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Running head: ALTERNATIVE SEXUALITIES CASE CONCEPTUALIZATION

Alternative Sexualities Case Conceptualization

Charles Gentzel

Wake Forest University

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Abstract

Sexuality and relationships are an important aspect of human growth and development.

The sexual and relational practices of those outside of the majority, such as kink or consensual

non-monogamy, can lead to practitioners feeling marginalized and experiencing stigma or

discrimination. This marginalization and discrimination can follow them into a counselor’s

office, leading to difficulties forming a working therapeutic alliance. This paper will discuss the

clinical issues around alternate sexuality, competent and respectful therapeutic practices, and

provide a case study outlining a case conceptualization and treatment plan for a client who

presents with issues pertaining to their alternate sexual identity.

Alternate Sexualities: A Review of the Literature

Sexuality is an important aspect of the human experience and sexuality contains a vast amount of

variation, yet sex that falls outside culturally-defined limits is considered abnormal, deviant and

is pathologized as if it is a sickness (Lantto & Lundberg 2021). These cultural norms often

involve sex “in heterosexual, married, monogamous contexts” (Kisler & Lock 2019 p. 43),

containing acts that would be considered generally non-risky and likely involve an “active man

in pursuit of a passive woman” (Mosher 2017 p.488). Sexuality and relationship experiences

that don’t fit into this societal view of “normal” fall into the category of alternate sexuality, a
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catch-all term for the plethora of activities encompassing kink and the myriad of consensual non-

monogamy’s (CNM) relationship models (Sprott et al 2017).

Kink covers a variety of sexual practices, but is most commonly thought of as BDSM.

This involves bondage and discipline, power exchanges involving dominance and submission,

and sadism and masochism- the eroticization of inflicting or receiving pain (Pillai-Friedman,

Pollitt & Castaldo 2014). CNM involves a variety of practices including swinging and open

relationships, as well as the more complex polyamory. Polyamory differs from other CNM

relationships in that it often involves “multiple relationships that are sexual, emotional, and/or

romantic in nature whereas in other forms of consensual non-monogamy emotional and/or

romantic connections outside the primary relationship may be discouraged, avoided, or even

prohibited” (Kisler and Lock 2019 p. 41).

It is of clinical significance that counselors develop an understanding of alternate

sexualities to ensure competent treatment is delivered to this nontraditional but large population.

Research suggests that roughly 6 million Americans actively engage in BDSM practices with 10-

15% of the population having engaged in kink practices at some point, while 15 million

Americans practice some form of CNM and 20% will at some point in their lifetime (Sprott et al

2017).

Despite these numbers, alternate sexuality is often stigmatized in therapeutic situations.

Practitioners report BDSM being seen as unhealthy, pathological, abusive, or a sign of

underlying pathology or trauma (Lantto & Lundberg 2021). It is important to note that research

has found no significant correlation between sexual abuse and BDSM activities (Sprott et al

2017) (Waldura et al 2016) (Pillai-Friedman, Pollitt & Castaldo 2014). The American

Association of Sexuality Educators, Counselors and Therapists has explicitly called for
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“professionals to refrain from automatically pathologizing alternate sexualities due to the lack of

scientific evidence for a connection between nontraditional sexual expressions or behaviors and

psychopathology” (Sprott et al 2017 p. 932). Kink activities can also be confused with intimate

partner violence (Waldura et al 2016). Practitioners of CNM report negative stigmas conflating

their relationships with adultery and a lock of morality (Kisler & Lock 2019). Some

practitioners even discover that therapists will refuse to see them unless they acknowledge they

are being abused (Sprott et al 2017).

Alternate sexuality clients in Sweden (Lantto & Lundberg 2021) were polled to

determine characteristics they would find helpful in a therapist and revealing that a professional

stance that holds space for the client and affirms them instead of trying to change them was seen

as most helpful, as was curiosity as long as it centered the individual’s experience. Like most

clients, they did not want to a core part of their identity to be seen as a problem to be solved.

Sprott et al (2017) gathered insights from clinicians that work with alternate sexualities and

determined that competent care should include knowledge of BDSM and CNM community

organizations and resources, skills to differentiate BDSM and abuse, understanding of core

values of the BDSM and CNM communities and “skills to assess the congruence between

clients’ behaviors and their personal values and the communities’ values” (p. 932), the ability to

examine jealousy and envy without the assumption that sexual exclusivity will resolve the issue,

the ability to see BDSM and CNM as cultural factors instead of presenting problems, and

awareness that alternate sexuality is often deeply embedded in a client’s identity and skills to

help with minority stress or the coming out process.

Sprott et al (2017) describe two levels of aware therapy. The first is knowledgeable

therapy where the therapist is familiar, comfortable and affirming of the client’s identity, but
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kink and/or CNM are not the central focus of the treatment or presenting problem. An example

of this would be a client with a polyamorous relationship dynamic and kink practices that is

seeking therapy for depression and anxiety related to the loss of a job. The second level, focused

therapy, would be when kink or poly behaviors, dynamics, and/or identity or central to the

presenting issue and treatment needs to focus on issues of alternate sexuality. A client wants

assistance navigating coming out about their polyamorous relationships to their family and

friends, for example.

