Department of Psychology, Soochow University, Taiwan
Presented at SSSSWR, 2006
Since the AIDs prevention publicity due to its epidemic in the 1980's, people have started to explore the motivation, cognitive-biological, and social-cultural factors behind the sexual behavior of an individual --the ingredients of the expanding field of sexology and related clinical research. Therefore, many researchers and professionals began to develop the treatment of sexual problems in the 1990's and evaluate their effectiveness. In addition, the initial sales of Viagra in 1998 brought about a drastic change in sex counseling, sex therapy and studies in sex in general. Men's sex life has been more broadly discussed, ranging from having problems to making progress in overcoming problems. Women, as well, have started to acknowledge the desire to enjoy sex. Both men and women began to realize that sex difficulty can be a part of daily life, with no one being immune. Accordingly, the concept of sex counseling and sex therapy has started to root in peoples' hearts, resulting in a greater willingness to seek help.
However, people are still not used to talking about "sex" and "love" to a stranger. Even in the United States, some married couples who have sexual disturbance will not speak directly. They would tell the counselor / therapist about their small conflicts before gradually divulging the real problems. Some female clients also continue to ask many sex-related questions, while saying to the counselor: "I really don't care about 'sex'”. When asked why she comes to the clinic, she would answer either that the husband asked her to come or that she comes in the hope of helping their relationship. Only very few of them will speak openly: "I have sexual problems! Because sex is an important part of my self-identity, I would like to discuss it and seek help." Foley, a senior clinical social worker at the University of Michigan, once said that women who had stronger sexual identity exhibited faster and more successful therapeutic response than those who do not. Because of this sexual identity, women had stronger motivation, better internal control, and better distress tolerance during counseling. Foley, however, also pointed out that sex counseling / therapy usually progressed more slowly than what the client and the counselor expected.
The situation is the same in Taiwan. The female client usually discusses first the commonly seen marital problems, such as the dissatisfaction with her husband or the disappointment with the marriage, then, some sex-related questions, and finally the problem about the dissatisfaction with her sexual life. Therefore, the counseling moves from the marital problem to the sexual problem. The status of sex counseling, however, continues to be an ambivalent one in Taiwan, as the course of sex counseling is long and arduous, and there are not many well-trained, experienced sex counselors. Sex therapy has been featured in some hospitals and private clinics currently. Sexual problems are also being treated in counseling institutes, regardless of their effectiveness.
In the past 30 years, women, as well as men, have had exposure with Western culture through telecommunication --such as computer, movies, television, books and magazines. Furthermore, women are exposed to the increasingly seen social movements on women's rights. They start to become aware of and develop concern about their own rights and needs by means of discussion and comparison. This is especially true with their sex relationship, which has been an area of taboo within the traditional marriage, both unable to speak and with the locking in of all such feelings.
Nevertheless, the number of women, coming individually or with the husband, to seek professional help has been increasing year by year. This is especially true in the cases in which females' realization of the disharmony of sexual life or the unfulfillment of their sexual needs are a significant, if not the major cause of their marital problems. Struggling within the traditional marriage, Taiwanese women have begun to see sex matters from the viewpoint of sexual equality and to pay serious attention to issues associated with satisfaction of their sexual needs. Thus, the demand for sex consultation and counseling is increasing.
This paper briefly reviews the commonly seen female sexual problems today and explains that there is still very little practice based on evidence, with sex counseling / therapy relying on clinical wisdom, professional training and the commitment of the client in order for treatment progress to occur. Four cases are described, in which the four clients, trapped in sexual disturbance in the beginning, became aware of their sexual needs in the initial sessions and achieved progress by committing to counseling and search for sexual identity and self-worth.
1. Feminism and Counseling Orientation
The society in Taiwan is experiencing a changing period in which tradition and modernity are co-existing. It is strongly impacted by Western culture, meaning the use of counseling, its related family relationship, and the social ideology of the changing female role. In addition, with political, economic, and social changes, women who are foreseers, urban residents, intellectuals, and feminists, form gradually the new ideology changing their awareness of female roles (Liu, 2004).
Females increasingly think about life and marriage as a result of the disillusion of marriage, frequent appearance of the women's movement, and step-by-step enactments of social welfare law involving the rights of women and children. From the feminist perspective, female virtues or other traditional roles are not by themselves adequate female roles. On the contrary, women's self-assertiveness and independence are regarded as very important within the new female image (Field, 2001). Also, the emphasis on counseling orientation, though different from feminism, advocates female independence, de-emphasizing traditional culture. Counseling orientation brings new perspectives to the traditional female roles, helping women achieve a balancing point among their family, marital, and individual roles (Marsh, 1998).
