Input: Write a detailed report on the cultural factors that influence sexuality and sexual dysfunction, including the role of religion, the impact of immigration and acculturation, and the challenges in diagnosing and treating sexual problems in different cultural contexts. Include case studies and examples to illustrate these points.

Response:
Silverstein, C. (2009). The implications of removing homosexuality from the DSM as a mental disorder [Letter to the editor]. Archives of Sexual Behavior, 38(2), 161–163.

Skidmore, W. C., Linsenmeier, J. A. W., & Bailey, J. M. (2006). Gender nonconformity and psychological distress in lesbians and gay men. Archives of Sexual Behavior, 35(6), 685–697.

Spack, N. P., Edwards-Leeper, L., Feldman, H. A., Leibowitz, S., Mandel, F., Diamond, D. A., et al. (2012). Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics, 129(3), 418–

425\.

Spitzer, R. L. (2003). Can some gay men and lesbians change their sexual orientation? 200 participants reporting a change from homosexual to heterosexual orientation. Archives of Sexual Behavior, 32(5), 403–417.

Taormino, T. (2008). Opening up: A guide to creating and sustaining open relationships. San Francisco: Cleis Press.

Toomey, R., Ryan, C., & Diaz, R. M. (2010). Gender-nonconforming lesbian, gay, bisexual, and transgender youth: School victimization and young psychosocial adjustment. Developmental Psychology, 46(6), 1580–1589.

van Rosmalen-Nooijens, K. A. W. L., Vergeer, C. M., & Largo-Janssen, A. L. M. (2008). Bed death and other lesbian sexual problems unraveled: A qualitative study of the sexual health of lesbian women involved in a relationship.

Women and Health, 48(3), 339–362.

Wallien, M. S. C., & Cohen-Kettenis, P. T. (2008). Psychosexual outcome of gender-dysphoric children. Journal of American Academy of Child and Adolescent Psychiatry, 47(12), 1413–1423.

Wingerson, L. (2009, May 19). Gender identity disorder: Has accepted practice caused harm? Psychiatric Times.

Available at www.psychiatrictimes.com/gender-identity-disorder-has-accepted-practice-caused-harm.

Yu, V. (2010). Shelter and traditional housing for transgender youth. Journal of Gay and Lesbian Mental Health, 14, 340–345.

1 LGBTQ: lesbian, gay, bisexual, transgender, queer. "Queer" includes other sex/gender variations, such as BDSM

and polyamory, or is used by some to indicate membership in more than one sex/gender minority.

2 The chapter in the fourth edition is coauthored with my dear late friend and colleague Michael Shernoff.

3 In fact, there is a virtual cottage industry of evolutionary psychological theories just to explain homosexuality, because according to a strict Darwinian model, genes for homosexual behavior should have vanished eons ago.

4 Polyamory is a specific form of "open" relationship, espousing multiple sexual and romantic partners, unlike

"swinging" and typical gay male open relationships, both of which emphasize sex and not intimate connection. In practice, the boundaries between these types of open relationships can get blurred.

5 "Cisgender" = the opposite of transgender. Cisgender people experience their gender as congruent with their body, presentation, traits, and behaviors and with others experience of them.

6 I will send electronic versions of my questionnaires upon request.

7 HIV appears to lower testosterone, as do some of the medications used to treat it.

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**CHAPTER 15**

Culturally Sensitive Sex Therapy

The Need for Shared Meanings in the Treatment of Sexual

Problems

Kathryn S. K. Hall and Cynthia A. Graham

**H** all and Graham challenge both clinicians and researchers to view culture as central to understanding sexuality. They begin with the following premise: "Sexual problems are experienced by people worldwide, but we contend that the sexual concerns of diverse cultures do not necessarily mirror those of Western populations."

Reviewing the literature on immigrant populations, as well as survey data and research from various parts of the world, the authors find that although Western-defined sexual dysfunction may be found in other cultures, the rates of occurrence, the significance of the problems, and the distress experienced vary greatly. In addition, the sexual concerns of other cultures sometimes differ significantly from those identified in the DSM.

Ethnic and cultural minorities seek out therapy less often, but when they do, they often drop out of treatment early. To more adequately address the treatment needs of culturally diverse clients, Hall and Graham describe a model for culturally sensitive sex therapy (CSST) that stresses the value of understanding sexual problems in a cultural context such that there is a shared understanding of the meaning and significance of the sexual problem between client and therapist. Recognizing that culture is not the problem but part of the solution, CSST necessarily requires adaptation, innovation, and flexibility in the treatment process.

**Kathryn S. K. Hall, PhD,** is a clinical psychologist in private practice in Princeton, New Jersey. She is the author of Reclaiming Your Sexual Self, a popular book on female sexual desire and is the co-editor (with Cynthia A.

Graham) of The Cultural Context of Sexual Pleasure and Problems: Psychotherapy with Diverse Clients. Dr. Hall is the book review editor for the Journal of Sex and Marital Therapy.

**Cynthia A. Graham, PhD,** is currently a Senior Lecturer in the Department of Psychology at the University of Southampton in the United Kingdom, a Research Fellow at the Kinsey Institute for Research in Sex, Gender, and Reproduction, and a visiting Research Fellow at the Rural Center for AIDS/STD Prevention, Indiana University.

She is Editor-in-Chief of The Journal of Sex Research and is an editorial board member for the Journal of Sex and Marital Therapy and the International Journal of Sexual Health. She is a Chartered Psychologist, an Associate Fellow of the British Psychological Society, a Fellow of the Society for the Scientific Study of Sexuality, and a member of the Sexual and Gender Identity Disorders Workgroup for the DSM-5. She was elected President of the International Academy of Sex Research in 2009.

Mr. Li looked at me blankly. He had been referred by an infertility clinic for repeatedly failing (refusing?) to give a semen sample. Now he sat expectantly in my office, wondering what I was going to do to help him. I was wondering the same thing.

Feeling incompetent in the role of sex therapist is an uncomfortable feeling. It is especially uncomfortable when you encounter this feeling midway through your career, 305

when you have long ceased to feel the anxiety of a newly minted therapist. Whatever our level of experience, when we encounter clients, situations, or problems that are alien to us, anxiety is a natural response. So it is for many ethnic minority clients who walk into a therapy office with little shared understanding of the process of sex therapy. Many of these clients, like Mr. Li, never return for a second appointment and remain an underserved population (Barrett et al., 2008; Moreira et al., 2005).

This chapter focuses on the need for cultural sensitivity in the practice of sex therapy.

We begin with the premise that sexual problems are experienced by people worldwide, but we contend that the sexual concerns of diverse cultures do not necessarily mirror those of Western populations. Culturally sensitive sex therapy is required to meet the needs of people in other countries and cultures and also to address the needs of cultural minorities and immigrant populations in the Western world.

**SEXUALITY IN A GLOBAL PERSPECTIVE**

Sexuality is best understood as a biopsychosocial phenomenon (Bancroft, 2009).

Although the biological, psychological, and social aspects of sexuality are clearly interrelated, the unique contribution of culture has been much neglected in the understanding of human sexuality and its problems and treatment.

