Introduction

The biopsychosocial model of sexual functioning predicts that human sexuality is influenced by biological, psychological, and sociocultural factors and that effective treatments for sexual dysfunctions will target these three factors as necessary [1]. In practice, therapeutic efforts have been primarily directed at biological and psychological contributions to sexual problems with scant attention paid to sociocultural context. Sexual medicine, which focuses on the physiological aspects of sexual dysfunction, and sex therapy, with its focus on individual and couple psychology, are flourishing in the West and are now being exported to other parts of the world. The expansion of sex therapy into other countries, along with the changing demographic of North America and Western Europe, has rendered sociocultural factors extraordinarily relevant as an increasingly diverse patient group is presenting for treatment. Spirituality, an important dimension of sexuality in many parts of the world, is a much-neglected aspect of the Western-inspired biopsychosocial model. Interpretations of this model also fail to consider sociopolitical factors, particularly as regards the status of women in many parts of the world. The restrictions placed on female sexual pleasure and agency in traditional cultures contravene the basic principles upon which Western-based sex therapy and sexual medicine are founded. At a minimum, an awareness of the diversity of sociocultural influences is necessary in order to adapt treatment to be effective for a wide-ranging patient population.

Culture is here defined as the constructed and shared values of a group that are important enough to be passed from one generation to the next. Culture is dynamic and is constantly being renegotiated and thus changing [2•]. It operates on various levels, from the macro level of the broader cultural group (often delineated by nationalities) to the micro level of families and neighborhoods. Cultural messages are transmitted and translated at various social levels, from the government, which may enact laws regarding marriage, prohibit sexual acts, and define age of consent, to media depictions of who and what is sexually attractive, to churches and schools which provide moral direction and education, to the family and neighborhood where many of these messages are synthesized into daily life [3]. Sexuality, while requiring the necessary biological underpinnings, is otherwise socially constructed, an observation supported by the cultural variation in sexuality and sexual behavior. The expression or experience of sexual difficulties likewise varies across cultures and presents both treatment and ethical dilemmas for the Western-trained sex therapist [4].

There are numerous calls for culturally competent, or culturally sensitive, sex therapy, and yet surprisingly, there is little research or guidance on how this might be accomplished. At present, culturally competent/sensitive sex therapy is left to the motivation, knowledge, skills, and sensitivity of individual therapists. Treatment guidelines for culturally modifying the practice of sex therapy are sorely needed, and these guidelines should be based on an empirically derived appreciation of cultural variation.

Culture and Sexual Dysfunction

Many studies have documented cultural disparities in sexual values, beliefs, and practices, as well as differences in the high prevalence of Western-defined sexual dysfunctions [4,5,6]. Sexual difficulties endemic to a particular cultural group, often called culture bound syndromes, are likewise receiving increased clinical and research attention. The picture that emerges from a review of this literature reveals an emphasis on men’s anxieties regarding pleasure and performance and women’s concerns related to performance and pain.

Premature ejaculation (PE) and erectile dysfunction (ED) are concerns of men worldwide with midlife estimates ranging from 8 to 30% for PE and 15 to 40% for ED [6]. Many more men in traditional cultures are concerned about the detrimental effects of semen loss that they believe may lead to physical ailments and sexual dysfunction. Dhat syndrome (excessive preoccupation about physical weakness or other ailments as a result of semen loss) is so prevalent around the world that its classification as a culture-bound syndrome is being questioned [7]. In a community sample of 894 men in rural India, over three times as many men were concerned about a defect in semen (64.4%) as compared with those who were concerned about loss of libido (21%) [8]. In a clinical sample of 364 men presenting to an outpatient clinic for sexual concerns, 28% of the unmarried men met the criteria for Dhat syndrome, while another 28% of unmarried males were concerned more specifically about nocturnal emissions. A high level of distress was reported by over two thirds of the patients (68.7%), and many of these patients had been to numerous doctors regarding their sexual problems [9]. Distress, a necessary condition for the diagnosis of sexual problems according to the DSM5, is often not measured in surveys of sexual dysfunction, and when distress is measured, the content and nature of it are not fully explored [10]. The distress associated with sexual problems may or may not be similar cross-culturally. Concerns about shortened pleasure for themselves and/or their partner or shame and anxiety about performance or fertility may be disproportionately and differentially experienced by men in different cultures. Indeed, in traditional societies, there is intense pressure on men to perform sexually on their wedding night with an unfamiliar bride, having little if any sexual experience and even less sex education and often with a waiting audience. The term “handkerchief stress” has been coined for the anxiety experienced by men, who are expected to produce a bloodstained cloth as proof, not only of the bride’s chastity, but of their sexual prowess [11].

