Saturday, March 28, 2009

Sexual Avoidance

Over the past few weeks, I’ve been working on updating the workbook. One major topic that is now included is the following concept.

Sexual Avoidance

One of the more difficult aspects of sexual avoidance is recognizing the problem. Therapists in this field often focus on behaviors that are measurable. Most of this workbook focuses on what a client does in the realm of sexual behaviors. Individuals can easily recognize how many partners they had, or acknowledge, “I did this behavior,” and so on. Less recognized and as a result less treated is the question of sexual avoidance. Some professionals use the term sexual anorexia. There is not agreement on a term that adequately describes the concern. For some people, obsessive thoughts are the problem; other individuals engage in sexual avoidance or have strong reactions such as of sexual aversion. In some cases the time between sexual contact and/or any significant relationships can be years. In a few circumstances, the comment from a client is that he or she hasn’t had sex in a decade or more. The key for many of these people isn’t that lack of sex, but the motivating factor in why they haven’t had sex. Thoughts and feelings of shame, fear, and hopelessness often shape why a person avoids sexual contact. Often the underlying dynamic for sexual avoidance is similar to the dynamic for sexual compulsivity. It is important for you to assess the pattern that results in the possibility of sexual avoidance. Examine your sexual history; there are a few questions relating to sexual avoidance. In each of those circumstances, review how the acting out cycle may have been present. You might be caught in the acting out cycle through a passive behavior (avoidance) versus an engagement behavior (compulsive). If you see this pattern, include sexual avoidance as part of your treatment plan.

Questions to consider.

1. Describe any circumstances where you have intentionally avoided sexual contact with a partner or significant other. Include any underlying thoughts and feelings.

Tuesday, March 24, 2009

Part two of the intimacy series.

"I read your article on types of intimacy and that's all well and good, but what I need to know you didn't cover. I know what I'm looking for but how do I actually find guys who like the same things?"

The short answer is get busy in the activities you enjoy. Guys with similar interests will naturally attract each other. Looking for a specific type of intimacy in the wrong place will leave you disappointed, bitter and jaded. Be honest with yourself.

How often are you going to bars or spending time online when these aren’t the best places to get your intimacy needs met? Are you willing to do the work you need to do to get your needs met? The following suggestions are just a starting place and by no means a complete list. By the way, you also need to put yourself out there by introducing yourself and talking to people versus simply showing up!

Emotional intimacy is the sharing of significant experiences and feelings.

* Find a support group. Pick a topic that is important in your life such as AA or other another 12-step group. For some people, a coming out group may be helpful. A wide range of topics exist that may fit your individual concerns.
* Examine your life events through therapy that hinders your ability to be in a relationship. These issues might be grief, abuse, and/or fear.
* Read Self Help Book. Believe it or not, the general series “_______ for Dummies” does a pretty good job introducing the reader to the basics on any give topic. I use the “Anxiety for Dummies” a lot in my practice.
* Appropriately share you inner thoughts, feelings, desires and needs with other people in your life.

Sexual intimacy is more than just the physical act of sex. It's also talking about the deepest and darkest sexual secrets.

* Attend a workshop on sexuality (for example Body Electric)
* Share your fantasies with your partner.
* Strategize with your partner about how to make a part or all of a fantasy come true (within the rules of your relationship).
* Read a book on sexuality (New Joy of Gay Sex) and share with your partner what you liked and disliked.

Intellectual intimacy is the closeness resulting from sharing ideas.

* Take a class. Check out community colleges, local art groups and area newspapers for classes that may interest you.
* Teach a course.
* Join a book club.
* Join a listserv on a topic of your choice.

Aesthetic intimacy relates to experiences of beauty.

* Beauty is definitely in the eye of the beholder, so what do you find beautiful? After you've figured it out, seek it out.
* If you like art, some natural ideas are to visit a museum, art space, play or movie.
* Love nature? Check out local hiking or outdoor groups to join.
* Missed your shot at American Idol? How about joining a local gay men's chorus?
* Traditional art not your thing? Walk through your city and photograph graffiti you find interesting.

