Friday, June 30, 2017

Consent 301: Consent, It's Discontents and Safety

In the first half of 2017, Susan Wright and I took our Consent Roadshow to the Society for Sex Therapy and Research (SSTAR) in Montreal on April 21, and I took the 2014 Consent Violations Survey to the 8th Community-Academic Consortium for Research on Alternative Sexualities (CARAS) in Chicago, May 26th.

I have finally posted the slides here.  The 2014 Consent Violations Survey slides follow the context material about consent and safety in the kink community.  Most of this material is already known to kink insiders such as those who frequent CARAS.  But we wanted more context for interpreting the data for therapists who might be less familiar with the social organization and ideology of BDSM social groups.


Consent 301: Consent, It's Discontents, and Safety

Tuesday, June 27, 2017

Kink’s Evelyn Hooker Moment

Cabaret

“Start by admitting from cradle to tomb
It isn’t that long a stay.
Life is a cabaret, old chum
Only a cabaret, old chum
And I love a cabaret”
Fred Ebb and John Kandler

From its modern inception, psychiatry regarded homosexuality as a sexual perversion and as psychopathology. You heard the beginning of this story on Elephant in the post on Richard von Krafft-Ebing, here: .Richard von Krafft-Ebing  In the early 1950’s, flush with huge administrative responsibilities for 16 million service personnel and veterans of World War II and the Korean War, the US army demanded an official classification system for all of the mental disorders. At that point, hundreds of different local nosologies were in use.  After all, the armedforces needed a systematic way to determine who was crazy, who was malingering, and a reasonable basis for knowing how to allocate their medical resources.  As a minor after thought, sexual perversions were included in the resultant volume:  Diagnostic and Statistical Manual of the Mental Disorders I constructed after much debate, by the American Psychiatric Association.  Sexual deviations were mentioned, but not described, in the initial 50-page mimeographed publication, which sold for the entirely manageable price of 50 cents, when a Coca-Cola sold for a nickel and a Saturday matinee cost 25 cents.  The so-called ‘Kinsey Report’ cost more!

The second half of the Kinsey Report (1953) was a close contemporary of the DSM - 1

And there the matter might well have rested but for the twist of fate that found a psychologist at UCLA living next door to an expatriate British writer.  Both had spent time in Germany during the rollicking period of sexual license that comprised the waning years of the Weimar Republic.  She was well acquainted with the gay life, and generally accepting of homosexuality.  Both were deeply affected by the rise of Nazism, and the holocaust that became World War II.   She had barged her way into the nascent psychology profession in the 1930’s when it was less than friendly to women, mainly through her reputation as a brilliant researcher.  He was working on a screenplay that would eventually become a brilliant little send up of the funeral industry.  Your blog author saw that film, The Loved One at age 14 at the recently reopened Heights Art Theater in Cleveland Heights, Ohio in the company of his parents.  It played not long after the foreshortened run of a more famous film, Louis Malle’s The Lovers (1958), which had played there just a few years earlier and had been shut down as obscene, leading to the Supreme Court Case Jacobellis v Ohio, in which Justice Potter Stewart entered the famous opinion the he couldn’t define pornography, but “I know it when I see it.” in the process of overturning the theater owner’s conviction.

Evelyn Hooker

Christopher Isherwood

The writer was Christopher Isherwood, who you are far more likely to know for his Berlin stories which included the tales of American expatriate Sally Bowles, and became the basis for the famous Broadway musical Cabaret.  The psychologist was Evelyn Hooker, an ardent early advocate for de-pathologizing homosexuality.  Isherwood challenged Hooker to use her skills to conduct what became  one of the most famous studies in diagnostic history.
 
As the professional discourse arose about whether homosexuality might not be a disease began to heat up, advocates for retaining the diagnosis claimed that they could use psychological testing to prove it was a mental disorder.  They could diagnose it using psychological testing protocols derived from projective testing.  Hooker arranged to test exactly that assertion, by taking three of the best projective tests, and challenging their star practitioners to blindly sort the protocols of homosexuals from those of heterosexual men.

She chose a leading authority on each test to evaluate the subjects’ protocols, into homosexual and heterosexual piles, and to evaluate the extent of each subject’s signs of psychopathology on the tests. She also collected their sexual preferences and gave each an IQ test.  Bruno Klopfer was a top expert in the Rorschach test which was widely regarded as the best projective test for assessing psychopathology.  His book was so famous that I read it in my first projective testing course in graduate school 25 years later in 1981.  Edwin Schniedman, the inventor of the Make a Picture Test, interpreted the protocols from his test, and Mortimer Mayer interpreted the Thematic Apperception Test protocols.  Hooker gathered the data in her home, typed up the testing transcripts, counterbalanced them for IQ, and then farmed them out to the experts for interpretation.  The ratings were blind because the test evaluators never actually saw the test subjects, only these protocols, as a protection against the possibility that some sort of information irrelevant to the hypothesis might account for the experts ratings of the tests.  When the results came in, the three experts all agreed that they could not sort the protocols effectively through test interpretation.  Contrary to the opinions of the clinical profession, their best experts could neither detect psychopathology differences in these two samples, nor could the correctly sort the heterosexuals from the homosexuals.  In 1961, Evelyn Hooker got a lifetime achievement award from the American Psychological Association for this work and became an ardent professional advocate of removing homosexuality from the DSM.  In the mid 70’s, it was replaced by the diagnosis ‘Ego-Dystonic Homosexuality’ in later versions of DSM – II, and taken out altogether in DSM -III in 1978.  Hooker’s study was the fatal blow to the idea that homosexuals were all suffering from psychopathology that prevented them from being healthy heterosexuals.