Case Study

Eric is a 32-year-old white cisgender heterosexual male with a bachelor’s degree that

works in sales at a small company. He has been married to Paula, a 31-year-old white cisgender

bisexual female for four years. They have no children. The couple met through work as Paula

was a receptionist at a firm that Eric frequently called to make sales. Eric reports limited sexual

and relationship experience before Paula, “a couple of girlfriends but nothing too serious.” Eric

and Paula have recently changed their relationship type from strict monogamy to a loosely

defined polyamorous relationship after Paula expressed a desire to explore her bisexuality. Eric

reports fantasizing about being sexually submission, but only recently shared these desires with

his wife. Eric reports she was initially interested and the couple had a few experiences Eric

describes as satisfactory, but Eric reports she has withdrawn stating that she does not wish to be

dominant in the bedroom all of the time. Eric has also begun to develop feelings of jealousy after

Paula has increased the amount of time she spends with her other relationships. Eric had one

sexual experience outside of his marriage, but reports not feeling a real connection. Paula

maintains a steady girlfriend and has recently begun seeing a man as well.
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Eric was raised in a strict religious background and describes his family of origin as very

conservative. Eric reports his father being verbally abusive to his mother and strict with his two

sisters, while paying little attention to Eric as long as he kept up his grades. Eric reports that as a

youth, he kept up appearances at home, but was often combative and argumentative with peers.

He was careful to stay off the radar of school authorities and his parents, but outside of that,

frequently engaged in fistfights and drug use (marijuana and hallucinogens). He reports “getting

his act together” in college after being placed on academic suspension. He reports little social

contact outside of Paula, citing difficulty making friends as an adult. He reports feeling

confident and capable at work on a sales call, but has difficulty making small talk and

establishing social connections. Eric describes feeling ashamed of his submissive desires, like he

is “less of a man for them.” He feels that since being submissive “is who I am” then he must be

weak. He is worried that his wife does not find weakness attractive and will eventually leave

him. Since coming out to her about them, he has withdrawn more after she asked that not all

sexual encounters involve a D/s (dominant/submissive) dynamic. Eric reports feeling

increasingly depressed and worried about losing his marriage. He remains committed to the idea

of polyamory as he “knows it is important to Paula” and wants her to be happy. He is

experiencing sleep disruption and intrusive thoughts about being left alone. He no trauma and no

previous counseling experience. Eric is coming to counseling to cope with his feelings of

jealousy and find a way to manage his submissive identity so he can maintain his marriage.

Time-Limited Dynamic Assessment

The dynamic assessment with Eric a\brought to light that he initially embraced his wife’s desire

for a polyamorous relationship as he had always felt his sexual experience was limited and he
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wanted to be able to explore his own identity, but struggled to make connections and let his

guard down with others. He reported always having a hard time being speaking up and being

assertive when pursuing friendships and romantic partners. Eric says he can successfully be

outgoing and confident at work because that is a part he plays, not who he genuinely is. He

compares his single poly experience with his wife’s perceived success and feels inadequate and

unsuited to polyamory. When he was younger, he would angry and frustrated when he couldn’t

connect, but reports that now he just feels sad and defeated. He describes feeling like he has no

middle ground between being aggressive and being withdrawn. He reports feeling sad that his

wife does not accept and embrace his identity as a submissive even while he struggles with it

himself. She did not reject him outright, but only wants to occasionally engage in a D/s

dynamic while Eric feels that engaging in “vanilla” or non-kinky sex, is a step backwards for

him.

Time-Limited Dynamic Case Conceptualization

Eric’s withdrawal and inability to find the assertive balance in-between passive and

aggressive communication likely is a response to his father’s emotional abuse of his mother and

his own emotional neglect by his parents. Eric expects that he will be ignored or left behind as

Paula branches out. Eric struggles with his identity as a sexual submissive and hoped Paula

would affirm it more by engaging only in D/s sex where the dynamic is reinforced. Eric has

become more depressed as a result, seeing his submissive identity as a weakness and is now

anxious about what his desires say about himself as a man. Eric does possess the ability to

socialize and be assertive, as his work success can attest, but he has internalized his submissive

desires into a rigid self-image that sees any assertiveness as disingenuous. This struggle with his

authentic identity keeps Eric from asserting himself, allowing him to accept a cycle of limited
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engagement with others. He decides he is defeated before he makes attempts. Eric possesses

several factors that will help him in his therapy. He is accepting of Paula’s identity, which

demonstrates an open-mindedness that could possibly be applied to him. He is capable of being

assertive when he is playing a part. He also benefits from a caring relationship with his wife

who attempts to support his search for identity.

Eric’s identity as submissive is part of his cultural identity, and his rigid view of himself

has allowed that submissiveness to subsume his entire identity. He struggles with what having

submissive desires says about who he is. This is partly due to it falling outside what society

deems is an appropriate position of power for a man. His feelings of jealousy that increased

when Paula began seeing another man may be due to an internalized view of women, likely

based on how his father treated his mother and sister. On some level, he has absorbed the

patriarchal view that men should control their women and guard them from other men. It

appears that both cultural and personality issues are involved and Eric would be part of Sprott et

al’s (2017) second level of aware therapy as his presenting issues are specific to his kink and

poly identity.