Creative intimacy is the intimacy of shared discovery.

* Bring a friend with you to any activity on this list.
* Join an art class.
* Read a book on “possibility”, such as the “Power of Now” by Eckhart Toll.

Recreational intimacy refers to the experience of play.

* Go to the gym, walk or physical activity.
* Find a club/group to join. (For example, most cities have hobby groups such as bowling or volleyball.) Do what you enjoy regardless of what others think. You might be surprise how many share your interests.

Work intimacy occurs in the sharing of tasks.

* Volunteer for work events/tasks. Join a committee at work.
* Talk with your co-workers about what is going on. Ask them what they did last night or over the weekend. Start sharing the basics with them as well.
* Volunteer with organizations or events that are close to your heart. This could be community activities like a Pride Festival or a political organization.

Crisis intimacy occurs as a result of major and minor tragedies.

* Volunteer for whatever jobs need to be done. This could include rescue, food drives and clean-up.
* Learn from the crisis to develop future plans.

Commitment intimacy is the experience of hope and possibility in response to addressing an issue, cause or event bigger than one person.

* Identify a cause/value that means something to you. Once you do that volunteer your time, talent or treasure to it.

Spiritual intimacy develops through sharing the values, meaning for life, and the core of our being.

* Join a church. Many traditional churches have gay-affirming components. There are also many gay churches to join, such as Metropolitan Community Church.
* Join a 12-step group. This could be AA but it might also be a 12-step group for partners of AA, Sexaholics, debtors, eating, and even “Emotions Anonymous.”
* Read/join an online group that discusses life values

Communication intimacy is the process of full disclosure with another person.

* Simply say what you mean, and mean what you say. Too often an individual will say what they think the other person wants to hear.
* Learn how to be present and listen to other people by attending a listening training program.

Conflict intimacy is the process of connecting, and facing and struggling with differences with others.

* Recognize that healthy fighting is a normal part of a relationship
* Learn how to fight in healthy ways by reading a book on conflict management/resolution such as “The Eight Essential Steps to Conflict Resolution.”
* Attend an anger management course.
* Attend a problem-solving course or reading material online.
* Attend an assertiveness training program.

Thursday, March 12, 2009

Sexual Health and the EAPA professional

This is an article I submitted to the Journal of EAP professionals.

Sexual Health and the EAP professional
Weston Edwards, PHD

Addressing sexual health concerns identified in the workplace.

The relationship between the work environment and sexual health issues is a significant but taboo area. The presence of minimal training and expertise in sexuality is a significant problem for EAP professionals. Consider the following: It is estimated that approximately 8-10% of the population struggle with sexual compulsivity/addiction behavior problems (SASH.NET). The use of the Internet at work for virtual sex is well documented (Cooper, 2002). The rise of social networking to cope with loneliness highlights the striving for human connection (Hu, 2008). Sexual satisfaction is correlated with relationship satisfaction (Rosen &Bachmann, 2008). Eberhart (2008) highlights how interpersonal stress impacts overall mood, with the corresponding impact on work productivity. One in four women and one in sex men report some type of sexual assault in their lifetime (Elliot, Mok, & Briere, 2004). The increase in the use of erectile dysfunction medications for both men and women highlight the importance of the sexual health concerns for clients. Furthermore, most researchers believe the statistics referenced are actually underreported. Taken together, this data suggest that the prevalence and incidents of sexual health concerns are significant. The EAP clinician needs a basic understanding of sexual health to address concerns for the client. When faced with a sexual health concern, accurate conceptualization and awareness is important for appropriate treatment and care. It is not expected that the EAP professional provide these services; however the quality and effectiveness of any referral can be improved by an awareness and assessment of sexual health issues.

Defining and Creating Sexual Health
The field of sexology has engaged in an ongoing dialogue defining sexual health over the past 25 years (see Edwards, 2004). Toward the goal of helping the EAP professional conceptualize sexual health, it is important to have a working understanding of sexual health. The World Health Organization published the most recent definition of sexual health. 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).

