A Sexological Approach to Trea9ng Compulsive Sexual Behavior

A Sexological Approach to Trea1ng Compulsive Sexual Behavior Assessing and Treating Sexual Concerns in Couples
Richard M. Siegel, MS, LMHC, CST, AASECT
AAMFT Winter Institutes for Advanced Clinical Training
Santa Fe, NM
March 9, 2013
Statement of Non-­‐Disclosure Mr. Siegel has no financial rela8onships or affilia8ons, or any other conflicts of interest to disclose. His presenta8ons at the AAMFT 2013 Winter Ins8tutes for Advanced Clinical Training are not being underwriMen or funded by any sponsor or exhibitor. Statements or opinions expressed during the presenta8ons are those of the presenter exclusively, and cannot be construed in any way as agreement, approval, endorsement or posi8on of the AAMFT. Though Mr. Siegel serves on the Board of Directors of the American Associa8on of Sexuality Educators, Counselors and Therapists (AASECT), he is not presen8ng in that official capacity; neither can any statements be taken to be posi8ons of that organiza8on. Contents of this presenta8on and all accompanying materials are considered covered by implied copyright. Please do not use any presenta8on materials without expressed permission of the presenter. Sexuality in Addic8on and Chemical Dependency •  Con8nues to be overlooked and under-­‐
studied, both in the addic8on field and in sexuality educa8on. •  Healthy sexual development is likely to be impacted by substance abuse and chemical dependency Sexuality in Addic8on and Chemical Dependency •  MANY areas where sexuality plays a role in addic8on, but the primary diagnosis does not change (i.e., addic8on s8ll refers to chemical dependency, not sexuality as a “co-­‐addic8on”) •  Sexuality issues can be iden8fied at every phase of chemical dependency, from early substance use (“experimenta8on”) to “ac8ve addic8on,” as well as in every stage of recovery from chemical dependency •  Switching addic8ons? Overlap of Substance Use and Sexual Development It is probably safe to say that many people, and the vast majority of those with chemical dependency, have had their sexual development affected in some way by being under the influence. Developmental Issues for Teens (and the Conflicts of Polarity) Asser1ng Independence and Rebelling vs. Adult Control -­‐-­‐ Need for Direc1on Separa1ng from Family & Expressing Individuality -­‐-­‐ Being Part of a Group Culture Need for Closeness -­‐-­‐ Fear of In1macy Resis1ng Limits -­‐-­‐ Needing Limits Thinking About Future -­‐-­‐ Oriented to Present Moment Sexually Mature -­‐-­‐ Cogni1vely Not Ready Forming Sexual Iden1ty (Defending Self) -­‐-­‐ High Risk Behavior (Endangering Self) -­‐-­‐ Adapted from Scheidlinger, 1991 Developmental Issues for Teens (and the Conflicts of Polarity) Asser1ng Independence and Rebelling vs. Adult Control -­‐-­‐ Need for Direc1on Separa1ng from Family & Expressing Individuality -­‐-­‐ Being Part of a Group Culture Need for Closeness -­‐-­‐ Fear of In1macy Resis1ng Limits -­‐-­‐ Needing Limits Thinking About Future -­‐-­‐ Oriented to Present Moment Sexually Mature -­‐-­‐ Cogni1vely Not Ready Forming Sexual Iden1ty (Defending Self) -­‐-­‐ High Risk Behavior (Endangering Self) -­‐-­‐ Adapted from Scheidlinger, 1991 “Sex Under the Influence” •  Acknowledge overlapping issues caused by the effects of alcohol and other drugs on sexual func8on •  Similari8es in the “medica8ng” aspects of sexual and drug-­‐using behaviors, but qualita8vely separate •  Not indica8ve of “co-­‐addic8on” Sex Addic8on? Can Sex Be Addic8ve? In a word: “No” Label is vague, sex-­‐nega8ve, moralis8c Narrow view of “normal” Concept based on flawed asser8ons and conclusions (“pseudoscience”) •  Historically persistent (the masturbator, the sex maniac, “Don Juanism,” the insa8able nymphomaniac, Satyriasis, etc.) • 