Culture is defined as the shared meanings and values of a group that are passed on from one generation to the next or, as defined by Williams (1983), "the way of life for an entire society." What constitutes ideal, acceptable, and offensive sexual behavior is culturally defined. To illustrate, we can examine the cultural variations in what is considered appropriate for marital sex. Although most, if not all, cultures sanction sexuality within some form of marital union, there is a great deal of variation in cultural dictates regarding how that sexuality should be expressed. In the West, marriage is presumably based on mutual love between two adults. There is a growing acceptance of same-sex marriage, with such marriages being legally recognized in Canada, Argentina, and some parts of the United States and Europe (Wright, 2006). Marital sex is expected to be pleasurable, intimate, and consensual. In Western cultures, the standard is that sex should be desired by both parties rather than merely consented to, a fact that has likely contributed to hypoactive sexual desire disorder becoming the most common female complaint seen in sex therapy clinics in the Western world (Robinson, Munns, Weber-Main, Lowe, & Raymond, 2011). In many other parts of the world, however, marriage is the union of two families and is therefore often arranged by the families (Uberoi & Palriwala, 2008). It is always heterosexual, although there is a great deal of variation in what is considered a marriageable age for females. Sometimes the couple has met and consented to the union, but sometimes consent of the individuals is not seen as necessary given that the family has consented to the union. There is usually the expectation that the marriage be consummated quickly, often on the first night following the wedding. This presumes that what is required sexually in a marriage is a potent male and a willing and submissive (and chaste) woman. In many cultures the 306

ability to consummate a marriage signifies not only the likelihood of offspring but also that the union has been blessed by spirits or ancestors (Savage, 2012). Many anxious brides and grooms have taken to cutting themselves in order to show a bloodstained cloth to relatives who are often waiting just outside the door for proof of virility and chastity (Sungur, 2012). So whether marital sex is expected to involve love, good communication, sexual desire, and the ability to give and receive sexual pleasure or whether it requires male potency, female submissiveness, ancestral or spiritual blessing, and ultimately offspring depends on the culture. Because culture defines ideals and norms, it will also then define what is problematic and what treatments are likely to be effective (e.g., medical, spiritual, relational, or psychological). A good resource for the clinician interested in learning about sexuality in different cultures is the Continuum Complete International Encyclopedia of Sexuality (Francoeur & Noonan, 2004), available online at www.kinseyinstitute.org/ccies/index.php.

**SEXUAL DYSFUNCTION IN A GLOBAL CONTEXT**

Most epidemiological studies on the prevalence of sexual problems come from the West (North America and Europe). With few exceptions (Laumann et al., 2005), most of what is known about sexual problems in other parts of the world is based on small numbers, clinical samples or case studies. Furthermore, what little research there is on ethnic minorities has often focused on issues of sexual health and risk for sexually transmitted infections (STIs) or unintended pregnancy rather than on issues related to sexual pleasure (Hall & Graham, 2012; Lewis, 2004)

The first report of a large multinational comparison of sexual dysfunction was the Pfizer-funded Global Study of Sexual Attitudes and Behaviors (GSSAB; Laumann et al., 2005). More than 13,000 men and a similar number of women ages 40–80 years across 29 countries were surveyed. The most common sexual problems reported by women were lack of interest in sex (26–43%), inability to reach orgasm (18–41%), and lubrication difficulties (16–38%). Early ejaculation was the most common complaint made by men (12–31%), closely followed by erectile difficulties (12–28%). The incidence of all reported sexual problems was higher in East Asia and Southeast Asia than in other regions of the world. The authors of the study concluded that "sexual difficulties are relatively common among mature adults throughout the world." (p. 39).

It is difficult to estimate the true prevalence of sexual dysfunction from surveys (Graham & Bancroft, 2006; Mercer et al., 2003). Epidemiological surveys have often resulted in inflated reports of sexual difficulties because both transient, short-term sexual problems (which are very common) and more persistent problems (which are less frequent) have been assessed (Hayes, Dennerstein, Bennett, & Fairley, 2008; Mercer et al., 2003). Although the criterion of "distress" is required for a clinical diagnosis of any sexual disorder (American Psychiatric Association, 2013), the cross-cultural GSSAB

did not assess distress about sexual functioning, but only the presence of symptoms.

More recent surveys that have assessed distress (Bancroft, Loftus, & Long, 2003; Oberg, 307

Fugl-Meyer, & Fugl-Meyer, 2004; Shifren, Monz, Russo, Segreti, & Johannes, 2008; Witting et al., 2008) show that prevalence estimates drop, usually by at least half, when distress is included in the determination of sexual problems (Brotto, Bitzer, Loan, Leiblum, & Luria, 2010; Hayes et al, 2008).

To further illustrate this point, we can look at the international prevalence data on premature ejaculation (PE). In two multinational studies of intravaginal ejaculation latency times (IELTs), Turkish men had significantly shorter IELTs when compared with their counterparts in The Netherlands, United Kingdom, Spain, and the United States (Waldinger, McIntosh, & Schweitzer, 2009; Waldinger et al., 2005). However, whether these Turkish men were distressed by their relatively short IELTs was not determined in these studies. Yasan and Gurgen (2009) found that Turkish men referred to a sex therapy clinic (usually for fertility-related concerns) who met the DSM-IV

criteria for PE were not distressed about their condition. This could be attributed to the fact that these men were more concerned about fertility-related issues, but it could also have reflected a genuine lack of concern about the duration of intercourse. Zargooshi, Rahmanian, Motaee, Kohzadi, & Nourizad (2012) reported that PE was the primary presenting sexual complaint seen at their clinic in rural Iran. Unlike their Turkish counterparts, men in rural Iran are distressed about the duration of intercourse, even when their IELTs far exceed the standard cutoff of 2 minutes. Zargooshi and his colleagues noted that with the high unemployment rate in rural Iran, sex was one of the few pleasures accorded to married men, and they wanted it to last as long as possible.

The opinion of Iranian wives was not solicited, and therefore it is unclear whether they shared a desire for longer lasting vaginal intercourse. Furthermore, whereas the Iranian men were distressed about the brevity of intercourse, Western men are often more concerned about the fact that they lack control over the timing of ejaculation, regardless of how quickly it occurs (Kempeneers et al., 2012). One might predict, therefore, that treatments that focus on extending the length of time before ejaculation (e.g., medications) may be more effective and welcomed in Iran, whereas cognitive-behavioral strategies to help men gain control over the timing of ejaculation will be the treatment modality of choice in the West.

Cross-cultural research invariably raises concerns about the adequacy of translating language and concepts for use with populations other than the originally designated group. This issue was directly addressed by the investigators of the SWAN survey, a study of multiethnic midlife women living in the United States (Cain et al., 2003).

Addressing the finding that Chinese and Japanese women were the least likely to report a desire to engage in sex, the authors note, "Despite careful translation, we cannot rule out the possibility that terms such as desire and arousal may have different meanings across cultures or that women will respond to them differently" (p. 275). Furthermore, as Ahrold and Meston (2010) pointed out, the more different a culture is from the mainstream or comparison culture, the more likely it will be that differences will appear in assessment. Therefore, another conclusion regarding the GSSAB and the SWAN

study dataset is that Asian sexuality differs significantly from Western sexuality and as such, when measured against Western standards will appear lacking.

The tendency to compare other countries to the standards of the West plagues cross-308

cultural research (Meston & Ahrold, 2008). The GSSAB asked specific "Western-defined" questions about sexual difficulties. Different sexual concerns may be elicited when the question is broadened to ask "What problems bring men and women to treatment?" For example, in a study of 1,000 consecutive patients attending a sex therapy clinic in India, apart from PE (the most frequent complaint, reported by 77.6%

of men), nocturnal emission (71%), masturbatory guilt (33%), and concern about penis size (30%) were all more frequently reported than were complaints of erectile dysfunction (24%; Verma, Khaitan, & Singh, 1998).

Other evidence that the sexual problems of diverse cultures do not mirror those of North America or Western Europe comes from what are typically called culture-bound syndromes (CBS). Examples of CBS include Dhat syndrome (excessive worry about penis shrinkage due to masturbation), found on the Indian subcontinent and koro or koro-like syndromes in West Africa in which men (predominantly) believe that their genitals have either been stolen or have shrunk inside their bodies and will cause their deaths. This syndrome of shrinking genitals is also known as Suo-yang (Mandarin) or Shook-yang (Cantonese) in China. Unconsummated marriage not due to any specific sexual dysfunction (Zargooshi et al., 2012), "handkerchief stress" (a term coined to reflect the anxiety of having to produce a blood stained cloth on the wedding night to prove virility; Sungur, 2012), and concerns regarding having luck (good and bad) transmitted through sexual behavior (Savage, 2012) may represent real challenges to Western-based notions of what constitutes a sexual problem. Hughes (1998) argued that instead of viewing CBS as a collection of bizarre or exotic sexual problems, they are best seen as examples of the way that culture influences the manifestation of psychopathology.