This definition highlights the multi-dimensional aspect of sexual health incorporating nearly 200 different variables. The major weakness of the field and the definition is the relative newness of the concepts. The exact nature and relationship between the variables is complex and not always understood. The chicken-and-the-egg phenomenon regarding causality between sexual health issues and other issues highlights the difficulty in conceptualizing and treating sexual health issues. For example, does one’s sexual functioning contribute to depression and anxiety resulting in chemical dependency; or does chemical dependency as a form of self-medication of anxiety lead to sexual functioning issues creating relationship concerns and ultimately depression? This multi-faceted reality highlights the need for increased awareness of sexual health by the EAP professional.

The Sexual Health Model (Robinson, et al, 2002)
In an attempt to better understand the definition of sexual health, Robinson et al created a model of sexual health that has 10 components. Of the 10 components, 7 are relevant for the EAP professional.

1. Talking About Sex is a cornerstone of the Sexual Health Model. Many times the level of shame and fear about sexuality leads the client to withdraw and avoid any discussion of their sexuality concerns. Appropriate assessment questions tempered by clinical judgment should be created to help increase the accuracy of treatment placement. For example when working with someone with a chemical dependency problem, asking about the relationship between his or her chemical use and sexual behavior might provide information for better treatment placement.
2. Culture and Sexual Identity are instrumental to understanding one’s sense of sexual self. It is important that individuals examine the impact of their cultural heritage on their sexual identities, attitudes, behaviors, and health. EAP professionals need to be sensitive to different sexuality cultures. This includes awareness of gender specific programming (women’s treatment programs) as well as sexual minority (Lesbian, Gay Bisexual, Transgender, LGBT) programming.
3. Sexual Health Care and Safer Sex assumes a basic knowledge, understanding, and acceptance of one’s sexual anatomy, sexual response, and sexual functioning. This component covers a broad perspective encompassing knowing one’s body, regular self-exams and responding to physical changes with appropriate medical intervention. Examination of one’s safer sex behaviors is critical. Admittedly, the EAP professional may have less focus in this area. The role of EAP professional can facilitate referral to a medical provider skilled in addressing these concerns; a rich referral network of medical providers may be helpful.
4. Challenges and Barriers to Sexual Health includes the major areas of sexual abuse, substance abuse and compulsive sexual behavior. Other challenges might include a history of sex work, harassment, and discrimination. Too often sexual health issues interact with depression, chemical dependency and/or abuse that are the source of mental health concerns requiring treatment. By recognizing the depth of the issues, the EAP professional might increase the effectiveness of appropriate referrals.
5. Positive Sexuality recognizes that all human beings need to explore their sexuality in order to develop and nurture who they are within a positive and self-affirming environment. Too often depression, anxiety, fear, and relationship satisfaction is negatively impacted by a fear of sexuality. By demonstrating a respect and awareness of sexuality, the EAP clinician can model sexual health for the client and provide a safe place to put the issues on the table.
6. Intimacy and Relationships. Intimacy can take many forms and is a universal need that people meet through relationships. Sexual health requires knowing which intimacy needs are important for the individual and appropriate ways to meet these needs. As highlighted by Rosen and Bachman, relationship satisfaction is positively correlated with overall mood.
7. Spirituality and sexual health assumes congruence between one’s ethical, spiritual, and moral beliefs and one’s sexual behaviors. Spirituality may or may not include identification with formal religions, but always addresses moral and ethical concerns and deeper values in order to integrate a person’s sexual and spiritual selves. The respect of individuals in the workplace is ultimately an ethical value. The high levels of sexual harassment require ongoing monitoring and awareness for treatment that can facilitate growth versus simply consequences and termination.