2. Commonly Seen Female Sexual Problems
Although the publishing of books on women's marital relationships has been flourishing for some time, books on treatment and studies of female sexual dysfunction only started in the 1990's. The available literature on therapeutic research and effectiveness of therapeutic techniques is very scarce, especially concerning the female psychosexual level (Wincze & Carey, 2002). The only documents found are the four categories of sexual dysfunction described in the DSM-IV-TR: sexual desire disorders, sexual arousal disorders, orgasmic disorders, and pain disorders. The etiology usually derives from biological and psychosocial factors. Clients with biological factors need to see the gynecologist, urologist or endocrinologist. Clients with psychosocial factors need to seek help from the psychiatrist, clinical psychologist, sex counselor or sex therapist.
Female sexual problems commonly discussed in sex counseling mostly belong to the above four categories and involve low sexual desire, high sexual desire or no desire at all, dry vagina without lubrication, lack of response to sexual stimulation, no physical arousal, delayed or no ejaculation, dyspareunia and vaginismus (Lin, 2002).
Even though the extra marital affair results from an inherent relationship problem, sex issues play an important role. One party in the marriage enjoys erotic and exciting sexual acts with a third person, while the other is living the routine sex life or is alone in bed. Does the disharmony of sex life result in the extra marital affair or does the extra marital affair result in the sex problem? There is the case of a female client, who, sexually harassed by her elder brother when she was a 4th grader, discovered that the sexual trauma impaired her sexual arousal by her college boyfriend. It was depressing for her to have sexual desire while not be able to be sexually aroused. A college girl who had had an abortion had no interest in sex. She attempted to kill herself after finding her boyfriend in bed with her best friend. Thereafter, she distrusted men and bottled up her sexual desire. Furthermore, a client who was brought up in a strict Christian family had vaginismus during her honeymoon due to lack of sex knowledge and having been conditioned negatively about sex. Her infertility resulting from no sexual intercourse led to her sense of inferiority and shame. Her refusal to see the doctor caused tension in her marital relationship (Lin, 2002).
Female readers' letters to the newspaper column are often asking why the boyfriends liked to do "the thing" whenever on a date. Afraid of losing him, even without sexual desire, the girl would “do it" for him, without any feeling of satisfaction or enjoyment (Lin, 2003).
3. The Premise of Sex Counseling
The above case examples involve both relationship problems and sexual problems, resulting from psychological factors. In order to deal with relationship problems, which derive from a couple's daily interaction and their mental states respectively, the couple should seek counseling together. The sexual interaction between the couple is very subtle, each one not telling the feelings and thoughts because she / he feels the issues are sensitive and do not know how to express these feelings to the other. Since there is no mutual recognition between the couple that they should solve the sexual problem together, even when they come together for help, often the husband blames the wife for low sexual desire or the wife worries about the husband's high sexual desire.
When the sex counselor does the assessment in the initial sessions, the counselor should explain openly the nature of the relationship / sex counseling and the possible treatment approach (Meichenbaum, 1977). Before sex counseling formally begins, the counselor has to teach the clients the skills of couple communication, evacuating their negative feelings and fostering rational communication, in order for them to realize the real sexual problems and other problems (Sharf, 2001). Both the individual client and the couple clients need to become familiar and comfortable with terms of sex and love, so that he / she can feel free to talk about his / her own sexual problem (Wincze & Carey, 2002).
In Taiwan, the rate of couples coming for sex counseling is much lower than that of the individual female client (Lin, 2003). Many of the women have had few or no outlets for expressing their problems, due to self-doubts in the relationship, such as sense of inequality, no sense of self-worth, being treated rudely or ignored, having physical and psychological dissatisfactions, and lack of understanding how issues of love and sex can be separated, etc. It is probably all right to complain to others about some marital problems, but hardly ever about sex problems. They usually suffer long-term distress, before they gather the courage to seek professional help, often initially through the channels of newspaper marriage columns or radio station marriage programs. Since the clients are women, before delving into the identified problems, they are better off first to understand better their sex concepts and behaviors and their own sexuality and physical states. Thus they will become better aware of their own sexual desire, accept their sexual identity and enjoy their own body. They are then better able to develop sexual desire and autonomy in both areas of sex and love. When leading a life of sexual health with confidence, women can better deal with sexual problems rationally, even guiding the partner to enjoy a better relationship and sex life.
