2025 Symposium Abstracts

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2025 ISST Abstracts

Theme — Bridging Theory and Practice in Psychosexual Therapy

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THE IMPACT OF ADHD ON RELATIONSHIPS AND SEXUALITY

LAURIE BETITO, PHD

Attention-Deficit/Hyperactivity Disorder (ADHD) can significantly impact an individual's sexuality, influencing sexual behavior, relationships, and emotional well-being. The divorce rate for individuals with ADHD tends to be higher compared to those without the condition, and thus, these couples often are overrepresented in the therapist’s office. Key challenges faced by individuals with ADHD in the realm of sexuality include impulsivity, attention issues, emotional regulation difficulties, and changes in sexual desire. Impulsivity, a core symptom of ADHD, may lead to risky sexual behaviors, such as unprotected sex or multiple partners, increasing the risk of unintended consequences like STIs or unintended pregnancies. Furthermore, difficulty focusing during sexual experiences can impair emotional and physical satisfaction, with individuals often struggling to maintain attention to their partner's needs. Emotional regulation issues, including heightened emotional responses and low self-esteem, may complicate sexual confidence and intimacy, leading to dissatisfaction in relationships. In contrast, hyperfocus—a phenomenon in ADHD—can lead to intense preoccupation with sexual thoughts or activities, affecting relationship dynamics and leading to emotional neglect. Variability in sexual desire is also common, with some individuals experiencing increased libido due to hyperactivity while others struggle with diminished desire due to emotional distress or distractibility. Medication side effects, particularly from stimulant treatments, can also impact sexual functioning, such as reduced libido or erectile dysfunction. Additionally, co-occurring conditions like anxiety or depression can exacerbate sexual difficulties. ADHD-related relationship dynamics, such as communication challenges and emotional imbalance, may strain intimate relationships and affect long-term sexual satisfaction. Understanding these challenges is essential for fostering open communication, providing appropriate counseling, and addressing medication side effects to support sexual well-being. ADHD's influence on sexuality is diverse and can vary significantly between individuals, making it important to tailor interventions to improve sexual health and relationship satisfaction for those affected by ADHD.

OUT OF CONTROL SEXUAL BEHAVIOR AS AN ACTION SYMPTOM: EFFECTIVELY WORKING WITH URGES

WENDY E. MILLER, PHD

This presentation will discuss the importance of a biopsychosocial model when working with out-ofcontrol sexual behavior (OCSB), with a focus on how OCSB functions as an action symptom, where action takes the place of thinking and mentalizing one’s inner experience. Because OCSB is an action symptom with often devastating consequences, there is a tendency in the field to overly focus on stopping the behavior while neglecting or underemphasizing the complex biopsychosocial process that the behavior reflects. Viewing a sexual issue or problem through a biopsychosocial lens allows for a complex and fluid framework that views the individual’s struggles as multi-determined and multi-layered. In OCSB, or any addictive or compulsive behavior, the biopsychosocial complexity gets collapsed into an urge for action. We will look at how to work with urges by inviting them into the room, and how to build the client skills needed to successfully tolerate and navigate an urge. Therapists often struggle with action symptoms and join with the patient’s urgency in feeling that an urge is to be avoided and that the primary goal is to quickly stop the destructive behavior; however, an urge can be the axis of change and the portal to understanding the behavior’s meaning and what it is communicating. In my presentation, I will address the importance of the therapeutic relationship in unwrapping the urge, urge surfing, and sitting with the urge using mindfulness techniques to aid in decision making. A biopsychosocial model allows us to help the patient gain a deeper understanding and appreciation of what their behavior is about, with the aim of pausing the action in order to explore, discover and articulate the underlying complexity and develop alternative healthier ways to express and care for what is reflected in the out-of-control sexual behavior.