Christian Joyal is a thoroughly French sounding Quebecois sex researcher with a crew cut, winning smile, and wry sense of humor.  In his SSTAR presentation on his 2014 Journal of Sexual Medicine article,  Joyal asked the awkward question, “Diagnostic and Statistical Manual?  Where are the statistics?” which left me imagining the Monty Python skit about the cheese shop with zero kinds of cheese.  The DSMs have not included these data since 1978!  In his day job, Joyal investigates subjects convicted of pedophilic crimes in a lab with fabulous virtual reality facilities.  There he can arrange all manner of stimuli and see how these effect patient's brain function using fMRIs.  He was utterly innocent of any interest in undermining the Paraphilia Section of DSM - 5 until he found himself wondering about the relationship of his subjects’ sexual fantasies and their illegal behaviors.  Joyal found many of his subjects had clear deficits in that portion of their brains related to executive function, which is implicated in processes of planning and impulse regulation.  But before he could draw conclusions about the relationship between pedophiles’ fantasies and their behavior, he would first like to have a baseline about the general population’s fantasies and behavior.  Having read the best books on fantasy and seen no studies worth reviewing, he concluded that his efforts to examine this connection required that he gather the data about ordinary peoples’ fantasies for himself.

Variant, perhaps, but far from statistically unusual!

He was aware that the diagnoses of the paraphilias, of which pedophilia was an example, depended on the recognition that paraphiles have ‘anomalous’ fantasies or behaviors.  So he made sure to include questions in his survey of fantasies examples that included all the major paraphilia categories from DSM – 5.  These are essentially eight classes of these fantasies and behaviors.  Voyeurism (looking at someone non-consensually for the purposes of sexual arousal) Exhibitionism: (exposing oneself to someone non-consensually for sexual arousal) Frotteurism: rubbing up against someone’s body without their consent for the purposes of sexual arousal) and pedophilia.  These acts were unethical, and in most cases heavily criminally sanctioned in Quebec.  He also looked at the consensual paraphilias:  Sadism, Masochism, Transvestism, and Fetishism.  These, of course, are the core interests of BDSM.  These are also the specific fantasies and behaviors that constitute the ‘anomalous’ content of the vast majority of paraphilias, even though countless other variations exist.

With the exception of pedophilia, none of these thoughts are criminal.  In some jurisdictions in the United states, any visual material of children under the age of consent (which itself varies depending on what state you are in) can be a serious criminal matter.  In Quebec, Christian can do fMRI scans of any image he wishes to construct on his fancy VR equipment as long as no real life child was used to make it.  In many places in the United States, it would be illegal to construct images of any sort that were intended to provoke pedophilic desires, even in a controlled research environment, and no IRB could approve such a research design that involved a researcher in criminal conduct.   So Dr Joyal is in a position where exploring the relationship between fantasies and behavior is important, and such research is possible to conduct, which might determine just when some fantasies might be genuinely dangerous, and when they are actually helpful to people who are trying to control behaviors that might be criminal or damaging.

The results of Joyal’s study, as summarized in his 2014 Journal of Sexual Medicine article, completely exploded the idea that sexual fantasies involving paraphilia content were ‘anomalous’.  Far from it.  A great many fantasies involving multiple partners, power exchange, sadism, masochism, and bondage, casual sexual encounters, and encounters with multiple partners were reported by more than half of Joyal’s samples of Quebecois. Individuals who reported none of these fantasies were in the extreme minority.  Only three of the 55 things he asked about were so uncommon that less than two standard deviations (a little under 2%) of his respondents reported ever having them.  Thus, hardly any fantasy was anomalous, and fantasies seemed to have no respect whatever for conventional sexual practices.  It is true that intimate relations with romantic partners, and romantic encounters on the beach were very popular, enjoyed by a large majority of respondents (85-90%).  But far more fantasies that the psychiatry manual referred to as ‘anomalous’ were extremely widespread, even among a nearly representative sample of Quebecois.

None of this should be surprising to professional sexologists, who have known since Alfred Kinsey’s landmark studies in 1948 and 1953, that sexual behavior is more varied than conventional wisdom endorses.   Later works by Friday (1973), Playboy (1974), and Janus and Janus (1993), Laumann, Gagnon, Michael and Michaels (1994), have reminded us that of that variability, although the latter study elided direct assessment of kinky behavior.  Recent studies suggest an uptick in interest and behavior, but most, with the exceptions of Richter et al, of Australia and Langstrom et al of Sweden, lacked representative national samples.

For over thirty percent, some variant behavior was acted upon one or more times in their lifetimes.  Here, Black Leatheramn cavort in front of the camera at the Folsom Street Fair in San Francisco.  The Folsom Street Fair is exceptional among kink events in its widely publicized open photography policies.  Cameras and smart phones are often banned at most kink events.

In immediate follow up to the JSM study, Joyal and Carpentier drew a representative provincial sample of Quebec, compared telephone and on-line admirations, and followed up their inquiries about fantasies with questions about abuse history, fantasy satisfaction, and behaviors.  They replicated a considerable body of research that has failed to demonstrate any statistical evidence for the widely held mythology that interest in kink is linked to early abuse.  This nearly representative sample established that 34 percent of Quebecois had acted on one or more of their variant fantasies within the DSM – 5 consensual paraphilia spectrum at least once in their lifetimes.   In yet a later article, they would demonstrate that 3 in 10 subjects had engaged in a knky behavior one or more times lifetime, up considerably from the 1.4-2.1% rate for behaviors in the past year Julia Richters et al had found in data from 2001 in Australia.  Joyal also found that subjects who admitted to masochistic fantasies had significantly more intense and satisfying fantasies than those who did not enjoy masochistic fantasy. 