Traditional cultures, as described in this paper, refer to those that espouse sexually conservative (usually religious) values. Such cultures restrict sex to marriage, stress virginity (more so or only for women), privilege male sexual pleasure, prohibit open access to sex education (except perhaps for abstinence only or faith based), and value duty over individual fulfillment. The status of women in traditional cultures is substantially lower than men’s. In traditional cultures, the values are significantly different than those upon which sex therapy was based.

Cultural attitudes that discourage women (more so than men) from discussing sex as well as reliance on Western-standardized measures of sexual dysfunction may distort a global perspective on female sexual dysfunction. When standardized measures such as the Female Sexual Function Index is used, orgasm and arousal/lubrication problems are the most frequently reported sexual dysfunctions of women in India, Iran, Nigeria, and China [4, 12]. However, when looking at help-seeking behavior or studies using interview or indigenous measures of sexual problems, vaginismus, unconsummated marriage, and sexual pain are the most frequently reported problems in the traditional cultures of the Middle East and Asia. The prevalence of sexual pain and vaginismus is often attributed to the high premium placed on virginity in traditional cultures [4]. While sexual pleasure is a right accorded to men worldwide, sexual pleasure for women is at best considered irrelevant and, at worst, treated as dangerous in sexually conservative societies. Therefore, it is often only those problems that interfere with male sexual pleasure or with procreation that are considered worthy of complaint or treatment. More research on the prevalence and nature of the sexual issues that are important and distressing to women is needed.

Female Sexual Pleasure in Cultural Context

As observed by Baumeister, cultural and societal pressures act more strongly to inhibit and constrain the sexual behavior of women [13]. Holding sexually conservative values, especially a belief that women should be passive in sex, can lead to sexual dissatisfaction in women [14]. The inhibiting effect of traditional cultures on female sexual pleasure is strong and can persist over generations and national boundaries. A recent and notable finding is that when describing their sexual experiences, Chinese Canadian women made reference to the sexually inhibiting effects of their Chinese culture, despite the fact of being born and raised in a relatively (sexually) liberal country. The female participants in the study, in contrast to their male counterparts (none of whom made explicit reference to culture), felt that their sexual desire would lead to social condemnation, embarrassment, and being perceived as “unladylike” [15, p. 319]. While this study involved only a small sample of ten women and ten men, it nevertheless provides an intriguing insight into the pervasive effects of culture and the significant impact of the family’s cultural value system. Acculturation, the process by which immigrants adapt from their culture of origin to their new culture, may bring with it conflicts, both psychologically and relationally expressed, when traditional values clash with more liberal ones [5]. The above study suggests that the process of acculturation may take generations, at least as regards attitudes towards female sexuality.

The inhibiting effect of traditional and sexually conservative cultures is more pronounced in countries in which there is marked gender inequality. Such cultures limit women’s opportunity for sexual experience and expression. In a comparison of 840 young Hispanic people from Mexico and Spain (countries that share cultural values regarding sexuality), gender differences in sexual experiences were more apparent in Mexico where there is a greater measure of gender inequality. Spanish and Mexican men reported a larger number of sexual partners and more sexual experiences outside of committed relationships or marriage than did their female counterparts who reported sex more often in the context of a relationship with a steady partner. Gender differences in these sexual behaviors were more pronounced for participants from Mexico, where gender inequality is endemic in the society [16]. In cultures where women’s status is markedly lower than men’s, sexuality is often only sanctioned within the context of a heterosexual relationship. The status of women within a particular culture is an important variable to consider when doing sex research or providing treatment for sexual problems. The status of a woman within her family or marriage has been identified as being of particular relevance when doing sex therapy. To participate in sex therapy, a woman must have the power to make her own sexual decisions and to have an expectation of sexual pleasure [11].

