The Sexual Therapies Obamacare Should Cover

The recent news that Obamacare will cover mental health raises some issues pertinent to a column on sex and politics. But before we get to that, let's go over a few guiding principles.

The premise of this column is that the way we orient ourselves to sex and gender helps form the pattern for much of what we do later in life—from our spending habits to our political beliefs. It's a major reason why liberals tend to be more permissive and conservatives tend to be more restrictive.

But not always.

Many conservatives also have a libertarian, freedom-loving side that can make them rowdy in the sack and surprisingly open to freakish behavior in others, while liberals are often driven by shame—they might want to put a dog collar on their spouses and make them crawl to the bed, but they don't because it's just not right. Puzzling out the relationships between these private sexual orientations and our political or philosophical beliefs is an important task in an examined life—even a spiritual mission, as William Butler Yeats so eloquently argued:

Love has pitched its mansion in the place of excrement.
For nothing can be sole or whole that has not been rent.

In my own life, I've struggled with these issues. For example, there was the time a dwarf had a crush on me. I liked her in every way, but I just couldn't go there. I told her I wasn't that good of a person. She kept telling me that goodness had nothing to do it, and I just didn't understand. About 10 years later, I had dinner with Betty Dodson, the great masturbation pioneer and "pleasure activist." She was in her sixties; her boyfriend was 27. They were very sweet together. Any ick factor I might have presumed from such a radical May-December romance faded quickly in the face of their adorable humanity.

As we walked away from the restaurant, Betty said, "I've always been a democratic fuck."

A democratic fuck?

"Yeah. Old, young, fat, skinny. You never know. Sometimes the ugliest people are the best in bed."

That got me thinking about something I call "threshold behavior." I came up with the term the first time my wife and I went to a sex club and went back and forth on the threshold about 10 times before we got the guts to go inside—because love has pitched its palace in the place of excrement and we're never sure if our sexual adventures are going to end in joy or turn to shit. So we take drugs or drink to get over the threshold. Or we insist on beauty as an entrance requirement, a gambit particularly important to men. As long as he or she is hot enough, we figure it's worth taking the risk of rejection.

Which brings us to Obamacare and mental health. Since sexual problems such as body dysmorphia and gender confusion are foundational to so many mental health problems, not to mention drug abuse and alcoholism, and since one of the rationals for universal health care is to encourage people to practice preventative health care instead of waiting for disease to strike, it makes sense for health insurance to take such problems seriously. Obviously there's a limited pool of money here, but it's still worth asking: What kind of sexual therapies would Obamacare cover?

I figured Kathleen Sebelius and the Department of Health and Human Services had enough to do this month with the debacle that's healthcare.gov, so I went direct to the health-insurance companies. At the national headquarters of Blue Cross Blue Shield, a public relations guy told me all treatment decisions are state-specific and gave me numbers for the spokespeople in California and New York. In California, I made contact with a spokesman named Darryl. I asked him what treatments Blue Cross authorized for sexual dysfunctions.

He seemed surprised. "This is not a question I've ever been asked before."

It was my turn to be surprised. Really? After all the publicity about Viagra over the last few years—and most insurance companies do offer some coverage for Viagra—not one reporter has called asking if they cover anything else? Spanish Fly? Oysters? Sex surrogates?

He wasn't too chatty. "If you give me your information, I can get you to the person who can answer your question."

Darryl never called back, though I left several messages. A few calls to the New York office went unanswered, too. So I tried contacting someone else who might know—Mark Shattuck, the "media chair" at the International Professional Surrogates Association. Shattuck's somewhat frosty e-mail reply helps explain why they left "sex" out of the name. "Before I get into your inquiry, some clarification: Although you can find surrogates who refer to themselves as 'sex surrogates,' for most of us the preferred terminology is 'surrogate partner,' and the process is Surrogate Partner Therapy. The surrogate 'partners' with the client and this partnering may take many different forms. We partner with the client to create a real-life environment for experiential learning related to touch, body image, relationships, communication, intimacy, emotional awareness and expression, overcoming fear and anxiety, and possibly sexuality, if the therapist, surrogate and client all agree that it's in the client's best interest and that it's necessary for them to reach their goals. Less than 15 percent of the time surrogates spend with clients is spent in activities that could be considered 'sexual.'"

Thanks for clearing that up! I can't imagine why people in America would need sex therapists when the sex therapists—excuse me, surrogate partners—themselves are actively sex-positive "less than 15 percent" of the time.

But I shouldn't be snarky. Shattuck and his colleagues are trying to do something that many Americans equate with prostitution, and not in a nice way. At least they're trying. And he did provide me with a piece of the answer I was looking for: "Currently, no health insurance in the U.S. pays for this type of adjunct therapy."

