Using Islamically Integrated Psychotherapy for the Treatment of Sexual Issues in a Muslim Male: A Pakistani Case Study

Sample Characteristics and Presenting Complaints

The client was an unmarried male of 30 years of age, belonging to a lower-middle socioeconomic class, with an undergraduate education, and unemployed at the time he reported for therapy. He presented with the complaints of wanting to abstain from performing non-marital sex and guilt about excessive masturbation.

Case Presentation

The client was a 30-year-old Pakistani Muslim male who reported to the client consultation unit of a Pakistani public sector university in the summers of 2016. His problem started sometime around the year 2008, when he was 22 years of age. He reported that he was -passing by a friend’s house when that friend’s wife stopped him to have a word with him. She complained to the client about her husband’s rude and aggressive behavior. His friend’s wife requested the client to talk to her husband about it. The client agreed to it and left for his own home. After that, the client reported that he had repeated encounters with that lady and soon they became close. According to the client, one day when the lady’s husband and her children were not home, she called the client and took him to her room to have intercourse with him. She showed him pornographic movie clips and performed the same kind of sex with the client as shown in the movies. According to the client, he neither gave his verbal consent nor protested and just let it happen. He also did not report feeling any emotion at that time.

The client accounted that when he came home the first time after that woman talked to him about her home circumstances, he discussed it with his mother and sought her opinion whether he should talk to his friend about it but his mother protested and stopped him from intervening in their personal matter. The client reported that he did so anyway and now he sometimes blames himself for doing so. He added that he was taking training for commission in the forces and had also started a diploma but left both midways because he had been in a mental fix due to this situation and could not concentrate on anything else properly. He said that he did not find it hard to concentrate otherwise but that his circumstances led to poor concentration.

Thereafter, the two of them had intercourse repeatedly. Sometimes the woman would call the client and at other times, he would go to her himself. The intercourse was always performed at the woman’s house. According to the client, he never felt any emotional attachment with that woman. The woman had three children from the client’s friend and when she divorced the client’s friend and married another man, the client still never felt any emotion. According to him, he never liked or loved her but only went to her to meet his need. He was even aware of the fact that whatever he does is morally wrong but according to him, it was a sudden drive that arose and took over his senses, ultimately leading him to contact that woman again.

The client reported that he had often tried to get away from her but somehow it all started again because either that woman would contact him or client himself would contact her. He had even deleted her contact number from his phone a couple of times but by now he had unintentionally memorized it and could always contact her when the same impulse overwhelmed him again.

According to the client, he was also habitual of masturbating excessively after having intercourse. He almost always masturbated after he returned home from her place. He said that he felt ashamed for masturbating because he believed it to be a highly immoral activity. He was extremely distressed for doing such immoral activities therefore, he seldom, if ever, masturbated or watched porn alone or for the mere purpose of enjoyment.

It was also reported that the same woman had tried to set the client up with other women but he never met them. He added that he never went to any other woman to have intercourse with whenever he felt the need nor did he have problems with controlling his desire when he saw other women. The only problem was that whenever he felt an urge to have intercourse, he always contacted that same woman though he did not even feel any emotional attachment. According to the client, the reason for this might be that this woman was more physically welcoming than any other woman and that she knew well by now how to satisfy the client.

The clinician inquired if the client was “guilty” of having a sexual relationship with his friend’s wife or for masturbating, to which he responded in negation for the former but in affirmative for the latter. He reported that he did not particularly feel guilty about his illicit sexual relationship because sometimes a complete year would go without them meeting, during which the feelings of minor shame and regret would subside. Another reason he did not feel guilty about it was that it was the woman who first approached him for this interaction; the client himself did not coerce her into it. The client also blamed the woman for being unrighteous and ignoble and for seducing random men to meet her physical needs. Though the client had reasoned with himself that it was not his fault that he was a full participant, he still felt somewhat ashamed for always falling into her trap. On the other hand, the reasons he gave for feeling guilty toward masturbation were religious in nature. Masturbation is what he did for his own satisfaction and he was extremely guilty for doing it because the religious scholars he sought counsel from had labeled it as haram (forbidden). When the client was asked if he had told anyone at home about his issues, he said that no one in his family or acquaintances knew about him meeting with his friend’s wife this often.

In July 2016, the client sought therapeutic assistance for the presenting complaints of feeling ashamed of having an uncontrollable urge to have intercourse with his friend’s ex-wife and excessively masturbating after having done that.

Religious Inclination

According to the client, he was really inclined toward religion. He prayed regularly and he had even been taking guidance from several religious scholars regarding the teachings of Islam.

Theoretical and Research Formulation

Until the first half of the 20th century, sexual relationship between two people prior to them being in wedlock was referred to as “premarital sex”. The term fornication was replaced for the negative connotation it held.

More recently, the term is used more for any sexual relationship a person has before marriage and less for the nature of the relationship between people involved. This definition is somewhat ambiguous. What remains to be decided is whether the term should be specified for those uninterested in marrying or those legally forbidden from marrying (Thomas, 2010).

