Tag Archives: Out-of-Control Sexual Behavior

Is Porn Addiction Really a Disorder? How Shame is Connected to Problematic Porn Use

What if the problem with frequent or problematic porn use was not the behavior itself, but how you, your partner, your religion and the culture around you judged it?  For the past twenty years since pornography became easily accessible online, there has been a tremendous amount of attention on the potential addictive qualities inherent in porn.  There has also been a huge growth in residential treatment facilities who offer sobriety and recovery programs for those that self-identify or whose partners identify them as “porn addicts.”

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There have been much discussion in sexuality research and clinical circles on possible new diagnoses and treatment models including: hypersexual disorder, Impulsive/Compulsive Sexual Disorder (ICSD), nonparaphilic compulsive sexual behavior disorder (CSBD) and Out-Of-Control Sexual Behavior (OCSB). As a sex therapist who sees clients who frequently come to treatment in crisis when their out of control sexual behaviors are threatening their marriages, relationships or jobs, I often hear clients self-diagnose as “porn addicts.” I recently began to run Out of Control Sexual Behavior Men’s Group in my practice. While there was not enough research to warrant a formal diagnosis in the most recent revision of the Diagnostic and Statistical Manual (DSM5) in 2013, in 2019 the World Health Organization included the novel diagnosis of CSBD in the 11th revision of the International Classification of Diseases.  

 

Porn Use and Relationship Challenges

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In a recent study by Beáta Bőthe et Al. from a large sample (13,778 participants) researching hypersexuality and problematic porn use, the results indicated that both impulsivity and compulsivity were weakly related to problematic pornography use among men and women, respectively. There is however, growing research that tells us that the frequency of porn use may not be the most critical variable associated with a person’s feeling dysregulated or out of control. Self-Perceived Problematic Porn Use (SPPPU) is a term referring to an individual who self-identifies as addicted to porn because they feel they are unable to regulate their porn consumption, and that use interferes with everyday life.

However, within academic research (Grubbs, Lee, et al., 2020; Vaillancourt- Morel et al., 2017) and my clinical practice, people who report problematic pornography use may do so independently of the actual number of times a week they’re using porn or the length of time spent online while watching porn. Thus, there is evidence that quantity or frequency may not be the only determining factor in whether a person reports feeling out of control in their use of porn. 

The problematic porn or self-described ‘porn addiction’’ use can be viewed more as a symptom of deeper psychiatric issues and/or relational conflicts the person has with others. 

In my clinical experience, which has been primarily with cisgender male clients, a client feels out of control due to the shame he feels when the type of porn he is watching is discovered by a partner and he/she feels disgusted by his erotic interests.

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In other situations, a client may feel angry with himself for paying a large amount of money to watch porn secretly. He feels guilty for what his partner and he may look upon as a ‘filthy habit’ that has eaten away at their joint savings.  At other times, if a client feels resentful of the sense of powerlessness he feels in his relationship or at work, his use of porn may be an unconscious expression of anger, freedom, revenge and liberation, a powerful antidote to this concoction of emotions that centers erotic and sexual pleasure to silence the feelings he can’t communicate effectively.

Part of the Sex Esteem model used with clients is to teach them how to identify what he is feeling by using mindfulness techniques to initially locate the emotion in his body.  If it’s anxiety, frequently a client will feel tightness in his chest, with shame he may report a nauseous sensation in his stomach. If he has not come to terms with his own rage, he may feel clenching his jaw area.  Frequently these clients report masturbating to porn then feeling deep guilt and shame afterwards. What he learns through individual and group therapy is that although he had a moment of reprieve from these intrusive feelings, his conflicts have not been resolved or communicated to the person about or to whom he feels angry, frustrated, ignored or worried.

