Vol. 8, No. 4 / October 2010

Overcoming barriers to care:
Sexual dysfunction in religious couples

• Sex and religion: Two uncomfortable topics • Religion in a global, mobile world • PRINCIPLE 1: Ask about religious beliefs during the initial visit • PRINCIPLE 2: Ask about religious teachings regarding sexual behavior • PRINCIPLE 3: When in doubt, consult with a religious expert • PRINCIPLE 4: Help couples set reasonable expectations consistent with their beliefs • Summary

Independent Practice, Baltimore, Maryland 

Counseling individuals and couples regarding sexual difficulties is generally a daunting process. It involves health care providers asking for details of intimate relationships in order to help improve people’s satisfaction with their physical relations. Providers who are screening for referral may find these interactions difficult because of their own discomfort with the topic.¹ In addition, many patients find such discussions to be a source of embarrassment and shame. Yet people do seek treatment, with the hope of improving their personal lives. Notably, men and women are more willing to talk about their sexual behavior when the “interview is conducted in a respectful, confidential and professional manner.”²

Sex and religion: Two uncomfortable topics

For many patients, the largest impediment to seeking therapy is their own feelings of inadequacy. For others, lack of therapeutic resources is the greatest stumbling block. For couples who follow strict religious doctrine, faith itself can be a barrier. This may be partly because health care providers do not have adequate training in or understanding of the beliefs and practices that govern these individuals’ sexual behavior. Religious patients may approach therapy with a sense that they will not be understood because the health care provider views their belief system as at best unusual and at worst unhealthy.

Discussing religion with patients may be as discomforting as discussing sexuality. In fact, a study in a group of physicians found that personal discomfort with discussing religious topics was the sole multivariate predictor of clinical religious behavior.³ At the same time, it appears that patients would welcome a discussion about religious beliefs and their relationship to health matters under various conditions.⁴ Patients have identified enhanced patient-physician understanding as an important outcome of such discussion.

Religion in a global, mobile world

The word “religion” is derived from the Latin “religio,” meaning “reverence for the gods.” We think of religious people as being faithfully devoted to their beliefs and observances. These beliefs help them order their world, provide meaning to their lives, and offer guidelines for behavior, including sexual activities. Violation of these teachings is therefore considered irreverence for God. Advice or treatment that countermands belief is also viewed as irreverent.

Today people enjoy great global mobility. Relocation from one continent to another is far simpler than it was 30 years ago. Along with their families and possessions, people bring their spiritual beliefs and practices, which may be as foreign as the names of the towns from which they emigrated. Native residents also may hold spiritual beliefs that are unfamiliar to providers. Consequently, health care practitioners may be approached by patients of various religious and cultural backgrounds who have questions or concerns about sexuality. By following the 4 basic principles outlined in this article, providers can help reduce barriers to care and improve outcomes for their religious patients.

PRINCIPLE 1: Ask about religious beliefs during the initial visit

The most logical time to inquire about religion is during an initial history taking and physical examination. A simple question such as “What faith were you raised in?” followed by “Are you still practicing that faith?” will provide sufficient information to go respectfully forward later on if sexual problems are presented. Such inquiries also alert patients to your awareness that religion may be an important component of their lives and demonstrate your respect for their beliefs. Done in a routine, matter-of-fact fashion, this simple intervention can open doors later on should sexual problems become the focus of treatment for a religiously observant patient.

This approach is similar to William L. Maurice’s⁵ guideline for discussing sexual matters with patients. He suggests that all patients should be given the opportunity to discuss their sexual concerns in a professional health care setting, and the most logical time to do so is while conducting a review of systems, personal and social history, or physical examination. Discussing sexual matters both acknowledges the importance of sexuality and allows the patient to articulate concerns or questions. Not initiating such a discussion may preclude patients from raising the topic. For a detailed review of how to inquire about sexual matters as well as an overview of sexual dysfunctions and their treatment, Maurice’s Sexual Medicine in Primary Care⁵ is a valuable resource.

