Kathryn S. K Hall and Cynthia A Graham (eds), 2013, The Cultural Context of Sexual Pleasure and Problems: Psychotherapy with Diverse Clients, Routledge, ISBN 978-0-415-63494-6
This new book, a collection of essays, is vast in its scope and diversity, something which is, almost inevitably, its major strength and weakness. Divided into five sections, ‘Minorities: The Need for Cultural Sensitivity’, ‘Sex Therapy is Not Practiced Here: Cultural Challenges’, The Emerging Practice of Psychotherapy for Sexual Problems’, ‘Cultural Adaptations of Psychotherapy Approaches to the Treatment of Sexual Problems’ and ‘The Other Side of the Couch: The Cultural Contribution of the Therapist’, the editors pose an array of questions related to normative and universal sexualities in their introduction, asking if cultural relativism is the same as cultural competence and stating that the book’s aim is “to widen our cultural competence” (Hall and Graham, 2013, p 2). Given the breadth of its international scope, (with essays drawn from every continent except Australasia and Antarctica), Hall and Graham acknowledge that the book is a sampling of cultural perspectives, rather than an exhaustive attempt at cataloguing the issues raised. Importantly, authors chosen had to be able to write in English and have expertise in treating sexual problems, meaning that most of the essays are helpfully grounded in clinical (medical and therapeutic) practice, often taking the form of extended case discussions. Finally and rather obviously, the authors also had to be willing to be published and the editors note that several people they approached declined their invitation on the basis of the political sensitivity of talking openly about sexual pleasure and problems, an important reminder of the inter-relationship between the cultural and political contexts of sexuality.
With the exception of the first and last chapters (the latter of which only comprises one essay), each essay focuses in on a specific country. Thus, though the topics differ, for example Youhn talks about ‘Challenged Facing Sex Therapy in Korea’ and Brendler discusses ‘Sexual Myths and Realities in Brazil’, they are geographically specific. Almost without exception every essay is interesting and engaging and they are of practical use to varying degrees; though the context their relative ‘usefulness’ would necessarily be in who was reading them and for what purpose. This links with some of the focus of Giami’s final essay, which discusses the primary background of those delivering ‘sex therapy’ or ‘sexual interventions’ internally, spanning as it does psychiatry, general medicine, psychology, midwifery, nursing, social work and no professional background at all. There are parallels here too with some of the cases presented in other chapters, most notably Sungur’s discussion of a married, heterosexual Turkish couple who, by the time of their seeking treatment at his clinic had variously sought help from a GP, a religious hodga or traditional healer, a gynaecologist and a psychiatrist, in addition to their wider their family, the consequences of which were often emotionally and physically traumatic (primarily for the female partner). Indeed in its entirety the book links well the broader philosophical questions about what should be done in various situations with the practical ramifications of either intervening or not intervening in various ways.
This is of course, most relevant to discussions of women’s sexuality, which is, unsurprisingly, more varied in its cultural context than male sexuality, with many of the essays describing environments in which women have very limited independent sexuality. The chapter, ‘Culturally Based Sexual Problems in Traditional Areas of Kermanshah, Iran,’ for example, is probably the most uncomfortable to read. Written by treatment providers from a large clinic, it focuses largely on the ‘problem’ of unconsummated marriage (what the authors call UCM). Women’s social role within marriage is described primarily as that of bearing children and her virginity is synonymous with family honour; “if the bride cannot produce this proof [a bloody handkerchief demonstrating her virginity] on her wedding night, her family and the groom’s family are shamed” (Zargooshi et al in Hall and Graham, 2013, p 139). The authors acknowledge the social double standards about premarital and extramarital sex and also present a short case study in which they did not take on a case referred to them by the courts, given that it was likely to result in divorce anyway (after which they describe that women are almost socially redundant, with few prospects of remarriage). They posit that in enabling women to have penetrative sex within marriage, achieved entirely by medical means of giving men sustainable erections (since any psychotherapeutic interventions are too lengthy and are also culturally anathema), they are maintaining women’s safety and cultural position. This is almost certainly true from a certain stance, but given women’s relative social, sexual and financial powerless in comparison to men’s, the lack of critique of the status quo is arguably problematic. Given the achievements of the Iranian Women’s Movement and the high levels of female educational attainment within Iran, there is also evidently a counter-discourse to that presented by the authors and readers should be mindful to remember that each essay represents simply one amongst many contexts to the culture or society being described.
In thinking about my own role as a mental health Social Worker and member of a family therapy team within secondary mental health services, I found the case discussions presented in Ramanathan and Weerakoon’s essay ‘Sexuality in India’ and in Alooni, De Paaw and Heruti’s essay ‘Israeli Sexuality at the Intersection of Tradition and Modernism’ particularly thought-provoking. The former tells of an integrated approach to helping a young man worried about masturbation and details aspects of physical investigation, psycho and sex education, sexual health, cognitive behavioural work, relaxation and practical advice, with a nod to the scope for family and couple’s work when he marries. The latter describes sexual therapy and rehabilitation for a disabled women using a (apparently widely available) surrogate partner and it is this consideration of disability issues in a practical context which is especially interesting. Both essays, like those in the first chapter, which discuss LGBT issues, African-American sexuality in the US and Latina women’s sexuality in the US, engage well with their cultural contexts in the broadest sense. So Kelly and Shelton for example, when describing the treatment of an African-American couple, spend time discussing race and gender expectations and norms. They talk about how these issues were introduced within couple therapy to explore the impacts of racism and sexism (not previously considered by the couple), so that they are considered in a very real, rather than theoretical context.
Given its practical bent and breadth of scope, this book would be of relevance to students, professionals and curious lay readers from a range of perspectives. It would also function as a useful starting point for those interested in social and sexual relationships within any of the countries discussed. Although largely designed to be read as stand-alone essays or chapters, in its entirety it also serves to raise important questions about the role of cultural contexts in any sexual or relationship intervention, not least because such contexts define what the problem to be treated is and whether is to be understood as physical, social or psychological.
Rosie is a Social Worker in a community mental health Recovery team in the South West. As part of her role she is involved in group facilitation for people struggling with intense emotions (‘borderline personality’ issues) and is part of a team delivering family therapy. She has a first degree in English from Oxford and Masters degrees in Cultural and Critical Studies and Social Work. Her research interests encompass a range of social work and mental health issues, including gender-specific services, provision for lesbian and gay people, hospital admission and critical and sociological theory within social work.