Thursday, September 25, 2008

Sexual Wellness at the PFLAG Conference

PFLAG Presentation: On Saturday 9/28, I'm presenting at the Northern Plains Regional PFLAG Conference. Their web site is:

As part of the submission/clarification process, I was asked to integrate a sexual health approach that could apply to everyone, and not just those who struggle with sexual compulsivity, sexual addiction and/or sexual anorexia. I've included the basics of this workshop here. If you have read other blog entries, you'll see similarity between this post and previous posts. The biggest similarity is with the blog "creating your personal definition of sexual health." This post reflects some further development in the past few months.

Toward a Personal Definition of Sexual Health.

To start with, it is important to define sexual health. The definition of sexual health that I like is published by the World Health Organization. They define sexual health as a . . .
“. . . state of physical, emotional, mental and social well-being related 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, 2002).

The definition is complex and represents nearly 30 years of scholarship and development. Sexual health is more a process than a dichotomy answered by a yes/no response. As treatment continues, the key is to help the client develop and improve his or her sexual health. The theoretical model within this workbook is based on Robinson et al (2002) who provides a model consisting of 10 components and highlights the necessary components of defining healthy sexual behaviors. Integrated into the treatment philosophy is an explicit goal of helping the client clarify his or her appropriate sexual behaviors.

1. Talking About Sex
I ask people to identify (or develop) 5 confidants. This means selecting individuals where they understand all aspects of your responses to the questions below. A common theme is the struggle to be open and honest with the important people in your life. I consistently see how people avoid talking with others, disclosing their sex history, or reaching out for help, or breaking the isolation because of fear and shame. A relevant 12-step tradition is "Our secrets keep us sick." Anything you're not talking with these individuals about is an issue to be addressed.

2. Culture and Sexual Identity

• What are my values I learned about sexuality from my culture, be it in a religious tradition, racial culture, social economic status, or sexual minority culture
• To what degree have these values shaped my thoughts about men and women?
• Do I agree with these values?
• In what way do I disagree?
• When values from different cultures are in conflict, how do I resolve this conflict?
• The five primary values that shape my behavior are?

3. Sexual Anatomy and Functioning
• What questions do I have about sexual anatomy and functioning?
• As I age, I have the following sexual functioning concerns?
• What do I need to learn about my primary partner to help him or her experience sexual health?

4. Sexual Health Care and Safer Sex
• Who is my primary physician? Do I have a relationship with my medical provider where I can talk with him/her regarding my sexual behaviors and questions regarding health issues?
• Identify your safer sex rules?
• Why do I have these boundaries?
• Think about your safer sex behaviors and risky sex behaviors. If I engage in unsafe sexual behaviors or if I place myself at risk for HIV, STD and/or pregnancy risk, my plans to address this are:
• If you are HIV+ what are your rules regarding disclosure of your status to your sexual partners?

5. Challenges and Barriers to Sexual Health
• Chemical Use
• Mental Health
• History of Abuse

6. Body Image
• What are three messages you have about your body?
• What are your plans to create a healthy body image?

7. Masturbation and Fantasy
• Identify three favorite fantasies. Write these out and be as detailed and specific as possible.
• What are my unhealthy fantasies, or fantasies I want to avoid?
• What are my current values toward masturbation and fantasy?
• What are my current appropriate masturbation behaviors? (Where, when how often?)
• What are my rules toward disclosure to my partner of my masturbation behaviors?
• What are my rules toward disclosure of fantasies to your partner?
• Have you reviewed these with your partner? Does he/she agree with these values? If there is disagreement, what is your plan to address the disagreement?
• What are my current values toward sexually explicit material?
• What sexually explicit material is acceptable? Why?
• What sexually explicit material is not acceptable? Why?
• What are the rules in your relationship regarding disclosure of your use of sexually explicit material?

