From Disorder to Sexual Health: Treating Out of Control Sexual Behavior (2/2)

From Disorder to Sexual Health: Treating Out of Control Sexual Behavior (2/2) September 9, 2016

By Lucie(n) Fielding

In part 1 of this post I began to introduce the OCSB framework as developed by Douglas Braun-Harvey and Michael Vigorito (2016). In discussing how the framework views OCSB as a behavioral problem rather than a disorder I briefly touched on how the work between client and therapist is focused on developing a shared understanding of the client’s vision of sexual health. We’ll now turn to the client-centered, sexual health foundations of the OCSB framework. Ready, Player One?

Anonymous image from 1854. In public domain.
Anonymous image from 1854. In public domain.

Sexual Health Foundation

One of the major distinguishing features of Braun-Harvey and Vigorito’s OCSB framework (2016) from the sex addiction model (and, I would argue, the Hypersexual Disorder [HD] model, albeit to a far lesser extent) is its sex positive basis. As both Marty Klein (2012) and David Ley (2012) have shown and as you can see by even the briefest perusal of the questions on a SAST questionnaire (an instrument developed to “help” a potential client, their partner, or a clinician assess whether someone is a “sex addict”), the sex addiction model is infused by a pretty sex negative set of assumptions.

One way to think about this is that the sex addiction model operates from what Braun-Harvey and Vigorito (building on and citing the work of William Stayton [2007]) called an “act-centered sexual values system.” An act-centered values system marks off certain behaviors, thoughts, and urges as problematic and immoral, and ultimately serves to “reinforce the procreative value of sex” (2016, p. 38). For example, the SAST instrument (in even its latest iterations) contains numerous items that privilege the pleasures of loving, committed, monogamous, intimate relationships, and frown on anything other than that, such as questions 37 (“I have maintained multiple romantic or sexual relationships at the same time”) or 43 (“I believe casual or anonymous sex has kept me from having more long-term intimate relationships”).

In an act-centered sexual values system, anonymous sex, one-night stands, or engaging in sexual relationships with multiple partners are no-nos. And consensual power exchange, the enactment of role play fantasies (as in age play or humiliation play), or the enjoyment of pain (giving or receiving) are often viewed with a side-eye too. Particularly suspect are porn viewing and excessive or secretive masturbation. And, historically, at least, as Braun-Harvey and Vigorito note, many sex addiction model proponents often labeled “the adjustment symptoms of sexual identity development for gay and bisexual men as an addiction” (2016, p. 26).

It is important to note here, as Eli Coleman did in his Institute panel and as Reay, Attwood, and Gooder (2015) do in their cultural history of sex addiction, the extent to which the sex addiction model as first described by Patrick Carnes in his book The Sexual Addiction (1983, republished later that year as Out of the Shadows: Understanding Sexual Addiction) is “a product of late twentieth-century cultural anxieties” borne out of the so-called sexual revolutions of the 1960s and 1970s. “The principal facilitators in this making […] were an addiction discourse (gambling, alcohol) that leant itself almost seamlessly to sexual matters; a strange and momentary combination of conservative Christian and radical feminist social purity; and the initial impact of AIDS in the 1980s that so dramatically intensified such sexual apprehensions” (p. 7).

The OCSB treatment framework, by contrast to the act-centered values system of the sex addiction (SA) model, is a “principle-centered values system,” relying on six sexual health principles, distilled from those developed in 2000 by a joint venture of the World Health Organization (WHO), the Pan American Health Organization (PAHO), and the World Association for Sexual Health (WAS), namely:

  1. Consent
  2. Nonexploitation
  3. Protection from HIV/STIs and unintended pregnancy
  4. Honesty
  5. Shared values; and
  6. (Mutual) Pleasure [N.B. the word “mutual” was removed during the Institute panel presentation to take into account pleasure derived through masturbation]

As a principle-centered values system, the OCSB framework does not designate certain behaviors, thoughts, or urges as problematic or attempt to define an acceptable, normal frequency of sexual behavior seeking or engagement. The protocol, rather, “focuses on behaviors that violate the sexual health principles.” Moreover, the principles are designed to help the therapist and client engage in direct, detailed, non-judgmental discussion meant to “help men change their self-discrepant sexual behavior” (2016, p. 31).

Thus, an integral part of the OCSB treatment pathway is to come to a shared understanding of the six sexual health principles, how the client’s presenting behaviors may violate one or more of these principles, developing a shared understanding of motivating factors (self-regulation, attachment regulation, and sexual and erotic conflicts), and developing a sexual health plan for aligning client behavior, thoughts, and urges with the six principles.

Consensual Sexual Behaviors

As explored above, “consent” is the first of the six sexual health principles grounding the OCSB framework. And one reason for the prominence of the consent principle is that treatment in the OCSB framework is limited to clients “who feel that their consensual sexual activity is out of control and who do not use force or use coercive behavior to engage in sexual activity with another person” (2016, p. 138). When in the screening, intake, or assessment stages a sexual behavior is identified as being non-consensual, the OCSB treatment protocol calls for the client to be referred out to a specialist. Braun-Harvey and Vigorito are insistent on this point, as they argue that non-consensual sexual behavior can only be assessed and treated by highly trained clinicians who specialize in non-consensual sexual behavior.

Non-consensual sexual behavior may very well feel out of control to a person who has committed said behavior but Braun-Harvey and Vigorito maintain that without a bedrock understanding of consent, it is impossible to move forward in engaging in a substantive discussion of the client’s vision of sexual health.