VAGINISMUS AND DYSPAREUNIA IN THE MIDDLE EAST: CULTURAL, PSYCHOLOGICAL, AND ETHICAL PERSPECTIVES

WAFAA ELTANTAWY

Vaginismus and dyspareunia are prevalent yet underreported sexual dysfunctions affecting women in the Middle East, significantly impacting marital satisfaction and personal well-being. Both conditions are influenced by biological, psychological, and socio-cultural factors, necessitating a biopsychosexual approach to treatment. This paper explores vaginismus (involuntary vaginal muscle spasms preventing penetration) and dyspareunia (pain during intercourse), emphasizing the role of cultural norms, traditional gender roles, and societal expectations within marriage. Biological factors such as hormonal imbalances, chronic medical conditions, and physical trauma are discussed alongside psychological issues like anxiety, fear, past trauma, and inadequate sexual education. Social influences—including religious teachings, family pressure, and societal taboos—further complicate women's experiences. Shame and guilt often deter women from seeking timely care, highlighting the importance of ethical, confidential, and culturally sensitive healthcare. Effective treatment strategies integrate medical interventions, cognitive-behavioral therapy, pelvic floor therapy, and culturally competent sexual health education. The paper advocates increased awareness, sexual health education, and policy reforms to address sexual health holistically, reduce stigma, and improve healthcare access, ultimately empowering women and fostering healthier relationships in the Middle Eastern context.

THE DECONSTRUCTED MEAL: INTERSECTIONALITY OF BODY IMAGE AND SEX POSITIVITY WITH CLIENTS WITH EATING DISORDERS AND SEXUAL TRAUMA

MICHELLE L. DEAN

This paper explores the intersectionality of positive, body image, and sex-positive through a depth psychology lens and provides examples of innovative interventions that are art-based, imagistic, and symbolic and are grounded in embodied and relational approaches for individuals with eating disorders who have experienced sexual trauma. While the relationship between sexual trauma and eating disorders is not causation, there is evidence to show there is a correlation (Madowitz, Matheson, & Liang, 2015). Sexual trauma often precedes eating disorders (Pike et al., 2008) and, thus, can be a precursor to an eating disorder (Telléus, Lauritsen, & Rodrigo-Domingo, 2021). In no other mental health disorder listed in the Diagnostic Statistical Manual-V (DSM-V) (American Psychiatric Association, 2013) has a higher mortality rate than those with eating disorders, including those who commit suicide from depression and it is estimated that 80 percent of people with eating disorders will recover while the remaining 20 percent will remain chronic or die (Anorexia Nervosa and Related Disorders, 2015; Smink, van Hoeken, & Hoek, 2012). Eating disorders are disturbances of relationships: Relationships to others and the environment, to oneself, to one’s emotions, and to one’s needs, desires, and imagination (Dean, 2019), which often require a disconnection from the body. Understanding the contributing factors to eating disorders, including sexual trauma and relationship issues, through a symbolic and expressive means is imperative in promoting body acceptance and a sex positive life.

SEXUAL DESIRE TYPES IN MARRIED COUPLES: FREQUENCIES AND CORRELATES IN A US REPRESENTATIVE DYADIC SAMPLE

MICHAEL SYTSMA, PHD

Conflict over sexual desire discrepancy is a common sexual issue in therapy. It is often rooted in misunderstanding sexual desire itself, especially in identifying and discussing the types of sexual desire, including initiating, receptive, and resistant types. Despite some discussion in the literature, limited research hinders targeted interventions for addressing attribution errors in desire discrepancy conflicts. An initial study using matched-pair data from a representative sample of 502 U.S. married couples provides valuable insights. Males typically endorsed initiating type of sexual desire, females endorsed receptive, and few identified with resistant desire as their primary type. Norms varied with some additional demographic variables like age and race/ethnicity. Dyadic data allowed identifying the couple desire type, defined by the interface of the spousal desire types. Exploring relational correlates of these patterns provided a nuanced understanding of marital dynamics that extended beyond which spouse has the higher desire level. Key findings showed associations between couple desire patterns and factors such as marriage length, marital satisfaction and orgasm frequency. For instance, while two initiating reported the highest sexual frequency satisfaction, two receptive-type spouses do not necessarily report lower sexual frequency or satisfaction. Finding support ongoing research in various types of sexual desire, especially as it relates to couple dynamics.