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Sex Addicts Anonymous Guiding Principles 1.  Sex is most healthy in the context of a monogamous, heterosexual rela8onship 2.  Sexual expression has “obvious” limits 3.  It is unhealthy to engage in any sexual ac8vity for the sole purpose of feeling beMer, either emo8onally or to escape one’s problems 4.  Strong religious bias 5.  “Disease” Model Elements of Sex Addic8on Screening Test (SAST) Patrick Carnes, 1989 •  Have you subscribed to sexually explicit magazines like Playboy or Penthouse? •  Do you oeen find yourself preoccupied with sexual thoughts? •  Do you feel that your sexual behavior is not normal? •  Are any of your sexual ac8vi8es against the law? •  Have you ever felt degraded by your sexual behavior? •  Has sex been a way for you to escape your problems? •  When you have sex, do you feel depressed aeerwards? •  Do you feel controlled by your sexual desire? Proposed Diagnos1c Criteria for “Hypersexual Disorder” A. Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges, and sexual behavior in associa1on with four or more of the following five criteria: (1) A great deal of 1me is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior. (2) Repe11vely engaging in these sexual fantasies, urges, and behavior in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability). (3) Repe11vely engaging in sexual fantasies, urges, and behavior in response to stressful life events. (4) Repe11ve but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, and behavior. (5) Repe11vely engaging in sexual behavior while disregarding the risk for physical or emo1onal harm to self or others. B. There is clinically significant personal distress or impairment in social, occupa1onal or other important areas of func1oning associated with the frequency and intensity of these sexual fantasies, urges, and behavior. C. These sexual fantasies, urges, and behavior are not due to the direct physiological effect of an exogenous substance (e.g., a drug of abuse or a medica1on). Specify if: Masturba1on
Pornography Sexual Behavior With Consen1ng Adults Cybersex Telephone Sex
Strip Clubs Other: Proposed Diagnos1c Criteria for “Hypersexual Disorder” A. Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges, and sexual behavior in associa8on with four or more of the following five criteria: (1) A great deal of 1me is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior. (2) Repe11vely engaging in these sexual fantasies, urges, and behavior in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability). (3) Repe11vely engaging in sexual fantasies, urges, and behavior in response to stressful life events. (4) Repe11ve but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, and behavior. (5) Repe11vely engaging in sexual behavior while disregarding the risk for physical or emo1onal harm to self or others. B. There is clinically significant personal distress or impairment in social, occupa8onal or other important areas of func8oning associated with the frequency and intensity of these sexual fantasies, urges, and behavior. C. These sexual fantasies, urges, and behavior are not due to the direct physiological effect of an exogenous substance (e.g., a drug of abuse or a medica8on). (???) Specify if: Masturba1on
Pornography Sexual Behavior With Consen1ng Adults Cybersex Telephone Sex
Strip Clubs Other AASECT & SSSS Statements to DSM Board “…a diagnosis of a mental disorder, especially in the Sexual and
Gender Identity Disorders section, can have a severe adverse
impact on employment opportunities, child custody determinations,
an individual's well-being, and other areas of functioning.
Therefore we urge the APA to remove all diagnoses of sexual
pathology that are not based upon peer-reviewed, empirical
research, demonstrating distress or dysfunction, from the DSM.
The APA specifically should not promote current social norms or
values as a basis for clinical judgments, such as the
pathologization of some erotic minorities who are not doing harm to
themselves or others, but who may feel ego-dystonic due to
societal stigma placed onto them by a naive or unkind culture.”