A large-scale study of 770 marriages in Hong Kong found that female sexual assertiveness was associated with higher levels of sexual satisfaction in both husbands and wives. Sexual initiation and refusal were overwhelmingly endorsed as acceptable practices by both women and men (95–97%), but when asked whether this was an accepted practice in their own marriages, only 28% of the couples agreed that female initiation was possible and only 34% of the couples agreed that female refusal was an option. Marital and sexual satisfaction was highest when men accepted the ability of their wives to initiate or refuse sex and when their wives exercised this option. The authors noted that this result is consistent with previous research showing that sexual passivity is related to lower sexual satisfaction. They state that men and women “may need to take active roles and express their authentic desires during sex. Female sexual assertiveness is not only good for a woman’s own sexual and marital relationship, but also for her husband’s satisfaction, so it should be promoted among married couples.” [17, p. 93]. Caution is needed before extrapolating from this recently reported but decades-old data, which was gleaned from couples’ answers to four questions. Cultural acceptance of the right to initiate or refuse sex is different from the culturally sanctioned ability to be assertive about one’s sexual needs and pleasure during sex. However, this is an intriguing finding worthy of further research and replication.

An interview study of sexuality in Malaysian women reporting sexual dissatisfaction provides further evidence of a link between sexual agency and satisfaction. The Malaysian women initially had expectations for marital sex that mirrored the Western values of love, intimacy, and equality. However, in practice, the women were more passive and conservative than they had expected or hoped to be. The women felt too shy, did not know how to speak to their husbands about their sexual needs, nor did they know what to do to achieve their sexual goals. Many of these women reported that they reverted to traditional roles and began to treat sex as a duty to be performed within a marriage and within their Islamic faith. As such, they continued to have sex without desire or arousal. The importance of being a good wife took priority over sexual pleasure, and being a good wife was translated into following more traditional sexual roles and values [18].

Nonconformity to traditional gender roles in other aspects of life may make it easier for women to hold more progressive ideas regarding the importance of their own sexual pleasure. Traditional Chinese sexuality is based on Confucian and Taoist philosophies in which sex for pleasure is viewed as detrimental to the social order and to personal health. On a survey conducted in 2000, the vast majority of women (82–96%) aged 20 to 64 reported never masturbating, compared with a recent sample of 235 Chinese women aged 16–58 years, who not only reported masturbating but also reported using a vibrator to do so. Of the 68.5% who used a vibrator, 44.7% reported using their vibrator at least once weekly. The Chinese women who reported non-gender-conforming attitudes on questionnaires were more likely to have more positive attitudes towards vibrator use, which in turn predicted actual vibrator use [19].

Although cultural pressures may act to constrain women’s sexuality, the impact of such beliefs may in fact diminish the pleasure men might otherwise experience. Even in traditional cultures, sexual satisfaction for both men and women is enhanced by female sexual pleasure and agency. An awareness of this fact may eventually help make treatment of female sexual disorders more acceptable in traditional cultures. While this approach situates the value of female sexual satisfaction only in the context of male pleasure, a placement that would be objectionable in the West, it may provide an initial inroad for female pleasure in patriarchal cultures, especially in those societies experiencing a transition from traditional to more Western value systems.

Sexual Rights

In an increasingly interconnected world, there is inevitably a spreading awareness of equal rights for women and sexual rights for people in all countries and cultures [20]. However, these rights are more aspirational than realistic in many parts of the world. In traditional cultures, serious consequences are meted out for women who violate cultural norms governing sexual behavior. Stoning, so-called “honor killings,” and banishment may follow the discovery or suspicion of premarital or extramarital sexual activity. As stated earlier, traditional cultures emphasize female virginity prior to marriage such that women fear bringing shame on themselves and their families, as well as hurting their chances for marriage if they are known to have prior sexual experience.