COMPULSORY HETEROSEXUALITY AND ITS ROLE IN THE FORMATION AND CLINICAL WORK WITH "FIREFLIES“

MALLORY K HANFLING

In recent years, particularly during the COVID-19 pandemic and with the advent of the social media platform TikTok, American society has seen a significant increase in the population currently referred to as “late-in-life lesbians” or “late bloomers.” The individuals who identify with this term tend to be cisgender women who have entered into a heterosexual monogamous relationship or marriage and, within the confines of said partnership, came to the realization that they are queer. The current popular term, “late-in-life lesbian” is restrictive in gender and in sexual identity. As a result, in 2021 Mallory Hanfling, LCSW, a PhD student at the California Institute of Integral Studies coined the term “firefly” for this population as a sexuality and gender expansive and inclusive option for individuals with this particular experience. This article reflects upon existing literature and clinical best practices pertaining to the role of compulsory heterosexuality in influencing the experiences of fireflies in regard to the trajectory of sexual identity development, sociocultural and political implications of living in a heteronormative society, medical/psychological gaslighting of female sexual dysfunction, social scripts regarding sexual pleasure and desire, media representation, and institutionalized forms of sexism, heteronormativity, and economic autonomy which influence choices pertaining to partnerships and family planning. The implications of these interwoven institutions, theories, and scripts, related to the experiences of “fireflies” will direct the question of whether compulsory heterosexuality and heteronormativity contribute to coming out later in life, and explaining sexual dysfunction through medical and psychological factors rather than exploring authentic sexual orientation prior to making a long-term commitment to a sexually incompatible partner. These considerations inform clinical assessment and treatment of clients entering into a therapeutic relationship and require specialized competency training, to be addressed throughout the article.

ETHICAL ISSUES IN PROVIDING SEX THERAPY TO CONVENTIONALLY RELIGIOUS MIXED ORIENTATION COUPLES

MARK A. YARHOUSE, PSYD

This paper engages the ethical issues that arise at the intersection of sex therapy, the experiences of mixed orientation couples, and conventional religiosity. Often people in mixed orientation marriages identify religious and religion can serve as a motivation to enter into a mixed orientation marriage for some couples. By highlighting provision of services to conventionally religious mixed orientation couples, this paper illustrates some of the ethical concerns for therapists working with conventionally religious client in general and in the area of sex therapy in particular. Key ethical considerations include respect for religious beliefs, values, and behaviors, use of therapist disclosure statement and informed consent, competence in sex therapy, cultural humility with respect to nontraditional social identities, and adapting clinical services to work with conventionally religious couples. Recommendations for clinical services will be offered.

A PHYSIOLOGICALLY-EXPANDED APPLICATION OF THE BIOPSYCHO-SOCIAL MODEL WHEN SPECIFICALLY APPLIED TO ADHD WHEN WORKING WITH CLIENTS IN SEXUAL AND ROMANTIC RELATIONSHIPS

TOMMY UNDERHILL

Originally proposed in 1977 by George Engel as an improvement to the biomedical model, the widely accepted, traditional view of the biopsychosocial model stipulates that well-being includes the effects of psychological, behavioral, physiological, and social dimensions. The application of physiology in this model is too-often limited to the basic ideas taught in a high school or college general biology class. When viewed from the modern conceptual understanding of the brain and mind, the traditional bio-psycho-social model presents a simplistic, 1950’s conceptualization that fails to include the complex interactions of neurochemistry and the nuanced implications of neurophysiological differences when compared to neurotypicality. The shortcomings of this simplistic model become apparent when working with clients in sexual and romantic relationships where one or both of the partners has attention deficit hyperactivity disorder (ADHD). People who suffer from the executive dysfunction of ADHD are held hostage by the demands of a world that was not created with them in mind and are doomed to failure by the very world that expects them to capitulate to its social and cultural norms and structured time demands. When combined with ADHD stereotypes and prejudices within the mental health and medical communities, the simplistic, traditional, time-honored medical and psychotherapy “treatments” for ADHD—especially as they pertain to relationships—present as if they were created by neurotypicals for a complex inner world they have never experienced and cannot understand, and can best be summed up with the statements “there’s a pill for that” and “just put it on a list”. This paper challenges the traditional, deficit-focused view of ADHD in the biopsychosocial model based on the current understanding of neurochemistry, and neurophysiology, especially as it applies to psychosexual therapists working with ADHD clients in sexual and romantic relationships.