4. Brief Introduction of the Cases
Case I #A (Individual Counseling: 9 sessions)
Basic Information:
39 years old: vocational school graduate of nursing: wife of a rich medical doctor: married for 13 years: housekeeping.
Presented Problem:
Owning nothing financially; no sense of security; and no willingness to have sex.
Identified Problem:
Dissatisfaction with sex life; having sex need; masturbation; ideation of divorce; and life planning in the future
Summary:
#A had lived a happy life with a very capable husband, who provides the wife and children with a good material life by buying and selling stocks and houses, while being an administrator in a medical business. Spending very little time at home, the husband always takes the beautiful wife in luxurious dress for business functions and family gatherings.
#A goes out with female friends for facial massage or afternoon tea in the daytime when she finishes housework. Listening to what the wives talked about and the information they exchanged, #A found that each has at least a house, a lot of land, or some stocks in her own name. #A gradually realized that she has nothing in her name, while receiving the monthly 50,000 NT dollars (approximately 1,500 US dollars) for family and personal expenses. Even the Mercedes-Benz she drives everyday is under her husband's name. She suddenly felt that since she had nothing she was nothing.
She heard about other women’s frequent sexual intercourses and orgasms and started to realize that sex could be so frequent and wonderful and orgasms could be ecstasy. She was shocked to learn that divorced women and the wives whose husband were away on business substituted masturbation for sexual intercourse. Being totally different from her own experience, she became anxious to enjoy “real sex life” and “orgasms”.
Ever since the wedding night, the husband had “enforced his right” to have sex with #A. Whenever he wanted her, he went to her, only caring about his own sexual need and falling asleep right after intercourse. #A, simple as she was, took compliance, being hugged, and inserted in as being loved.
She was sad and depressed about the fact that she possessed nothing while other women had something. Although life went on as usual, she refused to have sex with her husband and began to feel the pleasure of masturbation under some friends’ suggestion. She even had the thought of getting a divorce.
Mental State:
The thought that she has everything became the fear that she had nothing, once she were to be divorced. Even though #A felt shocked, fearful, losing, sad, lonely, helpless and unwilling, she could never ask for a divorce which would make her penniless. She was still living with her husband, but felt the distance between them. Worst of all, she could not stand his courting for sex, but could not help masturbating to enjoy orgasms.
“Is this my marital life? Am I going to live on like this?” #A asked herself. She cried very hard in the first 5 sessions.
Case II #B (Conjoint Counseling, 5 sessions, Individual Counseling, 6 sessions)
Basic Information:
45 years old; Master’s degree holder; part-time teacher; wife of an educator who comes from a rich family; married for 20 years; children still young.
Presented Problem:
Having extra-marital affair; unwilling to have sex with her husband but asking for a divorce. Despite the husband’s efforts to save the marriage, she was fighting for the custody of children.
Identifying Problem:
Great dissatisfaction with sex life; craving for companionship and passion; going after love and sex; living for herself.
Summary:
The husband, a workaholic and a loving father, did both teaching and administrative work in school and consulting outside school with many corporations. This work often involved seven days a week; while #B, a loving mother and a dreamer, only wanted a happy family life everyday. They gradually had less and less interaction.
By chance, #B got to know #H, who visited his hometown in Taiwan from Canada, and fell in love with him madly. She had never experienced such passionate caress and intercourse and was indulging in it by joining the tour to Canada three times for “honeymoon” gathering. With the husband’s refusal to divorce and no negotiation, she urged him to join her for counseling.
During her individual counseling sessions, #B cryingly gave catharsis of accumulated negative feelings for sex life, in which the husband only used her body for release, with no atmosphere or pleasure. She let him do it only because he was a hard-working breadwinner. Ever since she got to know #H, she realized what love was and how much pleasure sex could be. She felt like a real woman for the first time in her life.
Mental State:
#B had thought that both she and her husband were committed to family with mutual recognition being the key to successful marriage. She changed her mind gradually, as she was never taken good care of in sex, only submitting to his request for intercourse. The children involved their only genuine interaction in marital life. #H happened to be the trigger, leading to the marital crisis. #B had no feelings for her husband, no expectation for marriage, the only connection being the young children, whom #B wanted to take away with her. However, with the impact of her new love affair and her increasing self-awareness, she had made up her mind to start down the road of no return.
Case III #C (Individual Counseling, 6 Sessions)
Basic Information:
46 years old; high school graduate; married for 22 years; in charge of a family business owned by her husband through inheritance; who only fooled around with so-called “business friends”.