Importantly, potential clients who report sexual behavior that is consensual but exploitative can continue work within the OCSB treatment pathway (e.g., engaging in a secret extra-relational affair—this is exploitative because it is kept a secret from a (primary) partner but the sexual relationship was, itself, consensual in nature).

The Facilitating Environment

When discussing OCSB and the sex addiction movement (both here and in his book, America’s War on Sex: The Continuing Attack on Law, Lust, and Liberty, 2nd Edition (Sex, Love, and Psychology) [2012]) Marty Klein makes a crucial distinction between being out of control sexually and feeling out of control sexually.

Clients will often come into our offices distressed that they (or their partners, in the case of couples’ therapy) are engaging in problematic sexual behaviors. And some, given how deeply engrained the sex addiction model is in the popular imagination, will even refer to themselves as “sex addicts,” “sexually compulsive,” or “hypersexual.” But, argues Klein, “‘Sex addicts’ say they are ‘out of control,’ but this just a metaphor—i.e., they feel out of control […].”

Klein’s distinction between being and feeling is crucial to the OCSB treatment framework, for the emphasis, from the first moments of a consultation appointment is on the client’s subjective felt experience:

When a client’s chief complaint is sex addiction (SA), impulsive-compulsive sexual behavior (ICSB), or hypersexuality, this label may inaccurately describe the core issues causing [their] problems, because client perception rarely evolves independent from cultural or environmental influences (religiosity, social media, family values, etc. […]). From the start of psychotherapy, it is crucial to understand the client’s meaning and utility of [their] sexuality language and maintain a persistent curiosity about [their] subjective “out of control” experiences. In developing our OCSB protocol, we intended to create a process that encouraged a conversation about the client’s internal world (Braun-Harvey & Vigorito, 2016, p. 57).

One of the reasons I resonate so deeply with the OCSB framework outlined by Braun-Harvey and Vigorito is that I firmly believe that it is my clinical imperative to always keep the client and their process front and center. As is drilled into us in my counseling program practically each and every class, as a therapist you “meet the client where they are.” That is, the subjective feelings of my client are what is operative—their felt sense, their internal world, their vision of sexual health, their motivations, their values—and part of my job, as Braun-Harvey emphasized repeatedly over the course of the Institute, is to protect the client from me, and particularly my particular values and biases, and to get out of the way. The clinician provides, to use one of my favorite psychoanalytic theorist’s terms, a “facilitating environment” (D.W. Winnicott), a space to host the thoughts, feelings, fantasies, and anxieties that many clients dare not face alone.

For me, as sex therapist Joe Kort masterfully put it at the Institute, I am more interested in the client’s relationship to a behavior rather than particular behaviors in and of themselves. And at the end of the day, to adapt and paraphrase James Carville’s now oft-quoted internal directive to Clinton campaign staffers during the 1992 election, “It’s the client, stupid.”

Up next: For the final installments in this series, I will try my right-brain-dominated best to bring the science. We will look at some neuroscientific research which is challenging many of the key components of the sex addiction model. I hope you will stay with me. In the meantime, as we will apparently say in San Diemas of the year 2688, “Be excellent to each other!”

A special thanks to Douglas Braun-Harvey, MA, LMFT, CGP, CST and Michael Giancola, MA, MS, LMFT, who kindly reviewed and offered wonderfully helpful notes on drafts of these posts before they were offered to you.

Read the post series in order here:

A History of (Hyper-)Sexuality, Volume I: An Introduction (1/2)

A History of (Hyper-)Sexuality, Volume I: An Introduction (2/2)

From Disorder to Sexual Health: Treating Out of Control Sexual Behavior (1/2)

From Disorder to Sexual Health: Treating Out of Control Sexual Behavior (2/2)

Dreams of Black Swans: Falsifying Sex Addiction

The Metaphor of Sex Addiction

List of References (for your reading pleasure):

Braun-Harvey, Douglas, and Michael A. Vigorito. Treating Out of Control Sexual Behavior: Rethinking Sex Addiction. New York: Springer Publishing Company, 2016.

Coleman, Eli. “Impulsive/Compulsive Sexual Behavior: Assessment and Treatment.” Edited by John E. Grant and Potenza, Marc N. The Oxford Handbook of Impulse Control Disorders, 2011, 375–88. doi:10.1093/oxfordhb/9780195389715.013.0108.

Kafka, Martin P. “Hypersexual Disorder: A Proposed Diagnosis for DSM-V.” Archives of Sexual Behavior 39, no. 2 (April 2010): 377–400. doi:10.1007/s10508-009-9574-7.

Klein, Marty. America’s War on Sex: The Continuing Attack on Law, Lust, and Liberty. Santa Barbara, Calif.: Praeger, 2012.

Ley, David J. The Myth of Sex Addiction. Lanham: Rowman & Littlefield Publishers, Inc., 2012.

Reid, Rory C., Bruce N. Carpenter, Joshua N. Hook, Sheila Garos, Jill C. Manning, Randy Gilliland, Erin B. Cooper, Heather McKittrick, Margarit Davtian, and Timothy Fong. “Report of Findings in a DSM‐5 Field Trial for Hypersexual Disorder.” The Journal of Sexual Medicine 9, no. 11 (November 2012): 2868–77. doi:10.1111/j.1743-6109.2012.02936.x.

Reay, Barry, Nina Attwood, and Claire Gooder. Sex Addiction: A Critical History. Cambridge ; Malden, MA: Polity, 2015.

Stayton, William R. “Sexual Values Systems and Sexual Health.” In Sexual Health, Vol. 3. Westport, Conn.: Praeger, 2007.

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