ACT, SEXUAL DESIRE ORIENTATION AND ERECTILE DYSFUNCTION. A STUDY (SUMMARIES)
Análisis y Modificación de Conducta, 2003, Vol. 29, nº 124, 291-320
The case concerns a 30-year old man with higher education who was dealt with at a private practice. The problem he raised had a relation with feeling attraction since several years before to people of both sexes, which he experienced as something painful, and being afraid of loss erection. He informed that the sex to which he was predominantly attracted changed periodically. In the periods in which the homosexual attraction predominated he had a bad time, and felt more nervous, particularly so during the last year. He considered that once solved other questions of his life he was considering starting a stable relationship, but he did not completely feel comfortable with himself.
The attraction towards men began years ago, but he had only maintained stable relationships with women, while with men he only maintained sporadic sexual relations and only on rare occasions did he end up spending the night with one of them. He recognised that he avoided repeating or deepening in personal relations with men, so that although he had maintained relations with many more men than women he had never maintained a stable relationship with one of them. He reported that he did not like being attracted to men, that he aspired to form a heterosexual family, but that on the other hand he was not ready to stop maintaining sexual relations with men, even if the entered into a relationship with a woman, considering that she should knew this fact.
He showed a confusion between gender and sexual orientation (he would not see himself as a male when he was attracted to another male), which led him to question his identity (“who am I?”). He felt bad for not feeling attracted to women that others would consider attractive. He did not allow her "female side" to express itself for fear of "damaging his male side". During masturbation he resorted to fantasies in which only women appeared in order to hide those related to men. He reported episodes of compulsory search for sex with men, which he valued as "painful" because they did not solve his problem, took time and energy away from him, relations were unsatisfactory, and he ended up feeling even lonelier. According to him they corresponded to emotional needs not covered and which did not exclude nor were limited to the need to be with women.
In the relations with women he said that he was afraid of loosing his erection and to "just sex", meaning that he needed to maintain several relations to manage to come, which did not happen with men. He placed the origin of this problem in his first stable relationship, which finished traumatically, in which his partner never allowed him to maintain relations with penetration. He started then to blame himself, to feel fear of rejection, of being inadequate, of not being desired, and to loose his erection and not feeling relaxed. He informed of being "tired that it was so difficult to maintain relations with a woman with whom in fact he was contented".
Concerning the origin of his problem in the relations with men, he related it to the fear of disapproval by his parents, mentioning many occasions in which he was reprimanded by them because of behaviours considered not very masculine, and with fear of not fitting with which it was expected from him. He indicated that he had not informed his parents about his inclinations although he had done so to his friends and sisters.
Concerning his values, he emphasised love, both directed to the partner as well as to his friends and to the things that surrounded him. He also valued an open, sincere, honest and intense relationship. In the area of sexual relations he valued love, mutual satisfaction, desire and, if relation did not take place within a stable partnership, he valued the ability to share tenderness, to enjoy and "to have a turn-on with respect for the other".
It was considered that avoidance was the basis both of the non acceptance of his own sexual orientation as well as with the problem with erection. It was concluded that the problem could be included within the category of disorder of experiencial avoidance. The reduction of sexual relations with males to the minimum time, the avoidance or delay before meeting again another man, the resort to female fantasies in order to hide the masculine ones, or the practice of compulsive sex, might all have, hypothetically, an avoidance function. The person fought against the sentiments of attraction/excitement towards men, but this fight did not lessen the attraction and only contributed to increase his anxiety and rendered painful each of these experiences.
The problem was rendered more blurred by the confusion around his own sexual identity. It is considered that the current rule was "if I have a behaviour that I consider as feminine (among which is included the attraction towards males) I am not a man and if I am not a man, who am I?" It all led to feeling bad with himself. From our point it was a verbal trap, a confusion between sexual orientation and sexual identity and between the self-context and the self-content.
The person discriminated the contingencies of punishment from his parents during his personal history which would be at the origin of his fears and his avoidance. This verbal framework, which establishes that certain behaviour are considered unsuitable for a gender corresponds, from our point of view, to what has been named "homophobia".
The loss of erection is related to deliberate behaviours to have an erection and to the fight to have the erection, conducts that were ineffective and incompatible with such experience and which had as a consequence the well-known "role of spectator" and dissatisfaction. The origin is, hypothetically, in previous experiences that generated fear of rejection and the norm "if I do not have an erection, I will be rejected, I will not be desired, I will not be suitable for that person" and perhaps also the norm "if I do not have an erection, I am not enough of a man".
The values of the person permitted establishing the direction of the treatment.
PROCEDURESessions / Strategies
1 / - Informing and establishing discriminations between the concepts of "biological sex" (inherited), "gender" (socially constructed), "gender roles", "sexual identity", "sexual orientation" and "homo, bi or heterosexual identity"
- Metaphor of the actor that did not separate between the actor and the role (in this case the role was the gender role): in reality the actor was still the actor no matter which role he would adopt.
- Discriminating between choosing and deciding
2 / - "Man in the hole" and "Quicksand" metaphors
- “Polygraph” and of “two scales” metaphors
3 / - “Soldiers in the parade” exercise
4 / - “Chocolate Cake exercise " (Don’t think of…)
5 / - “Passengers on the Bus” metaphor
- "Buying thoughts"
- And/be out convention
- Suggestion of going to look for emotions previously avoided.
- "Passing next to a barking dog, next to a person of menacing aspect" metaphors.
