topics, such as sexual difficulties and honest
discussion regarding the support systems (family, social, and societal)
available for the clients. While the counselor may not have experience with the
specific challenges faced by their clients, it is important to be self-aware of
any personal biases that may be in place, which could prevent effective and
ethical counseling. The American Psychological Association has addressed the
ethical and educational requirements for counselors working with lesbian and
gay clients. Practice guidelines established by the APA address attitudes
toward homosexuality and bisexuality, relationships and families, issues of
diversity, economic and workplace issues, and education and training suggestions
(http://www.apa.org/pi/lgbt/resources/guidelines.aspx).
Some
characteristics that counselors should keep in mind when working with same-sex
couples include, “An accommodating posture, non-pressured speech, and a
willingness to admit areas of knowledge or ignorance,” (Palma & Stanley,
2002). Keeping a neutral lobby, complete with brochures relevant to gay and
lesbian needs can help to further establish a welcoming atmosphere, which may
lead to a more effective therapeutic experience (Palma & Stanley, 2002).
Just
as the communication and disclosure between the client and counselor are
essential, the communication between the two individuals within the
relationship is imperative in making progress in counseling sessions. The
communication between Sara and Amy appears to be a challenge. While Amy’s
primary complaint consists of her being angry and feeling rejected because Sara
doesn’t appear to have the sexual interest she had in the beginning of the
relationship, the communication breakdown may be contributing to Sara’s
diminished interest in engaging in sexual relationships with Amy.
While
couples therapy would be included when working with Sara and Amy, individual
sessions are also recommended. During individual sessions, counselors can gain
an insight into each woman as an individual, rather than her role in the
relationship. Additionally, counselors can crosscheck information gathered from
the other partner and also allow the client to say something to the counselor
that she wouldn’t feel comfortable saying in front of her partner. And finally,
individual sessions can allow for a full disclosure of a detailed sexual
history, including experience with heterosexual partners and possible past
sexual, physical, or emotional abuse (Nichols, 2005).
Biopsychosocial Approach
Using the biopsychosocial approach
when working with Sara and Amy may be quite beneficial. Such an approach views disorders
through a blended lens, including the influence of psychology, medicine, and
sociology on the individual (Sarafino & Smith, 2012). The stress Sara is
experiencing, both internal and external, can greatly affect her relationship
with Amy. While both Sara and Amy state that they rely on one another for
emotional support, the pressure Amy is placing on Sara regarding sexual desire
can negatively influence Sara’s health. A lack of emotional support can be
associated with several stress-related illnesses, including heart disease,
gastrointestinal issues, and even a weakened immune system (Sarafino &
Smith, 2012).
Individual health and emotional
wellbeing of an individual is influenced by a variety of factors, including
resources (skill, experience, and genetic factors), social support, and
environmental demands. When the demands are evened out by the resources
available, emotional health is easier to obtain (Frankenhaeuser, 1994). Working
with Sara and Amy to examine their relationship, their resources available, and
how more effectively communicate their needs to one another would be useful in
moving forwards in their relationship.
Physical Intimacy Suggestions
While the underlying concerns in
Sara and Amy’s relationship may stem from other factors (stress, religion,
attachment style), providing guidance on how they can increase their physical
intimacy may be useful. Some tips include (Parks, 2008):
· Schedule
sex
· Commit
to five minutes of foreplay
o Enter
into foreplay with no expectations
· Treat
your partner special
o Do
the dishes, rub her feet, compliment her
· Read
erotical aloud to each other
o May
allow Sara to explore her fantasies and/or desires
· Court
your partner
o Often
relationships become stale because of stagnation
· Try
something new
o Sex
toys, fantasies, location in the house
Conclusion
Sexual dysfunction often has
underlying causes, aside from medical issues. Often individuals are too
embarrassed to approach counselors to address sensitive topics, but with
continuing education and self-reflection, counselors can effectively assess and
support clients in need. Working with clients who identify as gay or lesbian
may pose additional challenges for counselors, especially if they are unaware
of the additional stresses that are experienced by sexual minorities. It would
be unethical to treat a lesbian couple the same way one would treat a
heterosexual couple, as sexual minorities often face obstacles which do not
apply to heterosexual couples.
Working with couples to understand
that often sexual dysfunctions occur not because their partner is no longer
attracted to them, but because of a myriad of reasons, is essential to
improving the strength of the relationship. Empathy, not only on the part of
the counselor, but in the couple for one another, is also key in addressing the
lack of sexual interest experienced by Sara. Both individual and couples
counseling would be one of the most effective approaches, as it would offer the
ability for a counselor to evaluate both Sara and Amy as a couple, and
individually.
Due to the limited availability of studies
addressing gay and lesbian sexual dysfunction, further research would benefit
not only individuals seeking counseling, but also the sexual minority
population and society as a whole.
**References Available Upon Request**