Overall, this series of papers by Joyal and Carpentier fail to answer the larger question that interests him concerning the relationship between fantasy and behavior.  Are fantasies a compensatory safety valve we use to salve our frustration for experiences which we prefer not to undertake the full risks of living out in reality?  Or are they precursors to plans and actual behavior?  The answer is not simple.  It is clear that many people in Joyal’s studies day dreamed of behaviors they did not actually carry out:  The fantasy endorsements were far higher than the behavior rates in all categories.  But some people actually do things in the kinky categories they also dream about.  The study design could establish base rates, but could not establish causality.  Furthermore, pedophilic fantasies were so infrequent in these studies that few inferences could be generalized from such tiny numbers.  So clearly Joyal has much more work to do in that fabulous lab.



ICD -11:


But on another level, Joyal’s research comes at just the right moment.  The revision of The Diagnostic and Statistical Manual of the Mental Disorders – 5 is not the end of the process of struggling to define the proper diagnosis and treatment of problems in variant sexuality.  In 2017 and 2018, the further revision of medical diagnoses continues with the revision of the IDC – 11, the International Classification of Diseases - 11, a system of categorizing all diagnoses and conditions that affect medical health.  The current recommended revisions of this document can be found on the NIH website, and is conducted under the auspices of the World Health Organization, part of the United Nations.  WHO offical site for the ICD -11 revision  This is extremely important, as this system of classification underlies the DSM -5, and serves as the basis for diagnosis and treatment for every billable medical code and procedure everywhere in the world.  Struggles over some of these codes have huge implications for epidemiology, insurance reimbursement, and public health in all western countries, and the behavior of NGO’s in the developing world.

The current beta draft of this document drops the consensual paraphilias; transvestism, fetishism, consensual sexual sadism, and consensual sexual masochism, from the classification system altogether.  Where ICD – 11 is adopted as recommended, these will no longer be paraphilias at all, as Kinsey had suggested 65 years ago and as Joyal has demonstrated again in his recent research.  These standards are recommended by WHO, but they are adopted on a country by country basis.  Indeed, the four Scandinavian countries, Norway, Sweden, Denmark, and Finland have already dropped consensual paraphilias from their national coding systems derived from ICD -10.  It is unlikely that places dominated by traditional thinking and religious conservatism will adopt the ICD – 11 as recommended.  In Uganda, homosexuality is still regarded as a both criminal and psychopathological, even though it was already dropped before ICD -10 in most other countries.  But the ICD – 11 is likely to have a major impact in the Europe, the West, and in parts of Asia such as Korea, Japan, and China.

Evelyn Hooker did not end psychiatric discrimination against homosexuality with a single study.  It took the work of Frank Kameny, Barbara Gittings and the Gay Liberation Front, and the inside work of gay psychiatrists, and disruption of APA’s annual conference by activists to force consideration of this data.  Compared to that difficult struggle, National Coalition for Sexual Freedom’s negotiations with the DSM – 5 Paraphilia Committee and Norwegian activists editing of the ICD – 10 have proceeded with little conflict.  But just as the data would never have provoked change without the hard work of activists, Evelyn Hooker and Christian Joyal and Julie Carpentier’s data armed activists with the scientific power they needed to complete the political work required to change diagnoses.

Those of you who read my summary of Michael First and Ken Zucker’s presentation at AASECT 4 years ago may recall that Zucker’s last words in that piece were a response to my concern about the DSM-5’s two-tiered diagnostic system because psychiatrists might fail to attribute distress of a paraphilia to social stigma, rather than anything intrinsic to sexual variation.  He had said to wait until ICD -11.  Ken Zucker and Michael First's DSM - 5 plenary at AASECT
’ 
That moment has arrived.  Much of the credit for the ICD – 11 change rests with this research.

© Russell J Stambaugh, June 2017, Ann Arbor MI, All rights reserved



Sunday, December 18, 2016

Further Discussion of the AASECT Position Statement

There has been considerable discussion of the AASECT Position Statement - Sex Addiction, and a great deal of media coverage, most of it favorable.  Despite the fact that no professional organizations were mentioned in the statement, there has been strong reaction from addiction organizations who vigorously disagree. 

The function of this post is to aggregate my further contributions to the discussion of this topic.


The International Institute for Trauma and Addiction Professionals is not a professional organization, but a privately held LLC operated by Patrick and Stephanie Carnes and directors picked by themselves.  It provides certification training in 'sex addiction'.  The link to their response can be found here:

IITAP Response to the AASECT Position Statement

That link was posted to the AASECT List on December 14, 2016 by Geoffrey Goodman, PhD, ABPP, FIPA, CST, CSAT-S, CMAT-S, RPT-S 

I responded December 16, 2016:

I, for one, am not very impressed.   That is code language for this being my official opinion, not necessarily that of AASECT.  So lets put on our decoding decoder rings.

This IITAP 'decoding' document is an attempt to reframe the AASECT statement a sort of promise of future support because it is less absolute than AASECT's previous statements on sex addiction is simply incorrect. 

1) AASECT has not had a previous advocacy position on sex 
addiction, at least as far back as 1990. But there was no time when we had the mechanism to do it before 2004.  For more on that, please see my blog post  from elephantinthehottub.blogspot.com.  Individual AASECT Members, however, have often ardently opposed it.

2). It is pure fantasy that AASECT will change its position in the light of new data that hasn't come in yet.  

That statement reflects IITAP's belief that such research is just around the corner, but that has been their position for thirty years.  I know the feeling,  I have believed that cheap nuclear fusion power was only 20 years away since the early 1970's!   Just between you and me, it's still more than twenty years away now!  

