Sex Addiction: A Dangerous Clinical Concept
Marty Klein, Ph.D
From the keynote panel presentation at the AASECT annual meeting, May
[note: references to Pat or Eli are to panel participants Pat Carnes & Eli Coleman.]
There is a question that we, as professionals, have all been devoting thousands and thousands and thousands of hours to: How can we conceptualize and evaluate, and diagnose and treat, if necessary, sexual behavior? And how do we do this in a sex-positive way? That's the question that our profession has been looking at since its inception. It's the question I was told I needed to look at when I first entered the field --how can we do our work in a sex-positive way? How can we maintain a model of sexual health that is sex-positive?
The media are not our ally in this, the government is not our
ally in this, even professions like medicine and psychology are not our
allies in this. And yet we are devoted to this quest. Some people say that
we are foolish for even trying to do this.
So I think it only makes sense that we should use sexological tools to examine why it is so difficult to do this. Let's use our own tools to look at our own questions.
The sex addiction movement focuses on important issues, and those issues deserve sexological attention. Here are some of the things that the sex addiction movement has been looking at since the mid-80s: Questions of lust and desire, the relationship of love and sex, decision-making and impulse control, guilt and shame, and brain chemistry. Pat, I didn't know how much you were going to talk about that today, but that is yet another thing that the sex addiction movement is talking about. These are important questions, and they deserve our attention.
But the sex addiction model is based on a group of assumptions that most sexologists do not share. The main ones are listed here.
Assumptions of SA model
* sex & sexual desire are dangerous
* there's one "best" way to express your sexuality
* relationship sex that enhances "intimacy" is best
* imagination has no healthy role in sexuality
* people need to be told what kinds of sex are wrong/bad
* if you feel out of control you are out of control
* laws & norms define sexual health
Based on these assumptions, unfortunately, there are serious limitations to how the sex addiction movement has answered key sexological questions. As you can see, I think most of the answers generated by the sex addiction model are pathology-oriented. They're clinically incomplete. As Eli was saying, they don't include issues of differential diagnosis, they don't alert us to the differences between character disorders, personality disorders, OCD, PTSD, and so on. And they pathologize sexual behavior and impulses that are not unhealthy.
The sex addiction movement's answers are culturally bound; as we progress through a new century, we're increasingly aware of cultural issues in sexual behavior, the differences between the way that people think and behave if they were born in Thailand or if they were born in California, the differences among age groups, differences in the ways that different people have been raised. Different behavior means different things when different people do it, particularly regarding sexuality.
And finally, a lot of the answers that have been generated by the sex addiction movement have been exploited politically. We have seen the ways in which some of these ideas have been used to harm the people that we try to treat, and even to harm the field of sexology. This may not be the intention of the sex addiction movement, but we need to be honest about how the ideas of that movement have been used by the government, the media, right-wing activists, and by other people, to harm the field of sexology. That's a reality, whether people like it or not.
The answers generated by the SA model have crucial limitations
* pathology oriented
* pathologize non-problematic behavior
* clinically incomplete
* acontextual--individually & situationally
* culturally bound
* exploited politically
Now, we as professionals, and all clinical professionals, not just sex therapists--marriage counselors, social workers, nurse practitioners--all professionals who work with a clinical population have certain requirements for their clinical models. Those requirements include: consideration of phenomenological or subjective context--in other words, how people experience themselves is important. Clinical sophistication. What all of us have said all along, or at least the way that most of us were trained, is that we want clinical models that emphasize personal agency, the ability to create change for ourselves. We want our models to value professional expertise, and so they should minimize self-diagnosis. And, finally, political and public policy utility: whether you are a therapist in a small office, or you're working in an agency, or you're working in a community, or with families, or whatever, we all want our models of sexuality and sexual health to be of value in the public policy arena.
What professionals require in a clinical model
* considers phenomenological context
* clinical sophistication, including differential diagnosis
* based in personal agency & responsibility
* cross-cultural insight
* minimizes self-diagnosis
* political & public policy utility
Models of sexual normality, and of course of sexual symptomatology, are constructed. As social scientists, we know that all models are constructed, and that they're part of a cultural discourse. And so the question is: What is the social context in which sexual normality and sexual symptoms are being constructed today? What is the discourse? Here, in my opinion, is the discourse. These are the features of America's cultural landscape that our patients, our colleagues, our legislators, and our media know as the discourse of sexuality in America today.
Things like the emphasis on victimhood. Things like the increasing medicalization and biological determinism in sexuality; the increasing legitimacy of religious concepts and solutions; the increasing political cloud of sex negativity. These form the discourse, the cultural context for anyone who's developing models of sexuality today and for anyone who is implementing clinical work. And, of course, there's the success of 12-step programs. That, too, is part of the cultural landscape from which models of sexual normality and symptomatology emerge.