Those are my italics. Because when you think about it in a rational way, it's a little shocking. In a country where we are bombarded with images of sexuality at the same time we're bombarded with priggish messages about "abstinence education," in a country where rape is rampant and gay kids commit suicide at depressingly frequent intervals, the only sex-related treatments that insurance companies consider valid are erection pills for men. Even the Catholic health plans that ban birth control support the use of Viagra. It's true that old-school talk therapy sometimes addresses sexual problems, but coverage for that is becoming rarer and rarer and "couples therapy" is usually not covered at all, a trend that's unlikely to change under Obamacare. Treating the symptom instead of the cause is fast, superficial and profitable for giant corporations.

Contrast this with Germany, which recently mounted a remarkable nationwide attempt to address one of the most pressing sexual problems of our time. Jesse Bering tells the story in his new book, Perv: The Sexual Deviant in All of Us. "In a creative effort to address child sexual abuse, the German government launched a massive media campaign in 2004 to encourage self-identified pedophiles to reach out and get help from supportive professionals. Using a blitz of public service announcements—highway billboards, prime-time television commercials, full-page newspaper ads, spots before movie previews in cinemas—in the hopes of coaxing police-wary pedophiles out of the closet, the ad campaign read, 'Do you like children more than you/they like?' This was accompanied by images of coquettish children. 'You are not guilty because of your sexual desire,' it went on to say, 'but you are responsible for your sexual behavior. There is help! Don't become an offender!'"

First off, the tone of forgiveness and non-judgement is astonishing for any government. But even more remarkable is what happened afterward. "Over the next three years," Bering reports, "808 men responded to the ads."

Think about that. 808 pedophiles contacted a government agency and asked for help. True, only 358 followed through with face-to-face meetings, but those included men who had traveled from as far away as Austria, Switzerland and England to get help. Imagine all the children who were spared abuse, not to mention all the ripple effects of misery that didn't happen.

But even this focuses on dysfunction rather than pleasure itself, which is also important to mental health. Internationally, the most progress on this front seems to be focused on easing the sexual isolation of the disabled—in Australia, for example, police tend to look the other way when sex workers service disabled men. But my favorite attempt at actual Marvin-Gaye-style sexual healing is the White Hands service in Japan, which provides "ejaculation assistance" for between 80 and 100 disabled Japanese each year. On their website you can see a remarkable documentary VICE Japan made earlier this year. The film opens with a pleasant young woman named Sayori Tanaka explaining why she got into the business after working as a regular caregiver to the mentally disabled. "Most people with mental impairments haven't had any sexual experience, and they haven't been taught how to deal with the desires welling up inside them. Often, they can't even comprehend what those urges are. As a result, often they would rub up against me, or if I moved out of their sight, they would get uneasy and start hurting themselves. They can't process the sexual excitement. This kept many of my clients from living fulfilling lives."

Moved by their dilemma, she adds, she felt "a sense of duty."

In contrast, the director of the White Hands program appears and tells a little story about a mother of a man with Down Syndrome who insisted that her son was "an angel completely free of sexual desire." But actually, the boy would get visibly aroused whenever he saw female pop singers on TV. "Clearly," the program director says, "the problem is with the mother rather than with the son."

From here, the camera follows the saintly Tanaka as she goes to service a client named Yuji Hosoya. When she arrives at his apartment, he's lying on a tatami mat, his body and arms severely twisted from cerebral palsy. While Tanaka washes her hands, they discuss the cherry blossoms, which are blooming early this year—god, I love the Japanese. Then she slips on some plastic gloves and gets to work.

It's all very kind, if a bit impersonal. "I'm going to pull your pants down, okay? ... I'm putting the lube on. … Do you want me to do it harder? … The tip? Here?" As she gets going, his twisted arm starts hitting the tatami rhythmically. It only takes a minute or two.

The really remarkable stuff happens afterward. With a touch of sadness, Tanaka says the whole thing usually takes only 30 minutes. "I arrive, prepare, massage them, they ejaculate and that's it, goodbye. It all feels a bit empty. I think our clients yearn for something that's more emotionally involving. Something that isn't just caregiving, you know?"

Then Hosoya says his piece. None of his disabled friends use the service. They just can't bring themselves to do it. "But I've always been open-minded with a fearless attitude, so I wasn't resistant to the idea. Disabled people are human, too. We also have needs and desires. I have particularly strong desires."

He grins, which is even more poignant since he's writhing around and his voice is horribly distorted by his disease. "It's only natural that I have sexual needs," he adds. "Because I'm human. Many people don't understand that. They just can't comprehend it."

All I can say is, thank god for the sisters of mercy. It's too bad they can't go beyond caregiving, but in this fallen world where universal love seems so impossible, a little human touch sure helps.

Alas, even in Japan, there are limits. In a brief e-mail exchange, a White Hands representative told me that the funding came from "service fees from users," with no contributions from government or business. So I wouldn't hold my breath for Obamacare.

But we can dream. We can become pleasure activists. And we can open our minds to the concept of the democratic fuck.


John H. Richardson is the author of My Father The Spy, In the Little World and The Vipers Club.

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