Western definitions of sexual dysfunction highlight the performance aspect of sexuality, our linear view of sexual response (first desire, arousal, and then orgasm), and the individualism inherent in our culture (the individual nature of the diagnosis and the criterion that the person him- or herself must be distressed about the problem; American Psychiatric Association, 2013). The prevalence of Western-defined sexual dysfunctions in other areas of the world may indicate the extent to which values diverge or are shared. For example, whereas low sexual desire is the most frequent complaint of women in the West, in more male-centric cultures, vaginismus is the primary sexual complaint for which women seek help (Yasan & Gurgen, 2009). The prevalence of vaginismus in these cultures has been attributed to the high premium placed on virginity and the fact that vaginismus interferes with intercourse (and therefore with male pleasure) and can significantly hinder reproduction (Sungur, 2012). Furthermore, as Yasan and Gurgen (2009) have pointed out, "It is understandable that women who have been forced to marry without consent and who know that they have to stay married for the rest of their lives, will have difficulties while experiencing sex unwillingly in their marriage" (p. 73). We agree with these authors that although this is clearly a problem, it is not one best viewed as the problem of an individual woman but a reflection of a culture in which there is little or no autonomy for women.

In summary, we find a paucity of good data regarding the experience of sexual problems in different cultures. Although Western-defined sexual dysfunction may be 309

found in other cultures, the rates of occurrence and the distress experienced vary across different countries (Laumann et al., 2005). The sexual problems that are significant for other cultures may be quite different from those found in the West. A good resource for the interested clinician regarding sexual problems and treatment options may be found in The Cultural Context of Sexual Pleasure and Problems: Psychotherapy with Diverse Clients (Hall & Graham, 2012).

**ACCULTURATION**

Given that sexuality is, at least in part, culturally determined, it follows that when the culture changes, so should sexuality. One of the most striking examples of this phenomenon involved a study of the interaction of two very different cultures: Iran and Sweden (Darvishpour, 1999). Iranian migrants to Sweden were found to have significantly revised their views about sexuality to more closely approximate the values of the host country. They went from a traditional, authoritarian, and patriarchal orientation to a more individualistic and egalitarian approach to sexuality. People who immigrate to another country will often retain their values and traditions but will also, to a greater or lesser extent, acculturate (adopt the values and traditions of the host country; Ryder, Alden, & Paulhus, 2000). It has been assumed that acculturation proceeds in a linear fashion, with immigrants increasingly assimilating the cultural values and mores of the mainstream culture. However, studies examining the effects of acculturation on the sexual attitudes and behaviors of immigrants have found conflicting results, with some finding that acculturation predicts sexual behavior and others reporting no effect (Meston & Ahrold, 2008). Although this may be due to the different measures of acculturation that have been used across studies (questionnaires, length of residency), it is likely that a linear assimilation model does not adequately capture the experience by which people adopt some or all of the tenets of the mainstream culture (Ahrold & Meston, 2010; Brotto, Chik, Ryder, Gorzalka, & Seal, 2005). Brotto and her colleagues found that the degree to which Asian women maintained aspects of their heritage culture influenced the effects of Westernization on sexual attitudes. Women who relinquished heritage ties adopted the more liberal sexual attitudes of the Western culture, whereas women who maintained strong heritage ties did not. Ahrold and Meston (2010) described two models of acculturation: In one the heritage and mainstream culture blend together and become a third entity—much like tea, "with one element blending into, and changing the original nature of the other" (p.

199). The other model is one in which the two cultures retain their original elements while coexisting, like oil and water when combined. Mutual engagement in both the heritage and the mainstream culture has been found to be the most widely used practice of Hispanic youth who blend their two cultures into a unique cultural identity, whereas Asians tend to retain aspects of their heritage culture while adopting some elements of the mainstream (Ahrold & Meston, 2010). It is not yet known what the impact of age, gender, and other personality variables is on the process of acculturation. Clinicians 310

need to be sensitive to the dual allegiance to heritage and mainstream culture and to be aware that despite assimilation of some aspects of mainstream culture (clothing, occupation, language), clients may retain heritage values with respect to family and sexuality. The same may be true for first-generation clients, who were raised with traditional values of the heritage culture but have greater exposure to mainstream culture.

Nina, a first-generation Italian woman, came to therapy depressed after having sex with a male friend in college, an occurrence that she deeply regretted. Nina explained, "I was taught that sex is very important, something sacred for marriage.

But for me, its only right if Im in a relationship that I could see leading to marriage.

I feel pressure with American men. Most of my friends think sex is fun, and it is of course, but I just feel so pressured, I want to say No, I dont love you! I would never marry you but then they would think I was some kind of freak, so I said okay when I meant no."

Cultural sensitivity needs to extend to an awareness and appreciation of various patterns of adherence to the old culture and adoption of the new culture.

**CULTURE AND RELIGION**

Religion is one way in which values and attitudes and rules regarding sexual behavior are transmitted within a culture. The degree to which a culture embraces religious prohibitions and sexual proscriptions varies. Religion is an important factor in determining sexual behavior in the Arab and Persian countries of the Middle East (Zargooshi et al., 2012) but is a less significant factor in many Western countries and Russia (Hall & Graham, 2012; Temkina, Rotkirch, & Haavio-Mannila, 2012). Gender may moderate the impact of religion and culture on sexuality. In Croatia, inconsistent and weak associations were found between religiosity and sexual behavior among women, whereas no relationship existed for men (Puzek, Stulhofer, & Bozicevic, 2012).

Sex guilt, defined as "a generalized expectancy for self-mediated punishment for violating or for anticipating violating standards of proper sexual conduct" (Mosher & Cross, 1971, p. 27), was found to mediate the relationship between religion and culture with sexual desire in women. Woo, Morshedian, Brotto, and Gorzalka (2012) found that the activation of sex guilt reduced sexual desire in Asian Canadian women but not in European Canadians. Simply put, a strong identification with ones heritage culture or religion will mitigate the liberalizing impact of Western acculturation on sexual attitudes and behavior. Strength of religious identification may explain within-ethnic-group differences in sexual attitudes and is therefore an important issue to be addressed during assessment and treatment of sexual problems.

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**HOW DOES CULTURE INFLUENCE SEXUAL DYSFUNCTION?**

Hughes (1998) outlined three ways in which culture influences psychopathology that we believe have relevance for sexual disorders. The first is the phenomenology of symptoms; for example, culture influences the way distress is experienced. The second is in the syndromization of symptoms into patterns, and the third is in the diagnostic process itself—for example, when the clinician does not understand or is unfamiliar with the culture of the patient, diagnostic errors may result (usually but not always in the direction of overpathologizing).