Presented Problem:
The husband never attended to the family business nor took care of the family chores, but had feasts with friends. There is alienation between the couple, but the relationship between the father and the daughter was very close.
Identified Problem:
Disharmony of sex life; little caress; difficult to reach orgasm; reluctant willingness to engage in anal sex with the husband for fear of his reaching out for other women.
Summary:
It seemed to have been the male superior marriage with the husband trying hard to keep the business by selling the lands and houses and #C taking care of the family and children. However, #C had to work hard to solve the financial problems and keep the business afloat. He gradually relied on her and became an idler, playing Machiang or drinking with friends.
Since the adolescent son was rebellious, the husband grew very fond of the young daughter and had close interactions with her. #C felt ignored and became jealous. Regarding sex life, she enjoyed good sex in the first years of marriage, but the frequency of making love decreased as years went by. She heard peoples’ gossip about his extra marital affairs although he never admitted to such. #C felt pain during their intercourse and eventually lost interest in sex, due principally to his requests for sexual variety, such as changing positions and both oral and anal sex. However, while feeling painful and uncomfortable, she reluctantly continued to yield to him, because of his threat to go to other women.
#C admitted during counseling that she did have sexual desire and felt curious about masturbation.
Mental State:
#C was not physically and psychologically satisfied in the traditional marital life, like a mother taking care of her husband without receiving an equal part of love and care in return. She had to follow the husband’s request for sex, having anal sex unwillingly. With sadness, helplessness, and loneliness, she dwelled on memories of past orgasms and felt needy with anger and confusion. She recalled her dream about marriage when young and resented her lifeless marriage of today.
Case IV #D (Individual Counseling, 10 Sessions)
Basic Information:
40 years old; college graduate; married for 14 years; wife of an owner of an enterprise; housewife and a volunteer at church; both Christians.
Presented Problem:
No feelings having sex with husband; wanting to refuse but feeling guilty.
Identified Problem:
Having an extra marital affair; addicting to erotic sex; feeling ashamed and guilty but could not help doing it; and afraid of losing sex enjoyment.
Summary:
#D joined group tours traveling alone or with friends, since the husband was busy at work and frequently had to go on business trips. She met a businessman, #G, on the tour, who took such good care of her all the way that she felt obliged to treat him to a dinner in return. Intoxicated from wine, she followed him back to his hotel room and was surprised to find that she could have multiple orgasms after his skillful caress.
Later, #D had to fantasize this sex scene with #G when she made love to her husband, in order to become aroused and realized how dull their sex life had been in the past. She started to see #G once a week in the hotel for four months, after she uncontrollably picked up the phone and called him. She was afraid of a split personality, because she led a Christian life in the family and a lustful life with #G on dates.
#D admitted that she still loved her husband, but had no sexual desire for him. She knew well that there was no love between her and #G, but she was so much attached to the sex with him that she could not quit. Feeling ashamed to God and suffering from guilt, she cried badly.
Mental State:
#D said: “I have love but no sexual desire for my husband, and I have lust for #G, enjoying sex so much with him. I have never realized that love and sex can be separated. However, happiness and distress cannot be separated. Why is my husband not a good lover in bed? If I had not had sex with #G, I would not suffer from such guilt now. Isn’t this wonderful sex part of real life, I wonder? Worst of all, I betrayed God, giving up my long-term beliefs. Am I the person who still has self-worth?”
Analysis:
Although each woman’s life and her presented problem is different in the above four cases, their commonality involves both love and sex relationships of marriage, which are either boring or awful.. It is obvious that the problem has been existing for a long time in marital life with no effective couple communication. It will be difficult for the female client to talk to her husband about sex problems abruptly, when she does not even know what she could do about it --being mostly anxious to find a way out, examine her own problem, and know more about herself.
After each client gave vent to her negative emotion and gained trust in the counselor, the counseling relationship became stable. Each admitted her own sexual desire and expressed concerns about the sex problem and what to do with the marital relationship. Among the four cases, #A had divorce ideation; #B wanted a divorce; and the other two chose to stay in marriage. The latter two are continuing their marriage for the wrong reasons, because they are still in the conflict between eroticism and rationality. The real problem lies in how they regain cognition of their sex life and sexuality and integrate them. Only when they become aware of their own sexual desire and sexuality can they empower themselves to live a life of an individual and a woman.