Because of the ambiguity of the term “premarital sex”, some alternate terms such as, youthful sex, young-adult sex, adolescent sex, and non-marital sex (which overlaps with adultery) have been used. To some extent, all these terms remain to be rather vague.

The present interpretation of premarital sex is any sexual relationship between two people who are not married. In the past, premarital sex was considered a sin by most religions and a taboo by many cultures. The latter half of the 20th century saw acceptance of it by most Western societies.

There is some data regarding the prevalence of premarital and non-marital sex in Muslim countries in comparison to Western countries. A study conducted on global morality in 2014 concluded that public opinion in many Muslim nations (e.g., Saudi Arabia, Indonesia, Egypt, and Pakistan) considered premarital sex unacceptable, with over 90% disapproval rate. Contrarily, Western European countries including Spain, Germany, and France expressed less than 10% disapproval and largely showed acceptance (Pew Research Center, 2014).

Indonesia accounts for the world’s largest Muslim population with over 209 million Muslims, 97% of which disapprove of adult premarital sex. Most religions strictly prohibit having sex before marriage. Therefore, countries that are ideologically religious, such as Pakistan and Jordan are also of the same belief. European countries including France and Germany show 57 percent and 47 percent acceptance, respectively. The statistics for the United States show that 29 percent of people consider premarital sex morally unacceptable (Statista, 2014).

A study conducted in the American Sociological Review concludes that Muslims and Hindus, especially those in the developing zone, are more likely to abstain from extramarital sex as compared to Christians and Jews. The study compares practicing people from all religions and the figures depict Hindus to be the least in number (only 19%) to have reported of premarital sex. Other faith practitioners included 43 percent of Muslims, 65 percent of Buddhists, 79 percent of Christians and the highest percentage was reported by Jews, with 94 percent. In most Muslim countries around the world, the interaction between the sexes is relatively lesser, therefore the chances of them meeting a potential partner are also few (Adamczyk & Hayes, 2012).

Incidence of masturbation by partners after intercourse has been studied in a recent study by Regnerus, Price, and Gordon (2017). Partnered sex in relation to masturbation has been explained by two main theories. The complementary theory says that the quality of partnered sex enhances as a result of masturbation. Therefore, masturbation improves the partnered sex. The compensatory model, on the other hand, suggests that desires which go unmet during partnered activity are substituted by masturbation by people in relationships. The study found that the compensatory theory holds true for men, and complementary for women.

Despite having a history of general religious and social condemnation, masturbation is considered a part of normal sexuality and a common sexual practice. While masturbatory taboos cause a pervasive sense of guilt in those who practice it, there is little evidence to a subsequent decrease in its occurrence. The guilt is caused due to violation of internalized standards and the person desires to make amends or punish oneself (Castellini et al., 2016).

Cantor and colleagues (2013) described cases of sexual guilt in which clients reported distress as a result of sexual behaviors, whereby they often reported sufficient symptoms to have been previously diagnosed as depression. Greenberg and Archambault (1973) found that 40% of university students reported feeling guilty of indulging in masturbation-related activities. More recently, Choi and colleagues (2000) examined the masturbatory experience of young Korean men in military service, 10.9% (132 of 1,212) of which reported feelings of guilt. Castellini and colleagues (2016) coined the term ego-dystonic masturbation (EM) for masturbation followed by a sense of guilt. Distress after masturbation may be determined by the act of masturbating per se or by an excessive involvement of sexual cognitions and behaviors. The latter condition has been associated with several psychopathologic features (Kafka, 2009). Hypersexual behavior is often characterized by excessive masturbation which the person is unable to control. It is often accompanied by a sense of guilt and leads to functional impairment (Kafka, 2009; Bancroft, 2008). Most researchers agree that subjective distress and/or impairment in at least one important life domain as a result of excessive inappropriate sexual behaviors or cognitions is a chief characteristic of EM (Black, 2000).

An explanation put forth by some researchers holds that compulsive sexual behavior disorders are repetitive in nature which are aimed at anxiety reduction and lowering other related dysphoric affects such as depression and shame. This behavior is symptomatic of an underlying obsessive compulsive disorder (Black et al., 1997; Coleman, 1987). On the other hand, a group of investigators including Castellini and colleagues (2016) and Hoyle, Fejfar, and Miller (2000) hold an opposing view; according to them, severity of ego-dystonic masturbation is not so much associated with obsessive-compulsive symptoms, which is one pole on the ‘obsessive-impulsive continuum’. In their studies, they concluded that the EM group reported fewer anxiety/phobia symptoms as compared to non-EM group. The other end of the continuum is “sensation seeking”, often similar in presentation to impulsive disorders. Impulse control disorder is defined by DSM as a failure to resist a drive, impulse, or temptation to perform an activity that end up harming the person himself or others. Usually, such an act is preceded by a heightened sense of arousal or tension which then results in immense gratification, pleasure, or relief at and immediately after the activity is done. The act may or may not result in self-reproach, regret, or guilt in the long run (American Psychiatric Association, 2000). As a support, the frequent occurrence of impulse control disorders in the studies by Raymond and colleagues (2003) and Black and colleagues (1997) confirm the impulsivity-spectrum hypothesis for EM.

