Existential Relationship Therapy
Chapter 6: Sexuality and Embodiment in Relationships
By Meg Barker and Darren Langdridge
In general what sets 'a relationship' (of the kind this book, and relationship therapy more broadly, focuses on) apart from other kinds of relationships (friendships, collegiate relationships, family relationships and so forth) is often taken to be the fact that it is 'sexual'. The phrases 'romantic relationship', 'intimate relationship' and 'sexual relationship' tend to be used interchangeably. Indeed, in popular magazines, television programmes and self-help books, the quantity and quality of sex within such a relationship is often taken to be a barometer of its success, or of the connection or love between the people involved (e.g. Gray, 2003; Star, 2004). This focus on sex in relationships has increased in recent years as part of what has been termed the 'sexualisation' of culture (Attwood, 2004), and with it levels of anxiety around sex: The 2000 UK national survey of sexual attitudes and lifestyles (NATSAL) found that 35% of men and 54% of women reported some kind of sexual ‘dysfunction’ (Mercer et al., 2005).
Clearly, therefore, it is important that an existential form of relationship therapy considers issues of sex and sexuality within an existential framework. It is also important to begin to detail what an existential sex therapy would look like in practice, and how this might be similar to – and different from – current forms of psychosexual therapy. To date, there has been relatively little written on sexuality within existential therapy (see Smith-Pickard & Swynnerton, 2005; Pearce, 2011), and even less on existential forms of sex therapy (papers which touch on this include Barker, 2011a; Kleinplatz, 1998, 2004; Adams, Harper, Johnson & Cobia, 2006).
Historically, relationship therapy has been intertwined with sex therapy within organisational contexts. In the UK, for example, the main organisation accrediting therapists in this area is the College of Sexual and Relationship Therapists (COSRT, 2011). In the National Health Service, the secondary care available to those with relationship difficulties takes the form of 'sexual and relationship therapy' clinics. The key international journals in this area are the Journal of Sex and Marital Therapy and Sexual and Relationship Therapy.
This chapter begins by presenting the dominant, medicalised, understandings of ‘sexual problems’ within psychosexual therapy. This is then contrasted with an existential understanding of sexuality and embodiment, drawing primarily on the work of Merleau-Ponty but also incorporating more recent feminist and queer scholars such as Elizabeth Grosz, who have built on and also challenged this foundation. The chapter then goes on to examine the multiple potential meanings of sexual experiences and practices, and the potential within existential therapy for sexual issues to reveal clients’ wider world views as well as relational dynamics. Specific examples are given of the multiple meanings of erectile difficulties, and of the relationship between vaginismus and the existential challenge of being-for-oneself versus being-for-others.
Dominant understandings of sex in sexual and relationship therapy
Conventional psychosexual therapy is based upon the understandings of sexual function and dysfunction presented in nosologies such as the American Psychiatric Association Diagnostic and Statistical Manual (DSM IV-TR, in section 302.7) and the World Health Organization International Classification of Diseases (ICD-10, in section F52). Briefly these both include pain during sexual intercourse, and disruptions to any phase of Kaplan’s (1974, 1979) adaptation of Masters and Johnson’s (1966) ‘normal’ sexual response cycle: desire, excitement/arousal, and orgasm.
In the desire phase, the DSM distinguishes between hypoactive desire (general lack of desire) and actual aversion to sexual contact. In the other phases (excitement/arousal and orgasm) it distinguishes between the genders, with ‘female’ and ‘male’ forms of both orgasm disorder and sexual arousal disorder (in men this latter is more commonly called ‘erectile dysfunction’, ED). Under male orgasm disorder there is also a separate category of ‘premature ejaculation’ (PE) whilst there is no equivalent category for women reaching orgasm too quickly. Under pain disorders there is a general disorder that applies to both men and women, and a specific category for women who experience uncomfortable vaginal muscle spasms in the outer third of the vagina during penetration (vaginismus). In addition to these categories, present in the DSM-IV-TR, the ICD-10 also lists two, gendered, forms of 'excessive sexual drive' (Nymphomania and Satyriasis).
Also of relevance for psychosexual therapy is the 'paraphilia' category (DSM-IV-TR section 302.8, ICD-10 section F65), which is again very similar in both nosologies and is considered to be a 'mental disorder', 'characterized by sexual fantasies, urges, or behaviors involving non-human objects (fetishism, transvestic fetishism), suffering or humiliation (sexual sadism, masochism), children (pedophilia) or other non-consenting person (voyeurism, frotteurism, exhibitionism)' (APA, 1994). There is not space, in this chapter, to deal with this in detail, but we will return to what an existential approach to such issues might look like later on.
Conventional psychosexual therapy begins with an assessment, a large part of which is undertaken to rule out possible organic reasons for sexual problems. This is important because many of the sexual 'dysfunctions' are linked to certain drugs (such as alcohol or antidepressants, notably selective seratonin reuptake inhibitors) or can be 'silent markers' for medical problems such as diabetes or coronary heart disease. Even if we take a critical stance towards the medicalisation of sexual issues, as we do in this chapter, it behoves any therapist working in this area to have a broad understanding of the basic physiology of sex, in order to make appropriate referrals when a medical issue is indicated.