We believe that the diagnosis of low sexual desire in women illustrates the three ways that culture influences sexual disorders. Although there is sometimes a biological basis for low desire, the prevalence of this disorder in North America indicates that there are multiple pathways for the diagnosis. The reduction in sexual desire for a loved partner is perhaps a very important way in which Western women manifest the stress, the unfair burden of housework, or other relationship unhappiness. Because refusing sex is a possibility accorded to Western women, a basic right not shared by women worldwide,1

low sexual desire may be accompanied by avoidance of sex. Nevertheless, sex, when it does occur, may still be enjoyable. Because desire is deemed important and is often equated with love, North American and Western European women often feel distress about their lack of desire. In North America and Western Europe, relationship distress may manifest in low sexual desire (a culturally influenced expression of unhappiness), which will be experienced as a distressing lack of interest in sex, a high rate of refusing sex initiated by a partner, and a somewhat paradoxical enjoyment of the infrequent sex that does occur (the syndromization of symptoms into patterns). This clinical picture will be familiar to Western-trained sex therapists, and a diagnosis of low sexual desire is likely to result. Because female consent, and certainly sexual desire, is not deemed necessary in some other cultures (e.g., traditional Korean culture), unhappy or stressed women may engage in frequent but unwanted sex, may experience disgust regarding sex, and may come to manifest hostility toward their spouses and disdain for men in general (Youn, 2012). This symptom constellation may be unfamiliar to a Western-trained therapist, who, upon encountering one Korean woman with this clinical presentation, may attribute her severe anger and hostility to underlying pathology (e.g., a mood or personality disorder).

**CULTURE AND ISSUES RELATED TO DIAGNOSIS OF SEXUAL**

**DYSFUNCTIONS**

The assumption that there is a universal model of sexual response leads to the belief in a universal set of sexual dysfunctions. Although there were efforts to enhance the cross-cultural applicability of diagnoses in DSM-IV-TR, critics argued that these efforts fell short and that "the DSMs underlying thesis of universality based on Western-delineated 312

mental disorders is problematic and has limited cross-cultural applicability" (Thakker & Ward, 1998, p. 501). Although the sexual problems of individuals from other cultures may fit into some of the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnoses for sexual dysfunction, they may more often need to fall into the category of sexual dysfunction not otherwise specified (NOS; American Psychiatric Association, 2013). In DSM-IV-TR, culture-bound syndromes were placed in the Appendix, where few clinicians would access them.

In recent years there has been a growing awareness of the importance of culture in diagnosis and this has been reflected in the development work for DSM-5 published in May 2013 (American Psychiatric Association, 2013). The research agenda for DSM-5

included publications related to cultural issues in diagnosis (Alarcón et al., 2002) and experts on cultural issues were appointed to some of the work groups, including the Sexual and Gender Identity Disorders Work Group (Jack Drescher, MD). There was a study group on gender and cross-cultural issues, convened to "address gender, racial, and ethnic issues in mental disorders, including differences in symptoms, symptom severity, and course of illness" (American Psychiatric Association, 2012). As a result the descriptive text accompanying the DSM-5 diagnostic criteria for sexual dysfunctions highlights the importance of considering cultural factors, such as inhibitions related to prohibitions against sexual activity, attitudes toward sexuality, and so forth.

**ASSESSMENT**

Culturally sensitive assessment evaluates individuals and couples in the context of culture. Culture is viewed as essential to understanding sexual problems, not as something ancillary or exotic. Cultural values and ties may also be seen as strengths that can guide the treatment process, not solely as part of the pathology (Ahmed & Bhugra, 2004; Hall & Graham, 2012; Kelly & Shelton, 2012).

When encountering an individual or couple from another culture, the clinician must try to understand the unique meaning of the sexual symptoms, rather than diagnosing them using his or her own cultural lens. For example, Ramanathan and Weerakoon (2012) described their treatment of a young Indian man who presented with fears that he had damaged himself by masturbating. The man was concerned because he felt weak, and he worried that his eyesight had been affected and that his acne was a manifestation of the damage caused by his masturbation. These concerns had not stopped the young man from masturbating, and now he worried that he could not control himself and that he would not be able to have sexual intercourse with his wife when he got married. If this young man had encountered a Western therapist, his symptoms might have seemed rather quaint, and the impulse might have been to paternalistically explain that masturbation is not harmful and can indeed help a man prepare for marriage by boosting his confidence in his ability to get and maintain an erection and also to identify what arouses him. Instead, the therapist in this case inquired about the meaning of the fears. The young man was indeed reaching the age where his parents would arrange a 313

match for him. He was anxiously looking forward to marriage, but there was tremendous pressure on him to represent his family well, to please his new wife, and to be found attractive and desirable by her and her family. Indeed, the process that young Indian men and women go through in being evaluated by their potential in-laws is rather daunting and is brilliantly described in the novel A Suitable Boy (Seth, 1993).

Ramanathan and Weerakoon (2012) did not try to dissuade the young man from his beliefs. Instead they addressed the meaning of the mans distress—his concern about his suitability for marriage. The young man was sent for tests to determine the basis for the weakness, prescribed good nutrition to add strength, had his eyesight tested, and was given a medication for the acne. He was also asked to refrain from masturbating for several days prior to each of the several medical tests. This helped him realize that he could have control over his masturbatory behavior. The therapist also provided information about sex to alleviate anxiety about what to do in order to consummate the marriage.

As in the case just described, we advocate for an approach to assessment in which the clinician tries to understand the presentation of symptoms from the clients perspective, recognizing that this perspective is strongly influenced by the culture in which that client was raised. At present, the best way to do a culturally sensitive assessment is to carry out a thorough diagnostic interview.

**ASSESSMENT INSTRUMENTS: TESTS AND QUESTIONNAIRES**

Many researchers have noted the limitations in regard to cross-cultural assessment instruments. As Rellini et al. (2005) pointed out, the majority of questionnaires used to assess sexual functioning in women were developed for, and standardized on, a Western, typically U.S., population. The lack of importance accorded to validation of measures in different cultures is grounded in the assumption that the constructs of sexuality that underlie the original questionnaire are unaffected by culture. Rellini et al.

(2005) translated the McCoy Female Sexuality Questionnaire into Italian and attempted to validate it on an Italian sample. They found that of the 5 factors that were apparent on the original questionnaire, only 2 had relevance for the Italian sample: sexuality and partnership. These two factors differentiated women with sexual dysfunctions from those who did not have such issues, but the separate constructs underlying the phases of the sexual response cycle (i.e. desire, arousal, and orgasm) were not meaningfully related to sexual problems in the Italian sample. Although these findings may have reflected translation difficulties, they may also reflect differences between Italian and American women in how they experience their sexuality. The Iranian validation of the Female Sexual Function Questionnaire (Quirk et al., 2002) also found a factor structure different from the original test (Khademi et al., 2006). Interestingly, the married women who responded to the questionnaire found a question on "enjoyment of nonpenetrative sex" confusing and rarely responded to it. Other researchers have questioned whether the methods of assessing sexual desire and sexual enjoyment used in North American–

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European contexts are appropriate in different cultural settings (Graham, Ramos, Bancroft, Maglaya, & Farley, 1995). For example, in a study of the effects of oral contraceptive use on mood and sexuality carried out in women living in Edinburgh, Scotland and Manila, Philippines, there were striking differences between the two samples at baselines. The Manila women, although reporting a somewhat higher frequency of intercourse than the Scottish women, were less likely to initiate sex, had less sexual interest, less sexual enjoyment, and were less likely to feel "close and comfortable" with their partners during sexual activity (Graham et al., 1995). Although the interview and questionnaire measures had been translated and back-translated and the Manila interviewers were trained, the authors questioned whether the method of assessment was appropriate for the Manila women. Personal pleasure for women and the individual (vs. relationship) orientation of many interview formats and questionnaires may be seen as less relevant in collectivist and/or male-centric cultures (Hall & Graham, 2012)

Similar issues affect the assessment of male sexual dysfunction. The International Index of Erectile Function (IIEF; Rosen, Riley, Wagner, Osterloh, Kirkpatrick, et al., 1997) is the most popular measure of erectile dysfunction (ED) and it has been successfully translated into a variety of European languages and validated for use in many European countries (Rosen, Cappelleri, & Gendrano, 2002). The applicability of the IIEF to non-Western cultures has not been established. It was difficult to translate the IIEF into Malaysian because the language often referred to sex obliquely (e.g., intercourse is translated as "joining together in one body") or with moral undertones (sex organs are literally translated as "shame"; Lim et al., 2003).

