Best Practices Review for Clinicians Offering Sex Therapy with Lesbians

I came out as lesbian at age 19 and have navigated that process repeatedly for three decades. The queer community is consistently neglected in research, and therefore our clinical knowledge is hampered. Pairing my passions of sexuality and queerness, my PhD dissertation was a systematic review of the literature—with a focus on best practices for clinicians doing sex therapy with lesbians.

Here are the highlights:

Women’s sexuality is most affected by the following factors: body image; family of origin and culture; attachment history; trauma history; physical ability; age; relationship to self and to pleasure. These are familiar elements of any case conceptualization; however, they are particularly pointiest when talking about sexuality with a woman. Her sex life cannot be considered in a vacuum, but rather, her age, history, family dynamics, experiences and temperament must be factored in.

In addition to the issues that affect all women, lesbians, as a marginalized population, have additional stressors and considerations that impact their sexuality. These include the following:

Social Stigma: Lesbians face numerous unique societal and cultural challenges with the combination of both homophobia – fear, dislike and prejudice against lesbian identities – as well as heterosexism, where society sees heterosexuality as the default, preferred or “normal identity.” Lesbian sexuality is both fetishized and dismissed as “not real sex.”

Coming Out: Coming out is a unique developmental milestone for LGB individuals and far from being a singular event – more likely a long process. Vivienne Cass identifies six common stages of development in the homosexual identity formation: confusion; comparison; tolerance; acceptance; pride; synthesis. In therapy with queer clients, we meet them where they are in their coming out journey—which often is not a neat, linear path through these stages. 

Power Dynamics: Role negotiation invariably arises with lesbian couples. When both partners are female, they must verbally or nonverbally assign roles and negotiate sexual initiation, relationship duties, and the power balance. Complementarity reflects how the couple’s characteristics are different, but interrelated. Each partner may be attracted to or aroused by different things, but it may be complementary to what their partner wants. Lesbian sex requires a greater degree of interaction, role differentiation, and coordination of behaviors and desire than most area of a couples’ life. Clinicians cannot assume the roles or responsibilities held by lesbian couple clients—in or out of the bedroom. Rather, they need to inquire and stay open to a fluid, intricate system co-created by the clients. While lesbians value fairness and equality, they may also be drawn to partnerships with power differentials. That does not mean that either partner holds all power in all areas, but rather, they likely share power in various contexts.

Sex versus Intimacy: Lesbians tend to prioritize intimacy over sexuality and same sex female couples took more time having sex and included whole body contact. Lesbians consistently reported higher levels of satisfaction with their sexual experiences. Lesbians also report longer lovemaking sessions compared to other couples, so the conversation starts to shift toward quality versus quantity. Researchers found lesbians (versus heterosexual women) rated giving versus receiving sexual activity was desirable and led to higher levels of satisfaction. Lesbian sexuality has greater fluidity than male same sex sexuality—meaning it’s particularly sensitive to situational, interpersonal, and contextual factors.

Clinicians working with queer women should also have awareness and understanding of the following: knowledge of queer history; knowledge of the social stigma attached to a queer identity; awareness of our own bias; awareness of clinician counter transference; awareness of privilege and oppression of minorities; understanding of the mechanics of sex between two women; signaling on the part of the clinician as to the comfort regarding the topic of sex in the clinical space.

Fortunately we are seeing more representation of queer women in research. In parallel to what we know from research, I’m continuing to form my own theories in the therapy realm with my clients. The field is ripe for contribution.