Once a diagnosis has been made, the likely therapy, in conventional psychosexual approaches, involves a combination of physical treatments (such as drugs or suggested sexual positions) with cognitive-behavioural therapy (CBT, such as systematic desensitisation and reinforcement). The medical model has become the dominant way of understanding and treating sexual ‘dysfunction’ in the past two decades (Winton, 2001), particularly with the success of drug treatments like ViagraTM (a PDE5 inhibitor) for erectile dysfunction.
It is not possible to go into depth about all of the different CBT based treatments here. To give just a few key examples, one common treatment for many sexual problems within relationships is Masters and Johnsons' (1970) ‘sensate focus’ ‘homework’: gradual progress between partners from touching with a ban on genital contact, to various kinds of genital contact, with a focus on them learning what each finds pleasurable and arousing. Vaginismus is frequently treated by encouraging the person to insert dilators of increasing size (or fingers) into the vagina. PE is often treated by encouraging the person to stop all stimulation when approaching orgasm several times before orgasm is allowed. CBT may also involve challenging common 'myths' and 'maladaptive beliefs' around sex, and some degree of sex education (Wincze & Carey, 2001).
It should be noted, here, that many private sexual and relationship therapists practice from positions other than the medical or CBT models (psychodynamic and systemic approaches being particularly common). Also, clinics may well consist of multidisciplinary teams of counsellors and clinicians who are informed by various approaches. However, the diagnosis and treatment model outlined here remains the standard approach conducted in clinics and outlined in the main texts on psychosexual therapy (e.g. Bancroft, 2009, see Barker & Richards, in press).
Before turning to specifically existential criticisms of conventional understandings of, and treatments for, sexual problems, it is worth briefly summarising some of the other criticisms that have been made of this approach (see Barker, 2011a, for details). First, many authors have challenged the medicalisation of sex broadly, and the pathologising language of 'dysfunction' specifically (e.g. Ussher & Baker, 1993; Kaschak & Tiefer, 2001). Linked to this is the criticism that psychiatric categories and psychosexual treatments construct what 'normal' (and by implication good, proper) sex is, as part of wider dominant discourses (Rubin, 1984). This constructed nature is revealed when we observe shifts in categories and understandings over time. For example, in the past masturbation was discouraged and homosexuality was included as a disorder (Kutchins & Kirk, 1997). Psychomedical constructions of sex are particularly problematic because they have a veneer of value-free scientific objectivity, which obscures the ‘intensely political and value-laden content of the discourse’ (Denman, 2004, p.275).
'Normal' sex is clearly constructed as heterosexual penile-vaginal intercourse resulting in orgasm, given that penises are required to be erect (ED) and to penetrate (PE), and vaginas are required to be penetrated (vaginismus). The use of this passive 'penetrated' rather than a more active 'engulfing' is also telling (Pearce, 2011). Various authors have criticised this model for excluding other forms of sex (e.g. oral, anal, manual, solo, kinky) and relationships (e.g. 'same-sex' and multiple relationships, see Langdridge & Barker, this volume), as well as for being androcentric, given that sex is considered to end with male ejaculation. HIV/AIDS activists have also questioned the focus on penetration (Jackson, 2006). Categories and treatments are invariably bound up in economic concerns (such as those surrounding the lucrative business of psychopharmacology) and particular kinds of conservative politics. For example, Boyle (1993) suggests that concern with ‘female sexual dysfunctions’ emerged when women’s sexual dissatisfaction began to threaten heterosexual marriage and the nuclear family.
On the level of the individual and the relationship, therefore, conventional psychosexual therapy can be seen as constraining and limiting what is possible, and being 'goal' rather than 'pleasure-directed' (Kleinplatz, 1998, 2004) in a way which dampens the erotic imagination (Denman, 2004) and prevents people from tuning in to their own unique desires and fantasies.
Existential understandings of sexuality and embodiment
These criticisms are very much in line with existential perspectives. Yalom (2001) states that therapists should avoid diagnoses because they prevent us from relating to the client as a person, and can become self-fulfilling prophecies. More fundamentally, existential therapy - following the anti-psychiatry approach of Laing (1962) and Szasz (1974) - sees such diagnosis and treatment on the basis of symptoms as missing the meaning of these symptoms and behaviours and therefore dehumanizing the individual. Kleinplatz's (2003) existential criticism of psychosexual therapy argues that the focus on relieving symptoms neglects the vital intrapsychic, interpersonal, systemic and sociocultural meanings of experiences and behaviours.
There is remarkably little consideration of sexuality and embodiment in philosophical literature in general, but there are some notable exceptions within the existential canon that may provide the basis for an existentially informed sex therapy. The existential philosopher who provides the most significant contribution to understandings of embodiment and sexuality is Maurice Merleau-Ponty (1962, 1968). His work offers a significant departure from other therapeutic theories on these issues.
