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One of the first things you learn in sex therapy training is the PLISSIT model. This is a tiered model of how we assess and intervene with our patients. I think the framing can be helpful to understand going into the sex therapy process, so you know what to expect. Your sex therapist has a reason for the pace at which they begin your treatment, and PLISSIT is likely the guide!
PLISSIT is an acronym introduced in 1976 by Jack Annon to help clinicians determine the appropriate level of intervention with a patient. Let’s break the acronym down. P Permission LI Limited Information SS Specific Suggestions IT Intensive Therapy Permission can be interpreted a couple of different ways. First, I like to think about getting permission, or consent, from a patient as we begin our work together. I also like to give them permission to revoke consent at any time! I will ask very personal questions about a patient’s sex life, identity, sexual and trauma history, and maybe anatomy depending on the issue at hand. I tell every patient that it takes time to build trust with me, and I don’t expect them to feel comfortable telling me everything on the first day. Or ever. It is up to them. I need to get permission to ask, and they have permission to refuse. Secondly, permission refers to giving our patient permission to change, or to stay the same. A good number of sex therapy patients really just need validation that what they desire is normal. Another good chunk just want permission to make a change. Having a professional to validate this, explain how normal they are, and create a container to explore their needs may be all the therapy the person needs. Limited Information ensures a patient gets what they need, and not a lot of extraneous information. In order to provide this, sex therapists complete thorough intake assessments with clients. Here’s an example. I have a lot of training on pelvic pain. The etiology of pelvic pain can be so many things, and different origin points might lead to different treatment plans. Because I want to give my patient limited information versus an overload, I’ll want to find out about their trauma history, any medical conditions, if the pain is global or situational (all the time or just in some circumstances), primary or acquired (it has always been the case, or it started later in life), and some other assessments too as indicated. Based on that, I might give my patient information on assistive sexual devices to help with pain during intercourse. Or maybe how trauma impacts our musculature. Perhaps some education on estrogen cream, or a pelvic floor physical therapy to treat hypertonicity. We want the laser focus here on what education a patient actually needs; not a firehose of data on every single potential that doesn’t apply directly to their case. Specific Suggestions are the “what to do next” pieces of sex therapy. What interventions might help this person? This is the “therapy homework” for the patient, and also potential referrals to other sexual health professionals. We will develop a treatment plan together, often with specific goals so we know if these suggestions are working. This level of intervention can be thought of as behavioral changes that will, we hope, ultimately change a person’s sexual experience into a more enjoyable and aligned version. Intensive Therapy is exactly what it sounds like. This might include treatment for past sexual trauma, anxiety, depression, and other mental health and wellbeing concerns that specific modalities of mental health therapy treat. Different therapists are trained in different modalities, but some of the popular ones include Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, Exposure and Response Prevention, Acceptance and Commitment Therapy, and Internal Family Systems. Intensive therapy can be done with an individual, or multiple people in a relationship, depending on the issue at hand. Sex therapists are trained to manage and facilitate each stage of the PLISSIT model. If you are interviewing potential sex therapists, asking them about their comfort level with each stage can help you understand their training and competency–remember, “sex therapist” is not a protected term! Anyone can call themselves one, even without training and certification. It is important to look for the initials “CST” after your therapist’s name, which means they are a “certified sex therapist,” or assurance that the therapist is currently in training toward their CST credential. Mary-Margaret Sweeney, MSW, LCSW, CST is a certified sex therapist licensed and practicing in the state of Indiana. You can read more about her practice and reach out about working together here.
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Advocates have been adding to the LGBT acronym for a while now. As of this writing, the most expansive version seems to be LGBTQIA2S+. Accusations of “alphabet soup” abound. People wonder if all the represented parties belong under the umbrella, and even for people who don’t question who is included, they might wonder if a shorter acronym is easier for practical purposes.
