A Missed Opportunity. (Subtitle: Sometimes therapists piss me off) TW: Discussion of sex/choking

A friend and I recently had a discussion about why people are sometimes hesitant to seek help with their mental health.. This friend showed me an op-ed published in the New York Times called “Sex and Manners” and asked for my thoughts.

Like most things I'm told about, I had a number of thoughts (ha). My first thought was, “wow, how judgmental of this licensed therapist.” My second thought was, wow, what a missed opportunity.”

Sex and couples (couples is a very exclusive term, I will use partner(s) from here on out) are not my areas of expertise, it’s not something I deal with explicitly in my coaching practice, but every helping professional deals with things outside of their area of expertise. I had a pretty strong reaction to this article.

First, I agree with her on a number of points. Consent is an incredibly important and overlooked part of sex and intimacy with your partner(s). Consent should be discussed, discussed again, and reviewed as any part of a healthy sexual relationship. I also agree that porn can be problematic, particularly when we don’t educate anyone on what healthy and enjoyable sex looks like. I also agree that choking can be dangerous.

That’s about where the agreement ends.

First of all, her entire perspective is extraordinarily binary and heteronormative. Much use of exclusive language. Moving on.

The logistical. Choking, otherwise referred to as breath play, is a form of “edgeplay,” or any sexual activity that involves a risk (in some cases of death, but some define edgeplay as anything that pushes the edges of ‘what one can bear’).

See article here discussing edgeplay https://www.dailydot.com/irl/edge-play-bdsm-examples/

.

Breath play involves intentionally cutting off air supply for you or your partner. Does it come with risk? Absolutely. Any time you cut off air supply to your brain, you run the risk of seizures, heart attack, fainting, and it can be fatal. A clinician should do a very thorough assessment in terms of consent and coercion, because choking and strangulation can be a deadly form of domestic violence for women, and has been used as a legal defense to hide domestic violence and homicide.

See article here: https://www.theguardian.com/society/2019/jul/25/fatal-hateful-rise-of-choking-during-sex

Breath play can be incredibly intimate due to the trust required of a partner. Some report that breath play enhances pleasure. Choking can be degrading and violent, and for some people that’s a part of their kink or being D/s. There are a number of other physiological and psychological benefits to breath play. Therapists should not kink shame. Breath play is something that healthy, consenting adults engage in. Like any other behavior that presents itself in a therapeutic space, risk analysis must be done. Is the benefit worth the risk? For some, the answer is yes. If you have clients where the answer is yes, you need to educate yourself so you can work effectively with them.

Articles discussing breath play in more detail:

https://www.healthline.com/health/healthy-sex/erotic-asphyxiation#solo-vs-partner

https://www.shape.com/lifestyle/sex-and-love/lets-talk-about-choking-during-sex

I feel incredibly sad for this woman’s clients who may have thought she was approaching clients’ sexual exploration with nonjudgment, only to read in the paper that she finds choking “alarming and violent.”

Like anything else in clinical practice, one should be assessing more deeply for any behavior that may endanger someone. This screams “missed opportunity!” for this therapist to engage with her clients, assess for safety, and provide a safe space for them to safely explore their sexual interests. Here is a list of potential questions and discussion points to spur conversation and education with your clients.

Questions for exploration:

· Have you tried choking/breath play? What interests you about choking your partner(s) or being choked? What was your experience with breath play (if they have indeed engaged in the practice)

· Are you consenting to choking?

· How does it make you feel?

· Are you practicing safely from a physical and emotional standpoint (i.e. safe word, trust, communication, aftercare)

· How do you tell your partner to stop? Is that clearly communicated? Does your partner listen?

· Do you feel safe?

· Is it enjoyable? What makes it enjoyable?

· Do you feel comfortable communicating the above with your partner(s)?

· Tell me about your safety plan (then explore a safety plan with client)

· Do you understand the risks of breath play?

· If you choose to engage in breath play, how can we make it safer?