PSYCHOSEXUAL THERAPY FOR PEYRONIE’S DISEASE

EFFIE SOULTANI & GIUSEPPE PICUCCIO

The interrelation between body and mind has always been at the core of psychosexual therapy. Yet, what is the role of psychosexual therapy in conditions, such as Peyronie’s disease, that seems to be solely medical, progressive and irreversible? Peyronie’s disease is a connective tissue disorder that causes the growth of fibrous plaques in the penis’ soft tissue, resulting in penile deformities. The limited medical as well as psychosexual research on the topic raises particular challenges when such presentation occurs in clinical practice. Following a brief definition of Peyronie’s disease, and its stages, this paper will demonstrate a treatment model based on theories of loss, grief and guilt and their manifestation at physical, psychological, interpersonal and relational levels. Through two case studies, two different therapists will demonstrate the use of such a model as it is interwoven with psychosexual techniques and transpersonal practices in the healing process. Both case studies focus on challenging and transforming individual perceptions of the body, psychosexual identity, and sexual intimacy in heterosexual and gay relationships. They also address the impact of the condition on the partners and the meaning it lends to all aspects of their relationships. The paper will also discuss the importance of the therapeutic relationship and its significance in altering the client’s expectations of their role in the treatment process, based on prior experience of their relationship with medical professionals. Issues of splitting between professionals may mirror the internal world of the client and may call for a strong collaboration between professionals to ensure a robust united containment of the client.

EMDR IN PSYCHOSEXUAL THERAPY

EFFIE SOULTANI & CLAUDINE BEST

Our clinical practice at the Psychosexual Service in a London Sexual Health Clinic, has increasingly observed the interrelation between sexual dysfunctions and trauma. Psychosexual difficulties seem to be the manifestation of a traumatic response to sex and sexuality. Whether this is due to sexual, relational, developmental, birth or other forms of trauma, it requires a trauma-informed approach in both psychosexual assessment and treatment. This paper will demonstrate the integration of trauma approaches, and more specifically of EMDR (Eye Movement Desensitization & Processing) in the psychosexual psychotherapy of adults with diverse gender and sexual identities and from all paths of life. Although the application of EMDR in Psychotherapy is well researched and constitutes an evidence –based practice (E.Solomon et al 2009, E. Wood & T. Ricketts, 2013) its application in psychosexual therapy has only recently been considered by clinicians such as Leigh Brown (2023) and Kimberly Keiser (2023). The paper will consider issues of technique, methodology and adaptation to individual needs as these are highlighted via vignettes from clinical practice. Additional theories, such Ego States, Somatic Trauma Therapy and Psychosexual techniques compliment EMDR in a holistic approach of trauma based psychosexual therapy. Lastly, there will be space for reflection on the limitations of the psychosexual trauma model when applied to a short-term therapy framework and the multifaceted implications especially for the assessment stage.

COMPULSORY HETEROSEXUALITY AND ITS ROLE IN THE FORMATION AND CLINICAL WORK WITH "FIREFLIES“

MALLORY K HANFLING

UNREALIZED EXPERIENCE FIXATION: A PSYCHOSEXUAL DEVELOPMENTAL UNDERSTANDING OF MINOR ATTRACTION

CALEB JACOBSON, PSYD, PHD

This study explores the concept of Unrealized Experience Fixation, wherein individuals develop a fixation on unfulfilled early sexual experiences, leading to disrupted psychosexual development. Drawing on three in-depth case studies, this paper examines how these unfulfilled early encounters, although never physically realized, became a recurring source of fantasy for the individuals involved. Over time, these fantasies persisted into adulthood, inhibiting natural psychosexual development and delaying progression toward age-appropriate relationships. The cases highlight a consistent pattern in which unresolved, formative experiences create a cognitive and emotional fixation, shaping an enduring attachment to inappropriate or age-incongruent fantasies. This analysis provides insights into the psychosexual impacts of unrealized experiences and offers a developmental perspective on minor attraction, emphasizing the need for therapeutic approaches that address the underlying fixations and facilitate age-appropriate psychosexual growth. The findings suggest that targeting these early fixations may be key to supporting individuals in developing healthier relational patterns and normative sexual interests.

YOUR THERAPY OFFICE: INVITING OR INTIMIDATING?