In fact, the existence of a similar mechanism for sex addiction and chemical addictions is a major piece of the puzzle neuroscientists need to achieve to make the analogy work.  They more or less have that now.  They must also reliably demonstrate that ordinary sexual response, non-addictive substance use, and other sources of pleasure that are not about drugs and alcohol do not respond in the same manner.  Otherwise, we are probably seeing evidence of generalized pleasure circuitry, not evidence of addiction.  Likewise, it would be advantageous to see overlap with other colloquial addictions in their conceptual model that addiction treatment is appropriate for the wide range of things they call addictions is correct..   

I am working on a blog post for Elephant that address this relatively high conceptual bar.   To put it very briefly, to show that correlation is probably causality you must demonstrate that your measures are reliable; that they correlate with those things you intend to predict, and they do not correlate as well or better with other measures deemed close to your concept, but yet which lie outside of it; and that they correlate even less well with extraneous things that your model doesn't include at all.  Frankly, we can rarely meet that standard with the evaluation of other treatment methods, including our prefered models.  But that is what you need to be able to do to defeat Roger Libby's awkward assertion that behavior is nearly impossible to interpret outside of its context.  Please remember that, reparative and conversion therapies have been found to be unscientific and ineffective, (here I'm referring to the late Robert O Spitzer's conclusion that 200+ anecdotes  of reparative treatment success did not constitute scientific evidence sufficient to oppose banning them altogether at American Psychiatric Association) not just inhumane, and that the overall efficacy of sex offender programs, in which treatment must be focused on changing sexual behavior, failure rates are extremely high according the O"Donahue and Law's pessimistic Chapter 1 in Sexual Deviance:  2ed (2008) Guilford Press.  There is no unambivalent changing of sexual behaviors that are persistent enough to raise problems severe enough that they might be seen as powerful as chemical addictions.

3). IITAP still comes around to implying they are much more open and inclusive than they are, mainly by grossly falsifying their history, and end by urging us to play nice. They have, in effect, over-personalized the statement.  

My brief version of the history reflects that of Eli Coleman, who lived it.  I was in grad school at the time and not at any of those meetings.  After a few years of working together on hypersexuality, the addictionologists broke with the sexologists over language, particularly the term 'addiction'.  Any characterization of AASECT minimizing that sexual problems are real is unfounded.  We demurred years ago that sex problems constituted, in and of themselves, 'addictions' and diagnosable mental disorders.  We still demure today.   Not because there are no diagnosable sexual conditions, but that that is a distinct minority of problem sexual behaviors.  Intimacy problems, relationship conflict, reaction to stigma, unmanaged stigma are all best conceptualized in psychological terms even though they have neurological concomitants.

In the meantime, members of other organizations who wish to work together on problem sexual behaviors are welcome!  This is what that work looks like.

4). When working on this statement, we were focused on principles, not organizations.   We are against shaming techniques, pathologizing sexual minorities, and over-grand conceptual schemes that are not backed by quality data and inference regardless of which organization does what.  Please do not do it here, either.  And we are for sexologically-informed treatment, not just that done by AASECT Certified professionals.

It is my opinion that the term sex addiction is indefensible.  If later proof validates the concept, well, we can rethink that.

I might add, that I do not think much of the argument that we must use the sex addiction terminology willy nilly simply because the client might bring it in.  I would not call my client a rabbit simply because he claimed to be one, and when organizations that broke with the larger community of mental health researchers over the use of this term sold it to the lay community, it is not the clients' term that we are seeing brought in, but the organizations' premature and incorrect construction.  And with it has come problems of labeling, shame, blaming, flight form personal responsibility, and confused public discourse that make treatment more challenging rather than easier in many instances.  Having resisted the term ineffectively, we are now stuck with the problem discourse.  

If we are on record as opposing this language, for every person who defensively declines to admit they have a problem because there is no such thing as sex addiction, perhaps there is a perfectionist somewhere who won't kill themselves in despair because they are too ashamed to face such a scary problem.  Perhaps routine desire differences between couples will be easier to address if one person is not prematurely labeled as having the identified problem.   Those are the hoped for benefits of putting this sex addiction Djinn back in the bottle.  Djinn gold  disappears with the sunrise, so spend it quickly if you are planning to rub that lamp!

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This provoked a further post from Dr Goodman addressing sex positive activist Roger Libby and myself but talking past us directly to the AASECT Membership.  He suggested that IITAP was much bigger than AASECT, that 1000's of 12-step sex addiction groups met every week in the US and they must be helping or people wouldn't come to them, and that the AASECT Position Statement reflected a desperate bid of AASECT, an organization in decline in numbers and relevance in the face of a veritable tsunami of public and political endorsement of the sex addiction model.  He urged AASECT readers to keep an open mind about sex addiction in the face of AASECT's position statement.  I paraphrase here as it would be a violation of AASECT listserv guidelines to quote any post but my own. 

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Dr Goodman also posted this excellent link to the work of Dr Voon, which IITAP feels definitively validates the sex addiction model 

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I then responded:

First, the process for writing to individual members of this list is to back channel them to their private email accounts.  But Geoff is already aware of that.

Second, he lost most readers here on the 'IITAP Decoding Statement', or should have, when he suggested that AASECT and sexology had a long history of undifferentiated enthusiasm for all sex activity regardless of consequences or contexts.  He suggested maybe we are finally coming around now to right-thinking about sex addiction.  How many times we have heard this lame criticism from moral entrepreneurs in the past?  Aside from being just a trifle patronizing, its just not grounded in history.

AASECT and our sex researcher and mental health allies participated in the original efforts to define and treat hypersexuality out of belief that sometime sexual desire could be too much of a good thing. We could have simply stayed away from those initial joint meetings if we believed that too much sex couldn't ever be troublesome.  

The addictionologists are the ones who broke up these efforts when they left the other mental health professionals working of hypersexuality over use of the unproven addiction terminology.  

Neither was it minimizing of our concerns about Problem Sexual Behavior to devote an entire 2016 Summer Institute to educate about how to treat it in ways that are less exploitive of social stigma and more empowering of clients than other treatments like 12-step groups and sexologically uninformed addiction programs that have been promoting shame for sexual variations for years.

IITAP, as you well know, has a pretty poor history, up to and including the present, of failing to expel reparative and conversion practitioners and certified addiction professionals who brazenly include advertisements for attempts to change homosexual orientation in their websites and publicity materials.  In the past, IITAP has graciously cooperated with the Family Resource Center, which the Southern Poverty Law Center classifies as an anti-gay hate group.  Likewise IITAP cooperate with the ridiculous Anti-FAP, Fight the New Drug, and Your Brain on Porn cultists who's hyperbolic readings of the existing science are embarrassments to their field and to ours.  So these addiction certifying bodies and their paneyrists are in a poor position to lecture AASECT about our boundaries.

I am a Member of AASECT because it is an alternative to that kind of destructive mis-contexting and mis-conceptualization of the normal variability of human sexual behavior.

It surprises me to see that numbers argument, having just read AASECT President Debby Herbenick's eloquent and ardent defense of quality studies and sound inference over citing quantities of publications and over-interpretation on this list.  Why would anyone would suggest the AASECT Position Statement -- Sex Addiction is a response to the sheer numbers of people in our organization, or in IITAP?  The problem isn't how many lemmings are out there, but whether they are going over the metaphorical cliff.  By now, you are all aware that lemmus lemmus does not actually hurtle over cliffs to their doom in the real world, but they are doing this constantly in polemics.  You'd almost mistake them for humans!  I cite this as just one more example of why science matters!

All of this reminds me of a great Gary Larson cartoon in which a desperate lobster is saying to an obdurate chef, while the pot steams in the background.  "Did I say three? I'll grant you four wishes"!   This is not a popularity contest, the fighting for quality education and treatment for sexuality.  AASECT has always been a minority specialization, and it is our responsibility to know things most others have been discouraged from pursuing.  Our Membership is at the highest level since I joined back in the mid-1990's, but that is beside the point.  Twenty-two hundred is a small portion of 320 million.

(C) by Gary Larson, used under fair use.


Well organized political minorities, many who are allies of organizations like IITAP, have militated successfully against broader implementation of sexual health programs against the wishes of a majority of Americans.  They have opposed women's right to chose to carry their pregnancies to term.  They have opposed the right of America's youth to have scientifically valid and emotionally honest sexual health instruction.  They are claiming there is a porn epidemic and it constitutes a health crisis on the basis of zero evidence beyond the fact that porn is widely available on-line.  They claim rising crime despite the fact that the best criminology data shows a 25 year long decline of 30-70% for most offenses.  And despite Diamond's work strongly and repeatedly suggesting that the increased social availability of erotica is negatively correlated with sex crimes.  Yes, correlation is not causality.  But such statistical links as we have suggests masturbation is associated with health benefits, not harms, and erotica availability is associated with less crime, not more.

So anyone opining on this site about our history would be at an advantage to know it, and not just post material that suits the author.  

I am here to encourage you not just to keep an open mind, but to do it in the skeptical way that scientists do.  Not to just listen to some ad hoc concoction that suits your immediate personal interests.  Scientists read and review the best literature, and find the places where their skepticism can be tested.  They argue and discuss the best tests.  They develop their theories, then test against themselves, rejecting the hypothesis that they are wrong only when the evidence is too great to discard their pet theory.  They are as rigorous about their own theories as they are about those they disagree with.

Test not just with statistics, but with empathy, a knowledge of history, and with your sense of social justice.  Test with context.  Just as liking sex doesn't make you a slut, rejecting somebody's poor track record at setting boundaries doesn't make you permissive.  That is just the same old slut shaming in new drag.

You want my personal decoding of the AASECT Position Statement?

1). No slut shaming.  Often people with problems only magnify them with shame.
2). Be scientifically rigorous and conservative.  Works great with sexological treatments and addiction treatments alike.
3).  Put the client first and don't power play them, or let others power play you.
4).  The numbers that matter are in carefully constructed statistical tests, not popularity contests.  We just saw millions of voters be wrong.  Happens all the time.  Don't let it happen to you!

Having overcome my heretofore unconscious fears of declining relevance, I'll close here for the time being.

"Did I say four wishes?  I'll grant you five wishes!  They used to feed lobsters to Confederate  prisoners, you know.  We're highly over-rated.  Shrimp, now shrimp are very tasty...

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Whether we agree with their reading of the data or not, there is great resonance to the observation that sex addiction advocates are not going to simply abandon their models willingly.  Certainly the collective scientific judgments that reparative and conversion therapies are not just a human rights violation, but are ineffective has not prevented their proponents from advertising them.  They claim that If the public demands snake oil, it i it is their responsibility to provide it.  I find this a disingenuous argument for these outlier sex-addiction therapists to make.  They come from a tradition in which the unrealistic demands of clients are confronted, not gratified.  

But in truth, sex addiction therapists are not coming to AASECT because they are looking to find clients for conversion therapies.  They want to do effective, sexologically-informed work.  They take the reality that people have problems sexual behaviors so seriously they have made it their life's work.  And the data suggest that, while sex addiction clients are mostly wealthy, white and male, and there is certainly defense of privilege involved in their selection of this method of treatment, our clients are often similar to theirs in race and class.  And the data show that, as of 2016, severe conflicts of desire have been difficult to treat since the inception of sex therapy.  

In this we are allied, and being scientifically open-minded means being respectful of the limits of our theoretical models and the effectiveness of our techniques.  It means subjecting our best techniques to rigorous evaluation even when it is expensive and hard to raise money for sex research. It is by no means clear that the sex addiction emperor is the only one with no clothes here.  The proof isn't all that great for calling most sexual disorders diagnosable mental disorder in the first place.  Behavior needs context.  And in the current research environment, the hope is that neuroscience will overcome this truth.  Do not bet the farm on that assumption.  We have been wrong so many times before.

Tuesday, December 6, 2016

The AASECT Position Statement on Sex Addiction

Last week, AASECT announced a new advocacy position regarding sex addiction passed by the its Board of Directors at their Fall Meeting on November 15 in Chicago.    That statement reads:



AASECT Position Statement — Sex Addiction

Founded in 1967, the American Association of Sexuality Educators, Counselors and Therapists (AASECT) is devoted to the promotion of sexual health by the development and advancement of the fields of sexual education, counseling and therapy. With this mission, AASECT accepts the responsibility of training, certifying and advancing high standards in the practice of sexuality education services, counseling and therapy. When contentious topics and cultural conflicts impede sexual education and health care, AASECT may publish position statements to clarify standards to protect consumer sexual health and sexual rights.

AASECT recognizes that people may experience significant physical, psychological, spiritual and sexual health consequences related to their sexual urges, thoughts or behaviors. AASECT recommends that its members utilize models that do not unduly pathologize consensual sexual problems. 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.

AASECT advocates for a collaborative movement to establish standards of care supported by science, public health consensus and the rigorous protection of sexual rights for consumers seeking treatment for problems related to consensual sexual urges, thoughts or behaviors.

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This position statement is, in my view, a crucial and inevitable step AASECT has taken at the time given the characteristics of the clinical and social environment.  This, indeed, is why I agreed to participate with Michael Aaron, Doug-Braun-Harvey, and Michael Vigorito, in creating it at the behest of Ian Kerner,  the AASECT Public Relations, Media, and Advocacy Steering Committee Chair.  The statement purposes are also consistent with my work as Kink-Aware Professionals Advocate for The National Coalition for Sexual Freedom, (NCSF) a position I accepted shortly before receiving the invitation to participate in constructing the statement.

Context:

Elephant is all about context, and like kink, therapy, and so many other things in social life, it is easy to misunderstand this statement without appreciating the context from which it arose.  So that is going to require excursions into organizational history, some discussion of the contemporary socio-political landscape, and AASECT’s history as an advocacy organization for fuller understanding.  But let’s talk a little bit about what the statement might or might not be intended to accomplish.

One important caveat:  While I speak as an author, and the document I helped create was adopted by AASECT, I do not speak for AASECT, or even the other members of the task force that created this language.  The history I shall present is as factual as I can make it, but the views are my own.  I am urging readers to view my observations critically in the interest of better therapy and social policy towards sexual variability, but it would be na├»ve to assume that all readers will share the values and assumptions that characterize this blog.


The AASECT Position Statement is an assertion that the best scientific studies do not currently support the theory that sex can be an addiction directly analogous to cocaine, heroin, alcohol or nicotine.  That similar neural pathways may sometimes be shared by sexuality and other sources of pleasure and reward, including those involved in true addictions, reflects correlation, but does not establish causation.  The scientific evidence is also weak that one will lose erectile function or partner desire from over-use of erotica.   These claims are the modern equivalent the 1880’s shibboleths that one will grow hair on one’s palms or go blind from masturbation.  Just last month a new study was reported that failed to replicate the long-touted study that partners who used high levels of erotica were more likely to divorce than those who did not.  The evidence is clear that clients sometime have problems with excessive and non-consensual sex behaviors, but not that they are ‘addicted’ to sex.

The statement is also an attempt to reframe the inept social language that defines sex problems such as excessive use of erotica or intimacy difficulties as ‘addictions’ because they are best treated by the same techniques as alcohol and recreational drug dependencies.  Neither is there scientific basis for claiming we are in a public health crisis caused by erotica use that requires emergency governmental intervention.

The position statement also states that it is not reasonable for the public to expect high quality treatment for sexuality problems from addiction specialists certified by addiction specialty organizations unless those professionals also have special training and certification in professional sexology.  The clear majority of sexual problems do not belong to the class of addictions, but are in the domain of the human sexuality professionals.

The position statement does confront the practice of using shame as a mechanism of social control for human sexuality generally, and specifically and directly opposes it as a therapeutic technique to attempt to change sexual behavior.  We made this statement confidently and assertively given the poor scientific track record of therapies relying on shaming techniques and the ubiquity of sexual shame in society generally which greatly risks over diagnosis of sex as the root cause underlying presenting complaints about a client’s sexual and intimate relations.

Thus, the position statement is not a blanket condemnation of all certified addiction specialists, some of whom already have, and others who are seeking, advanced competence in treating the problems of human sexuality.
 
While it is criticizing the use of the term ‘sex addiction’, it is not a blanket condemnation of all ‘sex addiction’ treatments.   Therapists, both sex therapists and so-called sex addiction therapists, use a great variety of techniques, and there is overlap between what good therapists of differing theoretical orientations do.  In fact, we are confronting the use of shaming and the uncritical defense of sexual conventionality, not specific theoretical orientations.

Neither is it an attack on other certifying organizations, especially SASH and IITAP, which are nowhere mentioned in the document, except in so far as they teach their memberships based upon unsound scientific principles, and fail to require adequate human sexuality training, or advocate for under-trained individuals to practice as if they were certified and licensed professionals.  It is anticipated that our opposition to the use of shaming behavior in therapy would be a bone of contention for some members of other organizations that deem shame to be condign.

It is not an attempt to expel persons seeking expertise in the field of human sexuality from our AASECT community because they hold certification in other organizations whose ideology we do not share.  That not only includes professional organizations like AAMFT, IITAP, or SASH, but religious organizations, or diverse minority communities some of whom hold sexual views with which we might disagree.

Immediate Context:

The immediate impetus to the AASECT PRMA Steering Committee soliciting this advocacy document and passing it was two-fold.   AASECT evaluates the educational programs of other organizations in the field to determine which of our education requirements outside providers might fulfil.   This work is conducted by the CE Approval Committee led ably by Sally Valentine, which, late last year, stopped approving sex addiction programs because they were not adequately sexologically grounded.  This raised the issue that if we had a principled reason to this, we had an educational responsibility to communicate to the Membership and public about it.   At around the same time, Susan Stiritz chair of the, AASECT Summer Institutes Committee, decided that years of controversy on the AASECT listserv about sex addiction might indicate an excellent programing opportunity.  If Members wanted to talk about it so much on the list, maybe they would pay to attend quality intensive training about it.  This simultaneously made for excellent opportunity to teach about the change in the CE Approval policy.  The Summer Institutes Committee assembled such a great line up, I coughed up the money to go and it was the best AASECT program I have ever attended.  PRMA Steering was moved to action because of discussion generated by the resultant program: ‘Revisiting “Sex Addiction”: Transformative Ways to Address Out of Control Sexual Behavior’.  It included a wide slice of AASECT participants, including many who held SASH and IITAP memberships.  Presenters included Eli Coleman, Joe Kort, David Ley, Nicole Prause, Rory Reid, Neil Cannon, Ruth Cohn, Dalychia Saah and Rafaella Smith-Fiallo, Michael Vigorito, Doug Braun-Harvey and Susan Stiritz.


Also influential in the timing of this position statement was the deteriorating social discourse associated with the then-current US Presidential Campaign.  Comment trolls and political flaming did not originate with this campaign, but it is highly significant that in it, blatantly false discourse and the promotion of strongly-held opinions as the equivalent of facts crossed the line from internet anonymity to daily public speeches by the candidates before thousands of partisans.  In this climate, organizations like “Fight the New Drug” have been spreading ideology that porn is the equivalent of heroin.  The Republican National Committee put a plank in their platform that erotica constitutes a public health crisis in defiance of STI rates, unequal access of poor and ethnic minorities to sexual healthcare, and sexual transmission of the Zika virus which constitute genuine public health crises.  It is the professional responsibility of AASECT to defend the practice environment in which quality sexuality education, counseling and therapy might take place.  The position statement is part of AASECT’s response.

How big was the lie, Donald?  "It was this big.  You should have seen the one that got away"!

AASECT History:

AASECT Founder Patricia Schiller, JD.  Photo taken by AASECT around 2008.

 
This year AASECT will celebrate its 50th anniversary.   It was founded by Patricia Schiller with the express goal of supporting high standards in the field of sexuality education.  It was not until 5 years later that AASECT’s mission was expanded to cover training psychotherapists and physicians in sex therapy.  Schiller founded AASECT because, despite social changes in the 1960’s that made for increased social discourse about human sexuality, academic institutions failed to provide adequate graduate and undergraduate programs to train in human sexuality.  The contemporary political environment made it extremely hard for colleges and universities to secure funding and legislative support for academic programs involving sex.  That sad reality remains true even today despite a handful of quality programs at Morehouse University, University of Minnesota, University of Michigan, Guelph and Widener University.   Sexuality education, sexuality counseling and sex therapy remain post graduate specialties to this day, and are marginalized and diminished as academic disciplines relative to supply chain management and forestry because of social stigma surrounding human sexuality.
 
So AASECT took up the task of certifying competence in the sexual health professions outside of traditional medicine.  This is the basis for its Continuing Education Approval Committee needing to make decisions about what programing has AASECT-approved sexuality content.

Although ratified by 35 states, the Equal Rights Amendment failed in 1979 sparking debate in AASECT about boycotting Colorado.  No permanent advocacy mission was established in AASECT until 2004.

Until 2004, AASECT had no official advocacy function.  Great controversy had attended AASECT’s decision to hold a conference in Denver Colorado about the time of the defeat of the Equal Rights Amendment in 1979.  But efforts to officially incorporate an advocacy function were deterred by three factors.   Tax-exempt educational associations like AASECT are strictly limited in their ability to lobby governmental officials, and cannot generally afford to do so and simultaneously fulfil their other responsibilities to their memberships.  Because of those regulations, AASECT existed in an agreement to carve up the domain of professional sexology with three other organizations.  The Society for the Scientific Study of Sexuality (SSSS) handled research, The Sexuality Information and Education Council of the United States (SEICUS) handled advocacy, the Foundation for the Scientific Study of Sexuality did fundraising, and AASECT was responsible for certification of professionals.  In that arrangement, advocacy was another organization’s job.  Third, these arrangements were mostly fine with sex therapists, who made up most voting members in AASECT and were reluctant to advocate, seeing it as a role conflict with their clinical work and a diffusion of scarce organizational resources.

The ACT UP die-in at The National Institutes of Health over experimental treatments for AIDS.

But in the late 1990’s NCSF formed and, along with the Victoria Woodhull Foundation, started exhibiting at AASECT Conferences, gently advocating for kink and consensual non-monogamy.  GLBT members became increasingly influential in AASECT Membership.  Many had learned that collective action and advocacy were essential to surviving the HIV epidemic.  And the practice environments of sex educators were steadily deteriorating due to the onslaught of abstinence-only education funded by the states and federal government. At about this time, the World Health Organization and World Congress of Sexology (now named The World Association of Sexual Health) adopted advocacy platforms, legitimating the argument that AASECT should advocate for sexual health too.

   
In this new environment, Barnaby B Barrett, then AASECT President-elect, persuaded the 2004 AASECT Board of Directors to create a Public Relations, Media, and Advocacy Committee with the tasks of amending the AASECT Mission to permit sexual health advocacy, and writing the AASECT Vision of Sexual Health.  In 2006, the Board was reorganized and the advocacy function was made a permanent Board-level position to support other initiatives that fell within the scope of the AASECT Vision of Sexual Health.  Since then, AASECT has passed statements opposing abstinence-only education, opposing reparative and conversion therapies, and supporting scientifically sound ideas of healthy sexual variability.  Because sex addiction therapies have been used reparatively against gay, lesbian, gender-nonconforming and kinky clients, these efforts involved intense discussion whether sex addiction should be specifically named in our statements against conversion therapies.  I opposed this as misplacing our focus:  we are against reparative therapies because they are a violation of human rights and scientifically ineffective regardless of the treatment methods involved.  But these earlier advocacy efforts were yet another source of impetus for AASECT to address sex addiction explicitly.  The formation of the AASECT AltSex Special Interest Group in 2009 became yet another focus for some of this advocacy discussion.

Hypersexuality , Sex Addiction, OCSB or Problem Sexual Behavior?

I will not review here the long history of the various theoretical constructs that have been offered to the American Psychiatric Association's Diagnostic and Statistical Manual revision efforts.  Back in the 1960’s with the publications of DSM – II, one set, ‘nymphomania’ and ‘satyriasis’, were mentioned in DSM – II.  Hypersexuality also had standing in the manual as a research diagnosis or component of the catch-all diagnosis; Psychosexual Disorder Not Otherwise Specified (NOS).  But AASECT is not alone in resolutely regarding the scientific evidence for ‘sex addiction’ to be too weak and pejorative to serve as a diagnosis.  Eli Coleman has long championed work to make some form of excessive sexual behavior a billable diagnostic code, but his efforts had foundered in a thicket of competing terminologies.
 
Back in the 1980’s, the addictionologists and the sexology community worked together in the effort to research, define and treat excessive sexual behavior.  In their second year of joint meetings, they even conducted mini-SAR’s to spread sophistication about sexual variability among the two communities, but starting in the third year of regular meetings, the addiction community decided on meeting separately and insisted on their own terminology, much bolstered by the success of Patrick Carnes book “Out of the Shadows”.  Over time, the addiction community became self-certifying, yet failed to incorporate sexual science-based sexual criteria in their certification standards.

I have written extensively on this blog about the 2014 publishing of the DSM – 5 with scant mention of hyoersexuality and the problems this has posed for the addictions community.  For those interested, here the links follow this paragraph.  But AASECT is neither premature, nor is it taking a radical position to assert that, even though the neuroscience is still coming in, sex addiction is not an appropriate clinical definition of most sexual problems involving high frequency or variant consensual sexual problems.

 
Finally, I chose to cooperate with Doug Braun-Harvey and Michael Vigorito on this effort because of a crucial concept in their writing that I believe constitutes a cornerstone of good clinical work.  Although every effort should be made by all practitioners to ground their work in the best science, the long history of clinical ideas illustrates that we have been providing good quality psychotherapy with inadequate, scientifically weak, but widely practiced treatment models.  Between Krafft-Ebing’s first modern attempt at nosology in 1886 and today, we spent the first 66 years with no classification system at all, and almost a hundred years without one based upon defined and observable symptoms.  So modesty about our methods and care not to abuse our clinical authority in treatment is exceeding important.  Sex addiction therapy is not client-centered, even if the client comes in with intense, ego syntonic shame and needs no urging to adopt self-shaming labels like ‘sex addict’.  David Ley has emphasized the risk to a client’s sense of agency regarding their sexual behavior through adoption of such labels.  And overstating the power of sexual urges feeds the shaming social discourses that underlie many clinical problems we as sexology clinicians see presenting for treatment.  Terms like out of control sexual behavior and problem sexual behavior are appropriately atheoretical, less stigmatizing, and appropriately modest about what science knows right now.  It is an ethical cornerstone of diversity-sensitive practice that we not employ terms that imply that we know more than we do simply because they constitute effective marketing techniques.  Such behavior is objectionable because it puts our welfare before that of our clients.

In Summary:

This discussion of AASECT’s Position Statement on Sex Addiction emphasizes organizational histories and missions, changing social forces, with emphasis on the changing social environment in which sex is practiced and discussed and in which quality sexuality education and therapy are conducted.  This is not because gifted individuals do not deserve recognition for their efforts to promote sexual health.  There are many heroes.  But none of these people would have been successful if their efforts were not supported by others, and didn’t take advantage of the opportunities their times afforded them.  In the actual event, the impulse to take a position on sex addiction came from AASECT’s program accreditation function, their own educational programs, their commitment to supporting good educational and clinical work for alternative sexualities, the opening of AASECT to increasingly diverse Members and exhibitors, and AASECT’s responsibilities to support a constructive practice environment.  Ultimately, it is within AASECT's primary mission to protect the field and the public.

I participated because I believed this is the correct step at the correct time in a long history, and I thank all my colleagues for their support in this effort.

 © Russell J Stambaugh, PhD,  Ann Arbor Michigan, December 2016.  All rights reserved.