The social context in which "sexual normality" & sexual "symptoms" are being constructed today
* self-help movement
* Oprah & other "therapeutic" talk shows
* emphasis on victimhood
* cultural anxiety about sexual violence
* increasing medicalization of sexuality
* increasing public awareness of non-normative sexual behavior
* increasing legitimacy of religious concepts & solutions
* increasing political clout of sex-negativity
* cultural acceptance & mythologizing of 12-step programs
Now let's consider the theoretical material that shaped public consciousness in America about sexuality after the Second World War and until about 1980. This theoretical material came from sexologists--Kinsey, Masters & Johnson, Hite, and Lonnie and Bernie. These people were sexologists, and it was the material they generated that shaped the consciousness of the people we work with, as well as our own as professionals.
The theoretical material, however, that has shaped the public discourse about sexuality in the last couple of decades has not come from sexology. It's come from a completely different source. Here are three of the most important books of the last 25 years that have shaped the way that people think about sexuality, both lay people and professionals. And here are some other cultural institutions and forces that, for the last 25 years, have been shaping the way that people think about thinking about sexuality.
Historical/cultural context from which SA movement emerged
* Women Who Love Too Much
* Men Are From Mars, Women Are From Venus
* The Courage To Heal
* repressed memory movement
* sexual trauma self-help movement
* pharmaceutical industry
* right-wing political activism
* Dworkin/McKinnon anti-porn movement
This is the historical and cultural context from which the sex addiction movement emerged. It's not a sexological context as much as it is a narrative about fear, danger, powerlessness, and victimization--things like trauma and repressed memory.
If you want to learn about the diagnostic criteria for sexual addiction, it's easy to find on the Web. There is, in fact, a Sexual Addiction Screening Test, which Pat developed in the mid-1980s. It's very popular, it's well-known and well-respected among a lot of people. The Sexual Addiction Screening Test has 25 questions. Here is a third of the test. We're told that these are the kinds of questions that clinicians can ask patients, or non-patients, to determine whether or not they're sex addicts. And I would like to draw your attention to these and ask if these are the kinds of criteria that you want to use to determine if your patients, or your mate, or your best friend, or yourself are pathological around sexuality-and, for that matter, are sex addicts.
Sexual Addiction Screening Test criteria (partial list)
* regularly purchase porn or romance novels
* preoccupied w/sexual or romantic thoughts
* feel behavior isn't normal
* partner complains about your behavior
* worried your behavior will be discovered
* multiple romantic involvements
* use sex or romantic fantasies for escape
* regular participant in S/M
There are inevitable implications for the sex addiction model that come from those kinds of diagnostic criteria. They're different implications than come from, say, Eli's model or some of the other models that we are called upon to evaluate. For example, the sex addiction model inevitably believes that eroticism needs to be controlled, and that erotica and commercial sex are dangerous and problematic. Of course, the way that the sex addiction movement is constituted, it would have to believe that public policy should be focused on controlling sexuality, and in that regard it has been very successful.
And the sex addiction movement inevitably must say that people are in danger of losing their ability to make wholesome choices, that people can become addicted, that people can go along and be okay and at some point something can happen-for example, they could consume a lot of pornography--and they can become addicted. And so people are at risk. So the sexual addiction diagnostic criteria problematize non-problematic experiences, and as a result pathologize a majority of people. This is a serious deficiency in the model.
Inevitable Implications of SA Model
* eroticism needs to be controlled
* erotica & commercial sex are dangerous
* public policy should focus on controlling sex
* people are in danger of losing their ability to make
wholesome sexual choices
* "unwholesome" sexual impulses are compulsive
* identifying & preventing sexual pathology is more
important than enhancing sexual health
The SA movement exploits people's fear of their own sexuality, which is one of the major public health problems we have today. Men and women are so frightened of their own sexuality that they project this danger onto other people, and become frightened of those other people's sexuality. People in America are frightened about their neighbors who are going to nude beaches, or their neighbors who are going to swing clubs. People in America have learned how to be afraid of their neighbor's sexuality because they've been encouraged to be afraid of their own sexuality.
And given the way that our culture is so sex-negative, the diagnostic criteria for sex addiction are culturally syntonic. If you grow up in America, of course you're concerned about your neighbors finding out about your sexuality. Of course you have parents who are frightened or ashamed of their sexuality. Of course if you use pornography, you're going to have the impulse to hide it from your mate. The kinds of things that the sexual addiction model says reflect problematic behavior are simply common sense--if you grow up in a sex-negative culture.
