The Cultural Context of Sexual Pleasure and Problems

Psychotherapy with Diverse Clients

Kathryn S. K. Hall, Cynthia A. Graham, Kathryn S. K. Hall, Cynthia A. Graham

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136220104
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Using rich case material and research presented by distinguished authorities in the fields of sex, couple, family, and psychotherapy, this edited book contributes to our efforts to help individuals and couples increase their sexual satisfaction. The authors explore social and cultural backgrounds, the meaning of sexual problems in specific cultural contexts, and the way in which culture presents challenges to traditional psychotherapy. More importantly, they answer the question: should therapists accept any and all behaviors, values, and attitudes that are considered normal, even if they violate the therapist's own cultural standards? The case studies identify challenging cultural issues and provide clinicians with culturally sensitive treatment options. The book's sections also separate chapters based on the degree to which psychological treatments are recognized and utilized for dealing with sexual problems in different countries, making it an ideal reference for professionals and students. The concluding chapter looks at culture through the lens of the provider, rather than the patient, and ties together the major themes and questions posed.

Introduction

Kathryn Hall and Cynthia Graham

People worldwide engage in sex. While sexuality may be universal, the expression of sexuality is not. What might be considered creative and imaginative lovemaking in one culture may be viewed as immoral or sordid in another. Conversely, what is regarded as “problematic” sexual functioning may be normative in a different cultural context. For confirmation of this cultural variability we need look no further than to reactions to same-sex unions, requirements regarding premarital chastity, and variations in the importance placed on female sexual pleasure, marital fidelity, and attitudes toward recreational versus procreative sex.

Given that sexuality, in its various manifestations, is recognized as a fundamental aspect of being human “the right to pursue a satisfying, safe and pleasurable sexual life” (World Health Organization, 2006) is considered a basic human right (International Council of Human Rights Progress [ICHRP], 2009). A satisfying, safe, and pleasurable sexual life is also considered a mainstay of healthy emotional and psychological functioning and appropriate personality development. Whether it is a mental health issue, a human right, or a private matter, people around the world experience sexual difficulties that greatly impact the quality of their lives. We believe that efforts to help individuals and couples increase their sexual satisfaction will only be effective if informed by an understanding of their social and cultural background, and of the meaning of sexual problems in specific cultural contexts.

There is very little published literature on the specific ways in which culture and ethnicity define and shape sexuality, both “healthy” and problematic. There is even less clear guidance for clinicians on how to provide culturally sensitive treatment (Brotto, Chik, Ryder, Gorzalka, & Seal, 2005; Lewis, 2004). This gap was the impetus for this book. This collection of chapters from experts around the world offers a contextual understanding of the sexual issues that affect men and women across a wide range of cultures, and the ways in which culture presents challenges to traditional psychotherapy. Most of the chapters are illustrated with rich case material, which identifies challenging clinical issues and provides clinicians with culturally sensitive treatment options.

The questions raised by the contributors to this book make for compelling discussion. Is there a universal sexuality? How important is culture in defining our sexuality, our sexual behavior, and our sexual problems? Is cultural relativism the same as cultural competence? In other words, in order to work with people from cultures different from our own, should we accept as normal any and all behaviors, values, and attitudes that are considered normal in that culture? Should we consider acceptable, sexual behaviors considered normal in other cultures, even if they violate our own cultural standards? What do we do as practicing clinicians when our own notion of “healthy” is challenged in this way? Sex research and clinical case material can help to expand the borders and boundaries of our knowledge about human sexuality and the ways in which culture shapes it. This book is intended to widen our cultural perspective.

We have divided this book into five sections. The first section of the book is comprised of three chapters dealing with cultures within cultures. We start with a provocative chapter by Margaret Nichols on sexual minorities followed by chapters on African Americans and Latinas, two distinct cultural groups residing in the United States. We begin with these chapters for the important reason that they orient readers to the need for cultural sensitivity. From there we delve into cultures from other parts of the world. We have divided these chapters into three sections based upon the degree to which psychological treatments are recognized and utilized for dealing with sexual problems. In Korea, rural Iran, and Cameroon there are no well-established psychological treatments for sexual problems. In Hong Kong, India, and Russia, psychotherapy and sex therapy¹ are emerging as viable options for people with sexual problems. Finally, in Northern Europe, Portugal, Brazil, and Israel, psychotherapy and sex therapy are well established and much utilized. We end the book with the thought provoking chapter by Giami, in which he looks at culture through the lens of the provider of therapy rather than the lens of the patient or client.

The Importance of Culture

When we refer to culture we are referring to the way of life practiced by a distinct group of people. This is manifested by the shared beliefs, values, and behaviors that are passed along from one generation to the next; as Williams (1983) defined it, “the way of life for an entire society.” While cultures vary in terms of how much diversity is tolerated, a shared group identity depends upon an expectation of similarity (Kelly, 1963). As will become apparent as you read through the chapters in this book, sexuality is culturally determined and defined. The meanings that are attached to sex and the value attached to sexual behavior or sexual abstinence vary across cultures.