8. Positive Sexuality
• Sexuality is a major focus of energy in your life. The following questions reflect that your sexual energy is healthy and when channeled in healthy ways can bring new life, energy and strengthen relationships both with your partner and with others in your life. The following questions are designed to be integrative. You should have a sense of harmony in your definition within these responses.
• How do you develop new ways of sexual expression?
• How do you express sensuality?
• Who is an appropriate sexual partner? (Age, sex, relationship, etc.)
• What types of sexual behaviors are healthy?
• What types of sexual behavior should be avoided?
• When is it appropriate to be sexually active?
• Where is it appropriate to be sexually active?
• What are healthy reasons to engage in sexual behavior?
• What are unhealthy reasons to engage in sexual behavior?
• What is the preferred level of physical touch?
• What kind of touch is acceptable?
• How will I ask to have my sexual needs met?

9. Intimacy and Relationships
• Identify the top three types of intimacy that are the most important for you.
• Identify 3–5 people who can help you meet those intimacy needs
• How satisfied are you with your level of intimacy in these three areas. If you aren’t satisfied, identify a plan to increase your level of satisfaction.

10. Spirituality
• Is anything listed in the previous 10 areas in conflict with your spiritual values? If so, reexamine and resolve this conflict. Are you living the life you love? To the degree that you are not, why not?
• What are your plans to resolve these differences?

Wednesday, September 24, 2008


Another issue sometimes connected with the acting out cycle is grief. Various theories have talked about the process of grief. The theory I like best is provided by Kubler-Ross where she identified five stages of grief. Her original research has focused on death of a loved one through terminal cancer. Subsequent researchers have modified or adapted her model, but the common reference in all of those models is a comparison to the original model. The five stages of grief according to Kubler-Ross are denial, bargaining, anger, depression and acceptance.

Three adaptations or expansions of the model that I include are: one, the role of perceived losses and two, the role of small losses, and three the “time focus” of grief. Sometimes feelings of grief result from a loss such as a death of a loved one as originally highlighted by Kubler-Ross. Grief from other losses can have a powerful impact in a person’s life. Feelings of grief may be due to the end of a relationship or friendship. It is important to highlight that grief may be due to the loss of hopes, dreams, and/or fantasies. For example, in the coming out process, depression is sometimes present because of the loss of the expectation that life was supposed to be a certain way and recognizing a same-sex identity brings an end to the expectation. Sometimes, the symbolic meaning of an event, location or person triggers a great experience of loss. Moving from your home results in a recognition of the end of a relationship. These perceived losses can have the same impact as a tangible loss. The feelings associated with the loss of a dream can parallel the loss of a partner. Third, some feelings of grief are anticipatory; in this situation, I might “see” the end of something. This may show up as “This is a bad relationship; I need to get out of it so I have sex with a third person to cause a rupture in the relationship causing it to end.” Another example is getting yourself fired because you don’t like your job.

As you review your acting out cycle, pay attention to how the following stages of grief may have played out. I’ve provided a few examples that are descriptive of how the stage might be expressed.

Denial. In this stage, this is an active thinking process of avoiding grief. For some people, they might start overworking and then use the overwork to justify the acting out behavior. With some clients who discover they are HIV+, their acting out behavior may increase because of the sense that it simply doesn’t matter anymore. Another example might be the loss of a relationship, and engaging in sexual contact because you’re lonely.

Bargaining. In this stage, there is recognition of the grief, but the coping mechanism is toward minimizing the impact of grief. “It’s not a big deal.” Or, starting to date before the grief is resolved. Another way this may be present is selecting a new partner with the thought “He/She is better than no-one.” A final example is “He/She isn’t like the last one!”

Anger: In this stage, the energy of the process of coping with grief is extended outward. Statements such as “All men are like that” may reflect an avoidance of relationships or forms of intimacy. As you could guess, these feelings might lead to isolation resulting in a subsequent acting out cycle.

Depression: Common thoughts in this stage might include “why try” or “it doesn’t matter” or even “It’ll never work out.” One of the difficulties is distinguishing between depression and grief is that depression is part of the grief process. Review the topic on depression. Might any of the symptoms you’re experiencing of depression be related to grief?

