What IS so important about the name of a pattern of sexual behavior? A new term called Out of Control Sexual Behavior is closer to the clinical frame I have used to help clients coming in to CLS for help to stop their compulsive sexual encounters. People diagnosed–casually, jokingly, or professionally–as suffering from “sex addiction” might want to think twice about what this term implies and how it in fact will impact their therapeutic treatment, how they feel about themselves and the relationship with partners (if they are in a relationship).
Although most people in the field of sexual addiction cite Patrick Carnes as a the father of the term sex addiction, it was actually a Cornell psychiatrist Dr. Lawrence Hatterer, who defined homosexuality as a pathology, conflating homosexuality/queerness with “addictive hypersexualized living” and “addictive sexual pattern.” The term he wrote about argued that a sexual orientation was an illness. He unfortunately stood by this opnion both before and long after homosexuality was removed as a diagnosis from the Diagnostic and Statistical Manual (DSM).
But Carnes popularized the term sex addiction, putting it on the map in America by creating a list of thoughts, feelings and behaviors that he cited were proof of of a pathological diagnosable disorder. He created the Sex Addiction Screening Test (SAST) that attempts to create a differential assessment of addictive vs. non-addictive behaviors. However, this assessment is still prone to pathologizing certain sexual behaviors deemed alternative, or kinky.
Many of the treatment recommendations in his curriculum and at many of the sex addiction programs or 12-step groups around the country are based on heteronormative expectations in sobriety including only having sex with one’s spouse, no casual sex at all and/or no masturbation with or without porn. There has been a long debate between Certified Sex Addiction Therapist (CSAT) and AASECT Certified Sex Therapists and Counselors. As part of their training, CSAT therapists have historically not received training in established Sexual Disorders in the Diagnostic and Statistical Manual, sexual anatomy, ethics nor education on the diverse practices of sexual health.
These are requirements in the AASECT Certification Training.
I would argue that Carnes regards the sexual behavior itself as the illness. Sex therapists view the sexual behavior as a symptom.
Sex therapists utilize a Sexual health model that understand that even though some people may feel tremendous shame about the erotic interests and sexual behaviors they enact, frequently there is nothing inherently pathological about them. The behavior may feel out of control because it’s against one’s values or it may be tied with an underlying untreated diagnosis. The term and treatment of sex addiction may not thoroughly assess and treat underlying established diagnoses like: Depressive Disorder, Biploar Disorder, Attentional Deficit Hyperactivity Disorder (ADHD), Panic Disorder or PTSD. Many clients who report years of Out of Control Sexual Behavior may have in fact experienced attachment trauma by a loved one who abandoned them, severe neglect or physical or sexual abuse early on.
The organization solely responsible for certifying Sex Therapists in the U.S., American Association of Sexuality Educators, Counselors and Therapists (AASECT), released a statement calling for the retirement of the term “sex addict” referring to it as a treatable illness including this section:
1) does not find sufficient empirical evidence to support the classification of sex addiction or porn addiction as a mental health disorder, and
2) does not find the sexual addiction training and treatment methods and educational pedagogies to be adequately informed by accurate human sexuality knowledge.
Therefore, it is the position of AASECT that linking problems related to sexual urges, thoughts or behaviors to a porn/sexual addiction process cannot be advanced by AASECT as a standard of practice for sexuality education delivery, counseling or therapy.”
There have now been several suggestions put forth by sex therapists and/or researchers for behaviors that contributes to negative outcomes socially, professionally and relationally. These include:
- Compulsive Sexual Behavior (Eli Coleman): “…the experience of sexual urges, sexually arousing fantasies, and sexual behaviors that are recurrent, intense, and a distressful interference in one’s daily functioning”
- Hyper-Sexual Behavior (Martin Kafka): “a sexual behavior disorder with an impulsivity component.”
- Out-of-Control Sexual Behavior (Doug Braun-Harvey): “a sexual health problem in which an individual’s consensual sexual urges, thoughts, and behaviors feel out of control [to them]” (p. 10, Treating Out of Control Sexual Behavior).
These are all different names that do NOT include the term addiction but instead utilize a model that points to underlying disorders, internalization of shame in the face of not living up to one’s values and the ambivalence around changing. They also point to behavior that is more linked to underlying psychiatric disorders than a process oriented addiction.
I believe two of the greatest strengths of the Out of Control Sexual Behavior model are that it not only addresses potential underlying causes of compulsive sexual behavior, but also that it is focused on organizing around and encouraging the individual’s unique expression of sexual health through wanted sexual behavior–which the Sex Addiction model fails to do.
When a client comes in to our office self-identified as a “sex addict” we look at the whole person, their family of origin, their religious beliefs, how and when the pattern of sexual behavior began, whether they have a history of abuse, whether their symptoms line up with a proven psychiatric disorder and how the secretive nature of their sexual practices play into the beliefs they have about sex, fantasy, consent, monogamy and desire. We ask them to create a sexual health plan that allows for all the disparate parts they’ve been splitting off into secretive sexual behaviors to come together into one person who is supported in their search for personal integrity and potential treatment for underlying issues.
What CLS therapists offer is individual therapy and couples work to help clients who are struggling with sexual behaviors that are negatively impacting their mental health, their job, and or their relationships. We work frequently with clients who are having affairs, hook-ups or encounters with sex workers that feel split off from their own sense of what it right, and hurts their partners or spouses when it’s discovered. On Oct. 20th, I’ll be co-leading a small group-oriented men’s therapy group that creates a safe space for all those in distress to come together and reassess how their sexual habits have gotten out of control and learn new skill to help their behavior align with their own values. Sexual shame thrives in secrecy, and addressing it head-on with others sharing the same difficulties helps to chip away at the shame while allowing a space to consider and create new choices that are supported in a sexual health plan that belongs to you.
I am co-leading the 6-week Men’s Out of Control Sexual Health group with my colleague Shimmy Feintuch LCSW. It is designed for those identifying as male who feel that their sexual behaviors are out of control and that they want to get more information on why they’ve continued these behaviors despite its negative impact. If you feel this group could help you or someone you know please email my intake coordinator for more information: firstname.lastname@example.org
The goals for this group include:
- Having each member define what their sexual health goals are
- Identifying the internal conflicts they have regarding these goals and their current behaviors
- Learning about potential underlying disorders which may have never been diagnosed and treated before that contribute to their behavior like: Depression, Panic Disorder, Obsessive Compulsive Disorder, ADHD, PTSD, Bipolar Disorder and finding sources for treatment
- Learning new stress and coping mechanisms including: mindfulness, CBT, Embodied recovery for trauma-induced dissociation
- Developing integrated and positive coping in their sexual lives
- Relational skills to communicate sexual desires to existing and future partners
- Increasing one’s core Sex EsteemⓇ
While the last task force of the DSM (#5) considered the term Hypersexual Disorder, they felt there wasn’t enough solid evidence to prove that this best describes a clinical pattern of behavior. The most recent International Classification of Disorders-#11 did include Compulsive Sexual Behavior Disorder, defining the pattern as repetitive sexual activities that may become an essential focus of a person’s life to the point that they neglect their health and personal care or other interests, activities and responsibilities. Other symptoms may include continued repetitive sexual behavior despite negative consequences or receiving little or no satisfaction from the behavior.”
So while there are many diagnostic names and criteria still being studied by American researchers and clinicians for a pattern of compulsive sexual behaviors, NONE of these terms include the wording or clinical treatment framework of addiction.