KELSEY CARD

What does our physical office look like and what message is it sending to our patients? Is it clinical, cluttered, warm, cold, comfortable or inviting? How are these terms commonly defined and how do they impact a patient's view of the therapist and the therapeutic relationship? In looking for guidance when setting up a private practice office, it has been half a decade since easily accessible articles on physical office space have been published1, and recent developments in environmental psychology and other fields that also rely on relationship building should be explored. Many of the findings reported in previous publications (wall color, furniture placement, and credentials) continue to be supported by new research. However, there are several new elements of physical space research that other academic fields have explored. From the effect of wooden furniture on wellbeing2, to the effect of potted plants on mood3, to lighting4 and finally on spatial constraints that limit self-disclosure5. By incorporating this new research into office space design, therapists can increase client comfort and confidence in the therapeutic relationship.

SEX AND RELATIONSHIPS: HISTORICAL CONTEXT FROM THE U.K.

JUDI KESHET-ORR

Both sexuality and relationships are part of the same continuum. However, many training organizations separate these out and make them distinct and separate. Through the lens of several decades of facilitation and teaching and looking at the themes which occur in the therapy room I will suggest that an integrative approach serves the client(s) rather than excluding one aspect or the other. This paper is based on my experience of psychotherapy with both relationships and sexuality presentations. There may be biases in practitioners which lend them to lean towards one aspect of the relationship over the other. Therapist competence is key in working with the client(s), and we will look at how focusing on one aspect solely may marginalize the client's experience and render them silent. Psychosexual and relationship therapy as a modality is an inclusive offering of therapy and supports a more holistic approach when working with clients.

READING ROMANCE: EXAMINING THE IMPACT OF READING ROMANCE WITH PARTNERS ON INTIMACY AND COMMUNICATION.

JENNIFER H. GREENBERG, PHD

Modern-day romance novels offer a captivating fusion of relatable yet heroic journeys that resonate with readers on a deeply personal level. These stories artfully intertwine the complexities of modern life, drawing upon the myriad issues and challenges that people grapple with daily. At the heart of this genre lies a powerful tool for exploring and enhancing the most crucial aspects of any relationship: communication and intimacy. Using an online survey completed by 586 participants, the current research aimed to determine the utility of romance novels as an adjunct to Integrative Sex and Couples Therapy by assessing readers' use of romance novels and whether they share reading with their partner. It also assessed readers' sexual, relationship, and communication satisfaction, as well as the potential shame associated with reading romance novels. This study compared two groups: those who read romance novels with their partner and those who did not. The findings indicate that readers who shared reading with their partner reported higher communication and sexual satisfaction. However, there was no significant difference in sexual communication and relationship satisfaction between the two groups. Interestingly, among readers who shared reading with their partners, time spent reading together was associated with improved communication satisfaction, sexual satisfaction, and relationship satisfaction. However, it did not correspond with enhanced sexual communication. Moreover, the results indicate that most readers no longer need to hide their interest in romance novels or experience embarrassment about their reading preferences. Findings are discussed within the context of utilizing romance novels as an adjunct to Integrative Sex and Couples Therapy, and practical suggestions for clinicians are provided.

IMAGINE THIS! THE USE OF ART AND IMAGERY IN SEX THERAPY

MICHELLE L. DEAN

Like archetypal images, art forms arise from a primal, divine source. Images, fantasy, and play are essential to psychological life as they are key to creating meaning, connection, and integration of the narratives we tell about our lives. Images in art may derive pleasure or pain and may be used to express and exert power control, sublimation, domination, and humiliation (Downing, 2024). Images are polyvalent, holding multiple meanings simultaneously. The experience of working with imagery is numinous, transformative, and powerful, whether it manifests from flow states or scenes of fantasy, kink, or BDSM. It may manifest as a “sexual alchemy, as the erotic space imagined can be as powerful and enchanting as hours of lovemaking”(Perel, 2015). Through an archetypal and depth psychology lens, this author will explore how art therapy can be beneficial for mediating and bridging external experiences, especially those experienced as overwhelming or traumatic. Artmaking in a therapeutic context can contain complex psychic material that words alone struggle to hold for individuals and their loved ones. Employing the arts in psychotherapy is about honoring the individual’s immediate context. Art provides a means to bridge individual and cultural deficits, such as individual trauma, cultural stigma, and oppression. It is the nature of art, imagery, and creativity to transcend boundaries: to dissolve, recreate, and redefine them. Art therapy shares the distinctive quality of defying easy definition (Dean, 2011; 2016); it is a means of restoring creativity and wellness to individuals, couples, communities, and society by connecting to the inner world of knowing through images. Creativity arises from clusters of experiences. Just as technological advances change societal attitudes and personal histories, art and the images held therein are transformative in working with clients to facilitate change, self-acceptance, and transcendence.

