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How We Interpret and Integrate the Principles of Sexual Health in Our Work

How We Interpret and Integrate the Principles of Sexual Health in Our Work

By Steph Auteri | From the August 2015 Issue

As an organization, AASECT acknowledges the essentialness of sexuality as it relates to overall health and well-being, laying out sexuality's fundamental value in its Vision of Sexual Health. But what do we mean when we use the phrase "sexual health"? And how can we then apply those principles of sexual health to the work we do?

In the feature story for this month's issue of Contemporary Sexuality, we explore how our definitions of sexual health were developed, and how they have evolved, touching upon the complexity and the inherent difficulties in this process. By the end, it is clear that this evolution continues. After all, there is no one working definition of "sexual health." And even those involved in the process of defining sexual health admit that these results are not the final word.

So when it comes to a concept that can be so slippery, how do we apply it to the work we do? Unsurprisingly, and similarly to the definition itself, there is no one way.

Here, we look at how some of our members are interpreting the concept of sexual health for themselves, and how they are then implementing those principles into their own work.

And while you'll notice that these interpretations and implementations are quite varied, it's interesting to note how, more and more, we are beginning to focus less on pathology and more on how sexual health can be integrated into concepts of medical health, mental health, spirituality, and overall well-being.

Healthy Sexuality Requires Healthy Sexuality Education

As Francis Bacon once expressed, "knowledge is power." Take this idea further and you come to a sentiment articulated in many inspirational social media posts: that knowledge can empower us to shape our lives for the better.

As such, it makes sense that doctoral candidate Laura McGuire, RYT, CD's personal definition of sexual health includes a reference to knowledge and understanding. "Sexual health is, by my definition, the medical, emotional, and spiritual understanding of sexual physiology, safety, and enjoyment," writes McGuire.

In explaining this particular element of her definition further, McGuire writes, "The foundational difference in the human experience that distinguishes us from other mammals is our ability to know and question. To understand the emotions, sensations, and beliefs that encapsulate our sexuality, we must have access to education and discussion. The knowledge of our physiology, our psychology, and our place in the macro and micro worlds we move through is our human right."

Healthy Sexuality Does Not Hurt Anyone Else

Sexual rights have recently moved to the forefront of many high-profile news stories. In the past six months alone, we have seen extensive discussions of rape and consent, and how they should be defined. We have seen a greater acceptance of those who identify as transgender, thanks to the high visibility of trans individuals in pop culture and other media. We have seen the legalization of gay marriage. We have observed the debate over flibanserin, and have discussed what its development and its trials on the road to possible FDA approval mean in terms of female sexual dysfunction, female sexual rights, pleasure, and arousal. A common thread through many of these topics has been acceptance of others' expressions of sexuality, even when we don't understand it... and assuming it does not harm others.

Mark W. Steege, M.S.W., an AASECT-Certified Diplomate of Sex Therapy, wrote to me about several elements he considers crucial to the definition of sexual health. One of them? "Experiencing joy and the joys of sex without victimizing anyone is healthy sexuality," writes Steege.

Healthy Sexuality Does Not Cause Distress To the Self

Assuming one's enjoyment of sex does not harm others, we then return to the individual's pursuit and experience of pleasure. In this vein, David Hersh, Ed.D., MFT, Clinical Director of the Hersh Centre for Sexual Wellness, provides me with a delightful metaphor for sex and sexual health:

"Except for procreation," writes Hersh, "sex is like chocolate. Some of us just like it more than others, in more types, with greater or lesser frequency, in different amounts, and at different times of day. If we replace the word 'sex' with 'chocolate,' I'd say that chocolate health is one that satisfies the eater, with no distress about it."

This definition hints at those things that can often impede our pursuit of healthy, satisfying sexuality, such as shame or guilt, often deriving from one's upbringing or from cultural or religious beliefs. Helping those with whom we work past these feelings of shame and/or guilt may be one way we integrate sexual health into our work.

Healthy Sexuality Is Open To Interpretation Depending Upon One's Values

At the same time, one's faith or culture or other personal values may be an important piece of the puzzle when it comes to how one approaches the world. For examples of this, we can revisit Elizabeth Boskey, Ph.D.'s piece on spirituality and sexuality, which appeared in the June 2015 issue of Contemporary Sexuality. In this article, Boskey explored how traditional religious values can affect how we approach treatment.

Considering this, the inclusion of personal values in Eric FitzMedrud, Ph.D.'s definition of sexual health is important, though issues of faith and culture are not necessarily at the forefront of his mind.

"Once I understand your values," writes FitzMedrud, "I can provide treatment that is respectful of those values." He explains further, writing that, "values can guide you toward health instead of simply guiding you away from pathology."