If choking is not enjoyed or discussed by all active parties, or someone feels coerced, degraded, or like the action is nonconsensual, or not done in a safe manner, then yes, we have a problem.

Not explored: why is it causing a rift? What does this mean for partner communication? Blog post for another time: the stigma of being a sex-positive woman and expectations for our (lack of) sexual pleasure. What about an open exploration about sexual desires and interests?

My training is as a psychologist, and our ethical guideline foundation is built on beneficence and nonmaleficence. The American Psychological Association’s (2017) preamble states, “Psychologists strive to benefit those with whom they work and take care to do no harm. In their profession- al actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons…” (p. 3). We also have written into our ethical code that we shouldn’t be practicing outside our area of competence, and that we have an ethical obligation to engage in continuing education about our field. Finally, the idea of autonomy is critical to any helping profession, and reality is that it is our role to help clients make their own decisions – even if we don’t agree ultimately with the ones that they make. We need to do due diligence in maintaining our client safety, but ultimately recognizing the legal decision-making capabilities that our clients have. We also are tasked with not placing our values on others. No one is grading this, but I’m happy to provide you with the ethical codes relevant to this summary if you don’t believe me.

I’m no social worker, but I could imagine that similar foundational concepts and ethics exist in the NASW ethical code.

A lack of education about safe, consensual sex practices is readily apparent in the writer’s judgment about the sex lives of her clients. As practitioners, we need to work on becoming more less reactive, and use any information our clients trust us to enough to disclose what can often feel shaming for clients. This means that many practitioners need to revisit their values surrounding sex, intimacy, partnership to be more sex-positive and inclusive. We need to be able to safely explore these thoughts, feelings, and behaviors with our clients because they trust us to go beyond the superficial and help them explore what they may not be able to discuss with others.

We don’t just represent ourselves when we write opinion articles like this, we represent entire professions. This kind of sex-negative approach will discourage individuals from seeking therapy not just from the author, but from anyone for fear of judgment and shame. This is probably what frustrated me the most about the article.

These kinds of discussions are especially important with teens as they explore sexual behavior. Teens are absolutely seeing pornography that involves breath and other edgeplay, and as practitioners, parents, and so-called responsible adults, we have a moral and, in some cases, ethical obligation to explore with our clients and teens their feelings, questions, and concerns about engaging in safe sex. It helps no one to shame or to run away from the difficult discussions. It’s really important to remember that safe sex goes beyond condom use. Sex education should involve discussions of consent, sexual pleasure, risk assessment, and intimacy.

Let’s talk more about why there’s an anecdotal rise in interest in breath play rather than superficially reacting with alarm (kink shame and shaming are real: https://everydayfeminism.com/2017/03/people-ashamed-of-their-kink/) When discussing these issues with teens, we also need to consider adolescent brain development, risk taking behaviors, and legal age for consenting to sexual activities.

Clinical Practice Guidelines for Working with People with Kink Interests: https://www.communitysolutionsva.org/files/Clinical_Practive_guidelines_for_dealing_with_people_with_kink_interests.pdf

Kink aware therapist: https://affirmativecouch.com/kink-aware-therapist-challenging-your-awareness/

Much like any other sexual behavior, it will be for some and not for all. I challenge the writer, and anyone else working with clients in any capacity, to check your judgment and utilize the information clients share with you in therapy as a tool, not for judgment. I wish the writer had taken the time to engage in continuing education, instead of taking the time to write a superficially informed and judgmental op-ed for the New York Times. Education would have been a more ethical approach and would have encouraged growth as a therapist.

Even if something is beyond your area of expertise, keep an open mind and consider the risk/benefit analysis and at minimum, make referrals to someone who does have expertise. This goes for coaching! I don’t do sex coaching, but I am sex positive and sex and intimacy is an important part of many individuals' lives.

Come on, helpers. Let's do better.

But hey, if nothing else, at least now you, dear reader, know that some very healthy and consenting individuals like a little breath play.