Strategies for the EAP professional
Recognizing the importance of sexual health in your work is the first step in the process. The following strategies are offered for professional development as well as enhancing the care for clients.
Self Assessment. Complete a self-assessment of your ability and comfort level in talking about sexual health concerns. What are your interests, strengths and weaknesses in the above areas? Clients will intuitively follow your lead in talking about sexuality. They may defer or minimize any concerns until the provider addresses the topic.
Training. What journals, seminars, conferences or other materials can you access to improve your clinical skills? Knowing where you can find the information to improve your skills is an ongoing part of continuing education.
Consultation and Referral. Who in your professional network has the necessary skills to work with clients in any of the areas? Developing the necessary referral network is necessary for long-term client care.
Supervision. Who in your network can provide clinical supervision addressing sexual health concerns? This might include seeking supervision for you in light of the self-assessment. If you have struggles talking about sex, seeking supervision in developing these skills is important.
Resources. What resources do you have to help clients with sexual health concerns? In your waiting room or on your website do you have resources for HIV/STD prevention, pregnancy, rape and abuse centers, 12-step groups or couples therapists. Many times clients are seeking information and specialized services that require expertise. By identifying resources for clients, clients may volunteer information that the professional can then follow-up.
Creating a safe environment. Through the professional development, the EAP professional can create a safe environment to allow the client to disclose information as appropriate. Developing skills, identifying resources, and setting the stage help create a resource that says, “it’s OK to talk about sex.” These steps provide a safe environment for client disclosure.
Informal Assessment. The EAP professional has two options in developing an assessment process. The first is an informal process. The EAP professional can ask the appropriately timed questions in the existing process. For example, in a chemical dependency assessment, simply adding a question similar to “How often are sexuality concerns linked with your chemical use?” Similarly for depression, asking “How much of the feelings of depression are linked with sexuality concerns?” This approach is less threatening, and likely to get a response when the question appears to be natural part of the process.
Developing a formal sexuality assessment. A more formal assessment might also be developed in the EAP professional assessment process. This section of questions would be like any other section regarding the intake and referral process. A great place to start is with the following statement: “I’m now going to ask questions about sexuality concerns that may be present. I want to affirm the importance of confidentiality and that this information is gathered to help in the appropriate referral.” The questions that follow reflect a series of specific questions that address common sexuality concerns. The content of the formal assessment is dictated by the needs of the setting so universal suggestions are difficult to provide. You might look at the 10 components of the sexual health model as a starting place. Questions might include issues about relationships, sexual functioning, sexually transmitted illnesses, sexual abuse, and so on. Given the limited role of the EAP professional, this approach might be less helpful in a brief therapy/intake model and more appropriate to a longer-term treatment setting.
Summary and conclusion
The breadth of sexual health highlights the need for the EAP professional to have a basic awareness. Both the definitions of sexual health as well as the components of sexual health model are a beginning place to understand the numerous variables. The goal is accurate assessment for appropriate referral and treatment ultimately resulting in increased quality of life for the client. Given the probability of underreporting of current sexual health concerns, the EAP professional is on the front line and a valuable person to triage these issues for clients. The specific strategies provided are a place to start.


