Introduction

Religious and cultural issues are known to have a great influence on individuals’ health beliefs and behaviors. These beliefs not only influence how we define healthy sexual behavior, but they also have a significant impact on the client–healthcare professional (HCP) alliance and the treatment process that ultimately influences outcomes. Sexual health issues have a particularly strong cultural and ethnic dimension, which affects their epidemiology as well as assessment and treatment strategies [1–5]. Mental health and medical professionals are eager to expand their knowledge and competency in working with diverse populations [6]. Students and individuals who are interested in cultural perspectives around sexuality and sexual health and behaviors should will find this paper of interest.

“WITHOUT KNOWLEDGE OF SELF, THERE IS NO KNOWLEDGE OF GOD”

John Calvin

An Overview of Religion and Mental Disorders

Religion and mental disorders have had a long and troubled relationship through which they have become “intimate enemies” [7]. Their concepts are used together, such as in the admonishment that “God will punish you with madness for disobeying his commandments”. Although there are many connections and a certain synergy between religion and psychology, they cannot exist in total peace and harmony. There is a persistent belief that sin and sinful attitudes are the cause of mental problems, and such notions are so pervasive that they exist even among mental health professionals [8]. There are not sufficient data to show that the less religious are more emotionally healthy or vice versa. Some religious beliefs that were once thought to be irrational are now found to be potentially helpful. Research suggests that the positive associations between religion and mental well-being outweigh the negative. Amongst 30 research studies, 14 showed a favorable relationship between religion and mental health, 9 showed no association, and 7 indicated a non-favorable relationship between the two [9].

Because religion and culture are inherently intertwined, a discussion of an individual’s religion cannot ignore the cultural context (both upbringing and current cultural environment), and vice versa. Religious and cultural rituals, teachings, and ceremonies are with us from birth to death. While an increasing number of practitioners have shown interest in learning more about the cultural diversity of their clients, when it comes to religion, it seems that most either do not feel competent or do not wish to address the subject specifically in a mental health setting, particularly with respect to sexual problems.

This avoidance may be largely due to the negative aspects of religiosity portrayed and projected every day by the news media. Many professionals would agree that an HCP who is well-versed in addressing cultural and religious diversity would be viewed as a help rather than a hindrance. It is all about how we approach such issues presented to us as clinicians. This article specifically addresses the context of work with Muslim clients in hopes of offering some points for reflection among colleagues as well as some practical tips for psychosexual therapy with practicing Muslim clients.

Various possible relationships between religion and an individual’s mental state can be summarized as follows:

  • Religious ideation may be an expression of a mental disorder such as in the case of delusions.

  • Faith can help people cope with negative life events, even in the case of extraordinary disasters, and may thus be a significant factor in preventing post-traumatic stress disorder.

  • Religion can serve as a protective agent for some disturbed behavior such as suicide.

  • Religion can aid personal growth through forgiveness and trust. Forgiveness is an antidote to destructive guilt, and reduces anger, fear, shame, and sadness.

  • Religion can enhance optimism, helping one to cope with mental disorders through spiritual commitment and involvement [7].

  • Religious beliefs may be one of the best predictors of abstinence from drug/alcohol addiction, abuse and cruelty, and nonparticipation in extramarital sexual activities.

  • Religion helps people cope with depression and anxiety, as in the case of ceremonies of mourning such as “shiva” and “ağıt” in eastern cultures.

    • Religion affects information processing.

    • Religion can work to either the advantage or disadvantage of the person, depending on their beliefs (a God to be feared or a God to be loved, a God of punishment or a God of forgiveness)

    • Each person’s faith operates in his/her particular world.

    • As extremism blunts perception and freezes the flexibility of cognitions, “The role of religion is paradoxical. It makes prejudice and it unmakes prejudice” [7].

Religion can strengthen moral commitments, enhance optimism, and stimulate development, but it can also cause disordered thinking or behavior. It can arouse guilt (obsession with guilt and sin, thereby lowering self-esteem) and it can reduce guilt. Thus a central goal of all religions should be that of collaboration and cooperation in emphasizing the importance of personal growth and maturity.

