Welcome back to my series on acephobia and therapy. Last time, I shared my personal experiences with confronting acephobia from my therapist. This time, I’ve interviewed a good friend of mine, who is a LMSW (Licensed Master Social Worker) in New York, and has been practicing since 2007. She currently does intake evaluations for an outpatient mental health clinic, in addition to doing per diem work in ER crisis services. We spoke about all manner of concerns many asexuals have before or during therapy, including what happens if flibanserin becomes an issue. For the purposes of this interview, I will be referring to her as Pocky.
Smrf: I’m assuming this kind of work gives you access to a multitude of different kinds of patients and patient stories, which would naturally include those who are asexual and/or have problems with sexual desire. Have you heard about flibanserin?
Pocky: I have, yes, but not in any context related to my work. Sadly, discussion of sexual orientation and gender identity issues in the community of mental health professionals tends to lag a bit behind when compared to discussion in online queer communities and online communities of mental health service consumers. I’m often getting my information from social media, and then being the one to pass it on to my colleagues weeks or even months after the fact.
Smrf: What tends to be the reaction when you pass the information on? Overall, does there seem to be interest in learning more about these discussions, or does it seem to be more in one ear and out the other?
Pocky: I’d say the vast majority of professionals I’ve had conversations like this with have a genuine desire to provide their clients with the best and most effective service possible. But when you have clinicians who have literally never been exposed to or educated about a particular issue, it can be like trying to teach them Greek. The desire to learn and do better is there, but there’s going to be a lot of stumbles and missteps along the way.
Smrf: So for someone who is going to see a clinician who may not be as tied into social media and intracommunity discussions as you are, what would your advice be on the best way to approach them about their sexual, gender, and/or romantic orientations?
Pocky: That would depend a lot on your individual reason for seeking therapy and what role your orientation(s) do or don’t have to play in that reason. If you’re in a position where you have a lot of different options for therapy, I’m a big believer in interviewing/vetting therapists before you even get started, so you have your best chance of working with someone whose therapeutic methods, style, and personality are a good match for yours.
Unfortunately, due to insurance, access limitations, and a whole bunch of other reasons, you may not have a say in who your therapist is, and then that may put you in the position of having to do some educating. Open up the lines of communication by asking, in a straightforward way, “What do you know about (blank)?” Ideally, the clinician will know something about it. A lot of times, they won’t, or will have limited or inaccurate information. It helps to come armed in a situation like that. Be able to offer up a couple of links or resources that you feel reflect your experience.
Smrf: Let’s assume that someone who is asexual has mentioned this to their clinician, and has received or perceived hostility from them. If they don’t have a choice in their clinician (or even if they do), what are some steps they can take to rectify the situation?
Pocky: A lot of people feel frightened or insecure about confronting their therapist or telling them that their needs aren’t being met. Please, don’t be! Barring a handful of yahoos who really shouldn’t be working in this field to begin with, any hostility or push-back you sense from your therapist is more likely to come from a place of ignorance than a place of malice, especially if they’re inexperienced in working with asexual clients. They want to provide good therapy as much as you want to get good therapy, and may not even be aware they’re doing anything wrong. So while it can feel very intimidating, bring it up, and talk with your clinician about it.
For people who are asexual in particular, you may need to stress the fact that you do not see your orientation as a problem. For clients who are not asexual, a loss or absence of sexual desire can be a symptom of Major Depressive Disorder, or a hallmark of past sexual trauma. And a therapist is going to reflexively go to the most likely reason for any piece of information they receive. As they say in diagnostic medicine, “When you hear hoofbeats, look for horses, not zebras.” You are a zebra. Your therapist is looking for horses. Your therapist may have never seen a zebra before. Unfortunately, it falls to you, then, to inform your therapist of what they’re looking at, and how their inaccurate response is making you feel.
Ideally, this should open up a good conversation with your therapist about how they can do better. But if they’re still resistant, or if you feel dismissed or invalidated, this may just not be the healthiest therapeutic relationship for you to be in. If you have the option of doing so, find another provider. If you’re working with, say, a public mental health clinic and your therapist was assigned to you, contact a supervisor or director to express your concerns. They may be able to reassign you or refer you elsewhere.
Smrf: Getting back to the discussion of flibanserin, this is a drug that is supposed to be targeted towards women who have HSDD. While it doesn’t seem to be a necessarily effective drug in general, Sprout Pharmaceuticals has come out and said that this drug specifically isn’t meant to target asexuals, either, and claims that they’re going to be providing information for therapists on the differences between asexuality and HSDD. In theory, a woman who has come out as asexual and explained it to their therapist shouldn’t be having it suggested to them, but there’s always a chance that it will be. What can be done if flibanserin seems to be becoming an issue between the therapist and the patient?
Pocky: This is where the difference between psychotherapy and psychiatry comes into play. A therapist is not in a position to recommend or prescribe medication of any type. That is outside our scope of practice, as we are not MD’s or nurse practitioners, and treatment with psychotropic medication is left to psychiatrists, who do have the necessary medical credentials.
You do sometimes see psychiatrists who also do therapy, but more often a therapist and a psychiatrist form a partnership in working with the same client. Oftentimes if a therapist thinks medication may aid a client’s progress in treatment, they may suggest or recommend consulting with a psychiatrist and make a referral. It is well within your rights as a client to say no to this. If you are already seeing a psychiatrist for medication and they recommend flibanserin, it is, once again, your right to say no and to explain to your provider why. For a lot of people who are not asexual, mental health professionals included, sexual desire is such an integral part of their lives that they can’t imagine being without it as ‘normal’, or even good. It’s horses and zebras again – they’re trying to help you with a problem that you don’t have, and what might be a welcome suggestion to someone who actually has HSDD, it can be offensive or demeaning to a person who is asexual.
If your provider starts treating you like you’re ‘uncooperative’ or a problem client because you’re not comfortable saying yes to a med you don’t need, once again, it’s time to go shopping for another provider, or to take your concerns further up the ladder. Good therapy is about the client. Good therapy is about meeting the client where they are, and addressing the problems that they identify as their priorities for treatment. If your therapist or your psychiatrist is trying to treat a problem that doesn’t exist, that’s not good therapy. I can’t stress that enough.
Smrf: One of the big reasons that someone might go to a therapist is that they have been sexually abused, in one of many different ways. I personally know a few asexual survivors who are apprehensive about going to therapy because they’re afraid that a doctor will try to persuade them that their asexuality is based just in this assault, or else make some sort of connection that may not be there, and claim that their asexuality can therefore be healed if they deal with their trauma from the sexual assault. Or, if not that specific fear, some nervousness about what their therapist will say about the association between sexual trauma and their asexuality that may or may not be true. What would you suggest for those patients?
Pocky: This is where it gets a little hairier, because there are a lot of sexual assault survivors in treatment who are troubled by lack of sexual desire or anxiety about sex. Once again, stress that you do not consider your orientation to be a problem. Make a comparison to other forms of sexual orientation if you have to – would the therapist suggest that a lesbian who was raped by a man be “cured” and become heterosexual once her trauma has been successfully treated? I think not, and just typing it out that way makes me feel gross.
Do not let anyone talk you into doubting your identity and your sense of self. It’s easy to think “This person is a professional, what if they know best? What if I really am just broken?” But the truth is that no one knows you better than yourself. Even if there is a relationship between your asexuality and your history of trauma – and for some people that is the case – you should still be making it clear to your therapist that this is not something that you feel needs to be fixed or cured.
Smrf: I think that’s all the questions I have for now. Thank you for your time, and your amazing answers. This was really insightful, and will help a lot of people.
Pocky: Glad to be of help!