As a sex therapist, and one with additional training and experience in gender exploration, transgender medicine, and queer relationship concerns, I’ve long used the LGBTQ+ acronym in my marketing. But it is not inclusive of everyone who seeks my help, or of my training actually. To more accurately describe my training and who I serve, I’ve adopted Pink Therapy’s term GSRD; Gender, Sexual, and Relationship Diversity. GSRD is Pink Therapy’s way of expanding the LGBT acronym without adding more letters (and numbers). Here is how they break it down: Gender: This encompasses gender diversity. Folks who are trans, non-binary, gender non-conforming, agender, gender fluid… they all fit under this umbrella. Sexual: Sexual diversity takes into account those who experience erotic marginalization. People who identify as gay/lesbian/pansexual, those involved in kink, and asexual people as well. If your sexuality differs from the mainstream, it is represented here. Relationship: Our friends in diverse relationships might identify as ethically non-monogamous, polyamorous, aromantic, sub/dom… the permutations are endless! Which is the fun part, right? I like GSRD as a term because it does feel like it captures everyone. A common email I receive from a prospective client reads something like this: “I am contacting you for sex therapy because I think you might be able to help. I saw you specialize in LGBTQ+ work, and while I’m not exactly queer, I sort of am?” This prospective client has likely felt welcomed in queer spaces, has learned a lot about themself from queer people and resources, but might appear very hetero- and cisnormative. But, they and their spouse are deeply involved in the local fetish/kinkster scene, and they want a couples therapist who will not shame that, who they will not have to spend their therapy hours teaching, and who will not pathologize a sexual interest. They may not even need to discuss their fetish in therapy! Maybe they are having an unrelated family problem, but they need to feel safe in the therapist's office, able to bring their full selves. For so long, “LGBTQ+” has been the signal for that, even if the term didn’t necessarily fit a specific client. GSRD also asks therapists, I think, to really get clear about our competencies. More and more therapy practices are posting a Pride flag on their website, and checking the “LGBTQ+ affirming” box. This is great! It is also different, however, from being knowledgeable about a community. Are you comfortable with people in an identity group, unwilling to try and change their identity? Great! You’re affirming. Have you received additional training and education, potentially including lived experience, with a certain identity? Now you can say you’re knowledgeable. The GSRD framing asks us to check in with the different ways of being in the world, and as any new term does, helps us identify where we might not be knowledgeable. Sources: https://pinktherapy.org/wp-content/uploads/2021/01/What-does-GSRD-mean-.pdfhttps://www.bacp.co.uk/media/5877/bacp-gender-sexual-relationship-diversity-gpacp001-april19.pdf Mary-Margaret Sweeney, MSW, LCSW, CST is a certified sex therapist licensed and practicing in the state of Indiana. You can read more about her practice and reach out about working together here. As a sex and relationship therapist, I spend my working hours helping people manage differences. Any time we share our lives with people in an intimate way, we have to navigate this. Partner A is a night owl, and Partner B is a morning person. Partner A is a beach vacation lover, while Partner B longs for the mountains. Of course, some differences feel higher stakes than these. Opposing political affiliations, cross-cultural and differing religious community membership are frequent flyers. The past few years have highlighted issues like differences on vaccination and gun ownership.