Similarities Among Religions

In the words of George Bernard Shaw, “There is only one religion [and that is to do good], though there are a hundred versions of it” [10]. The act of simply going to church or to a mosque does not make one a real Christian or Muslim any more than going to a garage makes one a mechanic. And despite the differences, there are many similarities among Muslims, Christians, and Jews. For example, they all believe in premarital chastity and marital fidelity [11,12••]. However, while female chastity has historically been held in high esteem among most western societies, it has lost its place of importance over the past few decades [13]. A similar trend has been observed among Muslims, especially those living in cities of western Turkey. In addition, marital infidelity has been increasingly discussed in recent years, although it is unclear whether this is due to an actual increase in the number of extramarital affairs or simply greater freedom of expression. Both seem possible. For example, infidelity is frequently on display in most popular soap operas, thus becoming normalized among the public. On the other hand, the increased openness may be a reaction among women against the long-standing male-dominant culture.

Extremists are everywhere and in every religion. Some individuals call themselves “warriors in God’s name” [7], and atrocities have been committed in the name of religion, as was seen with the 9/11 attacks in New York City by extremist Muslims. On the other hand, extremist Christians have propagated hate speech against Islam and Muslims, symbolized by the burning of the Qur’an. A religious fundamentalist protest at an annual cultural festival in the city of Sivas, Turkey, on 2 July 1993 had devastating results. Because of a lack of timely and effective rescue operations, victims were trapped for 7 hours in a burning hotel, leaving 37 dead [14]. After the 9/11 attacks, someone scribbled on a wall: “Dear God, save us from the people who believe in you.” [15]. However, while some religious authorities and groups are as rigid as bricks, faith is like water. Water always finds a route to flow, despite the obstruction of the bricks.

Sex Therapy and Religion

Sex therapists do not practice in a vacuum. They must have the flexibility to adapt their interventions to the needs of different cultures and religions. Societies with different religions (even different sects of the same religion) differ as to the specific sexual behaviors that will be accepted or tolerated, and thus sexual problems and their management are not free from the effects of religion and culture. It is critically important, therefore, that sex therapy programs are modified and tailored to the needs of the people and their cultural and religious value systems, as religious and cultural factors do influence the way that sex therapy is offered and welcomed. Religious laws govern sex and sexual behavior so that an activity does not become detrimental to the individual and to society. There is a considerable lack of empirical studies on the relationship between religion and sexual problems, especially with regard to the Muslim experience of sexual dysfunction and psychosexual therapy. Nevertheless, sex therapists can try to modify their approaches by improving their knowledge and familiarity with religious factors that shape an individual’s sexual beliefs, values, attitudes, and behavior [16••,17].

Does Being Muslim Change the Practice of Sex Therapy?

Religion and religious factors do influence the presentation and help-seeking behavior of Muslim individuals. This manifests itself:

  1. A.

    In the presentation of individuals or couples

    • Islamic teaching forbids the discussion of sexual issues outside marriage, which makes it difficult for clients to seek help and to collaborate with a therapist [12••,18]. However, although discussing sexual issues with others is not acceptable in Islam, it is allowed for treatment purposes, as it may help both spouses address sexual difficulties they may be experiencing.

    • Most of the time, sex is discussed only in relation to marriage, and therefore single women who are religious are not likely to seek help.

    • Any and all sexual relations outside heterosexual marriage are considered illicit and are punishable according to Islamic (sharia) law. As such, premarital sex, infidelity, homosexual activities, and sex with women working in the sex industry are illegal. A number of studies have provided empirical evidence of low rates of premarital sex and negative attitudes towards homosexuality in Muslim populations [19–21]. In this context, people—and especially women—who face sexual difficulties are not likely to seek help. In recent years, however, an increasing tolerance towards, if not acceptance of, the gay and lesbian population has emerged due to the success of activists working in gay and lesbian communities and professionals in the area of sexual health therapy. Gay and lesbian couples usually prefer to live in larger cities, where there is greater tolerance and acceptance. Stigmatization of homosexuality is still prevalent in small cities, however, which do not allow homosexual individuals to express themselves.