Although there may be measures that are developed and validated for use with other cultures, it is difficult to find them, if they do exist. When seeing clients from non-Western cultures, we suggest using assessment measures developed in the West with caution—checking to see that the measure in question has been validated for use with a specific population and carefully looking at the answers to specific items, including following up with the client to ensure that the meaning of the question was clear. As Kelly and Shelton (2012) have observed, it is also important to keep in mind that an overreliance on paper-and-pencil tests may be off-putting to certain cultural groups. A diagnostic interview may be the best way at present to gather a sexual history and to diagnose sexual problems.

The most important aspect of the diagnostic interview is the attitude of the interviewer. It is important to be flexible in our style and our openness to understanding problems from other perspectives. For example, an American patient of East Indian background was referred to one of us (Hall) for a court-ordered evaluation regarding homicidal threats she made to her husband. Her husband had succeeded in having her removed from the home and had a restraining order against her. She wanted to reconcile with her husband, but he feared for his life, and the judge was concerned that the woman was mentally ill. In the evaluation the woman readily admitted that she had told her husband (East Indian by birth and ethnicity) that she had put rat poison in some of his food and that she would tell him which food was poisoned if he asked. The background of the story was complex. The wife had recently undergone a hysterectomy 315

for medical reasons, and her in-laws came to visit shortly thereafter. She was required to cook and clean for her in-laws, despite medical advice to rest after the surgery. She also worried (correctly) that her in-laws were there to persuade her husband to divorce her since she could no longer have children. For weeks she cooked and cleaned and listened to her in-laws complain about her to her husband, who never stood up for her. He refused to listen to her worries or her complaints and refused to lift a finger to help her.

He felt that the answer to the problem was to show his parents what a good wife she was so that his parents would leave and stop pestering him to divorce her. Instead, his wife was doing the opposite and proving to them that she was not a fit wife for their son. The husband felt caught in the middle and did not know what to do. Ultimately he stopped speaking to his wife altogether. In desperation, she bought rat poison and displayed it prominently in the kitchen (she denied using it, and no food was ever discovered to be poisoned). We believe this was not a case of individual pathology on the part of the wife, or the husband either, but rather an example of the tremendous stress and pressure that couples face and the apparently bizarre ways in which their distress is manifested. The judge and lawyers wondered, "Why didnt she leave him? Why didnt they go to therapy?" Her physicians told her, "You cannot keep doing this housework, you are making yourself sick, you have to stand up to your in-laws. Tell your husband that you cannot cook and clean for 6 weeks. Cant you hire a cleaning lady?" All these are reasonable questions for Western-born and -raised couples, but they fail to understand the context of the distress of this couple.

**FROM CULTURALLY COMPETENT TO CULTURALLY SENSITIVE**

**SEX THERAPY**

Cultural competence "denotes the capacity to perform and obtain positive clinical outcomes in cross-cultural encounters" (Lo & Fung, 2003, p. 162). Successful treatment of sexual problems will require tailoring treatment to the unique cultural requirements of the individual or couple. In some cases traditional psychotherapy or sex therapy approaches can be modified (Ahmed & Bhugra, 2004; So & Cheung, 2005). Culture-specific modifications to the method of treatment may be most successful when the sexual problems are similar to those for which sex therapy was designed—problems of sexual function, such as erectile dysfunction, ejaculatory problems, and orgasm difficulties—and when the clinician is familiar enough with the culture to make the necessary modifications. For example, So and Cheung (2005) outlined ways in which sex therapy could be modified for Chinese couples, including the admonition that sex therapists be directive and authoritarian. However, tailoring therapy in this way requires the therapist to be a chameleon, may modify the therapeutic relationship to the extent that it is no longer therapeutic, and requires that treatment approaches be adapted in ways that may alter the success of therapy (Sue & Zane, 2009). It also requires a breadth of cultural knowledge that most clinicians simply do not possess, and, as the vignette at the beginning of the chapter illustrates, clients will often not return for the second 316

appointment (when you have done your homework and understood a little about the culture). It is simply not workable to have a model of cultural competence that requires that treatments be modified for each culture. This approach also promotes overgeneralizing (Sue & Zane, 2009) or stereotyping, as clearly it is not feasible to understand the diversity and nuances of all cultures.

We believe that a culturally sensitive approach to sex therapy is one that recognizes the centrality of culture in shaping sexuality. Moreover, we argue that the importance of the therapist and client sharing meanings is central to the success of therapy and that, with sensitivity, a shared meaning can be developed between therapists and clients of different cultural backgrounds. Therefore, we prefer the term "culturally sensitive sex therapy," which stresses a flexible attitude, rather than the term "competent," which emphasizes knowledge and behavior.

**CASE DISCUSSION**

Suleman and Nasreen were a married couple in their early 30s. Both were of Pakistani origin; Suleman was raised in the United Kingdom, while Nasreen was primarily raised in Pakistan and spent only 2 years in London prior to moving to the United States. At the time they came to therapy they had been living in the United States for 2 years.

Nasreen made the initial request for therapy, stating on the phone that she had found me (Hall) through an Internet search. She explained that her marriage was in trouble and that she wanted help to fix it. She confirmed that the problem had to do with sex.

When the couple presented together, they seemed to be a bit of a mismatch. Suleman was tall, light-skinned, athletically built, and very attractive. He wore jeans and a t-shirt.

Nasreen was short, plump, and rather plain, with a dark complexion. She was dressed in a designer dress and high heels with a scarf loosely draped around her head and neck.

(Her appearance bespoke her dual cultural allegiance, as well as the fact that in all things she was trying very [too?] hard). Nasreen explained her worry that her husband had

"problems" because he did not seem to want to have sex very often. The frequency of sex was once every 3 weeks or so, but it had been steadily declining since their move to the United States. When asked why this distressed her, Nasreen began to talk about all the hurts, slights, and insults she perceived coming from Sulemans family. Of Suleman, she reported that he was a kind husband and a loving father to their 3-year-old daughter.

Suleman sat quietly and never interjected. He answered politely when asked questions.

He said that the frequency of sex was not a concern to him. He explained that he was tired during the week from his long commute and that he often brought work home on the weekend because he wanted to be successful in his new job and get a promotion, which would allow them to move into a house and have more children. Suleman agreed to come to therapy to make his wife happy. He was unsure as to whether there really was a sexual problem.

Suleman was the second of three sons born to a Muslim Pakistani family in East London, England. He had been married previously in a match arranged by his parents.

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Unfortunately, his first wife had been bullied by her family into the marriage and refused to have sex with Suleman in order to annul the marriage. The families got involved, with the brides family claiming that if Suleman could not have sex with his wife, he must be impotent. Ultimately Sulemans family agreed to a divorce with a monetary settlement in order to avoid further scandal. Suleman felt extraordinarily shamed by the failure of his marriage and betrayed by his parents, who were supposed to vet the bride for him. He isolated himself from friends and family and spent his free time working out at a gym and watching pornography. He began to drink. As Suleman became increasingly estranged from his Islamic faith and his community, he became depressed. In his isolation, Suleman went online to a chat room for Muslims, which is where he met Nasreen.

Nasreen was the only child born to her Pakistani parents. Her father had a business, which had been lucrative at one time, but her fathers health began to fail soon after she was born, and after a series of failed financial transactions, the family moved in with her fathers eldest and more successful brother. Nasreen reported that although she was treated well, she was aware that her cousins had better clothes and more opportunities than she did. When Nasreen was in her late teens her fathers fortunes changed, and the parents moved into their own flat and sent Nasreen to London to go to university.

Nasreen was depressed and lonely in London and dropped out of the university after her first term. She tried waitressing at an Indian restaurant for a short period of time, and she did not tell her parents that she had left school. Nasreen felt socially awkward and spent much of her free time on the Internet.