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In a 2021 paper by Joshua B. Grubbs and Shane W. Kraus, the authors state that “although there is evidence that pornography use can be longitudinally predictive of negative relational outcomes, it is not clear whether such links are causal in nature, how prevalent such associations are in practical terms, and whether third variables (e.g., sexual orientation, sexual dissatisfaction, sexual misalignment between partners, religious differences between partners) are potential moderators.”  As a couples sex therapist, I hear about longstanding conflicts and misunderstandings that have been swept under the carpet repeatedly for years at times resulting in both partners feeling angry, defensive and frustrated.  The porn use may then be a strategy to avoid further conflict with a partner and more of a symptom of a deeper relational conflict.  

 

Porn Use and Internalized Cultural Shame

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For clients brought up in highly strict families or communities, sexual activity is rarely discussed among family members and informed sex education may be missing from one’s development. Frequently children and young teens internalize shame and guilt about sex in general including the experience of having sexual fantasies. 

Many self-perceived addictions are shame-based. Unlike diagnosed addictions to substances, porn addiction which one prescribes to oneself is, more often than not part of an internal conflict with values learned implicitly and explicitly in one’s family of origin and larger culture as to the:

  • “Right” way of having sex
  • “Normal” masturbation frequency
  • Accepted sexual orientation
  • Unacceptable fantasies if one identifies as heterosexual 
  • Potential sinful nature of masturbation in general 
  • Derogatory views of a person paying for pornography

Therefore, part of the Sex Esteem assessment is an in-depth inquiry into the implicit and explicit lessons learned from childhood around sexuality, religious beliefs, cultural norms, familial expectations regarding marriage, erotic taboos and the use of sexually explicit media.  I have worked with clients who have had strict Catholic, Muslim, Hindi and Jewish religious upbringings and educations. While they may still practice these religions and believe in a deity, they have not come to terms with how they want to have sexuality in their lives and relationships. 

In another study by leading porn researchers Joshua B. Grubbs, Samuel L. Perry, Joshua A. Wilt & Rory C. Reid the authors regard the problematic sexual behaviors a person who self-describe as porn addicts better understood “ as functions of discrepancies—moral incongruence—between pornography-related beliefs and pornography-related behaviors.”

This study puts some finality into the answers as to whether porn addiction is a true addiction. By reframing “porn addiction” as an “an incongruity between morals and behaviors,” the paper showed that the amount of time spent using porn does not predict problems with porn; rather, religiosity seems to be the bigger problem.

 

New Findings About Religiosity and Porn Addiction 

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An exciting new 2021 study from the Archives of Sexual Behavior by researchers David C De Jong and Casey Cook found that religiosity–the belief in a deity–had indirect effects on perceived addiction via shame. “…religious primes were associated with higher shame, and in turn, perceived addiction among individuals high on both organizational religiosity…” With regard to pornography addictions, those who self-reported as religious and who were more morally disapproving of porn were more likely to perceive addictions.

Religiosity, then, emphasizes the moral incongruence of porn by forming a system of belief. For those who worship a god, the use of porn depends less on the amount of minutes spent watching porn than the amount of pressure a sense of religiosity imbues on the time spent watching porn. Time is subjective. The misalignment between religious beliefs and pornography use can alter time.

 

Larger Cultural Myths in the Media 

Unfortunately, the self-help industry is able to perpetuate this sense of shame for their

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profit. In this way, religiosity and capitalism promote feelings of shame in their own self-interest. These are some things a “porn addiction clinic” may try to shame people into thinking:

  • People can become addicted to pornography in much the same way they can become addicted to drugs.”
  • They often conflate “sex disorder” with “porn addiction.”
  • “Porn addiction is the result of smartphones, social media and the Internet.”
  • “There is too much pornographic content in the world.”
  • Do not thoroughly examine the root causes of the problem.
  • They encourage a separation between the stresses of daily life and pornographic addiction. 
  • “There is such a thing as excessive porn use.”

The treatment models of Sex Esteem and the Out of Control Sexual Behavior used in my practice looks at porn use as an expression of all sorts of internal conflicts including moral incongruence, relationship struggles and potential symptoms of some underlying disorders that have never been assessed or diagnosed. For example, a client may have ADHD and plays  out in the distraction of porn to avoid doing mundane aspects of their jobs.  He may have a debilitating Anxiety Disorder and the porn use is a way of overwhelming feelings of anxiety. 