    • As heterosexual marriage is the only acceptable means for sexual gratification, most of the time it is married people or couples who seek help.

    • According to Islam, procreation is not the sole purpose of marriage [22], and thus the Qur’an does not ban sex when a woman reaches menopause (Qur’an 19:8 and 19:9). In a secular Muslim country like Turkey that is not bound by Islamic law, if procreation were the only reason for sex, we would not observe the considerable demand for help coming from various parts of the country. In daily practice, couples seeking therapy to improve their sex life are not apt to reject sex therapy techniques for religious reasons, and most are easily able to reveal their problems to the therapist. Companionship and enjoyment of the spouse are also secondary purposes. Islam encourages married couples to enjoy sex and to be sensitive to each another’s needs [12••]. However, women are subjected to certain discriminatory expectations, such as keeping their sexual desires under control and shouldering the entire burden of preventing sexual advances or illicit sex [23]. In addition, men are allowed to have more than one wife as long as they can meet the financial and other needs of additional wives. In one of the surahs (Surah 4), it says, “Men are in charge of women and good women are obedient”. A recent study explored the meaning of sexuality among Iranian women living in Australia. Although they believed that it was a wife’s duty to satisfy her husband’s sexual needs at all times, they did not view themselves as subordinate in their married lives. Instead, sexual obedience became a symbol of idealized Muslim femininity, modesty, and self-respect [3].

  2. B.

    Motivation for seeking help

    Religious beliefs are one of the factors determining whether sexually dysfunctional persons will seek out a therapist. The act of searching for help on the part of religious individuals is an indication that they are strongly motivated to change. However, religious beliefs may cause them to resist therapy or may influence their ability to make good use of therapy. For individuals with strong religious backgrounds, some aspects of sexuality may be unfamiliar or taboo. Such persons may require patience, respect, and understanding in order to be motivated to alter their behavior. Sensitivity to clients’ religious beliefs thus enhances the likelihood of successful treatment outcome. On the other hand, religiousness does not follow a coherent pattern, even across members of the same religion [24–27]. Therefore, successful outcomes for Muslim clients also require therapists to be aware of religious heterogeneity across the Muslim population and to show an interest in how they practice religious ideals in real-life situations [28,29•].

  3. C.

    Choice of the source of help

    Many religious people come to the clinic not as their first source of help, but after having tried faith healers such as “hodjas” [12••,30]. Couples may be fearful that the therapist will unconsciously stigmatize their belief system based upon negative stereotypes, and they simply do not want to contribute to negative stereotypes about Islam [12••,31]. If the “hodja” encourages the couple to seek secular therapy, his recommendations will be seriously considered. At this stage, the therapist’s non-judgmental and flexible attitudes may become an important factor in establishing a good therapeutic relationship and maintaining motivation. In addition, therapists may try to ascertain whether clients had benefited from healers or hodjas and, if possible, may try to integrate this within the therapeutic context.

  4. D.

    Attribution of the cause of sexual dysfunction

    In many instances, the cause of the problem is attributed to supernatural factors such as genies or black magic and is described as being “struck by an evil spirit” [16••]. Thus individuals seek help from healers who can purify them from evil spirits or magic. These healers (i.e. hodjas) sometimes give them special amulets to put under their beds or “magical” water to drink that has been prayed over, in the hope of resolving their sexual problem.

  5. E.

    Compliance with homework instructions

    There is generally no resistance to completing homework tasks, as many Islamic women, although very conservative outside the home, are quite open to sexual activities and satisfaction of their husband at home. Sex with a husband is generally accepted as a religious duty. A recent Tunisian study that included 110 men and women reported that the majority of participants believed that women were always obligated to have sex with their husbands, even when they did not wish to [32•]. In instances where resistance to homework tasks is likely to be strong, a step-by-step approach that addresses religious concerns provides a greater chance of success. Trust in the therapist helps to ensure compliance with homework instructions. This may be difficult during women’s menses, however, as Surah 2, Verse 222 tells Muslims to avoid sexual activity during these times.