CROSS-CULTURAL AND LEGAL PERSPECTIVES ON INVOLUNTARY PSYCHIATRIC TREATMENT FOR SEX OFFENDERS: A COMPARATIVE REVIEW OF GERMANY AND SPAIN

BRYSON KELPE

This review examines cross-cultural and legal differences in Germany and Spain regarding involuntary psychiatric treatment for sex offenders. Germany prioritizes rehabilitation, viewing sexual deviance as a treatable mental health condition, while Spain emphasizes public safety, reflecting conservative cultural values. Germany’s cultural hesitance toward involuntary treatment and incarceration stems from its historical experiences. These differences are analyzed using Hofstede’s cultural dimensions and Erin Meyer’s frameworks, alongside European Court of Human Rights (ECtHR) rulings such as M. v. Germany and Ilnseher v. Germany. The ECtHR emphasizes medical justification over preventive measures in forced treatment cases, adding complexity to national legal frameworks. Germany’s rehabilitation model has notable structural gaps, including limited formal training in psychosexual therapy. Existing certifications, such as those by ISP and DGSP, emphasize sexual health counseling over therapeutic interventions for offenders. Training for legal psychologist which provide assessments of recidivism, does not include modules or courses specific to sex offenders. Additionally, accessible and specialized training in psychosexual therapy is hindered by the high costs and limited availability of accredited master’s programs. These gaps leave practitioners ill-equipped to assess recidivism risk in legal contexts. Proposed reforms to Germany’s post-conviction probation, reducing supervision to six months for certain offenders, pose further challenges. Such changes could increase reoffending risks by depriving offenders of the structured monitoring and therapeutic support needed for successful reintegration. Spain’s approach, while prioritizing public safety, lacks rehabilitative elements, relying quite heavily on punitive measures. Therapeutic interventions delivered by qualified sex therapists could reduce recidivism while balancing public safety with offender support. This review recommends expanding psychosexual therapy training in Germany, refining preventive detention laws, and encouraging Spain to incorporate rehabilitative measures. By integrating cultural competence and balancing public safety with rehabilitation, both nations can align more closely with ECtHR principles, fostering more effective and ethical legal practices.

BIO-PSYCHO-SOCIAL IMPACT OF PSYCHOTROPIC MEDICATION ON SEXUAL HEALTH

CHRIS WILHOITE

Sexual dysfunction is an often-cited concern when clients are faced with taking medications. Sexual dysfunction is one of the most-distressing side effects and is the foundation of client resistance and compliance when using medications. One common concern associated with the use of SSRI is PostSSRI sexual dysfunction (Balla, Nguyen & Hellstrom, 2018). Sexual side effects are additionally associated with clients experiencing a poor quality of life and a negative attitude towards therapy, (Bella & Shamloul, 2013). This paper attempts to give clinicians a better understanding of the biology of medications that impact sexual functioning, the psychological impact of taking medications, and the social stigma and mixed messaging around the use of medication, especially psychotropics. This paper will additionally give clinicians a basic understanding of of the mechanisms of how medications work, commonly-prescribed medications that have sexual side effects, and the role of the clinician in recognizing problems and explaining medications to clients. This paper also explores the ethical limits of non-prescribing clinicians and how to co-ordinate care with prescribing providers. The primary medications that will be explored are SSRI, SNRI, anti-psychotics, ADHD medications, and often-used, off-label medications used in treating mental health symptoms and the sexual side effects of those medications. A brief overview of over-the-counter mediations, statins and blood pressure medications, and the potential sexual side effects will be explored. The clinician will have a basic understanding of the potential side effects of medications and interventions that can be used to increase efficacy and compliance, and improve sexual functioning and compliance with therapy. The purpose of this meta analysis of the research is to increase the non-prescribing clinician’s knowledge and provide information to aid their clients in successfully treating sexual dysfunction and client-centered coordination of care with prescribers.