6 / - “Chessboard” metaphor
- “Joe the Bum” metaphor
- “Gardening” metaphor
7 / - “The Path Up the Mountain” metaphor
- “Swamp” metaphor
- “Expanding balloon” metaphor
Sessions / Verbal reports
3 / - realising the amount of times that dug and tried to control emotions
- first reports of abandoning the fight
- feeling oneself always "ridiculous with the old scheme of things"
- "bring to mind an emotion"
- allowing emotions to flow
- "if the fear is to that me they may hurt me, the purpose is to maximise the surface of contact, to open myself to fear",
- in a sexual relation with a girl, look for "to enjoy more than to take away", satisfactory even if no orgasm takes place,
- steps to establish a more lasting relationship with a male.
4 / - "I have lost the fear of labels", "I am me and not the words that people put to this, I am going to enjoy life"
- "the fact to have an erection is not the most important thing, the important thing is to be happy"
5 / - evaluating an episode of compulsive sex as "digging", "flight from solitude", "lack of control as a consequence of unsatisfied needs"
- "things being the way they are, I am me, I do not need labels"
6 / - reporting of having maintained relations with a man by first time in his own house and to have experienced them differently
- when he saw himself having fantasies with male, to abandon the fight and to think "I am me and this is a fantasy"
7 / - maintaining relationships with different women
- being surprised of controlling his fantasies and loose control and laugh of that
(7 months after intervention) / - feeling "more readjusted within himself", "more comfortable with himself", quieter
- having begun two successive relations with girls
- no episodes of loss erection
- decrease in sexual desire in his relation with a girl which he attributes to his having been for too long without maintaining relations with men, describing both types of desire as equivalents to "being hungry and thirsty", in the sense that "the thirst is not satiated if you eat", when he had again relations with men he recovered the desire towards women.
- He reported a difference in respect to the period prior to the treatment: when he controlled he now knew what was happening and could change of gear easily
The intervention with ACT was effective in a very limited number of sessions. A change in the way of living the fears in the context of the attraction and sexual relations was achieved. Avoidance behaviours diminished involving them in relations no matter the gender of the other person, open to the possibility of not having an erection. It was possible for the client to "open a hole" for conducts that others could consider as fitting for the other gender and not to fight against them, without this leading him to question his identity. It is an example of the effectiveness of ACT in an area of psychological intervention, sexual behaviour, in which it had still not been applied.
The consideration of homosexuality or bisexuality as hardly modifiable orientations of response has been useful. Sexual behaviours were seen as internal and external events in reaction to stimuli evaluated culturally as sexual (although in this case also evaluated as not being the suitable ones for a person of that gender by a sector of society or even by the same individual). These orientations of response are understood as different from what would be the identity of gender (self-identification as a man or a woman). Hypothetically we are dealing with conducts that cannot be modified through verbal norms due to their non-responding nature or operating but not governed by norms (see Hayes, 1994). Our position is that these conducts that the individual tries to change it is very not very likely that may be amended since they would correspond to one of these two categories. Rather the opposite, the evidence shows us that the fight against internal events captures the individual and it is an essential component of the experiential avoidance of anxiety, fears and relations, and the consequence is that in many cases the attempts to change maintain or increase the avoided behaviour.
It seems to us important to put forward the consideration that the psychologist has to be critical with his/her own therapeutic experience, because he/she can perpetuate this homophobic pattern, encouraging new ways of amending internal events which in fact are ineffective as well as promoting the non acceptance. They do not promote either the steps intended to lead a coherent life with the desires or tendencies of the person. In this sense, the A.P.A. has recently reaffirmed its position by declaring that it supports the dissemination of correct information on sexual orientation and mental health, and suitable interventions addressed to counter prejudices based on ignorance or unfounded beliefs on sexual guidance (A.P.A., 1997).
From the perspective adopted in this paper, the key when considering the aims of a treatment would be the client's values which are the ones determining the actions of the individual, and the psychological acceptance of his desires or tendencies would become more precise through actions in one sense or the other.
Besides, the therapist should be critical with the idea of bisexuality as avoidance of homosexuality. The experience of the this and other cases and studies published from Kinsey (1948,1953) up to our days (see by example Weinberg, Williams and Prior, 1994) show how in an individual coexist the same kind of responses of attraction and desire in front of two types of different stimuli (people belonging to one or the other gender). The disorientation, disinformation and contradictory societal rules in general and psychological in particular may foment the confusion of the individual and complicate acceptance.
The confusion between orientation of sexual desire and gender identity also underlines the question of the "self". Although we affirm that there is a gender identity, we affirm also that there is also a heterosexual, homosexual or bisexual identity. Is the latter a recent social construction (Guasch, 2000) but of necessary consideration if we want to understand the process that a person showing a behaviour of attraction and desire towards people of his/her same gender goes through in his/her process of self-acceptance (Soriano, 1995). That is, to the identity of gender ("I am a man" or "I am a woman") it would be added the homo or bisexual identity ("I am homosexual" or "I am gay" or "I am lesbian" or "I am bisexual").
The phenomenon of homophobia cannot be separated from the "repression" in males of behaviours, inclinations or emotional responses not directly linked to sexuality but evaluated socially as feminine. Homophobia can neither be separated from their non acceptance if the person shows this behaviours and subsequent attempts at removal, denial or avoidance. This above-mentioned "emotional repression" keeps subject in a fight against himself that limits his chances of personal, emotional, affective, social and professional development, or of increasing his autonomy (by example see Devlin and Cowan, 1985).
The problems of erection, from this point of view, besides showing equivalences with other problems in which conducts of avoidance predominate, would have a relation with that arbitrary rule about what it is considered to be masculinity (where erection becomes an absolutely defining element), so that the rule is "not having an erection means not being (enough of a) man", which implies that "if I am a man I have to fight against loss of erection and recover it as soon as possible". It does not seem too risky to consider that both fears, of loosing the erection and of being homosexual, are connected.