PRINCIPLE 2: Ask about religious teachings regarding sexual behavior

If sexual problems are on the patient’s agenda, ask about the specific teachings of his or her religion with regard to sexual behavior and, specifically, the behavior that is problematic to your patient. The average practitioner is unlikely to have in-depth knowledge about every religion, and such knowledge is not expected. Most practitioners, however, possess some basic knowledge, such as how major Western religions view sexual intercourse: it is acceptable within the confines of marriage. However, for patients who adhere to more strict constructs, there will be nuances to this rule of thumb. Certain sexual behaviors, for example, including intercourse positions or non-intercourse sexual behavior, may be prohibited. Patients may be able to explain how they interpret the teachings. Their perceptions of acceptable behavior can be used as a guideline.

For example, it would not be unusual for a sex therapist to discuss masturbation with a female patient who reported that she had never had an orgasm and wanted to become orgasmic. Most protocols for treating female orgasmic disorder include masturbation activities.^6,7 Before suggesting these activities, a clinician should discuss the religiously observant patient’s understanding of her religion’s stance on these activities.

In addition, an informative source on various sexual matters is the Religious Institute’s Denominational Statements resource.⁸ This online resource contains the official teachings on sexually related issues of many major US religious denominations. Not all denominations are represented, however.

Besides religious teachings, certain cultural practices or taboos may influence a patient’s ability to seek help or accept treatment for sexual problems (TABLE). The International Encyclopedia of Sexuality, available online, has a section on religious and ethnic factors affecting sexuality in various countries.⁹ A quick check of this resource can reveal that a patient recently emigrated from Bahrain grew up in a country in which a general aversion to speaking about sexual matters, or even the urogenital system, extends to the doctor-patient relationship.¹⁰ This would be useful to know in advance of recommending a urogenital examination.

PRINCIPLE 3: When in doubt, consult with a religious expert

When working with religiously observant patients, speaking directly with a member of the clergy is the best way to access accurate information about the religion’s teachings. Sometimes a consultation is essential, particularly if a patient has misinterpreted doctrine and this poses a barrier to therapy.

For example, according to the Catholic Church’s view, “masturbation is an intrinsically and gravely disordered action.”¹¹ However, the Church also strongly favors procreation within marriage. Consider the case of a married man who has a longstanding case of premature ejaculation that is so severe he is unable to achieve intromission prior to ejaculating: He is prescribed a behavioral treatment for the problem that includes having his wife stimulate his penis to the point of ejaculatory inevitability and then stopping so that he does not ejaculate. After a sequence of 3 trials he is allowed to ejaculate. The treatment assumes that as the man learns greater ejaculatory control, he will be able to accomplish insertion of his penis in his wife’s vagina, increasing the possibility of conception. This couple might be concerned that the treatment violates Church teachings. Before proposing this therapy, it is advisable to consult with the couple’s priest for an understanding of the doctrine and a discussion of the purpose of the therapy. Often, clergy can help a couple understand how the therapeutic intervention will help them achieve the Deity’s ultimate wish that they procreate, allowing them to participate in treatment without guilt.

Similar proscriptions exist in the most orthodox versions of Judaism. Jewish tradition ascribes 2 primary functions to sexual intercourse: procreation and the giving of pleasure within a marriage. As a result, extravaginal ejaculation, which prevents the possibility of conception, is unacceptable sexual behavior. Many treatments for sexual problems include sensate focus exercises.^12,13 This graded series of sensual massages emphasizes tactile, verbal, and visual interaction designed to increase a couple’s level of physical pleasure without performance goals or need to reach orgasm. However, in following the treatment protocol, arousal sufficient to cause ejaculation can take place. One way to address this is to have the couple confer with their rabbi before initiating treatment; providing for rabbi-therapist consultation is essential to prevent guilt or shame and potential anger directed at the therapist, leading to early termination of therapy.¹⁴

Traditional models of sex therapy can sometimes be modified to fit the particular religious observances of this group. For example, where the original model for sensate focus does not allow for intercourse during the initial stages of treatment, “permission” might be given to patients to have full sexual intercourse if the husband’s arousal level approaches his control threshold.¹⁴ By directing couples to take no chances at violating the proscription against “spilling seed,” their anxiety is reduced and a barrier is lowered. Such exercises are defined as pleasurable and relaxing rather than intensely sexual.¹⁴ This can reduce sexual expectations and create an atmosphere that is more aligned with the couple’s belief system as well as reality.