Healthy Sexuality Is About More Than Just the Avoidance of Pathology

Speaking of pathology, our movement away from a focus on what is "wrong" vs. what can be "right" (whatever that happens to mean on a case by case basis) continues to come up when we look at the history of sexual health as a concept. One area in which this shift in thinking is especially evident is in the kink community (kink is often defined as non-normative sexual practices or desires).

"The argument for sexual health is complicated in the world of kink," explains Russell Stambaugh, Ph.D.  "Although lifestyle advocates are very keen to avoid pathologizing labels, a foundation value of kink is passion. Any health-based discourse threatens to undermine activities that are passionately endorsed, but might carry health risks."

Stambaugh goes on to explain various concepts and guidelines specific to the kink community. He mentions an effort to play down Safe, Sane and Consensual (SSC) guidelines, focusing instead on efforts to assure the public that kink activities are safe and healthy using the philosophy of Risk-Aware Consensual Kink (RACK), which emphasizes awareness of risk instead of health and safety.

"Another example of this diminished role of health in kink discourse is in the name of the lifestyle itself," writes Stambaugh. "Formerly known as S&M or BDSM, the lifestyle is switching to Kink, in part to get away from medical terms like sadism and masochism that imply pathologies."

The Principles of Healthy Sexuality May Change Across the Life Span

One thing J. Dennis Fortenberry, M.D., M.S. mentions in our feature on sexual health is that many of the definitions that have been developed don't account for how sexuality can change as one ages. Steege addresses this, writing, "My wife and I just celebrated 59 years of marriage and still consider ourselves to have a satisfying sexual relationship. We practice healthy sexuality, which involves experiencing the sexual parts of our lives in the ways we are able to achieve. We still walk hand in hand and this is healthy sexual behavior. We hug and kiss and sit and sleep with and touch each other and this is healthy sexual behavior. We talk about our sexual feelings and our memories and this is healthy sexuality."

Healthy Sexuality Is Complex

Of course, the one thing all of these varying definitions of sexual health make clear is the fact that healthy sexuality is a complex thing. Which is why some AASECT members have developed even more in-depth definitions of the term.

Sex therapist and author Ginger Manley, MSN, MPRN lays out her Model of Healthy Sexuality in Sexual Addiction & Compulsivity, Volume 2, Number 3 of The Journal of Treatment and Prevention. Manley takes an entire chapter to explain this model and its application but, in summarizing it, she writes:

"Healthy sexuality is the experience of feeling whole and worthy as a sexual person, willing and able to consent to a variety of relationships with appropriate boundaries, including an established, committed, primary sexual relationship in which expression of sexual behavior is by personal choice and is consistent with one's value system, wherein a full range of sexual functioning occurs within one's physical capabilities, and further that one is connected in all parts of one's sexuality to one's spiritual core." This definition touches upon what Manley sees as five essential components of healthy sexuality.

Douglas Braun-Harvey, MFT, CGP, CST, has developed six fundamental principles of sexual health, and has written two books on the subject. Principles of consent, non-exploitation, protection from HIV, STIs, and unplanned/unwanted pregnancy, honesty, shared values, and mutual pleasure form a foundation upon which to build a personal vision of sexual health.

In his book Teaching Safer Sex, which won the 2013 AASECT Book Award, Bill Taverner, M.A., CSE includes several lessons designed to help people define sexual health for themselves. One of these lessons, "Defining Sexual Health," written by Kirsten deFur, M.P.H., seems to mirror the process organizations so often go through in creating their own definitions (and in fact the lesson quotes the World Health Organization definition). In showing this process, deFur has only underlined the fact that sexual health as a concept that has so many different components.

Among the questions deFur suggests students ask themselves:

How might disease, dysfunction, or serious illness affect sexual health?

What steps can a person take to develop positive and respectful attitudes about his/her sexuality and sexual relationships?

What steps can a person take to help respect, protect, and fulfill sexual rights for her/himself and others?

Other lessons in the book, related to issues of sexual health, touch upon sexual rights and sexual pleasure.

How Are Sexologists Implementing the Principles of Sexual Health in the Work They Do?

Considering that there seem to be as many interpretations of sexual health as there are sexuality practitioners, there are also a variety of ways in which the principles of sexual health are being applied within the field of sexology. This piece is meant to give just a snapshot of that application.

Steege speaks of the work he does with juvenile sex offenders. "I go back to the Masters and Johnson concept of Roadblocks to Effective Sexual Functioning," says Steege. "I have changed them to Speed Bumps to Effective Sexual Functioning. If there is a block to sexual behavior, it does not stop them from being sexual but frequently leads to maladaptive behavior, just like speed bumps in a parking lot."