    Another exception to compliance can occur in reaction to masturbation exercises, which are prohibited in Islamic teaching. This may prohibit the prescription of masturbation—the most common method for clients without a partner or those whose partners do not want to be involved in therapy—as a means of treatment. Studies in Muslim countries have revealed differences between genders in the rates and acceptability of masturbation [33,34]. Clinical observations of clients with sexual dysfunction are consistent with these findings, and suggest that masturbation is more common and acceptable in men than in women [16••]. Aside from those who are very strict and rigid, Muslim clients generally do not question masturbation exercises. For those who are more flexible, masturbation exercises are prescribed as homework to be conducted with their partners. Manual stimulation is one of a wide variety of sexual therapy techniques, and may be used in the treatment of PE and vaginismus; its practice is encouraged in treating lack of sexual interest and orgasmic disorder. Depending on the flexibility of couples’ sexual repertoire, oral sexual activity may be encouraged to enrich their experience in cases of low sexual desire and orgasmic disorder as well. For those who refuse masturbation and do not have partners, it may be appropriate at times to prescribe pharmacotherapy. Anal sexuality activity is not suggested by sex therapists, but it is welcomed if it is a part of the couple’s sexual repertoire.

  6. F.

    Need for conjoint therapy

    Interestingly, studies conducted in Turkey, a secular Muslim country, have suggested that it is generally women who motivate men to seek any kind of help. Other studies have shown that after men present to a therapist, their attitudes influence their adherence to and success with the sex therapy [35,36]. A considerable number of male presenters are unwilling to bring their spouse to therapy sessions. In some couples, the wife is unwilling to come and discuss private matters (the subject of sex is taboo). Therefore, a kind of “remote-control” therapy is used, and the clinician has no direct way of knowing whether the program is implemented.

  7. G.

    Extent of involvement of other family members in dealing with sexual problems (more cultural)

    While the collectivistic nature of Islamic families is almost universal [37], couples exist on a continuum, with rigid boundaries on one end, and loose, permeable, and diffuse boundaries on the other. Those with loose boundaries must deal with enmeshment, where parental figures know the details of and intrude into the couple’s sex life. The over-involvement of other family members puts the couple under pressure. In some cases, interference by significant others has gone so far as wanting to be in the same room with partners who were doing homework in order to check whether it was done properly. In cases such as these, a culturally sensitive approach may be embraced, which consists in providing information regarding the situation to the significant other and explaining the importance of privacy, rather than assigning blame. This approach gives significant others the chance to discuss their concerns directly with the therapist, which may help to prevent intrusive acts on the part of family members.

  8. H.

    Public and school education

    The topic of sex is seldom discussed openly in Islam. Women’s sexuality has historically been viewed as something to be controlled, hidden, or conquered, most often by men. The shame associated with sexuality and being taught that touching of the genitals is wrong may prevent natural curiosity and discovery of the genitals, which may lead to fear of penetration (vaginismus). The lack of sex education in schools encourages the propagation of sexual myths, which in turn cause performance anxiety and sexual disorders in both men and women [38,39].

    Various interpretations of Islamic teachings may also negatively affect sexual health. For example, using contraceptive methods such as condoms may be viewed as putting a barrier to procreation against God’s will. A study conducted in Istanbul suggested a negative impact of cultural and religious beliefs on the use of medical contraception methods [40]. Thus, some couples may resist the use of condoms as advised by sex therapists to prevent pregnancy or the spread of sexually transmitted diseases.

    The use of explicit material for education may be problematic. Premarital sex is prohibited in Islam, leading to a lack of experience, lower sexual expectations, and performance anxiety. Concerns about the hymen as a marker for virginity are much less prevalent now than in the past, and people are more open to discussing the issue. For example, hymen repair has become a subject of considerable controversy in the Sunni Arab world in recent years [41]. While both male and female virginity are emphasized in Islam, there is no text in the Qur’an or Hadith that addresses the intactness of any part of a woman’s anatomy as a marker for virginity.