What is Compulsive Sexual Behavior (CSB)? Compulsive sexual behavior (CSB) is a puta8ve clinical syndrome characterized by the experience of sexual urges, sexually arousing fantasies, and sexual behaviors that are recurrent, intense, and a distressful interference in one's daily life. -­‐-­‐ Eli Coleman, 1987 E8ology of CSB • 
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E8ology assumes disease rather than symptom Maladap8ve behavior paMerns Trauma Personality disorders Paraphilic, “non-­‐paraphilic,” “normophilic” Depression Anxiety “neurotransmiMer dysregula8on” (eg, DA, 5-­‐HT) “Ero8c Scripts” Socio-­‐Ero8c Codes •  Procrea8ve •  Rela8onal •  Recrea8onal -­‐ Levine & Troiden (1988)
Sexological Approach • 
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Sex posi8ve Sexual behavior con8nuum healthy problema8c Social and Developmental context Sexual behavior is symptoma8c, not primary Sexological Approach • 
Treatment based on appropriate diagnosis and recognizing underlying issues and concerns – 
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Anxiety Depression, all affect-­‐spectrum disorders Personality disorders Paraphilias Rela8onship/situa8onal issues Neurological Who is Presen8ng for Treatment? •  Pa8ents present with “hypersexuality,” compulsive sexual behavior, impulse control disorder, non-­‐paraphilic, psychosexual disorder •  Personality disorders –  Key issues may be sense of en8tlement, narcissism •  Self-­‐ or Internet-­‐diagnosed “sex addicts” •  Legal system referral •  Physician referral Treatment Goals Successful treatment will allow individuals to: •  Develop sense of control over their sexual behavior (incremental) ₋  Frustra8on tolerance and delay of gra8fica8on ₋  Work toward “natural remission” or self regula8on •  Set boundaries around sexual behavior •  Recognize triggers and develop more effec8ve anxiety-­‐reducing strategies Treatment Goals •  Recognize problema8c behaviors and redirect to more effec8ve expression •  Develop greater ego strength and desire for in8macy in their rela8onships •  Involve partners in senng rela8onship goals and boundaries •  Address and treat psychological disorders •  Address and treat sexual dysfunc8ons and disorders Treatment Protocol Sex Therapy –  thorough psychosexual assessment, including masturbatory status and rela8onship history –  explore types and sources of gra8fica8on –  understand ero8c fantasies (and restructuring) –  discuss the rela8onship between behavior and sense of self –  explore partner-­‐related issues that prevent posi8ve sexual connec8on Treatment Protocol Psycho-­‐educa8on –  Explore concept of “out of control” –  View as part of OC or affec8ve spectrum, not as a separate disorder –  Values conflict clarifica8on –  Belief-­‐Behavior disconnec8ons Treatment Protocol Group therapy –  homogenous, closed, carefully selected, open-­‐ended Treatment Protocol Adjunc8ve individual, family, and couple’s therapy Treatment Protocol Pharmacotherapy –  An8-­‐androgens –  Seroternergics –  Atypical An8depressants –  Others Treatment Protocol Outpa8ent, inter-­‐disciplinary, mul8-­‐modal Treatment Protocol Integrated prac8ce model Final Thoughts •  “Addic8ve personali8es” or “born addicts”?? •  Behavior is contextual (eg, Vietnam junkies, college drinking, adolescent sex) •  Ordinary people can find basic human experiences powerful and overwhelming •  Many people, at various 8mes, exhibit both a tendency toward and the ability to overcome CSB Final Thoughts •  Avoid biological reduc8onism •  Three out of four “addicts” (pick one!) achieve remission without any treatment •  The more pleasure-­‐producing or anxiety-­‐reducing a behavior is, the more “compulsive” it can become •  Avoid the “vic8m/perpetrator” narra8ve; if individual is in a rela8onship, should include re-­‐structuring the narra8ve in individual, couple’s and family therapy. Leading
Voices
Siegel, L. and Siegel, R.
“Sex Addiction:
Recovering from A
Shady Concept,”
Taking Sides, 10th Ed.,
Edited by Bill Taverner,
[Chapter 1: Can Sex Be
Addictive?]