As a sex therapist, the differences I specialize in helping couples navigate are usually very vulnerable topics for the parties involved. It can be made even more difficult when the concern carries stigma from the culture at large. Sero-discordant couples face this uniquely, and also betray our society’s ignorance of sexual health advances. What is a sero-discordant couple? A sero-discordant couple is typically defined as a partnership where one member is HIV positive, while the other is HIV negative. Of course, sero-discordance can also be a part of non-monogamous relationships, where not all partners have the same HIV status. This dynamic is most often associated with gay men, given the history of the US AIDS crisis, but it certainly is not contained to gay male relationships. Anyone can be in a sero-discordant relationship. And anyone can thrive in one. Risk Our current fear around HIV/AIDS does not align with the scientific advances. This is not to say we should treat HIV/AIDS prevention casually! But, we can hold the dialectic that HIV is a serious health concern that we should take steps to prevent, and that living with HIV is no longer the death sentence it was. HIV positive people live long, happy, healthy lives. Additionally, they can do so with HIV negative sexual partners. Risk profiles do not discriminate based on identity. Identifying as a “gay man” does not make one more able to contract HIV; sexual activities are how we assess risk. Unprotected anal sex is much more likely to spread HIV than other ways of having sex. While gay men might report having more anal sex, certainly people of all identities can engage in this activity, and not all gay men engage in anal sex. New Developments No matter your identity or sexual activities, we’ve got so many amazing tools now to really protect folks. And due to that, HIV positive people are living longer, healthier lives; with appropriate treatment, they are living as long as their HIV negative counterparts! Some argue that many HIV positive folks are living longer than some HIV negative people, because HIV+ patients, when they have access to good health care and make use of it, see their physicians more regularly than HIV- people, resulting in early detection of other health issues, and may also be inclined to take better care of their overall health to support a long life with HIV. One of the more important advances in HIV care comes via drugs for controlling the virus in patients. The drugs partients take (antiretroviral, or ART) lower the viral load in the body to such a degree that it becomes undetectable on blood tests… and it prevents the virus from being transmitted to a sexual partner! The public health catchphrase for this is U=U; undetectable equals untransmittable. This is a startling advance in medicine! And the good news keeps coming: the HIV negative partner can take a prescription pre-exposure prophylaxis medicine. You may have seen public health campaigns refer to this as PrEP. This preventative medication is 99% effective in preventing new HIV diagnosis in an HIV negative partner. Couple that with an HIV positive partner compliant with their ART medication, and those partners are having very safe sex. Many of my clients have added condom use to this equation as well for added protection (and of course, if the couple is non-monogamous, there are other STIs to protect against, as well as pregnancy, depending on the anatomy of partners involved). Sex Therapy with Sero-Disordant Couples So why would a sero-discordant couple need sex therapy? The good news is, I am doing less of this work than I used to, given the advances described in this blog post that make living in a sero-discordant relationship much easier. However, the stigma HIV still carries can weigh heavily on a relationship, and certainly a new diagnosis can feel traumatic for some, and at very least an adjustment for most. Sometimes patients do not feel they get enough time with their physicians, and having a full therapy hour to get more psychoeducation can be helpful. Therapists are also trained in helping couples communicate, set boundaries, and develop plans for management of life stressors; the additional training in sexual health that sex therapists receive can enhance that conversation for sero-discordant couples. The good news is that for those of us who remember the 1980s, we are in a very different era for HIV positive people. Yet, it can be hard to let go of that fear instilled in us as we recall our loved ones who did not live to see this new technology and possibility. Celebrities are helping to break down the stigma by talking openly about their status, normalizing a life well-lived, in long-term partnerships. Jonathan Van Ness of Queer Eye writes beautifully about this in their memoir, and references their status on the show and their social media, with their adorable husband by their side, and a rigorous yoga and gymnastics practice too! HIV is treatable and liveable. It is also part of a community trauma history that defined our queer community. It makes sense if you are struggling. There is help available. Mary-Margaret Sweeney, MSW, LCSW, CST is a certified sex therapist licensed and practicing in the state of Indiana. You can read more about her practice and reach out about working together here. Sources and Resources: https://www.cdc.gov/hiv/basics/prep/prep-effectiveness.html#:~:text=PrEP%20is%20highly%20effective%20for,99%25%20when%20taken%20as%20prescribed. https://hivinfo.nih.gov/understanding-hiv/fact-sheets/hiv-treatment-basics https://www.aidsmap.com/about-hiv/life-expectancy-people-living-hiv#:~:text=Many%20people%20living%20with%20HIV,adhere%20to%20their%20HIV%20treatment. https://damien.org |
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