Each client’s sex problem has existed for a long time and has evolved to such a degree that each has begun to realize and act on her own desire and needs. Being a middle-aged woman, it is time to reposition herself now. Like peeling the onion, revealing their thoughts and feelings during counseling, each has dialogues not only with the counselor but deep down with herself.
The counseling progressed smoothly, due to each client’s high motivation of seeking help, compliance to, and alliance with the counselor. With each client’s greater understanding of her sexuality and eroticism, each wiped off the tears and became calm, confident and assertive. Each was guided to read about love and sex issues and could comfortably talk about her feelings and thoughts, actively raising questions about “love” and “sex”. Each client has achieved self-growth.
The homogeneities of the four clients are as follows:
1. Taking Initiative to Seek Help, with High Motivation to Change:
Although counseling the couple has better effectiveness than the individual, the four female clients each bring her own sex problem to the counselor. Three husbands were not informed, and the one who came with #B only participated in conjoint sessions.
In Taiwanese society, women who initiated counseling help must have suffered from the problem for such a long time that she needs to have a breakthrough. This represents anti-traditional behavior, as well as a modern trend. They learn that individual needs are of the same importance as the family needs, so that after her taking care of the family members, their own needs and feelings have to be taken care of too. Therefore, once women take the courage of seeking counseling, they tend to exhibit high motivation and a strong willingness to change.
2. General Marital Problems Presented:
The problems presented by the four clients are the commonly seen marriage problems involving money, extra marital affair, alienation between the couple, and disharmony of sex life, etc. Of course, individual sexuality is the core of sex counseling. #A and #D, housewives, and #B, part-time teacher, with no financial pressure, have been taking care of the family and children. Even #C, who additionally had to take charge of her husband’s business, always attempts to keep a good financial balance, working hard with traditional values for the both family and business.
It can be seen, however, that the long-term tradition and inequality in marriage not only affected not only the daily life relationship between the couple but also the frequency of their sex. This sexual problem was invisible, while gnawing at the intimacy of their relationship and brewing the potential crisis.
3. Lack of Communication between the Couple:
Although the family structure seems to be stable, there is neither real closeness nor intimate communication between the couple. The routine of many years reflects only the physical contacts of the sexual intercourse sex pattern first established. Consequently, passion disappears when the husband habitually asks for sex and the wife accepts it routinely. However, the wife begins to question sex matters and to wonder whether the erotic and passionate love making scenes in the movies or novels may exist in reality.
The sex acts of the leading male and female characters in the erotic and romantic Hollywood movie plots indeed have a cultural impact for modern Taiwanese women, igniting ripples in the traditional marriage. With most Chinese men continuing to be conservative in sex concepts, which only exist deeply in their mind, a gap develops between these men and women in terms of sexual practice and expectation.
4. Holding the Belief that Sexual Behavior Should Meet Expectation or
Request:
Among the four female clients, their “first man” was their husband. Each one of the four clients thinks that sexual intercourse is required in a stable marriage if the wife really loves her husband and the family. Therefore, she follows the traditional cultural myth (Apfelbaum, 2002) and tries to put aside her own feelings in order to satisfy the husband’s sexual desires, even when her experience is not good and pleasurable. Eventually, however, she gradually becomes averse to sex or resentful of having to fulfill the “obligation”. Since this routine sex is not what she wants, she has little motivation for sexual intercourse and might want to avoid it as much as possible.
5. Mid-life Crisis:
The dullness of long-term marriage will cause women, who become aware of themselves and of the need for an intimate relationship to consider running away from the suffocation of the traditional relationship.
Most daily life activities, no matter large or small, are conducted by individuals without consideration of sex role, except, of course, for cooking and family chores expectedly done by the female. Only when love and sex are involved, do male and female roles become more obvious. The partner of each female client in this study, seems to care only about himself. Consequently, he does not know that a full sex life needs to be learned and seldom shows his care and love for his wife, verbally and nonverbally. He never dreams of discussing their sex details in the hope of improving sex life together. Accordingly, the wife is not satisfied sexually and psychologically, because her desires and needs are not attended to. In the mid-life she starts to feel the need to pay attention to herself, explore her own needs and desires, and look for sexual identity under the impact of modern socialization.