Acceptance: By this point, the grief is recognized, integrated and while present, has lost most of the power. In my mind, this means that you can acknowledge the loss, but the loss doesn’t result in a barrier to healthy relationships or daily functioning of the individual. In some cases, the loss may actually facilitate transformation. These are signs of successful adjustment to grief.

One of the critiques of Kubler-Ross’ model is the perception that the process of coping with grief is linear; that you simply go through one stage to the next, followed by stages 3, 4, and 5. My experience suggests that is cyclical; you might see parts of each stage in the moment and depending on the circumstances of the moment, experience the grief differently. The key for me is to recognize whatever the situation, it is acceptable and healthy to be present to your thoughts and feelings. A second critique is the implication that process occurs once and is rather “quick.” The manual used by the mental health field suggests that grief only lasts two months which may be too short. My experience also suggests that in some circumstances grief can exceed a year or more. And you can re-experience grief when certain rituals, anniversaries or memories are triggered.

In addressing grief and the acting out cycle, I will request clients complete the following task: Take a piece of paper, and create three columns. In the first column, list 100 experiences of real, perceived, major and/or minor experiences of loss. While 100 may seem like a lot, my experience is that people can identify more losses than they realize. Usually, this part of the assignment can take days and weeks to complete. Complete this part of the assignment before you move to columns two and three. In the second column, explain why this loss still impacts you today. Why does it have so much power now? In the third column, identify possible thinking errors or plans to address the loss. The example below can be helpful.

Type of Loss
Major loss (death)
Minor loss (plans cancelled)
Real (relationship ended)
Perceived (loss of my idea how the future would look. Explanation.
How does it impact me today?
Why does this loss have so much power? Plans and corrections.
How will you address this loss?
Is the loss based on a thinking error, if so, what is your correction?
My partner left me. I feel alone and hurt
Shame (it’s my fault).
I will never find anyone
Nobody loves me
I will talk about it with my support group and therapist. I will read a book on dating.
I didn’t get the job I’m no good
They don’t like me. I can find another job.
My job doesn’t define me.
I’m gay.

I won’t be able to have children. Everybody judges me.
I will be alone
It is a sin. I could adopt.
There are happy gay people in connected loving relationships.
Not everyone believes it is a sin; in fact some people think it is a blessing.

Monday, September 22, 2008

SASH Conference

This past weekend was a national conference for the Society for the Advancement of Sexual Health (SASH.NET). My last conference was 5 years ago when the conference was held in Minneapolis. In reflecting on the conference, I am grateful to meet so many people and reconnect with old friends and colleagues. I returned home energized, focused, and inspired for a larger vision!

What struck me about this years conference is the committment by so many people to address sexuality concerns. While we may not always agree, I do share the same concern with many others on helping others in their healing process.

Some of the topics that stood out for me include: relationship issues, disclosure and healing, neuropsychology of compulsivity, sexually explicit material and defining sexual health. My plan is to address these issues again over the next few entries.


Wednesday, September 10, 2008

Male on Male Rape

One of the more difficult issues I struggle with is helping guys cope with their experiences of being raped. The presence of this phenomenon simply isn't talked about in our society. In the gay community, the lack of any dialogue highlights the unspoken tragedy. There are few resources available. One of the first books I read on the material is by Michael Scarce "Male on Male Rape." His book reviews many of the issues including fears, embarrassment, masculinity issues, perceived issues of invulnerability, sexual desires, cultural issues regarding sexual prowess to name but a few of the issues. All of these concerns need to be addressed in recovery. The consequences of male on male rape are significant and parallels many of the experiences of male/female rape. Typical feelings include:

lacking self-confidence

In a previous post, I highlighted the concerns of abuse and sexual violence. In those posts are a few ideas to become aware of as you look at the consequences of abuse and assault. Please review these two posts as part of the process.

One important idea to highlight is that during a sexual encounter if consent is removed, the experience is ASSAULT. You have the right to say no at any point. I strongly encourage you to talk about any sexual assault with your support issue.