After Nasreen and Suleman met in an online chat room for young Muslims, they began talking on the phone and then meeting for coffee. Both described a feeling of comfort and belonging with each other that they had not felt before. Suleman stopped drinking and going to clubs and was welcomed back into his family. They ultimately accepted his decision to marry Nasreen, as his divorce had negatively affected his chances for a "good" match. Nasreen was Pakistani and Muslim, but she had several points against her, according to Sulemans family: She was not educated, her skin was too dark, her father was not educated nor a professional, and she had worked as a waitress. Soon after their marriage, Suleman was offered a good position at a financial services company on Wall Street. The couple settled in New Jersey in a Muslim Pakistani community and lived close to Sulemans older brother and his wife. Suleman began to drink again, although only in the privacy of his home, and also returned to watching pornography and masturbating for his sexual pleasure. Nasreen also masturbated to orgasm, although she had never had an orgasm with partnered sex. The couples sex life had never been very satisfactory for either partner and had consisted of brief kissing and caressing followed by intercourse.

When asked in individual sessions about the reason for their infrequent sex, the couple had two very different interpretations. Suleman said that he loved Nasreen and that she was a good mother and a good wife. However, he did not find her very sexually appealing, and it was easier for him to get his sexual needs met by masturbating to pornography, which he enjoyed a great deal. Suleman had been taught to masturbate by his older cousin when he was 12 years old. His cousin had masturbated him to orgasm 318

and instructed Suleman how he could do this to himself. Suleman did not view this as sexual abuse despite the fact that his cousin was 7 years older than him at the time.

Suleman felt pleased to have received the information and instruction, and he remained on good terms with his cousin. Suleman said that he wished someone had taught him how to have sex with a woman, and he still felt very ashamed of the failure of his first marriage. To Suleman it was a good thing that he was not strongly attracted to his wife, as he felt that he needed to be more successful professionally in order to be happy and that the only thing lacking in his family life was a son. He was concerned about his wifes unhappiness, however.

When asked for her belief about the reason for her unhappiness, Nasreen could not stay on topic for any length of time. Instead of talking about her relationship with Suleman, she digressed to discussing slights she perceived coming from his brother, or more particularly her sister-in-law: "She doesnt invite me over, she didnt talk to me at this party or on that occasion, she did not thank me for the gift, she did not put out the food I brought over. . . . " Nasreen expressed the wish for Suleman to talk to his brother so that her sister-in-law would be better behaved toward Nasreen.

**An Attempt at Sex/Couples Therapy in the Western Style**

At first it appeared that Nasreens unhappiness about the frequency of sex was due to her unhappiness regarding the relationship. She wanted to have a closer relationship with her husband, who worked a lot and was somewhat withdrawn. Because she was relying on her sister-in-law to help her integrate into the community, she felt lonely and isolated. Also, it appeared that this situation mirrored the situation she was raised in, relying on an older and more successful brother for status in the community. Goals for therapy were to help Nasreen make more connections in the community (without having to rely on her sister in-law) and to increase the connection within the couple using their sexual relationship, which might increase in frequency, but which certainly could improve in the level of pleasure and connection experienced by both.

Suleman became very engaged in treatment and agreed with the goal of improving their sexual relationship. Nasreen also expressed interest in doing "homework" to improve their sexual relationship. Sensate focus I (touching and caressing the body without touching breast and genitals) was assigned with the goal of improving comfort and communication.

**Failure**

The next several sessions followed a similar path. Suleman made efforts to get home early to be able to spend time with Nasreen and to do the exercises. But there was always a reason Nasreen gave for why the exercise could not happen; she was too tired, their daughter was still awake, she had a stomachache, she had to Skype with her parents in Pakistan. In session it was again hard to keep Nasreen on topic; she continued to obsess 319

and ruminate about slights from her sister-in-law. She did not make any efforts to reach out and make other connections in the community, even when it involved doing things she had expressed an interest in (play groups for her daughter, asking other mothers to come over, going to the library for childrens programs). Was Nasreen a help-rejecting complainer? Was she depressed and stuck in obsessive thinking about being slighted?

Were her family-of-origin issues significantly interfering with progress? Or was the problem that the therapist had not yet understood what Nasreen was desperately trying to tell her?

**Becoming Culturally Sensitive**

Amazingly, Suleman and Nasreen continued to come to sessions despite the lack of progress. I determined that I had not sufficiently understood the problem and needed to listen to Nasreen more closely (as she was the one presenting the obstacles). This time I listened to the meaning inherent in her story. Her meaning seemed clear: The problem was that Sulemans family had never really accepted her or the marriage. She felt that this was holding Suleman back from truly loving her. The solution, she felt, was that the marriage needed to be sanctioned by Sulemans family.

I agreed with Nasreen that it was important for the two of them to have family approval for their marriage. When Suleman protested that his family had consented to the marriage, I stated: "Now Nasreen knows it is important that they accept the marriage." Both agreed that they could do the sensate focus exercises to strengthen their intimate connection while they also worked on ways to increase familial acceptance.

Increasing their intimate connection would help others to see them as a happily married couple and would help Sulemans family see that the marriage was a good one. Nasreen was enthusiastic, but Suleman was pessimistic.

The next week the couple returned and had done the first sensate focus assignment three times. It was very pleasurable for both and new in that Nasreen had been able to communicate her likes and dislikes to Suleman. Suleman felt very pleased with the exercise as well and found it enjoyable to touch and be touched without the pressure to have intercourse. He could tolerate what he would otherwise perceive as criticism, as Nasreen was now the "teacher" he had wanted. Suleman reported that he felt sexually attracted to his wife. The two had also discussed ways in which they could address the family issue. They had decided to have a small gathering, as the youngest brother and his wife were coming to New Jersey from East London for their annual visit. Last year they had not come to Nasreen and Sulemans home—a slight Nasreen felt intensely. As they planned and discussed the party, they reported feeling close to each other. Nasreen felt optimistic about the marriage, and both readily agreed to proceed to sensate focus II

—caressing, including breasts and genitals. This exercise again went well. Nasreen worked on communicating her pleasure more overtly and guiding Suleman in constructive and positive ways. Suleman reported feeling more comfortable and confident and basked in his wifes praise during the session. He also reported that he liked the way the Nasreen touched him and that he had an erection during times he was 320

touched and also when he was touching Nasreen. This pleased Nasreen greatly, and she reported feeling desired by Suleman for the first time in their marriage. Nasreen also felt certain that the party would be a success and that the oldest brother, who was the de facto head of the family in the United States, would surely send his parents positive reports about Sulemans wife.

Disaster struck, however, and the next meeting was difficult. The couple did not discuss sex at all. Instead they reported on family events. The sister-in-law had taken exception to Suleman and Nasreen planning a party for the younger brother. She insisted that the party be held at her home, which was a larger and more appropriate venue, as the eldest brother should host. Suleman accepted the situation and shrugged it off, saying that there was nothing to do. Nasreen felt deeply depressed and hurt. She expressed suicidal ideation. Nasreen did not see her reaction as too intense. Rather she felt it was an appropriate reaction to not being treated like a wife and sister-in-law.

**Consulting Experts**

It was difficult in the session to help Nasreen gain a perspective on the situation that would help her feel less depressed. Suleman offered several options: he would talk to his brother, they would boycott the sister-in-laws party, they would still host their own party; all to no avail. Nasreen continued to be despondent, and Suleman was losing patience. I was unsure of how to proceed. It was time for the experts. My cultural sensitivity was failing me. I knew that Nasreen "Skyped" with her family and felt supported by them, so I encouraged both Nasreen and Suleman to talk to their parents about the situation and ask for guidance. Sulemans parents ultimately supported the older brother, but Sulemans discussion with his parents became known to the younger brother and his wife. While in New Jersey, this sister-in-law reached out to Nasreen, and the two found that they both had difficulties with the superior airs of their eldest sister-in-law. Finally Nasreen had found an ally in the family. Nasreens parents had been alarmed at the situation and alarmed by Nasreens depression. After speaking with her, they decided that they needed to come to visit—for 3 months.