6. External Stimulation
Why does the change in self-identity within these women start with sex life, despite no sex between the couple? When there is little communication within the relationship, stimuli from other people in the wife’s circle may more readily stir her heart and stimulate her thought. In modern society, the range of people’s conversation topics has less limit, with taboos of love and sex increasingly becoming topics among women or between men and women. Stimulation from others forms new cognition of many things, but especially matters of sex. Take #A, for example, who, after exchanging information with friends, learns that erotic love can be so pleasant and that masturbation can be a substitute form for intercourse. #B and #D, having an affair with a man besides their husband, experience the tremendous difference in intimate relationship and sexual interaction. In addition, in #C’s case, the envy of the good interaction between her husband and daughter and the feeling of being threatened by the invisible same sex enemies become her dynamites to self-retrospect and self-explore.
7. No Sexual Dysfunction but Lack of Sex Knowledge:
Although the presented problem is disharmony in sex life --not wanting to make love with the husband-- the four female clients appear not to have sexual dysfunction and to be very normal, with no hyper or hypo sexual desire. Three of them have never examined their sexual desire, abiding by the belief that having sexual intercourse means normal marital life, even with their sexual desires being repressed. In the past many years, they did not have the concept of “sexual desire”, but they did have sexual desires and became wet when having physical contact.
This means that physical arousal is normal but psychologically arousal is scarce. #A never had orgasms until her masturbating; #C lost her orgasms when the husband asked for anal coitus, which she resisted. These psychological factors do not meet the criteria of sexual dysfunction. Furthermore, after 14 years of a traditional marriage, #D was able to obtain multiple orgasms from her sex partner. Under the lover’ guidance, she liberates herself from the ignorance of no sexuality education and from sex act passivity, her upbringing from her own family. Fortunately, this traditional upbringing did not lead her to an insurmountable poor self-image and negative viewpoint of sex. As long as she has the opportunity to receive adequate sexuality education under proper guidance, she will have healthy love and sex concepts.
As Apfelbaum (2002) mentioned, many people, men or women, feel right to “do it” only so that men can be masculine and women will not be lonely. It becomes “compulsive reciprocity”. Therefore, the first step in counseling is to stimulate the client’s self-awareness and reintegrate her love and sex concepts. Before solving the marital problems, they have to deal with their own sexual problem. Dealing effectively with the client’s feelings of grief and loss after their self-disclosure and self-awakening is a critical stage for the counselor in managing the change. Then, the counselor will help them to focus on sexual identity and self-empowerment.
Marriage counseling is multi-phased and complicated, while sex counseling focuses on sex problems. With these four cases, the need to deal with the clients’ real problems emerging from the bottom of their heart is urgent. The treatment should be simple, concrete, and optimistic.
The main points of the counseling process are as follows:
1.Self-awareness:
The counselor asked the client many questions by using “let’s ask the women’s approach” (Tefber, 2002). Being stimulated by questions, the client can be guided to thoroughly explore how she sees her own body, what role the body plays in her life, what her spiritual level is like, and what she looks like in sexual practice (Hawton, 1985).
Take #A for example, who had never explored her own body and had taken the “obligation” to her husband to be sex life. When she obtained all kinds of information on sex and erotic love from friends, she realized the extent of her physical and psychological needs and was able to reach and enjoy orgasms from masturbation. However, she came to counseling with fear, anxiety and pain, unsure of her own feelings and behavior. As for #C, she enjoyed sex in the beginning years of her marriage, but became alienated in the conjugal relationship, feeling like a sex object due to her husband’s interest in oral and anal sex. She was dissatisfied with and had anxiety about her reluctance to submit. She also felt painful and confused, feeling her own sexual need and craving for love. She even considered masturbation. #C did not feel shamed to disclose her own story. This is another reflection of the long and gradual self-awakening process in the traditional marriage of each female client. Each needs the empathy and feeling of companionship with the counselor while going through this process.
2. Sexual Identity:
The four clients did not have any specific negative attitude toward sex when young. It is their sex pattern and related daily interaction in marital life that causes the deeply hidden crisis. They avoid having sex with the husband, but feel that they are the sexual persons. Therefore, the counselor guides them in counseling process to accept themselves as a sexual person, to create positive meaning for their sexual identity. The clients need to appreciate that, nowadays, enjoying one’s own body and love / sex is not seen as immoral anymore. Both man and woman are given permission to have freedom to have his / her own lifestyle, especially the idea that the woman, who has strong sexual feelings and regards sex as important in life, is normal and acceptable by many people (Kelly, 1998). Accordingly, it is needless to suppress, ignore, or conceal one’s sexual needs and feelings. Sexual behavior and sexual concerns are part of human life and “sex” is absolutely the actions of genitals.