Religion overlaps with culture but it is not synonymous with it. The degree to which a culture embraces religious prohibitions and sexual proscriptions varies. While most religions tend to restrict sexuality in some way, the impact of various religions and the translation of religious practices into sexual behavior and attitudes fluctuate across cultural lines. The chapter on Russia provides an illustration of how the reintroduction of religion can influence sexual behavior. Temkina, Rotkirch, and Haavio-Mannila point out that the loosening of state restrictions that came with glasnost brought with it religious freedom, which, paradoxically, resulted in religious restrictions on sexual behavior. Interestingly, Aloni, Heruti, and DePaauw observed in their chapter on Israel that Russian immigrants to Israel often become more restrictive in their sexual behavior as they embrace Judaism. As chapters in this book demonstrate, religion is a factor of greater or lesser importance in understanding the sexual behavior, attitudes, and issues of a particular cultural group.

Race is also not the same as culture (Lewis, 2004). There are instances, however, where race may (partially) denote a specific cultural group within a larger cultural context. This is why we have included chapters on African Americans and Latinas in this volume, whereas elsewhere we define cultures by the boundaries of nations. We recognize that distinct cultural groups exist across and within a country’s borders. The chapter on African Americans provides a good example of the difficulties facing a longstanding cultural group that is distinct from the mainstream culture of the United States, whereas the chapter by Melendez et al. on the large Latino culture that exists within the United States provides an illustration of the experience of more recent immigrants. Where possible, authors in this book have described the different cultural groups, but have focused primarily on the main or dominant culture in their country.

There are, perhaps, no other dimensions that so fully encompass an individual’s identity as their sexuality and their cultural heritage. That these two facets of the self are interwoven there can be no doubt. Nowhere in the book is this as apparent as it is in the chapter on sexual minorities living in different cultures. In this chapter, Nichols aptly points out that the self-identified exclusively gay individual is an artifact of Western societies. She notes that in other cultures same-gender relations take various forms; for example, some homosexual relationships involve one partner assuming a “female” role, or more often one partner is considered a “third sex.” She gives the examples of “two spirit” people in Native American culture, “ladyboys” in Thailand, and travesti in Brazil. While in Western culture it is the gender of one’s partner that determines sexual orientation, in other cultures it is the particular sexual acts engaged in, and the role one plays that are important. Citing Jeffries (2009), Nichols observes that in many Latin American cultures, the “insertor” in anal sex is not considered homosexual, only the “insertee.” All of these examples point to the complexity of how notions of gender and sexual orientation interact with culture.

Culture is Dynamic

Cultures are dynamic, not static, and often change rapidly. Many of the authors in this volume highlight the fact that people of different age groups will have different experiences of their cultures. Zargooshi and his colleagues, for example, noted that Iran is a society in transition, and Temkina and her coauthors observed that in Soviet Russia, the men and women who came of age in previous generations differ distinctly in sexual values and behaviors from those coming of age now. In the chapter on South Korea, Youn chose to focus on the aging segment of the population that grew up in a time of rigid and gendered sexual mores. Consideration of this generation highlights some of the obstacles to sex therapy that are ingrained in Korean culture.

One of the most notable changes in many societies is the greater value now accorded to female sexual pleasure. According to Temkina et al., female orgasm is a matter of recent interest in Russia and Youn discusses how the rights of women to regulate their sexual activity (e.g., to say no to unwanted sex) is an idea gaining ground in South Korea. In Hong Kong and Brazil, women are recognizing sexual pleasure as a “right.” In contrast, in some chapters, most notably those on India and Iran, women are conspicuously absent from the discussion on sexual pleasure.

The dynamic nature of culture is also due to the interaction between different societies. Cultural boundaries are porous. To quote Thomas Friedman (2005), “the world is flat.” The globalization of world economies means that businesses developed in one area of the world are branching out to others, bringing with them merchandise, people, and culture. Travel and tourism are increasingly bringing people of different cultures in contact with each other. The Internet has made sexual content available to most (one notable exception is Iran, which continues to restrict the sexual content its citizens can access). At times, cultures clash. In India, young men can easily access pornography over the Internet, where sex is depicted in ways that may conflict with the values imparted by their parents. This makes the cultural prohibitions against masturbation extremely difficult to follow and is relevant to the culture bound syndrome known as Dhat syndrome. This syndrome is characterized by symptoms of anxiety, guilt, erectile dysfunction, fatigue, and depression related to the loss of semen through masturbation or nocturnal emissions (Ahmed & Bhugra, 2004). In those countries with limited sex education, the Internet may become a source of sexual knowledge and pleasure. However, some of the pornography available over the Internet may contribute to the sexual anxiety experienced by both men and women, especially those with little or no sexual education or experience.

