When Consent Isn’t Simple

A few years ago, a 3-minute video called Consent: It’s as Simple as Cup of Tea blew up online. You may have seen it. I like the video; it’s fun and engaging, and the message is important. Better yet, it got the whole world talking about consent. But my years of experience as a sex therapist have taught me that consent is much, much more complicated than a cup of tea.

Rape and assault are, horrifyingly enough, common in our society. Yet many people are suffering under a more subtle and more pervasive form of consent violation. This kind of violation arises, not when your partner ignores “no,” but when you, for whatever reason, can’t say it. This happens in abusive relationships, but not exclusively. In my experience, there are a host of reasons why someone might not be able to say “no,” even if they really want to:

  • They’ve been enjoying the sexual interaction up to now, and feel like it would be unfair to stop or change course
  • They want the experience of closeness and intimacy that comes with sex, without the actual sexual interaction, but don’t know how else to be intimate
  • Penis-in-vagina sex (or some other sex act) hurts and they don’t tell their partner because they’re ashamed or feel broken
  • They think that one thing has to lead to another, and then to “going all the way”, and for whatever reason, just aren’t up to it right then
  • They don’t want their partner to feel unattractive, rejected, or disappointed
  • They believe a “good woman” or a “real man” doesn’t say no or ask for course-corrections

However harmless these interactions may seem in the moment, they each represent a denial of self. Over time, a partner who continually chooses to have sex they don’t really want will begin to feel more and more trapped in the relationship, and sexual interactions will begin to feel like, at best, an obligation, and, at worst, a violation. Slowly, these small violations erode the connection between partners.

Sometimes I work with couples who haven’t touched–not even a kiss on the cheek, or a quick hug–for years. As we work together to unravel how this came about, we often discover that it started with a pattern of these non-communications, in which one or both partners were unable to express what they prefered in the moment. Might it have been simpler and more effective for each to speak up in the moment, even if it felt challenging?

Consider: are you holding back a portion of your whole truth from your partner? Are you too afraid of hurting their feelings to express your preferences, desires, and perceptions? Can you take a leap of faith and reveal your complete, flawed, unvarnished beautiful self–your self who sometimes is not in the mood, sometimes experiences pain in certain positions, or prefers some kinds of touch over others? What would happen if you shared these honest realities? More importantly, what would happen if you didn’t?

Life After STIs: The Therapist’s Role

For most of my clients, the first few weeks after diagnosis are the hardest time.

As a midwife, I diagnosed people in a busy gynecology clinic. I’ve been up close and personal with the fear, shame, and trauma that people experience when they learn they have an STI.

As a therapist, I work with clients who are struggling with their diagnosis. I’ve seen people overcome the trauma, find the courage to disclose, and come to terms with having an STI.

The biggest hurdle is overcoming the fear that having an STI means the end of a relationship, or of intimacy, the end of love. Over time, and particularly with skillful help, the client will discover that being diagnosed with an STI is not the end of their ability to experience intimate connection and pleasure. Here’s how you can get that process started.

  1. Give them the facts. Getting accurate information about the particular STIs in question is a crucial first step.
    • How is it transmitted, how likely is transmission, what activities are particularly risky, and why?
    • Are there treatments that are effective?
    • What are the consequences to having the infection?
    • What preventative measures are there, and how effective are they?

    There is a lot of misinformation out there. Some of it even comes from the offices of physicians. Most physicians aren’t specialists in sexual health or STIs, and staying up to date is difficult. Also, there is a lot of variability in skill of support staff who do client counseling and provide information.

    Primarily, though, people are traumatized when they learn they have an STI. That makes it incredibly hard to take in information and retain it with accuracy, no matter how skilled the counselor or educator. Fact-checking at a later date just makes sense. The most trustworthy resources I am aware of are the Centers for Disease Control and Prevention and the American Sexual Health Association.

  2. Be realistic about risk. Normalizing risk is one of the most powerful things you can do for your client. Make sure they know that there is no safe sex except self-pleasure. Being sexual with others is a risk management project, and people have very different risk tolerance, relational skills for disclosing difficult things, self-esteem, resilience, values systems that contribute to meaning-making, trust in their partners, and so on. All of this is such important fodder for therapy.
  3. Work on differentiation and flexibility. Disclosing STI status to a potential partner is a highly differentiated communication. It depends on a perspective that holding to one’s values (in this case, perhaps, honesty and integrity) is more important than being with any particular partner. It requires sufficient resilience to bounce back from a hard rejection, potentially many rejections. It also requires adopting a flexible and improvisational style of intimacy if certain activities are not feasible.It is easy to look down on someone who is unable or unwilling to disclose STI status, and the ethics around that are certainly complicated. However, it’s no surprise that this is a significant hurdle for most people. As a therapist, you are uniquely placed to help with the big underlying problems: differentiation of self, identifying and strengthening values, and building resilience. The therapeutic challenge is to attend to the medical and ethical content while also attending to the underlying process.
  4. Understand your responsibilities. What are your responsibilities when it comes to STIs and ‘duty to warn’? Is there a limit to client confidentiality? Where is the line?The short answer: it’s complicated.Here, law, ethics, and professional practice guidelines all intersect; the requirements vary from state to state and profession to profession. You will have to do some legwork to find out what the laws and guidelines are in your state and profession. Keep in mind:
    • Some states have a legal requirement that a person who has been diagnosed with an STI disclose it to their partners, with risks of civil and criminal charges.
    • Some states have specific legislation regarding HIV reporting.