There could be more forms of the sharing of physical feeling and sex, which may enhance the individual or the couple’s physical enjoyment and affectionate expression. Take #B or #D for example. The counselor never judged her extra marital affair nor tried to deal with her triangle relationship. She led the client to see herself as a sexual person, who fully enjoys the passion and lust in the extra marital relationship, while avoiding intimate contacts in the conjugal relationship (Laan, 1994). The counselor then discussed with her the connectedness of these two kinds of sexual activities within her inner mind, making her understand that she has been trying to please others instead of herself. It was good that she now realized she was not just doing “sex” and was able to connect within herself her own sexual feelings in sexual intercourse --feeling the enjoyment and finding the meaning of her existence.
3. Grief Work:
Why sex, which was neutral or positive before, becomes a source of pressure or displeasure stems from the female client’s awareness of a void in her life. It is essential to explore the client’s anger in marital relationship and sex life, i.e. to understand what had happened and did not happen in her past, her upbringing, cultural expectations, her ignorance of sex matters, and, ultimately her growing feelings of unfulfillment. In the cases, the clients realized that, in the past, they missed what could have been wonderful experience. Thus, sense of loss and sadness arose. After several sessions, the clients started to describe negative feelings in detail.
Only when the counselor then effectively deals with grief and loss can the work for sexual identity be done (Foley, 2003). The counselor guides the client in tracing her sexual development, sex information learned, anxiety or confusion in adolescence, history of sexual interaction in marriage, and her changes sexually. In addition, the discussion of her body image becomes indispensable.
During this stage, since both #B, anxious to leave the marriage, and #D, guilty and fearful but still indulging, wanted to find a quick solution, they had less patience with grief work. Progress was stagnant or absent for a few sessions. Fortunately, #B later understood that a next marriage might not be a better substitute for the current marriage and that she had to face her own sexual needs and desires. By establishing sexual identity she can be more sure of what she is looking for in life. Whether getting a divorce or coming back to marriage, she would have little regret later on. After lengthy, in-depth dialogue, #D started to realize what she wanted. The sexual pleasure she could have had could be obtained in marriage, if she tried hard with her husband. Leaving #G did not necessarily mean that this would be the only way to achieve sexual enjoyment, notwithstanding that #G was the person who ignited her sexual desire and potential. Her real problem was that she was so afraid of losing sexual ecstasy that she could not see things clearly.
Recollecting in detail can trigger sense of loss and grief emotions. The clients mourned the underdevelopment and denial of their sexual needs and instinct to enjoy sex after guided questioning. Grief is at the forefront of reconnectedness, since the so-called “change” is not to change into a totally different person, but, rather, to connect the new self with the past and get along with new and old peacefully.
4. Empowerment:
The counselor taught sexuality education, self-assertiveness and benefit of masturbation to the clients for the purpose of raising women’s sense of personal empowerment. They are entitled to uplift their self-life without guilt and anxiety in order to attain self-sexual identity.
Take #A for example. After she shared what she heard from friends and her subsequent “sexuality education” with the sex counselor, she was able to learn more correct sex information and knowledge and better understand equal rights of the husband and the wife. Even though not being the breadwinner, she had the right to have self-identification with her name on property title and similarly to equally share the pleasure of sex in marital life. While she had to work out these two major problems with her husband over time, she could meanwhile explore her own body freely and enjoy masturbation without guilt.
#B, stopping blaming her husband for being boring, tried to talk as a friend with him about many things in the past marital life and even comfort him when he cried. She found her own strength and became able to look at her marriage calmly and deal with her problems rationally, instead of crying helplessly when quarreling.
#C, by the end of counseling sessions, knew not only how to say “no” for anal sex, but take initiative for vaginal intercourse with passion, in the hope that both could attain satisfying sex.
#D was able to know from the beginning that the intense and addictive sexual desire in the relationship with #G, would not be long lasting. So, she did not act on any desire to leave her husband and marriage. She also knew that ending the extra marital affair was the only way to get rid of guilt and make her rebirth, but she yet lacked this strength. The counselor told her that self-empowerment is the for growth of self-strength and that exploring and pursuing one’s sexuality is a woman’s growing process. With encouragement, she became more assertive and confident. She engaged in role play and communication rehearsal in the sessions, enhancing her ability to communicate these sex matters with her husband and urge him to come for counseling.
