Positive Approaches Journal, Volume 10, Issue 1

Hipple,Tennille, & Bohrman | 35-44

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This article is a love letter to our past, present, and future clients, to our communities of helping professionals, to one another, and to ourselves. It blends musings born of lived experience and remembered missteps, and provides a brief case study presentation to consider, from the perspective of three academics who are eager to see a more robust integration of addressing sexuality and gender in treatment spaces. We reject the notion that behavioral health providers (social workers, psychologists, medical professionals, and the like) can ever assert “expertise” on a topic so complex. We created this writing to offer reflection on our vulnerabilities as clinicians, educators, and humans. We invite you to be vulnerable as well, insofar as it feels resonant to do so.

As a result of the lack of comprehensive sexual literacy at all levels of education, behavioral health providers and clients alike might struggle to bring up issues of sex. Regardless of their level of comfort with sexuality, these providers may find themselves as a first point of contact for clients arriving for other concerns irrespective of or secondary to their sexuality. A lack of understanding of sexuality concepts may make even unrelated therapeutic work more difficult. Also, depending on a variety of factors including location and socioeconomic class, clients may not have the option of a referral to someone who specializes in sexuality issues, which makes basic skills related to conversing about sexuality even more necessary among providers.

We must enter into these conversations willing to make mistakes. For example, five years ago, the second and third authors were invited to deliver a training on Motivational Interviewing (MI) for persons identifying as transactivists tasked with reaching into their community to encourage the use of Pre-exposure Prophylaxis (PrEP) for prevention of HIV infection. We identified as trainers and scholars who thought a lot about heteronormativity, one of us identifying as a member of the Lesbian Gay Bisexual Transexual Questioning+ (LGBTQ+) community. We still made mistakes. The most harmful of which was misgendering individuals identifying as non-binary, accidentally using the wrong pronouns at different points throughout the 2-day training. We learned the importance of humbly apologizing, moving forward, and making concerted efforts to get pronouns correct in the future.

Brief Case Study Presentation

Early in the first author’s career, I worked with an individual whom I will call Kai. When they first came for an intake, they were struggling with relationship issues with their partner related to an infidelity that had occurred. As Kai and I explored their experiences of distrust related to the infidelity, they began talking about some of the dynamics of their relationship. Based on what they shared with me, it sounded as if their partner, a cisgender man who worked in a corporate job, was very controlling of them. Kai talked about how their partner controlled the finances, told Kai what to wear each day, and made most of the major decisions of the household.

Kai was very satisfied with these elements of the relationship and was clear and consistent in expressing that their main reason for therapy was to process the infidelity. However, I remember sitting with feelings of worry and frustration. My prior training in domestic violence was influencing my view of this situation. I spent a lot of time with this client processing their ambivalence about the relationship, expecting that at some point they would realize that the relationship was abusive. It had never occurred to me that my assessment skills were limited to my educational and professional experience/orientation thus far and my client was not, in fact, in an abusive relationship.

It wasn’t until a year into my relationship with this client that they disclosed that they and their partner were in a caregiver/little (CG/l) relationship. A CG/l relationship is a subset of Bondage and Discipline, Dominance and Submission, Sadism, and Masochism (BDSM) that involves age play. BDSM and age play can exist across a variety of genders and sexual orientations, can be sexual, non-sexual, or some combination therein. A ‘Little’ can identify themselves as a toddler, child, or teenager, and within the CG/l relationship, the Little might behave in a way akin to regression, with behaviors potentially associated with their identified ‘age.’ This is sometimes referred to as accessing ‘Little Space.’ This should be differentiated from pedophilic fantasy in that the satisfaction is not derived from the fantasy of an adult having a sexual relationship with a child, but rather the Caregiver is helping to hold a co-created space for the Little to express themselves freely, to allow them to access innocence and curiosity. Additionally, sexual activity does not generally happen when the Little is in Little Space.

Age play also differentiates from incest fantasy in that for individuals who assume these roles, the satisfaction comes from the sense of being able to nurture or provide nurturance, not the idea of fantasy related to biological relation. This is evident in the terms used. For example, the submissive person might be called the ‘little’ or ‘girl/boy,’ not ‘child/daughter/son.’ In conjunction with this, the ‘caregiver’ or ‘daddy/mommy’ may play a variety of roles as well. In the case of Kai and their partner, Kai’s partner saw the ‘daddy’ role as that of a protector, teacher, disciplinarian, and nurturing support. Kai and their partner used the language of Daddy Dom/little (DD/l). As with any client-centered care, it always makes sense to allow the person in the relationship to tell you the language that they want you to use for it.

There is limited research about this style of relationship, and yet, many who are in CG/l and other iterations of BDSM relationships report experiencing safety, healing, opportunities for exploration, among other therapeutic benefits.^1,2,3 Despite the reported strengths of CG/l relationships, many clients I have worked with have experienced stigmatization by behavioral health providers toward the practice of CG/l and other BDSM relationships. Individuals who are open about age play in online forums are often labeled by people outside their community as deviant. They experience stigmatization from outsiders despite their ability to demonstrate highly nuanced and reflexive responses to questions about their sexuality. Many individuals in age play and other BDSM-related communities also show high levels of emotional literacy and clear understanding and communication of boundaries and consent—often more so than the general population.

Shifting Perspectives and Reflection

Providers can already be quick to pathologize client sexual practices, and this is especially so when an individual has identified that they experienced sexual trauma. Providers often do this without considering the strengths and benefits of sexuality in client healing. Rather than assuming that sexual practices are pathologically derived of trauma, a powerful shift in perspective is to consider how sexual practices are actually healing.

One of the ways we can reduce the likelihood of unintentionally harming clients when discussing issues of intimacy and sexuality is to be self-reflective. We would propose that while we should be asking our clients to reflect on their experiences of sex and sexuality, we must also turn inward and reflect on our sexual landscape and how it was shaped. I would invite my fellow clinicians and anyone reading this to consider the following reflection questions as a gateway to greater comfort when talking about sexuality in therapy spaces: