One of my biggest frustrations as a mental health professional is that certain ideas and terms, promoted in pop psychology circles and then spread throughout media, get established in the culture as legitimate without widely-accepted scientific knowledge and research. Here’s a perfect example: “codependency” was a popular “diagnosis” in the mental health field several years ago. Many people entered therapy with the presenting problem “I’m codependent”. Treatment programs popped up all over the country, many of them very expensive, claiming they “treat codependency.” Codependent Personality Disorder was even proposed as a diagnosis in the DSM-III, the publication of mental health disorders, in 1987 but thankfully failed to be included due to a lack of scientific evidence.
As the two sayings go, everything old is new again and those who fail to learn from history are doomed to repeat it.
This is and has been happening again with the concepts of “sex addiction” and “porn addiction”. Once again many people, and statistics are showing that it is predominantly men, are entering therapy with the presenting problem “I’m a sex addict” or “I have a porn addiction.” Once again treatment programs have popped up all over the country, many of them very expensive, claiming to “treat sex addiction and porn addiction.” And once again Sex Addiction was proposed as a diagnosis in the DSM-V in 2013, its most recent publishing, but thankfully failed to be included due to a lack of scientific evidence.
I certainly do not expect the general public to understand the controversies and conflicting research surrounding such provocative “diagnoses” of “sex addiction” or “porn addiction”. Yet it is still paramount we, the mental health profession, ask questions like:
- Why are “sex addicts” predominantly men? They also tend to have more conservative and negative
attitudes about sex - why is that?
- What is the influence of mental health issues like depression, anxiety, OCD, or a personality disorder on their sexual functioning and sexual decision-making?
- What are the stressors (marriage, relationships, parenting, money, health, work) in these men’s lives and how are they coping with them?
- What messaging and values (from family, from religion, from culture, from friends, from his spouse) did he internalize about his sexuality? How do those square up with what is actually going on in his sexual self? Does he really believe those messages and values now? What are the consequences if he does and does not follow them?
Many manifestations of so-called “sex addiction” can be summed up with the following statements: “I like X and I shouldn’t like X” or “I do X and I shouldn’t do X.” What a wonderfully succinct description of an inner conflict! This is exactly what psychotherapy is here to help with - better understanding of self. “Why” is a question about motivation and it is a fundamental question in psychotherapy. It is a fundamental question sex addiction treatment providers generally fail to explore with their clients, other than ascribing it to the “diagnosis” of “trauma”. Another reason sex addiction treatment providers give for "sex addiction" is “because it’s addiction”, yet that’s a circular explanation that does nothing to illuminate the inner workings of the individual’s psyche.
So why would a man do X when he feels or believes he shouldn’t do X, you ask? Maybe he feels he shouldn’t do X because it’s illegal and he doesn’t want to get arrested and go to jail. Or because his family-of-origin messaging/religion said so. Or because if his wife found out he’s afraid she will judge him for it and that prospect is painful him. Or maybe because it’s a symptom of his depression but because he’s a man and male depression often presents differently than in women he (and his doctor) failed to recognize it. Or maybe because he’s angry at his spouse and can’t tell her so this is how he has been displacing and sublimating his anger. Or maybe because he hasn’t had sex with his wife in years and doing X is a way to stay monogamous.
These are just some of the reasons I’ve seen in my male clients for doing what they do. They are explanations and not excuses. That being said, explanations matter because when we understand the "why" we can better begin to change what we want to change. Calling yourself (or your husband) a “sex addict” jumps over the “Well, why is that?” question itself and the necessary exploration of the possible answer(s) to that question. As Douglas Braun-Harvey and Michael Vigorito described in their book, “Treating Out-Of-Control Sexual Behavior; Rethinking Sex Addiction”, when someone enters therapy saying “I’m a sex addict” and the therapist accepts this without much of an assessment, this is akin to you telling your doctor “Hey doc, I have cancer” and your doctor responding “When would you like to start chemo and radiation?”