5. Masturbation and Orgasm
Many women, who have little or no experience with masturbation, do not feel this sex need until mid-life. Whether single, divorced, or married, she becomes shamed, guilty, and in anxiety with no sex mate or with a partner who cannot or does not satisfy her. She also may worry that frequent masturbation might decrease the excitement and pleasure of vaginal intercourse in the future. However, she still enjoys temporary masturbation pleasure while continuing to have these questions.
#C chose masturbation, after enquiring about its advantages and disadvantages, because she did not enjoy the traditional sex with her husband. Masturbation enjoyment of #A, led to her wish to understand the nature of orgasm. The counselor explained that masturbation was the not only a healthy outlet of sexual tension but also a good way to learn sexual response (Kelly, 1998). Masturbation is one of the therapeutic ways methods currently in use for the treatment of female orgasmic disorders, both chronic / general and acquired / specific, ( Wincze & Carey, 2001). Further, she was taught to focus sensate and to employ the right way, to enhance body arousal and meet her expectation of orgasm. The counselor emphasized that orgasm does not happen like having earthquake each time; rather, it is most pleasurable when associated with continuous gentle to strong rubbing.
Although the sex counselor helps clients to understand and discuss sexual problems in a practical way, he / she cannot simply start with the routine way of treatment in the presented problem to improve the couple relationship and increase their sexual satisfaction. The counselor should first identify, assess, and diagnose the real sex problems and not ask the female client to be compliant with male sexual identity or please the male client for the sake of their relationship stability. There are certainly the physical and cognitive differences between men and women. However, women have to expand their own horizons, especially involving sexuality and interpersonal relationship and understand the mutuality and equality of the needs of each.
Since the effectiveness of sex counseling is not instant and sexuality education and sex counseling have to go together, women’s sexuality and sexual identity need to become an important topic in the first few sessions. If necessary, the client’s personal experience in loss and grief needs to be dealt with promptly so that emotions can be released. These emotions may include startleness, embarrassment, fearfulness, anxiety, and loss. The client will be better able to face herself and gain motivation to make the right choice.
Stated in another way, only when the client has better self-sexual identity is she able to make better choices in counseling / therapy for the development of requisite self-empowerment and achievement of a more rich life. With the experience of counseling these four clients, the author fully realized that, once establishing the counseling relationship, if the counselor can talk with the female client about the issues of sexuality and sexual identity in the initial sessions, counseling has a greater ability of proceeding productively and achieving better life integration and sense of fulfillment for the client. This coincides with Kleinplatz’s (2002) new direction in sex therapy.
The clients hoped to experience real life changes over the longer term through counseling, as the life circle of these clients was not large enough for this type of change to happen on its own. Even #C, who took care of the family business, had routine purchasing interaction with customers but lacked having deeper interpersonal interaction. Furthermore, it is difficult to achieve such life change through simply discussing with the husband (or lover). Attending the community study group, joining the marriage counseling group, or, even better, participating in a marriage enhancement program is strongly recommended.
Also important is the degree of trust the clients have for the counselor. It might have much to do with sex, age, and professional experience. In the past, the author learned how to gain client’s and group members’ trust and mutual identification, perhaps due to her sex, age, occupation and divorced status. Of the cases described in this study, #B insisted on seeing a female counselor after she and her husband had had only one meeting with a male marriage counselor, who was recommended by his friend. She feared that the male counselor might not understand women and take sides with the husband. They came for couple counseling in the beginning, but she then insisted on individual counseling later on, ignoring the husband’s wish to come together. He also came for two individual sessions.
Since the topics in sex counseling are very private and sensitive, the client will not disclose her / his situation until she / he feels secure and trusting. Obviously enough, no trust, no progress, nor counseling effectiveness. Therefore, one of the questions raised by this study is, whether the junior or male sex counselor would overcome the special limitations of being “too young” or “male”, especially the young male sex counselor. It also easy to experience transference or counter transference in the counseling relationship, no matter how shy in expression or eloquent in speech.
Sex counseling / therapy has not been widely practiced in Taiwan and has been pursued by a few counseling psychologists or marriage counselors. Participation in sex therapy often formally appears in the urology department or psychiatric department in the large hospitals (Liang et al, 2004) or informally in some counseling clinics. Indeed, sex counseling, an important part of counseling field, needs to be recognized and given special attention by all health care professionals who are expected to develop an indigenous sex counseling approach which fits the Taiwanese cultural background.
This study is the pioneer exploratory clinical study of female sexual dysfunctions. To this end, the author expects that in the future there will be more and broader indigenous clinical studies on female sexual dysfunction as well as male sexual dysfunction, since there are many differences bio-medically and psychosocially between the sexes.
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