Cooper, Al (Ed) (2002). Sex and the Internet: A Guidebook for Clinicians; New York: Brunner-Routledge.

Eberhart, N. (2008) Interpersonal predictors of stress generation and depressed mood. University of California, Los Angeles.

Edwards, W., & Coleman E. (2004). Defining sexual health: A descriptive overview. Archives of Sexual Behavior, 33(3), 189-195.

Elliot, D., Mok, D. & Briere, J. (2004) Adult Sexual Assault: Prevalence, Symptomatology, and Sex Differences in the General Population. Journal of Traumatic Stress. 17:3, 203–211. DOI: 10.1023/B:JOTS.0000029263.11104.23

Hu, M. (2008) Social use of the internet and loneliness. The Ohio State University.

Robinson, B. E., Bockting, W. O., Rosser, B. R. S., Miner, M., & Coleman, E. (2002). The Sexual Health Model: Application of a sexological approach to HIV prevention. Health Education Research, 17(1), 43-57.

Rosen, R. & Bachmann, G. (2008) Sexual well-being, happiness, and satisfaction, in women: The case for a new conceptual paradigm. Journal of Sex & Marital Therapy, 4, 291-297.

Intimacy doesn't only mean sex.

"Dear Dr. Edwards,
It seems sex has become an overwhelming preoccupation. How important is it and why? It appears sex is not viewed as an expression of love but has become a tool for self-satisfaction (me,me,me)?"

My whole reason for writing articles is to get people talking with their partners, friends, and family (yes, family as appropriate!). So I was thrilled with the number and diversity of responses from my articles Negotiating Sex with Your Partner, Part 1 and Part 2. Looking at these comments showed me that many people, both gay and straight, have a difficult time understanding what intimacy actually is.

Intimacy occurs with everyone we meet, everyday of the year. Friends, family and even strangers fulfill some part of our total intimacy needs. The husband and wife team of Howard and Charlotte Clinebell are counselors who identified 12 of these intimacy needs back in the 70s. If you boil down all their findings you'll discover something most people get confused about: one person can not meet all of our intimacy needs. In reality it would be unfair to expect them to.

I want you to try something. From the list below identify the three most important types of intimacy for you and then answer the following questions:

* How satisfied are you regarding this particular intimacy?
* Who in your life helps get these needs met?
* How am I helping others fulfill their intimacy needs?
* If I’m unsatisfied, how do I plan to address the needs?
* In my primary relationship, what type of intimacy do WE need to work on together?

Forms of intimacy
Emotional intimacy is the sharing of significant experiences and feelings. Emotional intimacy is the foundation of all other forms of intimacy. It is the ability to talk without fear. When fear is present, talking about that fear can facilitate a stronger and closer relationship. Emotional intimacy includes the ability to share one’s hopes and dreams.

Sexual intimacy is more than just the physical act of sex. Talking about the deepest and darkest sexual secrets is a form of sexual intimacy. For some of my clients, I am the first person they talk to about sexuality.

Intellectual intimacy is the closeness resulting from sharing ideas. There is a genuine respect for each individual’s opinion. Agreement on the topic isn’t required for intellectual intimacy. It is the process of sharing, reflection and discussion that highlights the aspects of intellectual intimacy.

Aesthetic intimacy relates to experiences of beauty. This can include expressions of art such as music, plays and movies but also natural beauty such as sunrises, listening to a thunderstorm, and taking a day hike.

Creative intimacy is the intimacy of shared vision. The key component is the process of co-creating with another person. Both you and the other person are growing in deeper ways as a result of the experience.

Recreational intimacy refers to the experience of play and stepping outside of the struggles of life, and simply spending time together. The types of play include sports, outdoor activities, and indoor activities. Sometimes other intimacies are incorporated into recreational activities such as going to a movie (aesthetic) and then talking about it afterward (intellectual).

Work intimacy occurs in the sharing of tasks. It can include projects, events, or the process of long-term commitment regarding work or family. These tasks vary in type, intensity and duration and could include completing a project at work, or finishing cleaning up the house. The feelings of satisfaction when completing a task with another person are examples of work intimacy.

Crisis intimacy occurs as a result of major and minor tragedies. Personal crises may be illness or accidents. Larger forms of crisis intimacy can be community experiences of a natural disaster. In these situations individuals step outside of their limits and connect. Strangers will go above and beyond typical behaviors. The long-term response of the gay community to HIV is a great example of this type of intimacy.

Commitment intimacy is the experience of hope and possibility in response to addressing an issue, cause or event bigger than one person. This can range from a short-term task (completing a social service project) to a never-ending task such as social justice, or providing HIV services. It is the process of transforming the world relative that is the source of intimacy.

Spiritual intimacy develops through sharing the most important areas of concerns including values, meaning for life, and the core of our being. It's an experience of possibility and transcendence beyond the daily experience of who we are. It can be connected to religious traditions and practices, but ultimately it is about how we connect with God (in whatever way we understand God).

Communication intimacy is the process of full disclosure with another person. It is the process of being open, honest and truthful. This includes giving difficult and constructive feedback even when it is difficult to do so.

Conflict intimacy is the process of connecting, respectful fighting and facing differences with others. Through the conflict there is a process of closeness that transcends the conflict ultimately leading to a closer relationship. The power of make-up sex highlights how conflict intimacy is so powerful.