Other issues that may become relevant when considering whether a threat falls under ‘duty to warn’:

  • has the threat already occurred? Is there future threat?
  • is it lethal?
  • is there an identified victim?

To jumpstart your thinking on this issue, check out this excellent article about HIV and ‘duty to warn’: Is there a Duty to Warn When Working with HIV-Positive Clients?

If you missed part 1, check it out here!

Postpartum Low Desire: Improving Intimacy and Strengthening Relationships

My last two posts were about dealing with the effects of birth on your body and your mind. This week, it’s all about teamwork. It’s about finding that connection that brought you and your partner together in the first place–and rebuilding it stronger than ever.

When you or your partner are experiencing low desire postpartum, how can you increase intimacy and closeness, reduce frustration, and get the teamwork feeling back in your relationship?

In order to encourage arousal, you need to be able to relax and let go of your worries and calm the “mama lion” protective instinct for a short time. Can you leave your baby with a deeply trusted friend or relative? Is there a hotel near your home? Could you and your partner connect during nap time? Planning intimacy may not feel romantic, but think of it as planning a mini-vacation–a time to escape your anxiety and really connect.

Performance pressure will not help, so don’t put too many expectations on your mini-vacations. Focus on enjoying one another, on pleasurable touch and emotional connection, rather than on meeting specific expectations.

Couples I see often report that they can’t connect because their lives are too busy. I have news for you: no matter how busy you are, the remedy for “not enough time” is not something you need to pay a therapist for. If you can’t find time to listen, talk, connect, and enjoy one another, your marriage will suffer until you do. Eventually it will suffer beyond repair. You absolutely must find at least a little time to give one another undivided attention. Why not commit to do that starting with 10 minutes today?

If one or both of you are emotionally exhausted, you may need to reconnect with a sense of self before intimacy can bloom. Make it a priority to nurture yourself and your interests, even if only by listening to an audiobook that ignites your imagination while driving or rocking the baby. Although this may seem an indirect route to closeness with one another, it will nurture your loving connection and create an environment where desire can emerge.

One of the most important (and most difficult) ways to nurture yourself is by trying to love and appreciate your body the way it is right now. Self-consciousness about your body is a common experience postpartum. Try thinking about it like this: if there is one moment in your life to feel PROUD of your body, it’s now! Your body created a miracle, without conscious effort on your part! And if there’s one time in your life when your body deserves all the love and support you can give it, it’s now. If you catch yourself in negative self-talk about how your body looks, take a moment to appreciate all the amazing things your body can do. No matter what, it’s a miracle. Your body is perfect exactly as it is, and if there is one time in your life you should be certain about that, it is postpartum.

A big key to staying intimately connected during times of great change is flexibility. This looks a little different for every couple. For instance, it can look like:

  • Adjusting your expectations of how interested you have to be in order to begin intimate touching, and maybe taking willingness as your starting place.
  • Scheduling intimacy so you can connect during naptime.
  • Agreeing not to pressure one another, so that you both can initiate physical affection without either of you feeling obligated to follow through in any particular way. This also gives you both the experience of feeling wanted rather than pushed away.
  • Adding self-pleasure to your couple intimacy repertoire.
  • Expressing your love and attraction in non-physical, non-pressuring ways, in order to remind one another that you look forward to returning to increased feelings of desire in the future.
  • Whatever activities you engage in, can you make connection the primary goal and help one another stay curious, engaged, and loving even if some intimate interactions don’t go as planned? I don’t know what flexibility will look like for you, but I know it’s an extremely powerful tool for maintaining desire with changing health, hormones, and bodies. Over a lifetime, you will have many chances to use the flexibility skills you develop now.

If you think frequent disagreements are part of the desire problem, things may improve if you feel like your partner hears and cares about your feelings and the challenges you are facing, even if they can’t entirely relate. Here’s the hitch: this goes both ways. You also need to validate your partner’s experience, express empathy even if you can’t entirely relate, and accept that you have different and equally valid challenges right now. This can feel like a big hurdle; nonetheless, it is a necessary step towards emotional closeness. Accepting your differences and loving one another despite (and for) them is one of the building blocks for keeping things spicy in a long term relationship.

All of these skills will serve you, your long term relationship, and your intimate life in multiple circumstances, not just now. The time you spend building these skills will really pay off. You are building a strong, intimate relationship where you each feel loved and valued for your whole self.