Steege approaches these speed bumps in several ways. "I talk about early notions about sexuality," says Steege, touching upon McGuire's emphasis on knowledge, "which, if not corrected by good sex education, lead to myths about sexual behavior. Early notions for many of the kids today come through exposure to pornography, which includes dangerous ideas about using women for sexual satisfaction without regard for the needs of the woman. If the kids are to have a knowledge of healthy sexuality," he continues, "these early notions must be eliminated and replaced by ideas of appropriate touch and the joys of such touch, which is healthy sexuality."

Steege speaks also to the necessity of redefining sex, in a way that calls attention to the possibility for more varied forms of intimacy. "I believe that the average male thinks sex is intercourse/orgasm and, consequently, that is the goal of all sexual behavior," says Steege. "Forgotten is affection, non-demand touching, or caressing, and the joy and warmth of skin on skin or at least body to body closeness. I introduce them to the goal of sexual behavior I learned long ago, in a talk by Ron Pi, who said, 'The goal of all sexual behavior is to end that behavior feeling good about self, good about our partner, and good about what we have just done. This does not necessitate an erect penis and a lubricated vagina to experience.'"

McGuire speaks of the educational work she does. "I teach sexuality from a holistic perspective," says McGuire. "I talk about the life span's evolution in terms of sexuality and how sexuality affects our hearts, minds, and bodies. I discuss the medical facts of sexual anatomy and physiology and partner that with the socio-cultural aspects of the human sexual experience."

Braun-Harvey, meanwhile, disseminates his principles of sexual health in several ways. "I have written two books on using these six principles of sexual health as fundamental lessons for men and women in drug and alcohol treatment to guide their integration of sexual health within their recovery from addiction," says Braun-Harvey. "My next book uses these six fundamentals of sexual health as the treatment frame for men to define and enact their own personal vision of sexual health." 

Braun-Harvey, co-founder of The Harvey Institute, also speaks of how his company uses these six fundamentals as a lens in which to teach the Los Angeles County Department of Child and Family Service a curriculum titled Sexual Health Conversations. This required half-day training is directed at improving the confidence, willingness, and readiness of the over 4,000 employees to provide a basic repertoire of sexual health conversations responses with youth and parents. 

Other AASECT members chime in on how they are implementing the principles of sexual health into their practices. Isadora Alman, MFT mentions that on the back of her brochure, and on cards she passes out to clients, she has the following, adapted from the work of Virginia Satir:

Guidelines for a Healthy Person and a Healthy Relationship

1) Focus on now. See what is happening in the present instead of what should be, what was or what could be.

2) Feel your feelings. Feel what you do feel instead of what you think you ought to be feeling.

3) Speak up. Say what you feel and think instead of what you imagine is expected of you.  Be tactful as well as honest.

4) Say what you want clearly and directly instead of hoping it will be offered.

5) Take risks in your own behalf instead of settling for the status quo.

6) Learn to say no firmly, kindly and unmistakably.

7) Learn to hear no with good grace.

These guidelines can be applied to one's sexual life as much as they can be applied to the other issues that often come up in marriage and family therapy.

Cashel Campbell, soon to be a dance movement therapist and also planning to become a sex therapist as well, defines sexual health as a balance of mental, physical, emotional, and spiritual willingness to engage in intimate relations with another person. In keeping with this, she plans to integrate these principles into the work she does with potential clients by encouraging a safe, supportive, and nurturing therapeutic environment for them find and explore their authentic sexual selves.

Jennifer Valli, LCSW sometimes struggles with how to handle sexual health in the south, where there is a great deal of stigma surrounding sexuality. Still, there are a number of ways in which she manages to integrate the concept into the work she does with her clients, often in the resources she provides to them. Sometimes, she refers people to Betty Dodson's video on the internal clitoris. ("She is like the Bob Ross of vaginas," says Valli.) Sometimes, depending upon a person's comfort levels, she sends them this video of women looking at themselves for the first time. She tells them about Nick Karras's Petals, a book of photography that captures the full flower of women's vulvas. She sometimes sends along an articles on fetishes, called "You're not as strange as you think." Valli even has an open letter on her website she feels helps people understand that sexuality is a basic health need. Perhaps this last resource, more than anything, helps to make clear Valli's views of sexual health.

Then there is Max Lencl, LPCC, CDCA, a clinical counselor in Columbus, Ohio who tends to follow the World Health Organization's working definition, as well as what is stated in the AASECT Vision of Sexual Health. "I try to remove some stigma from the topic by addressing that sexual health is essential to our overall health," says Lencl, echoing the goal that so many other organizations have had as they have sought to redefine sexual health for themselves and in the interests of public policy.

"Sometimes I do it directly by saying just that," says Lencl, "and other times I employ that principle indirectly by openly asking about sexual satisfaction during the intake process, even if the person is presenting for something seemingly unrelated, like depression."

How do you address and incorporate sexual health in your own work? It's not too late to enter the conversation. Click on over to this complementary post on AASECT's blog, AASECT Express, and share in the comments.