The integration of religious teachings and spirituality with the mainstream psychotherapy (or Western models of mental health) has been long studied. The significance of spirituality and religion has been endorsed by many health care professionals who frequently incorporate spiritually oriented approaches into their clinical work (Jackson, 2014). The efficacy of spiritually oriented mental health treatment is evidenced by a number of psychotherapy outcome studies (Anderson et al., 2015). A term, Islamically Integrated Psychotherapy (IIP), has been assigned to the mode of psychotherapy that integrates Islamic principles, teachings, philosophies, and intervention modalities with Western therapeutic approaches (Al-Karam, 2018). Likewise, RCBT is a relatively newer therapeutic approach which incorporates principles of theism into the standard CBT, based on the faith of the client (Pearce et al., 2015).

Diagnostic Formulation

The client’s problem was categorized under the following DSM-5 code: V65.49 (Z70.9) Sex Counseling

Prognosis

The client had been very vocal about his problem and he entrusted the therapist readily with his information. He was also observed to be very compliant to treatment protocol and the inclusion of religious references, for he was greatly inclined toward religion and frequently sought advice of the imams of his local mosque. When asked about his family’s financial condition, he accounted that he only had one brother who was married. The client’s brother was employed as a lecturer in a government sector university. He was very supportive of the client and encouraged him to complete his education before looking for a job. The client’s father was deceased and his mother was alive. His relationship with his mother was congenial. These characteristics of the client showed that he had good prognostic features. In addition, the client was, in Schofield’s words (1964), YAVIS (Youthful, Attractive, Verbal, Intelligent, and Successful); these characteristics lend themselves toward a better prognosis in therapy.

Aims and Objectives

In a Muslim-majority, conservative country like Pakistan, the ratio of public opinion condemning non-marital sex and subsequent masturbation immoral and unacceptable is among the highest. It is likely to lead those who practice it to feelings of shame, guilt, or distress. They may make deliberate efforts to abstain from it. If practicing such acts leads the person to mental health issues and guilt, which mainly stem from religious grounds, it is assumed that a wide array of techniques under the umbrella of IIP and RCBT will be able to bring relief to people who suffer from it.

Method

The case in question was approached via a single subject AB design. The client presented with the complaints of wanting to abstain from performing non-marital sex and guilt about excessive masturbation. On the premise of Religiously Integrated Cognitive Behavioral Therapy (RCBT), whereby religion is incorporated in the already established techniques of CBT, the client was assisted to develop distress-reducing thoughts and behaviors informed by his own religious beliefs, resources, and practices (Pearce et al., 2015). This approach will extend the literature and add strength to what is already known, as prior research has not addressed the step-by-step application of IIP and RCBT for helping a client deal with sexual issues.

Outcome of the Therapy

Huge improvement was seen in the client as a result of the aforementioned therapeutic interventions. He reported that he now felt very positive about himself. In his own words, “It seems now I have a queer force inside of me that can deal with any negativity I might experience in the future”.

The improvement in client’s symptoms has been depicted in the pre- and post-assessment visual analogue.

Graphical representation of pre- and post-visual analogue ratings of the presenting complaints.

Post-formal Assessment

Negative Attitude towards Masturbation Scale

Quantitative Analysis

Scale	Score	Status
Negative Attitude towards Masturbation Scale	60	Low level of guilt

Table 2.

Comparison of Pre and Post Assessment of Client’s Visual Analogue

Presenting Complaints	Pre-ratings	Post-ratings
Giving in to the urge to perform sexual intercourse with friend’s wife	10	2
Having negative attitude about masturbation	10	1

Graph 1.

Comparison of Pre- and Post-Assessment of Client’s visual analogue

Qualitative Interpretation

The client scored 60 on the post-assessment level of Negative Attitude towards Masturbation Scale, which shows a considerable 56 points decrease in his guilt regarding masturbation, thereby, suggesting that the therapeutic interventions had helped in bringing down his level of guilt.

Discussion and Conclusion

This case study had two main arguments. The first concerns the use of religious mode of psychotherapy as quite beneficial for treatment of sexual concerns as exhibited in the amelioration of client’s condition. Especially incorporating credible references from religious aspect can be efficacious in convincing a client with the same characteristics as the present case. However, the attributes that resulted in good prognosis of the present case may also be needed in future cases for therapies like R-CBT to be successful, lack of which thereof may question its usefulness.

The second argument revolves around establishing sexual behavior as an impulse or an obsessive tendency. There has been ample evidence for both in the past, as discussed under theoretical background but the present case adds weightage to it being an impulse, as in the words of client himself, “I feel a sudden urge to do so”, which can clearly be interpreted as a drive or impulse and not an activity done merely in order to reduce anxiety or stress as a consequence of a thought. The latter explanation, advocated by proponents of obsessive compulsive extreme of continuum may however be a consequence of delayed impulse, an idea which is open to debate.