When seeking help for what one might experience as problematic porn use, it is critical to ask a potential therapist what their beliefs are regarding pornography.  Many therapists are also impacted by the culture at large and may regard frequency as a sign of compulsivity rather than using a larger biopsychosocial lens to help clients get more focused on what the behaviors mean, if they want to moderate them and giving them tools to do that individually, in a group and/or in couples therapy. 

What’s in a Name? Is Out of Control Sexual Behavior Treatment Really Different from Sex Addiction Recovery Programs?

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: 

AASECT:

 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: coordinator@centerforloveansex.com 

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.

“Prurience” Exposes 3 Controversial Topics in America: Sex, Porn Addiction & Recovery

While I’m not sure in what order they should be listed, I have spent years helping people say the unsayable, articulate what turns them on, and supporting their journeys in coming to terms with the particular consensual erotic interests they find most compelling. At CLS, we also help those who tell us they have a porn addiction or who find that their porn gazing has become out-of-control.  In a recent performance called “Prurience” created and performed by Christopher Green at the Guggenheim’s Works & Process Series, Green created a space in The Wright restaurant that while not a safe therapeutic environment, still encouraged some participants/audience members/performers to communicate what they are erotically drawn to when watching porn or how their porn watching became what they deemed to be an addiction.

Christopher Green in “Prurience”

Green invited participants into an unusual immersion/theater which was a combination of a 12-step sex addiction meeting, a confessional, a one-way-mirror-interrogation, and a-funhouse-mirror-maze. I was lucky enough to interview Mr. Green during his show’s run in NYC given how it reflects on some of the issues our clients are confronting given their porn use whether as an out-of-control behavior on their own or wanting to incorporate the fantasies they enjoy with a partner or spouse

I wondered if the impetus to create the piece coincided with the changes in UK laws regarding pornography. Green stated: “Funnily enough no, it happened all at the same time. Suddenly when I was writing it, David Cameron became obsessed with it and started legislating and talking about porn all the time.” In 2013 Prime Minister Cameron proposed having all porn blocked by internet providers in the UK, where Green grew up.

The audience is invited by the person we think of as the leader of the Prurience group, an American artsy-man with an effeminate inflection in his speech played by Green, to make a circle with the chairs as usual before the “meeting” begins. He is apologizing for being late and haphazardly setting up the product table in the corner, offering up swag printed with the Prurience logo. Once settled, he begins the group by asking participants to share their first memory of seeing porn for the first time. This question aligns with many of the questions we ask at CLS when conducting a Sexual History as part of a full bio-psychosocial assessment to learn about our clients, their families of origin, their education regarding sex (formal and otherwise) both through self-pleasuring and/or partner sexuality.

In this immersive theater experience, several participants shared the discovery of their father’s Playboy, or a friend’s older brother’s stash of videos, or searching online at sites like Pornhub. In our practice, clients express how they watched their parents hold hands, or kissed a “crush” for the first time in 5th grade at a friend’s house party or happened upon porn online at age 14. The firsts of our lives leave an imprint, and at times it is so strong that it becomes a go-to fantasy that one seeks to recreate again and again whether in one’s imagination, online, or with a partner.

In “Prurience” we are led to believe that the members of this so-called self-help group are struggling with so called porn addiction. While the term sex addiction was not accepted as a formal DSM5 diagnosis, nor has it been accepted by the American Association of Sexual Educators, Counselors and Therapists (AASECT), the terms sex or porn addiction has been popularized enough by people like Patrick Carnes, the unscientific YourBrainonPorn site and the many rehabs that continue to charge thousands of dollars to help people with sexual behavior they may find out of control, sinful, shameful and unfaithful.

At CLS we work with people who struggle with Out of Control Sexual Behavior or hyper-sexual behavior that have put their relationships, family and livelihoods at risk. In a structured, thorough assessment process we discover what other overlapping challenges, potential diagnoses, past trauma and/or relationship dynamics are contributing to the behavior and collaborate with the client on the treatment goals and individualized plans we recommend.