Treatment Plan

The challenge for Eric will be to recognize that his submissive identity is a part of who he

is, but it doesn’t have to extend to the entirety of his identity. This recognition will allow him to

utilize the social skills he has developed in his role as a salesperson in other areas of his life.

Eric will also be able to leverage these abilities when he needs to ask for reassurances and

comfort from Paula.

The goals will be to help him find the assertive middle ground between passive and

aggressive so he can fully communicate his needs to his partner, while also being open to
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engaging in non D/s sex occasionally as that meets his partner’s sexual needs of not always being

the dominant one. Therapy will focus on insight, communication skills, and corrective emotional

experiences. Treatment goals will include assertiveness, utilization of social skills, a reduction of

depression and anxiety, and corrective interpersonal experiences. Treatment that is focused on

patterns in his relationships, including his own relationship with his submissive identity, will

keep these goals prominent in therapy. The therapeutic relationship will be utilized to explore

identity, revise cyclic patterns, and corrective emotional experiences. Interventions will include

role playing and DEARMAN skills, and exploration of gender and sexual norms and how they

relate to Eric’s identity. Treatment obstacles may include being passive and trying to please the

therapist without putting skills into practice outside of therapy. Continued lack of success

forming new relationships could reinforce negative perceptions of self. Since there is a larger

community around alternate sexualities, connecting Eric to the kink and poly community in his

area could help increase his sense of connection. In addition to attending munches and meet-ups,

Eric will be recommended to a support group for submissives to help with normalizing and

navigating his identity. He and Paula will also attend poly-friendly couples counseling to help

improve communication and assist in processing feelings of jealousy and inadequacy. Since

kink and poly have strong values associated with consent and boundaries, those values can be

incorporated when exploring his rigid view of himself and kink terminology can be utilized to

increase understanding and normalize behaviors. This culture and vocabulary can also be

utilized when challenging internalized gender norms and roles. Given that Eric possesses many

of the skills he needs to overcome his obstacles, has a supportive relationship, and can become

involved in a larger community that values his identity, Eric’s prognosis is good to very good.
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Advocacy and Legal/Ethical Considerations

The main way for therapists to support clients with alternate sexualities is to become

knowledgeable about them and make that knowledge widely known. Numerous trainings and

certifications are available. AASECT offers a kink friendly certification. There are many

resources and databases therapists can include themselves in so potential clients can get

connected with therapists that will affirm their identity. One such database is the Kink Aware

Professionals run by the National Coalition for Sexual Freedom. In addition to therapeutic

certifications, the kink and poly communities hold numerous workshops, meetings and support

groups. Therapists can attend and become involved. Therapists can also normalize clients with

alternate sexualities to other therapists during supervision and other appropriate clinical

environments. Most importantly, therapists should be aware of their own sexual values, watch

for counter-transference, not make assumptions, and not pathologize alternate sexualities.

While alternate sexualities are not inherently immoral or indecent, some practitioners are,

just like in the vanilla and monogamous world. Therapists that advocate for clients to involve

themselves in the kink community must be aware that all communities have predators and clients

should be made aware that being kinky does not automatically make someone trustworthy or

safe. While not all kink activities are risky, many are and that risk should be mitigated with a

strong support network, safety protocols, and knowledge. Counselors should be careful not to

support clients without helping them plan for safety. Counselors should always seek to maintain

strong boundaries with clients on sexual topics, alternate or not, and always strive to maintain

proper ethical behavior.

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References

Kisler, T. S., & Lock, L. (2019). Honoring the voices of polyamorous clients: Recommendations

for couple and family therapists. Journal of Feminist Family Therapy: An International

Forum, 31(1), 40–58. https://doi.org/10.1080/08952833.2018.1561017

Lantto, R., & Lundberg, T. (2021). (Un)desirable approaches in therapy with Swedish

individuals practicing BDSM: client’s perspectives and recommendations for affirmative

clinical practices. Psychology & Sexuality.

https://doi.org/10.1080/19419899.2021.1918230

Mosher, C. M. (2017). Historical perspectives of sex positivity: Contributing to a new paradigm

within counseling psychology. The Counseling Psychologist, 45(4), 487–

503. https://doi.org/10.1177/0011000017713755

Pillai-Friedman, S., Pollitt, J., & Castaldo, A (2015) Becoming kink-aware – a necessity for

sexuality professionals, Sexual and Relationship Therapy, 30:2, 196-

210, DOI: 10.1080/14681994.2014.975681

Sprott, R. A., Randall, A., Davison, K., Cannon, N., & Witherspoon, R. G. (2017). Alternative or

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73(8), 929–937. https://doi.org/10.1002/jclp.22511

Waldura, J. F., Arora, I., Randall, A. M., Farala, J. P., & Sprott, R. A. (2016). Fifty Shades of

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