Table 1 suggests ways to adapt a consultation based on the culture and religiosity of the patient [42].

Table 1 How to Adjust a Consultation in Response to a Patient’s Culture/Religiosity
Full size table

Application of Culturally Sensitive Interventions in Place of Standard Sex Therapy: Case Examples

As discussed above, religious beliefs may have an impact on the presentation of couples. Two brief examples are presented here.

Case 1:

A Muslim couple married for 2 years was admitted for sex therapy due to vaginismus. In the first interview, the woman was very shy and reluctant to discuss anything related to her sexual feelings and experiences. When the therapist guided the conversation using a culturally sensitive approach, the woman admitted to feelings of guilt in talking to a male sex therapist, as her understanding of Islam did not allow her to discuss sexual issues with men other than her husband. Her request to be referred to a female therapist was handled with respect and in a nonjudgmental way, and she was asked whether the inclusion of a female co-therapist in subsequent sessions would an acceptable solution for her. The patient agreed and acknowledged that the presence of a female co-therapist would ease her guilt and shyness. This approach allowed the woman to provide the necessary information about her sex life and experiences. It also made it possible to provide the patient with education about genital anatomy and facilitated her ability to carry out her homework instructions.

Case 2:

A 29-year-old male patient who sought help for premature ejaculation (PE) and who did not want to reveal this problem to his wife was advised to conduct masturbation exercises. He told the sex therapist that he could not apply the “stop–start” masturbation technique, as he considered this a religious issue, and this was not acceptable according to his faith. He also reported that he had not attempted to masturbate since adolescence and that he would not share this problem with his wife, although she was most likely aware of the problem. After providing information about the treatment of PE, the therapist convinced the patient to invite his wife to attend the sessions so that she would be included in the process. The stop–start technique was successfully applied by the wife instead of self-masturbation, followed by resolution of the problem.

Conclusions

  • Sexuality and religion (within a cultural context) are interrelated, and each has an impact on the other.

  • In Islam, the rules governing sexuality are more restrictive, and religion may thus give rise to contextual sexual problems (such as performance anxiety). However, this is not always reflected in the volume of demands for help, as individuals may avoid the sharing of confidential information, and individuals may have difficulty in accessing qualified health care professionals who are trained in addressing sexual issues in countries with majority Muslim populations.

  • This restrictive nature of Islamic teaching may increase the suppression of natural sexual desire, which may impair an individual’s sex life.

  • As Islam prohibits any interaction on sexual issues between a female and a male outside the family, some degree of resistance to collaboration with a male therapist is generally expected. Therefore, some women prefer to interact with female therapists. A respectful approach is advised for those clients. On the other hand, it is important to note that Islam allows sharing sexual issues with others (e.g. healers, physicians, therapists) for treatment purposes.

  • Although Islam restricts all sexual activity outside heterosexual marriage, it encourages married couples to enjoy sex and to be sensitive to each other’s needs.

  • Interpretation of Islamic principles and their practice in real-life situations varies widely across different Muslim populations; hence, some are very conservative and inflexible, while others are more liberal and open to sex therapy.

  • Under these circumstances, professionals working in the field of sex therapy must develop a set of personal values that are both respectful and non-judgmental.

  • Therapists are responsible for assessing and working within the clients’ religious and cultural norms.

  • Tailored treatment programs that are sensitive to couples’ cultural and religious norms are more likely to succeed than standard package-type treatments.

  • There is no doubt that the religious dimension represents a challenge for sex therapists. But this should be seen as a welcome and healthy challenge, and it is certainly a rewarding one.

  • Special attention should be paid to religious issues in the training of therapists.

  • Most importantly, a major predictor of treatment success is therapist sensitivity to and respect of religious beliefs. This attitude may help overcome resistance to sexual behavior and sex therapy.