Negotiating Sex with your partner part 2

Last week I saw a tremendous response to Negotiating Sex With Your Partner. Many of you emailed me saying you have tried everything I mentioned in my first article but are still having problems. So if you're like many others who've tried to talk to their partner and still have issues, this article is for you.

That first article was an introduction into the basics of negotiating sex in your relationship. If you have shared your likes and dislikes and are still having problems, the next step requires a bit of hard work and honest discussions with your partner and also with yourself.

Some relationships are not focused on sex because they are rich in other ways, such as shared values or emotional connections. Consider the importance of your sexual request. Are you willing to live without it? In looking at the whole picture you might have to agree not to engage in the behavior. This is often the case in 'kinkier' types of sexual behavior. If you absolutely are unwilling to live without the type of sexual behavior, consider the next two ideas.

If your need or desire is important enough that you choose to not live without it, you and your partner need to negotiate an alternative way to get your sexual needs met. This can be difficult and elicit significant fear, jealousy and raise other issues. It may or may not require changes in the type of your relationship. For example, if your partner loves BDSM and you don't, would you be comfortable if your partner visited these kinds of websites in order for him to chat with others so he can indulge in the fantasy? Or, if you are both "bottoms" you may have to incorporate "toys" into the relationship.

In my experience, ongoing and significant issues regarding sex can be symptoms of underlying problems with the relationship. While no one likes to hear it, the failure to arrive at a solution might suggest the relationship may not be a healthy one. A hard and honest look at your relationship may reveal it isn't healthy and may need to end. An example of behavior in an unhealthy relationship might include saying things like “Yes I’ll do it” but never intending to follow through. Or constantly trying to persuade your partner to engage in a behavior is also manipulation and not a healthy sign. If you are both stuck in this area and don't see a solution, seeking outside professional help may be the best and possibly the last option for you.

Sexual satisfaction is a major component of overall relationship satisfaction. Research has repeatedly stressed overall health is connected to relationship satisfaction. If you continue to struggle in this area, I strongly recommend seeking additional help from a qualified professional.

Negotiating Sex with your partner part 1

"My partner wants me to talk dirty to him, be rough and call him names. I have a real hard time with any of that even though he's asked me to on more than one occasion."

One of the most difficult tasks in any relationship is being able to comfortably talk about sex with our partners. The issues can range from simply how often and what to do to whether or not the relationship should be open, monogamous or some variation thereof.

The main goal in any couples counseling relationship is open and honest communication about what you want, what makes you happy, and what you don’t want. A key component of sexual health is a similarity between your values and your behaviors. It's your responsibility to communicate these values with your partner(s). The decision about the degree to which any behavior is consistent with your values ultimately rests with you.

As you think about sex with your partner, there are four general subjects that are important to address.

1) Tell him – Have you communicated what you like and don’t like with your partner? Too many times I’ve run into couples saying to one another “I didn’t know that.” For any number of reasons (shame, self-esteem, fear of being judged, not wanting to upset their partner), clients won’t talk about their likes and dislikes. Now is not the time to be bashful.

2) Ask him – Once you know what you like, do you know what your partner likes and dislikes? It's important not only to know what but why he or she has these interests. For example, I worked with a couple where one guy wouldn’t bottom because it physically hurt. It turned out the pain was due to anal warts, and once those were addressed, the problem went away.

3) Learn – Don't be shy if you don't know how to do something. Whether you're a top or a bottom, you need to learn some basics regarding foreplay, stretching the sphincter muscle, proper clean up and so on.

4) Get help – If after going through the first 3 steps you find you are still having problems, you may want to seek some outside help. This doesn't necessarily mean therapy or counseling, although professional help is a very good option for more challenging problems. Try having a frank, "out of the box" conversation in which you look at creative outlets and avenues to get your sexual needs met. These could include talking to your spiritual adviser, attending a body electric or similar sexuality workshop, or reading "The Joy of Gay Sex." Each of these interventions might be helpful in breaking the log jam in your relationship.