For most Americans, a 3-month visit from family, in a small one-bedroom apartment, would be a disaster for sex therapy. In this case it was a bonus. Sex therapy, which had come to a standstill during this time, was restarted anew. Nasreens parents knew that the couple were having sexual problems and knew that they had exercises to do. So they did what they could to make the exercises easier for the couple. They readily babysat their granddaughter, making dates possible. They cooked and cleaned, alleviating the household burdens for Nasreen. While they slept in the one bedroom in the apartment, the 3-year-old daughter slept in their room, and they agreed not to walk into the hallway during certain hours (necessary to use the bathroom) so that these hours would be available to the couple for working on sex. While his in-laws praised him and extolled Sulemans virtues at every turn, Nasreen felt that their visit really showed their love for her and gave her a sense of family. It was Nasreens mother who provided the key to success. She told Nasreen, "You are the second wife of a very good 321

man, who is the second son from a very good family. This family accepts you. It is you who does not accept your place in the family. If you dont like it, you dont have to stay here. This is America; you have choices here." In session Suleman and Nasreen agreed that they did not like the option of staying in a second-class place. They began looking for a community to move to, each weekend going to a different town within commuting distance from New York to check it out. These were pleasant family outings (complete with daughter and parents).

Sex therapy proceeded with renewed energy and at a faster pace. With his in-laws staying with them, Suleman had no opportunity to drink or watch pornography.

Without his usual diversions, Suleman was more interested in having sex with Nasreen.

Pleasing his wife sexually was culturally valued and also valued by Suleman, who genuinely cared for her. With the support of her parents and the knowledge that she did not accept the marital family, not the other way around, Nasreen felt that she needed to attend to being a better wife. She made an effort to stay up at night and talk with Suleman about his work, and she began to plan meals and fun outings for the family. It also meant doing the sex homework, which she came to enjoy very much. Nasreen had an orgasm for the first time with Suleman, which thrilled the two of them equally. At the end of 3 months the couple was nervous about the departure of Nasreens parents, but they were moving to an ethnically diverse town several hours away where they felt a sense of community was possible. Nasreen had already signed up for a "Mommy and me" class with her daughter, and Sulemans commute was considerably shorter, so he anticipated being home earlier in the evening.

The couple asked for a referral to continue therapy, which they felt was very helpful to them. However, they reported back after several months that they were doing well and were continuing to have regular and enjoyable sex. They declined a referral.

**Summary**

The important elements to the ultimate success in this case highlight some of the important elements for successful culturally sensitive treatment. It is imperative that therapy begin with a shared understanding of the problem. The way in which the individual or couple discuss their sexual problems provides important information about the meaning of the sexual problem. This will guide treatment. Embracing the culture, which means seeing the culture as a potential source of strength rather than solely a source of problems, allows the clinician access to factors that may further treatment progress. In this case it was extended family. As this case demonstrates, the sex therapy techniques themselves did not radically change, nor did the therapist radically change her therapeutic style, although the context was culturally unique.

**FUTURE DIRECTIONS**

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Sex research, sexual medicine, and sex therapy are either nonexistent or marginalized professions in many parts of the world. As Stulhofer and Arbanas (2009) stated, "The absence of tradition and lack of professional training programs, as well as financial and status-related disincentives for young aspirants, makes sexual problems and dysfunctions nobodys business" (p. 1044). We believe that bringing sex therapy to many parts of the world can raise awareness of sexual problems and can inform the public and related professions that treatment options are available.

It is important to note that although we advocate cultural sensitivity, we are not condoning cultural values and practices that we believe are intrinsically harmful. Gender inequality, which is often culturally entrenched and which affects sexuality, is a case in point. Sexual well-being, as measured by emotional and physical satisfaction with ones sexual relationship, satisfaction with sexual function and stated importance of sex, was higher for men than for women in all the countries surveyed in the GSSAB (Laumann et al., 2006). In many parts of the world, female sexual pleasure is not considered important, or it is considered dangerous. Female genital cutting, forced marriages of girls and women, and the sex trafficking of women and children are dangerous practices. There is a high rate of intimate and partner sexual violence, perpetrated primarily by men against girls and women (World Health Organization, 2005). Sex therapy promotes the equal right to sexual pleasure and safety for men, women, and transgender individuals of all sexual orientations. The ubiquitous presence of sexual medicine, which at present has little to offer women in terms of enhancing sexual pleasure (Hall & Graham, 2012), may further this imbalance if it is also not practiced with sensitivity and augmented with at least some education and counseling. Sex therapy might not save the world, but it can do its part to improve the lives of the people in it.

Improving the lives and the sexual health and pleasure of women and men cannot wait for psychotherapy to be culturally accepted and practiced in communities in which it is not yet established. As Alain Giami (2012) asked, "Who in the culture is authorized or privileged to hear about the sexual problems and offer help?" Often it is the traditional healers. The explanations traditional healers give regarding sexual dysfunction often match the patients own understanding. They use a common language, and their treatments are based on this mutual understanding, making for better treatment compliance. Perhaps even more important, in cultures in which there is no formal psychotherapy, traditional healers take the time to listen, and this

"therapeutic relationship" may be at the core of their effectiveness as healers (Ahmed & Bhugra, 2004). If psychotherapy is to be relevant to the treatment of sexual problems in an ever-changing and varied cultural landscape, adaptation, innovation, and flexibility will be necessary (Hall & Graham, 2012).

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1 Interestingly there is evidence from a study in sub-Saharan Africa that women who have greater autonomy in general household decision making also have greater ability to choose the timing and frequency of sex (Hindin & Muntifering, 2011).

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**CHAPTER 16**

Body Image and Sexuality

Michael W. Wiederman and Sabina Sarin

**B** eing distracted during sex diminishes pleasure and contributes to a variety of sexual dysfunctions.

Performance anxiety has been identified as a common distraction, but body image concerns may be as prevalent. In this chapter, Wiederman and Sarin integrate the growing empirical social psychological literature on body image and sexuality into clinical sex therapy practice. "The aspect of body image most relevant for sexual functioning appears to be the experience of anxious self-consciousness during sexual intimacy with a partner. . . . [T]he important question appears to be how much body image concerns are on the mind of the individual during sex."

Wiederman and Sarin suggest that evaluating body image concerns while taking a sexual history should be standard, as available research clearly shows that body image is only weakly correlated with attractiveness as judged by others. In addition to standard cognitive techniques (e.g., reframing), they also emphasize the utility of exercise, yoga, mindfulness, and body work in order to help individuals overcome "anxious self-consciousness" about their bodies.

**Michael W. Wiederman, PhD,** is professor of psychology at Columbia College, an all-womens college in Columbia, South Carolina. A former Assistant Editor and Book Review Editor for the Journal of Sex Research, he is the author of Understanding Sexuality Research and co-editor of the Handbook for Conducting Research on Human Sexuality. Currently Dr. Wiederman serves as one of a few psychologists answering questions at www.askthepsych.com.

**Sabina Sarin, MS, MPhil,** is completing her PhD in Clinical Psychology at McGill University. Her research examines the psychophysiology of sexual desire, arousal, and the factors that influence and distinguish these experiences in healthy and clinical populations. Also a psychotherapist and yoga teacher, Sabina has specialized in the treatment of sexual disorders, eating disorders, trauma, mood and anxiety problems, and couple/relationship difficulties.

Sexual activity requires bodies, or at least one. Yet perceptions, thoughts, and emotions are at least as important as bodies for understanding variation in human sexual functioning. So therapists must consider the intersection of the body and the individuals perceptions, thoughts, and feelings about that body (i.e., body image).