PRINCIPLE 4: Help couples set reasonable expectations consistent
with their beliefs

Religiously observant couples usually do not exist in a world isolated from popular culture. While they may restrict or carefully select the television programs and movies that they will see, a sexualized world is not totally out of their view. They may be unable to avoid the covers of sexually suggestive popular magazines at the grocery checkout or advertising material that employs sexual messages. As a result, they may acquire expectations of how sex “should be” if “done right.” If they do not experience more reasonable teaching about sexually appropriate behavior, their unrealistic expectations can create a barrier to treatment. Patients may think, for example, “I can never behave like that, so why attempt to resolve my sexual problem?”

There are ways to create reasonable expectations for patients in sex therapy that have value for religious patients of most faiths. One model suggests that therapists discuss sexual interactions with the idea that there are no “ultimates” in sexual interaction.¹⁵ Instead, couples are encouraged to see that sex can vary from encounter to encounter, ranging from very good to mediocre or worse. Therapy focuses on the concept that sexual interactions that produce mutual satisfaction and comfort are a reasonable goal. This varies from couple to couple and from instance to instance. Done with respect for the beliefs and values of the religious couple, this approach can be powerful because it allows each couple to decide what is comfortable for them.

Summary

Patients with strong religious beliefs and practices do present with sexual problems. Awareness of the belief system and teachings of the particular religion regarding sexual behavior is essential to be able to provide optimal care for these individuals and to reduce barriers that could prevent problem resolution. By following the 4 principles outlined in this article, health care providers can offer respectful, useful advice that allows patients to operate within the constructs of their religion. For providers with general practices, it is always useful to have a set of referral options for more complicated cases or those that are beyond the scope of their skill set.

Therapists who specialize in sex therapy can be found through the Web sites of the American Association of Sexuality Educators, Counselors, and Therapists (www.aasect.org); the American Board of Sexology (www.americanboardofsexology.com); and the Society for Sex Therapy and Research (www.sstarnet.org). Information about specific religions and their teachings on sexuality can be found at the Web sites of the Religious Institute (www.religiousinstitute.org) and The International Encyclopedia of Sexuality (www2.hu-berlin.de/sexology/IES/index.html).

References

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6. Barbach LG. For yourself: The Fulfillment of Female Sexuality. Garden City, NY: Doubleday; 1975.
7. Heiman J, LoPiccolo L, LoPiccolo J. Becoming Orgasmic: A Sexual and Personal Growth Program for Women. Englewood Cliffs, NJ: Prentice-Hall; 1976.
8. Religious Institute.Denominational statements. www.religiousinstitute.org/denominational-statements. Accessed July 14, 2010.
9. Francoeur RT, ed.  The International Encyclopedia of Sexuality. Vol 1-4. New York, NY: The Continuum Publishing Company; 1997-2001. www2.hu-berlin.de/sexology/Ies/index.html. Accessed July 14, 2010.
10. McCarthy J. Bahrain. In: Francoeur RT, ed. The International Encyclopedia of Sexuality. Vol 1-4. New York, NY: The Continuum Publishing Company; 1997-2001. www2.hu-berlin.de/sexology/LES/bahrain.html#2. Accessed July 14, 2010.
11. Religious Institute.Offenses against chastity—masturbation. www.religiousinstitute.org/statement/offenses-against-chastity-masturbation. Accessed July 14, 2010.
12. Masters WH, Johnson VE. Human Sexual Inadequacy.Boston, MA: Little, Brown and Co; 1970.
13. Kaplan HS. The New Sex Therapy: Active Treatment of Sexual Dysfunction. New York, NY: Brunner/Mazel; 1974.
14. Ribner DS. Modifying sensate focus for use with Haredi (ultra-Orthodox) Jewish couples.J Sex Marital Ther. 2003;29:165-171.
15. Metz ME, McCarthy BW. The “good-enough sex” model for couple sexual satisfaction. Sex Rel Ther. 2007;22:351–362.

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