In the Prurience porn addiction meeting one soon hears from people who are revealing ever more detailed descriptions of what they like to watch, what they desire and the level to which these desires haunt their waking and sleeping hours. The comments are sharp, humorous, disturbing, self-flagellating, erotic, disgusted and intriguing.

SC: How important was it for you to create an Uber-reality of a 12-step meeting?

CG: “Yeah, I wanted to unsettle people because one of the effects of porn as we know one of the effects of porn is it’s deeply troubling, or arousing in the fundamental sense of the word. It alerts us and wakes us up…I wanted to try and replicate that in a theatrical setting”.

SC: “Like in a parallel process kind of experience?”

CG: “Yeah, absolutely.”

The term I used in this last question, “parallel process” is a psychotherapeutic term to express the feelings or dynamics that crop up in the relationship between a supervisor and a therapist who is telling the supervisor about a particular client. While relaying the issues, the dynamic may well unconsciously mirror the dynamic that is occurring between the therapist and their client.

In his run on the West End in London, Green told me that some audience members got up at the break and walked out, never to return. They were too disturbed, or embarrassed or uncomfortable to stay through the 2nd part. The topic of porn is still rarely brought up in general therapy but in sex therapy, we try to help clients describe what turns them on so that they can articulate it to their partner(s). If a person is into porn, or erotic novels or other fantasy-type trigger, describing a scene or exchange can help them formulate what it is that fires up their erotic ignition.

Green wondered how I felt at witnessing his role as group leader who didn’t really “hold” the members of the porn addiction recovery group in a safe space by setting clear boundaries on the length of people’s contributions or the intensity of what was shared even when someone seemed to be in a high risk situation.  I thought it was an astute question since in fact I was quite aware that the experience was theater and that his playing the role in a passive manner was intentionally done.  It certainly unnerved some folks who felt unsure of what was to come. Much like getting on a roller coaster that might make you nauseous, many audience members were rattled by the tea break. 

This lack of structure and support that one sees in the group is NOT like a professional therapeutic experience where a therapist lets a client know what comes next in the process, allows the client to ask questions, holds their fears so that they don’t become overwhelmed and may stop someone who becomes hurtful to another.  The therapist closely monitors the clients’ experience, and checks in to ensure that the sessions are going at an emotional pace that they can handle.

I asked Green about the fact that the group didn’t seem to have a performer playing a partner who has suddenly discovered their partner/spouse’s compulsive sexual habits and come to the group to express their shocked, hurt and angry reactions. He let me know that in fact in the original version of the piece there had been a female character who had discovered her husband’s porn use and ostensibly came to the meeting as almost one would go to AlAnon to get more education and support but that in the final edits made by the dramaturge, he lost this character which saddens him at times.

In our work with a client wanting help with their compulsive sexual behavior at Center for Love and Sex we at times work with the individual and refer the couple to another therapist for couple/marital counseling. in other cases we’ll work with both the couple and each partner individually if it seems like a better plan. Like any secret kept hidden for years, the ripple effect after the discovery of an out-of-control porn problem has tremendous impact on both the partner with the issue and the relationship. For many of our clients the recovery of Out-Of-Control sexual behavior includes the opportunity to speak about all sorts of issues (including their sex life) which had been swept under the carpet for years.

We help them understand the behavior, treat the underlying or coinciding disorders that might have contributed to the behavior and then help them and their partners begin the long road to rebuilding trust, expressing hurt, articulate anxiety, and describe erotic desires. The split-off part of their self that was continually numbed out through the compulsive behavior can now emerge and be known not only to the individual but to their partner. And the therapist helps them stay grounded through the at times painful,  anxiety-ridden process.

I’ll quote Chris Green with his perceptive reflection on therapy and theater to end this blog:

“I think a lot of therapy is sitting with discomfort isn’t it? It’s being able to turn your face towards the thing you normally turn away from. And it’s.. to put that into theater you have to sit with discomfort, you have to encourage people to sit with discomfort. And it’s only through that that we make any breakthroughs in life” .