Before considering the intersection of body image and sexual functioning, it is necessary to deconstruct the multifaceted concept of body image.

Often the term "body image" is used to refer to an individuals self-assessment of overall appearance, or the extent to which a person is satisfied with how his or her body looks. Of course that is only one definition, albeit a popular one. "Body image" also could refer to self-assessment of the appearance of particular body parts or even self-assessment of bodily functioning as opposed to appearance. Then there is the issue of how important these self-assessments are to the individual; what they mean to the person, or how invested the individual is in his or her body image.

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When it comes to the relevance of body image for sexual functioning, there are numerous aspects of body image to consider. Which ones are most relevant for sexuality? What are the mechanisms or mediating variables by which body image affects sexual functioning? Do the answers to these and other questions vary across different types of people? Hopefully continued research will provide increasingly accurate answers. For now, what do we know?

**RESEARCH ON BODY IMAGE AND SEXUALITY**

Research on body image and sexuality has grown steadily since about 1990. However, the existing research is limited in several ways. For example, Woertman and van den Brink (2012) performed a comprehensive review of the research on body image and sexual functioning and behavior. However, they limited their focus to women because of a relative lack of corresponding research on males. Many researchers have assumed that, because body image concerns generally are associated more with women than with men, the same would be true for sexuality-related body image.

Woertman and van den Brink (2012) found 57 relevant studies published since 1990

but noted that these studies were based predominantly on European American college students from the United States and Canada. Indeed, very little research has been published on body image and sexuality outside of Western cultures. Of the 57 studies Woertman and van den Brink (2012) reviewed, only two included non-Western samples (one from China, one from South Africa). Although the samples that make up the relevant research have been relatively homogeneous (young women from Western cultures), a variety of body image measures have been administered. As a result, some general conclusions have emerged across studies.

**General Body Image**

One consistent finding across studies is that global body satisfaction is the type of body image least predictive of sexual activity and functioning. More relevant are measures of body image as experienced during sexual activity and measures assessing perceptions of those body parts most relevant to sexual activity or sexual appeal (e.g., breasts, genitals).

In other words, global body satisfaction is not synonymous with body image in the bedroom, and understandably it is the latter that is most relevant for understanding sexuality. The overall prevalence of body image concerns during sexual activity is difficult to assess, but in college student samples approximately one-third of women have reported experiencing such concerns at least some of the time (Woertman & van den Brink, 2012). The prevalence in clinical settings is unknown, but presumably greater.

The aspect of body image most relevant for sexual functioning appears to be the experience of anxious self-consciousness during sexual intimacy with a partner.

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Regardless of whether those concerns are focused on physical attractiveness (e.g., Pascoal, Narciso, & Pereira, 2012; Sanchez & Kiefer, 2007; Yamamiya, Cash, & Thompson, 2006) or appearance of the breasts or genitals (e.g., Schick, Calabrese, Rima,

& Zucker, 2010), the important question appears to be how much body image concerns are on the mind of the individual during sex. To the extent that a person is focused on body image concerns, he or she may focus less on aspects of the sexual interaction that should be arousing and enjoyable.

Another consistent finding across several studies is that respondents who report experiencing greater body image self-consciousness during physical intimacy with a partner also report more problems with sexual functioning (e.g., Cash, Maikkula, & Yamamiya, 2004; La Rocque & Cioe, 2011; Sanchez & Kiefer, 2007). The forms of self-reported sexual problems identified in these studies included greater aversion to sex, less desire for sex, decreased arousal, increased anxiety during sexual activity, and, ultimately, less frequent orgasm. Also, research has demonstrated that those with negative body image report less motivation to avoid risky sexual behavior (Schick et al., 2010) and more experiences of unsafe and unwanted sexual activity (e.g., Littleton, Breitkopf, & Berenson, 2005). The proposed explanation has been that such individuals feel less able to assert their own desires and boundaries due to the perception that their relatively lower sexual attractiveness exalts the sexual partner to the position of greater power.

**Genital and Breast Body Image**

As erogenous zones, self-perceptions of genitals, as well as womens breasts, seem especially relevant for understanding sexual functioning. However, relatively little data exist on these aspects of body image. In a survey of college students in Canada, males indicated more positive genital body image overall compared with females (Morrison, Bearden, Ellis, & Harriman, 2005). The most common genital concerns for males involved the size and appearance of their nonerect penises (indicated by approximately one-quarter of respondents), whereas for females vaginal odor and the amount and texture of pubic hair were the most common concerns (again indicated by approximately one-quarter of respondents). Approximately 10% of females reported dissatisfaction with the size and/or shape of their labia.

The largest survey regarding genital body image involved more than 52,000

heterosexual respondents (ages 18–65 years) who responded online to questions pertaining to their perception of penises (Lever, Frederick, & Peplau, 2006) and breasts (Frederick, Peplau, & Lever, 2008). Most men (66%) reported that they believed their penises to be of average size (22% rated their penises as large; 12% as small), yet 45% of the men wanted to have larger penises. Apparently, mens desire for a larger penis did not translate into shame or partner dissatisfaction: Only 3.5% of the men reported concealing their penises from sexual partners, and 85% of the women indicated being satisfied with the size of their male partners penises. Unfortunately, a single survey item assessed perceptions of penile size, with no distinction between length and 329

circumference.

Although the extent to which dissatisfaction with penis size results in surgery to increase penis size is unknown, men who seek such surgery typically have penises of average size (Vardi, Har-Shai, Gil, & Gruenwald, 2008). Perhaps because the gain in penile size from such surgeries is typically minimal (1–2 cm increase in length and 2–3

cm in girth) and rates of complications relatively high, patient satisfaction tends to be low (Vardi et al., 2008).

In some cases, congenital deformity or physical trauma may be the catalyst for negative genital body image. Consider the case of Jason:

Jason, a single 36-year-old Jamaican male, sought treatment for low desire and erectile dysfunction during partnered sexual activity. Exploration of his concern quickly revealed negative genital image. Jason explained that he had always believed his penis was not large enough and claimed to have been told as much by previous partners. His concerns became markedly worse after he suffered injury to his penis during intercourse. He had been only partially erect at the time but continued to let his partner "ride him" until he felt severe pain as his penis bent inside her. Not long after, he noticed that his penis became "deformed." Jason did nothing, hoping it would heal, but as the months passed, the downward curvature worsened, and scar tissue (plaques) began to form. He felt like a "monster."

Jason soon stopped initiating sexual activity, and when unavoidable he would have sex in the dark to try to conceal the appearance of his penis. Still, Jason had become so afraid that his partners would notice or comment on his "deformity" that he found he was unable to focus on his sexual experiences and would promptly lose his erection. As Jasons erectile difficulties progressively worsened over time, his fears of losing his erections led to avoidance of sexual activity altogether. Jason had consulted various medical practitioners without success. His only remaining option was an invasive surgery that would almost certainly shorten the length of his penis.

For Jason, this was an unacceptable option, and so he decided to seek counseling. By that point, Jason was ridden with shame and self-loathing.

Whereas males who are dissatisfied with the size of their penises virtually always desire larger ones, there is less consistency among women who are dissatisfied with their breasts. In the large online survey noted earlier (Frederick, et al., 2008), most (70%) of the women were dissatisfied with their breasts, whereas a slight majority (56%) of the men were satisfied with their female partners breasts. Younger and thinner women were most likely to desire larger breasts than they had, whereas older and heavier women were most likely to indicate dissatisfaction with droopiness or sagging of their breasts. Apparently the ideal breasts hold the contradictory distinctions of being relatively large and full yet gravity-defying and perky. Despite the high rate of breast dissatisfaction, only 9% of the women overall reported hiding their breasts during sex.

The high prevalence of breast dissatisfaction among women corresponds to the fact that, according to the American Society of Plastic Surgeons, breast augmentation surgery is the most common form of cosmetic surgery performed in the United States 330