Preserving virginity becomes increasingly problematic in traditional cultures where rape is endemic. In the Democratic Republic of Congo, the high incidence of sexual violence against women has led some younger women to question the status quo and wonder how men can insist on marrying virgins when they pressure their girlfriends to have intercourse and/or rape girls and women. The immediate solution has been to marry both boys and girls off at increasingly younger ages, but the specter of sexual violence has made women more vocal about their rights under the existing double standard [21•]. It may be somewhat paradoxical that the heavy burden being placed on women to preserve traditional cultural values may in fact lead women to ultimately question and reject sexual restrictions and the values upon which they are based.

Culture and Sex Therapy

Given the documented variations in sexual values and sexual practices, it is understandable that a one-size-fits-all approach to sex therapy will not be effective worldwide. We are poised on the brink of developing culturally sensitive approaches to sex therapy, but at present, specific guidelines are lacking. Other fields of psychotherapy, most notably cognitive behavioral therapy (CBT), have culturally adapted treatment protocols with empirical validation for their efficacy over nonadapted treatments [22]. Cultural adaptations are those that facilitate a strong therapeutic alliance, encourage patient disclosure, and develop a shared understanding between patient and therapist of the problem and agreement as to treatment goals [23]. The process of therapy must be explained in culturally accessible terms while the use of culturally appropriate language and metaphors is important during the therapeutic process. The differences in therapeutic language are illustrated by an ancient Chinese sexual skills approach (Fangzhongshu) recently proposed as a treatment for PE in modern-day China [24]. Written in a style that may appeal more to Eastern than to Western cultures, some of the advice is very similar to the squeeze technique and the stop-start method, while more general advice to focus on sexual pleasure is also provided:

“the three peaks, which are the tongue above, the breasts in the middle, and the vaginal orifice below, can cause high sexual desire in women, with increased secretions in the vagina when touched. Thus, men can hold and fondle women gently, close their mouth and grit their teeth, place their thoughts elsewhere, insert the penis into the vagina and perform sexual intercourse following the method of 9 shallow thrusts followed by 1 deep thrust.” (p. 177).

Recently, guidelines have been proposed for incorporating spirituality and religious beliefs into CBT. Sufism and Hinduism are highlighted as compatible with Pakistani and Indian patients suffering from a variety of disorders [25••]. A belief in ancestral spirits, the importance of duty to God, and the value of traditional healing methods were highlighted as important in West Africa [26••].

Whether spiritual beliefs, values, and practices can be successfully integrated into sex therapy is at present unknown and largely untested. However, the integration of mindfulness (originally a Buddhist based practice) in sex therapy is one example of a successful cultural modification with spiritual undertones. The success of this blended approach to treatment may pave the way for the incorporation of spiritually based interventions into Western sex therapy [27].

Conclusion

The ethical and effective practice of sex therapy worldwide awaits cultural modifications. More work is needed to develop and test specific cultural adaptations to sex therapy. Sexual pleasure and agency for women are important avenues to explore regarding improving sexual satisfaction for women and men around the globe. Female sexual pleasure in a cultural context may differ from Western notions of pleasure that are more individualistic and less spiritually based. The caveat Do no harm applies to sex therapy. Aggressively promoting sexual agency and pleasure may endanger women in some cultural contexts.

The call for ethical practice guidelines regarding female genital cutting and female genital cosmetic surgeries is an important step in the development of an ethical and culturally sensitive sex therapy [4]. Importantly, sex therapy cannot be ethically practiced if it ignores the rights of women. Child marriages, forced marriage, and rape are realities that face women around the world. Yasan and Gurgen [28, p. 73] note “It is understandable that women who have been forced to marry without consent and who know that they have to stay married for the rest of their lives, will have difficulties while experiencing sex unwillingly in their marriage.” The cultural adaptation of sex therapy relies on an awareness of relevant cultural issues related to the target problem (sexuality) and a sensitivity to barriers to treatment. Working within patients’ cultural value system is important for developing a positive therapeutic alliance and enhancing the probability of treatment compliance and completion [29]. The challenge is to do all of the above in a safe, ethical, and effective manner.