Please look at this chart, which lists behaviors that clinicians see in our everyday practice. From the sex addiction perspective they are easily seen as symptoms: Masturbates twice a day--Marty Kafka certainly believes that's sex addiction. Enjoys S/M--that's a very common indicator, it's 4% of the Sexual Addiction Screening Test--do you enjoy S/M. Are you're interested in non-monogamy; are you married and you cruise public bathrooms; these are the kinds of things that are labeled symptoms of sex addiction by the sex addiction model. However, look at the possible diagnoses that a different kind of clinical sexologist could make. I underline possible, because each one of these is only one possible diagnosis, because diagnosis depends on the person.
A person who, for example, has extramarital affairs--maybe what that's all about is that they're having an existential dilemma--they're 50 years old and they're wondering, 'is this how I'm going to spend the rest of my life?' A person who enjoys S/M, well, maybe they're just fine. A person who wants non-monogamy, well, maybe they're Borderline, or maybe they're adventurous. I would have to talk to the person. I would have to find out a lot more about a person before I could say what it means that they're interested in non-monogamy. A person who's interested in commercial sex--that may be that that person is committed to their marriage, and rather than leave their marriage, or even rather than have an affair and take a chance that they'll fall in love with somebody, they go to a prostitute once a week. I'm not willing to say that that person is a sex addict, even though they feel terribly guilt-ridden about the fact that they're seeing a prostitute once a week, and they can't even really afford it, but they're doing it anyway. I'm not willing, without doing one or several interviews, to say that that person is out of control and is therefore a sex addict.
Evaluating behaviors: sex addiction, something else, or non-problem?
||Possible Dx for clinical sexology|
|masturbation twice daily||
|wants partner sex daily||
||OK; personality disorder|
||socially inept; narcissism|
|married, cruises bathrooms||
||tormented about orientation|
||committed to marriage; social anxiety|
||depression; dissatisfied with partner sex|
Now here's a history of sexological diseases. If we look at the last 150 years, these are conditions that the finest scientific minds of their age said were diseases. If you go back to the 1860s, '70s and '80s, the finest scientists said that libertinism was a disease--that's somebody who's just too much into sex. If we look at the turn of this century, the finest medical minds said that masturbating was a serious disease. We've seen nymphomania as a disease. Carol Groneman's wonderful book, A Brief History of Nymphomania, shows how that diagnosis has been used for the last 100 years as a form of social control. People who advocated birth control in the 1920s--it was labeled a psychiatric illness if someone was too attached to birth control. And we all know that frigidity and homosexuality have been labeled psychiatric diseases. Sex addiction fits right into that tradition.
History of sexological diseases
* birth control advocate
* sex addict
America needs a model of sexual health. America is desperate for a model of sexual health, a model that is clinically complex. Eli, I have to disagree when you say let's call it Syndrome X. I don't think there's one syndrome. I think that this stuff is so complicated that we can't just say there is a Syndrome X with a bunch of sub-things. I think there are a lot of syndromes, and some of them, I don't think they're even syndromes, I think they're real life.
So we need a model of sexual health that is clinically complex and culturally informed. And by culture we don't just mean what race is a person, we don't just mean what country was that person born in. Cultural considerations are much more subtle, and there are many, many of them. People who are twins are, in their own way, a subculture. People who are in marriages where one of them is 25 and the other is 50 have cultural considerations just from being that kind of couples. Now we've discovered that there's a subculture of five or six million people in the United States who swing, according to Terry Gould's wonderful research [The Lifestyle, ed.]. So there are many kinds of cultural groups with sexological considerations that we need to know a lot more about.
We need a model of sexual health that does not pathologize a broad range of eroticism. We need a model that is supportive of adult identity. Being an adult is complicated and it's scary, and sometimes it's very difficult, and a lot of people would like to make their sexuality so simple that it's not scary to be a grownup. And our job is to help people understand that while it is, in fact, scary to be a grownup, we can provide some tools that can help them deal with their fear. We don't have to strip down their sexuality to take away the darkness, the complexity, the ambiguity, just so people can be more comfortable.
And finally, America needs a model of sexual health that is sex-positive.
And that's the challenge that the sex addiction movement is posing to sexology.
They've come up with their model. Can we come up with something different
that's culturally sensitive and has all those other sex-positive criteria?
That's the challenge that we as a profession face. How are we going to
respond to that challenge?
Please do not quote without permission. To contact Dr. Klein, email Klein@SexEd.org. For more of Dr. Klein's articles, see www.SexEd.org.
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