Being a sexual person means accepting the consequences of your sexual choices. Hell, being an adult person means accepting the consequences of your choices. And let’s face it: that’s painfully difficult to do at times. For many it’s even more so when those consequences happen in the sexual arena of their lives and they lack an understanding of their motives. I work with these issues every day and see first-hand the consequences in people’s lives.
Sexuality, and more importantly sexual choices, do not exist in a vacuum and they are not solely driven by biological processes. Sexuality and sexual decision-making exists in a context that includes biological, psychological, and social factors and is constantly taking in and responding to the internal and external stimuli of these factors.
What ultimately matters is that I, as a sex-positive clinician, understand how a person’s relationship to sexual activities and/or pornography can be problematic in their lives and relationships. What also matters is that I hold a humane and judgement-free space for curiosity and respect for my client's lived experience while we explore their underlying motivations. I get that many people do not understand their sexual selves and may even be afraid of examining their sexuality. I am here to help.
Finally, I have no idea how far and wide (or not far and not wide) this blog post will travel. Many others with bigger and better credentials than mine have written about all of this before. Some of those people have received not just troll-y emails and comments for their opinions on this topic but some of them have even received threats of harm to themselves and their families. So not cool, Internet. It is alarming that a difference in opinion can generate such animosity and aggression. Tension can be healthy and has the potential to move us towards a better outcome; it is not inherently a threat. And as a society we need to learn to better tolerate our differences without resorting to attack.
A common issue I see is low or absent sex drive in women who report previously having a high(er) sex drive. These women usually, but not always, have been with the same partner for years. Their emotional reactions to the phenomena run the gamut. Some of these women are distressed by its decline/disappearance while some women are ambivalent while even others are relieved. Remember, sex is never one-size-fits-all and if I’ve taught you anything, dear reader, it’s that there’s always good reasons why she feels the way she does.
So I ask questions and learn about her sexual history. Was there a time when she had a high(er) libido? Was it with her current partner/relationship? When did it start to decline and what was going on in her life? What has she (or they) tried to increase her sex drive? Were those attempts successful? Why or why not? Why is she seeking treatment now for this issue? What are her partner’s thoughts and feelings about (A) her lower libido and (B) her seeking help for it? Are there any drawbacks to having an increased sex drive? And so on.
It’s incredible what these questions uncover. For example, maybe her sex drive changed after the birth of their first child when life, and her priorities, went a new direction and not to mention she felt fatigue like she never had before. Maybe after baby and baby weight she did not like her body and felt deeply insecure and judgmental about being sexual with it. Maybe her sex drive took a nosedive after her alcoholic mother was diagnosed with cancer and their historically tumultuous mother-daughter relationship became even more draining when she began to take care of her mother. Maybe her libido went underground as a result of growing resentments she had towards her partner. Or maybe she’s just plain bored and unsatisfied with the sex she and her partner do have but doesn’t want to tell her partner her truth for fear of hurting their feelings.
We examine these life and relationship issues and their impact on her libido but there’s a powerful detail in all this that gets easily missed. Often what is revealed is that at some point, she decided to sacrifice her right to sexual pleasure. She traded it in for something else she deemed more valuable: sleep, time with the children, advancing at work, completing household chores, or preferred emotional states like not feeling bad about her relationship, not feeling bad about her partner, or not feeling bad about herself. This usually seems like a worthwhile trade-off for a period of time until it doesn’t and the consequences become big…and she finds her way to my office.
Ladies, you must stop doing this! Sexual pleasure is not something to be bartered. When you make your sexual pleasure optional and unimportant you make sex optional and unimportant. You have a right to sexual pleasure so honor it. Pursue it. You have unique anatomy that allows you immense pleasure. Even the World Association of Sexual Health’s Declaration of Sexual Rights has stated we have a right to sexual pleasure. It’s #7 if you’re curious.
I am a licensed Marriage and Family Therapist and AASECT Certified Sex Therapist and Supervisor located in Sonoma county, California.