Merleau-Ponty (1962) provides an elaborate account of sexuality that is at once radical and also fundamental. He argues that, rather than separating sexuality off as a distinct aspect of existence, we should instead recognise the way that it infuses all of our embodied being-in-the-world. It is therefore a fundamental aspect of intersubjectivity, always present in our relations with others. Sexuality in these terms moves beyond everyday notions of sex and sexuality towards recognition of the inherent sexual element in all encounters. Sex does remain an aspect of sexuality that is driven by desire, but sexuality becomes much broader than simply sexual acts.
It is desire that is central in our sexual being in the world with others. Sexuality, like all other aspects of embodied consciousness, is intentionally directed towards the world. This is not simply through conscious decisions about our sexual predilections but also through a pre-reflective desire that emerges through our bodies. Desire reveals that we are fundamentally embodied beings and cannot split off our selves from our bodies in the way we are often encouraged to do by popular culture. There is also no existence without sexuality for we are always in relation with others and this relationship is always characterised by sexual significance.
According to Merleau-Ponty's position, we need to recognise the diverse and diffuse nature of sexuality in all our relational encounters. This may not be driven by sex (though of course it sometimes is) but by a sense of embodied connection grounded in desire (e.g. to be intimate with another person, to connect with them). The meaning of sex and sexuality is therefore open to different and diverse understandings but the power and potency of our relationships speak not only to everyday concerns about intimacy and sexuality but also to broader aspects of how the world appears to us.
Through thinking of sexuality in such a way that sex is maintained but sexuality broadened beyond sex alone we can see the potential in counselling and psychotherapy for sexuality to alert us to important aspects of our lives and the meaning they have for us. For example, we may find in sex therapy that sexual difficulties relate to much broader aspects of a person's life. For example, someone who has trouble reaching orgasm may struggle to let go and be vulnerable in relationships more generally. Someone who is engaging in 'virtual' (online) sex in a variety of roles may find this a safe space to engage in a creativity of self that they find anxiety-provoking in everyday life. Similarly, in therapy which is not explicitly psychosexual in nature, Merleau-Ponty's understandings would suggest that sexuality would always be relevant and should be part of what we explore with all clients.
Beyond these explicit accounts of sexuality and embodiment the developmental-psychological work of Merleau-Ponty (1964, 1993) also has relevance for bringing the body more directly into existential counselling and psychotherapy. Whilst there is not the space to discuss this in detail here, one of us has elsewhere outlined one possible way in which a 'fusion of bodily horizons' between therapist and client might be achieved (Langdridge, 2005, p.96) using techniques more commonly associated with gestalt therapy. There is considerable potential for this to be extended when working with clients in relationship therapy such that they might physically enact aspects of their experience directly within the therapeutic space to better understand the emotional quality of relationship dynamics. Traditional relationship therapy already uses such methods where couples (or people in other relationship structures) are given practical communication tasks to perform both within and outside the therapeutic session. There is, therefore, scope for bringing together existential understandings and traditional ways of working in relationship therapy so that both are enriched and the importance of sexuality and embodiment foregrounded.
Whilst this existential work opens up a new way of understanding sexuality and embodiment that moves beyond a simple focus on the mechanics of sex, it has not escaped criticism. In particular, some more recent feminist philosophers, working broadly within the existential tradition, have questioned some of the assumptions underpinning this work with regard to gender difference and sexism (Grosz, 1994; Le Deouff, 1991). Grosz (1994) raises the issue of sexual difference in Merleau-Ponty's account, asking a critical question about the kind of body that forms the basis for his theory. His theory may appear general, not tied to any one type of body, but for Grosz this is the problem. There is no recognition of how differently sexed and sexualised bodies might experience sexuality and desire in different ways. Merleau-Ponty's model is cisgender[1] heterosexual male sexuality and this is taken as the foundation for his theorising. Cisgender heterosexual female sexuality, whilst sharing some common features, might also demand a different phenomenological analysis, as might different varieties of trans sexuality, genderqueer[2], genderneutral[3], lesbian, gay, and bisexual sexuality.
Beyond her belief that Merleau-Ponty has failed to take sexual difference seriously, Grosz also raises the issue of how sexuality and desire in Merleau-Ponty's terms are almost de-sexualised, in contrast to those of Freud for instance. There is no recognition of the potentially disturbing and disruptive power of sex and sexuality in Merleau-Ponty's theories. Grosz concludes that:
'Where Freud perhaps too strongly emphasizes desire (enabling it to be readily equated with instincts), Merleau-Ponty does not provide it with a central enough role...' (p. 110).
There is clearly more work needed that builds on the insights of the work of writers like Merleau-Ponty and others but which also takes seriously the impact of the phenomenology and socio-political aspects of sex and sexual difference.
So what does this mean for an existential form of sex therapy? In the rest of this chapter we focus on two key aspects, acknowledging that there is much more that could be taken from this work. We consider the multiplicity of meanings of sexual experiences and the potential for sexual issues to reveal wider patterns of relating to others.