The collision of cultural beliefs, when it arises quickly and represents different ends of a spectrum, may have unforeseen consequences. In her chapter, Savage attributes the unconventional sexual behavior now occurring in Cameroon to the overlap of modern and traditional values. In their quest to attain the outward trappings of modern success (e.g., wealth, cars, fashionable clothes), women, following the direction of their spiritual leaders, are having sex with “mad” men in Doula and other public places in Cameroon. Brazil has the second highest rate of cosmetic surgery worldwide (Domeles de Andrade, 2010), and Brendler notes that women in Brazil are having silicone breast implants in record numbers in order to more closely resemble the Western notion of a “sexy” woman. Reviewing the literature on gender differences in erotic plasticity, Baumeister (2000) argued that the female sex drive is fundamentally more malleable than the male’s in response to sociocultural and situational factors. As Western notions of sexuality cross borders, we may see that female sexuality shows the most dramatic changes as a result.

Culturally Sensitive Psychotherapy for Sexual Problems

The U.S. Surgeon General and the American Psychological Association have issued statements regarding the importance of and need for culturally informed and sensitive treatment (American Psychological Association, 2003; U.S. Department of Health and Human Services, 2001). Although there is a dearth of research on sex therapy with ethnic minority clients, what little evidence there is suggests that the dropout rate from therapy for members of ethnic minorities is high (Christenson, 1988; Sue & Sue, 1999). Part of the problem is that despite the emphasis on evidence-based treatment, most psychotherapeutic interventions have been designed by Westerners and are evaluated with White, middle class, heterosexual clients. It is no wonder that these groups show the greatest treatment gains (Lewis, 2004).

While there is woefully little research examining effective psychotherapeutic interventions for improving sexual pleasure and performance among ethnic minority groups, there is in contrast a voluminous literature on problematic sexuality and its consequences, such as unplanned adolescent pregnancy and sexually transmitted infections in this population (Lewis, 2004). This emphasis on problematic sexuality may further contribute to stereotyped notions of ethnic minorities as sexually promiscuous and irresponsible. As greater numbers of ethnically diverse clients present for treatment, there will be an increased demand for culturally sensitive and effective therapeutic methods. Without adequate research or clinical evidence to challenge stereotypes and inform treatment, clinicians will be ill-equipped to deal with these clients.

The introduction to the section on sexual dysfunctions in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000) includes the following statement: “Clinical judgments about the presence of a Sexual Dysfunction should take into account the individual’s ethnic, cultural, religious and social background, which may influence sexual desire, expectations, and attitudes about performance” (p. 495). However, beyond this, there is no specific information about the role of cultural factors in influencing sexual problems (Brotto et al., 2005). In planning for the upcoming revision of the DSM (DSM-5), the recognition that cultural issues are of fundamental importance has been more explicitly acknowledged, with a special study group on culture and cross-cultural issues.

We join those who argue for a “culture-centered,” or culturally competent, approach to psychotherapy (Hall, 2001). A “culture-centered” approach “recognizes culture as central and not marginal, fundamental and not exotic, for all appropriate counseling interventions” (Pederson, 2007, p. 5). Cultural competence “denotes the capacity to perform and obtain positive clinical outcomes in cross-cultural encounters … generic cultural competence is the knowledge and skill set needed in any cross-cultural therapeutic encounter, and specific cultural competence enables clinicians to work effectively with a specific ethnocultural community. To provide culturally competent psychotherapy, both are essential” (Lo & Fung, 2003, p. 162). Successful treatment of sexual problems will require tailoring treatment to the unique cultural requirements of the individual or couple. In some cases traditional psychotherapy or sex therapy approaches can be modified (Ahmed & Bhugra, 2004; So & Cheung, 2004). Culture-specific modifications to the method of treatment may be most successful when the sexual problems are similar to those for which sex therapy was designed; for example, problems of sexual function, such as erectile dysfunction, ejaculatory problems, and orgasm difficulties. Sexual issues unique to a culture, such as Dhat syndrome, may require an entirely different approach.

Often culture is blamed for creating sexual problems, especially when the perception is that the culture espouses negative and erroneous beliefs about sex. As one example, many cultures value semen in a way that Western society does not. Culture bound syndromes relating to fear or guilt regarding semen loss may therefore be difficult for Western therapists to understand or treat. The value placed on female chastity may represent a similar clinical challenge, but because female virginity has historically been esteemed in Western society it is perhaps better understood. And yet, as Sungur suggests in his chapter, the degree to which a culture emphasizes the need to protect female virginity may be directly related to the prevalence of vaginismus within that culture. A culturally sensitive perspective goes beyond blaming a fault in the culture (e.g., the premium placed on semen or virginity) for sexual problems.

However, just because a belief or practice is culturally based does not mean that it should be condoned. Female genital cutting is a culturally entrenched practice, which is often abhorred by people from other cultures. The practice continues and is the subject of much debate about whether medical doctors should perform female circumcision to ensure sterile procedures and minimal genital damage or whether they should refuse to perfor...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• Editor Biographies
• Contributor Biographies
• Acknowledgements
• 1. Introduction
• Section I: Minorities: The Need for Cultural Sensitivity
• Section II: Sex Therapy Is Not Practiced Here: Cultural Challenges
• Section III: The Emerging Practice of Psychotherapy for Sexual Problems
• Section IV: Cultural Adaptations of Psychotherapy Approaches to the Treatment of Sexual Problems
• Section V: The Other Side of the Couch: The Cultural Contribution of the Therapist
• Index