Wednesday, May 29, 2013

Our Story So Far

John Godfrey Saxe (1816-1887)

This blog began with a 19th century American adaptation of a Jain poem about the near impossibility of communicating across different assumptions.  That cross-cultural communication is possible is admirably exemplified by John Godfrey Saxe’s adaptation of the parable from a religion that scarcely anyone in America has ever heard of.

A symbol of Jainism

The reason the Jain religion is little understood in America is that the Jain themselves were rather masters of assimilation.  Jainist beliefs underlie Hindu and Buddhist ideals of non-violence and respect for all life.  The concept of samsara, the illusion of temporal existence and reincarnation based on karma, stems from Jain beliefs.   Vedic Hinduism and Jainism lived side by side in ancient and medieval India (1500BCE to 500 AD) until they nearly merged.  Modern Jains comprise .4% of the Indian population, Hindus over 80%.  Saxe never visited India, but the parable is one of the exports of the British Raj.  The integration of Vedic rituals and Jain philosophy seems to have been accomplished through a great deal more scholarship and much less violence than the later Mughal and British colonizations.  With respect to the integration of Hinduism and Jainism, the blind men somehow thrashed it out without resorting to violence.

I then proceeded to suggest that studying kink was something like the epistemological puzzle posed in the poem:  that the different sexual variations themselves proceeded from a lot of different desires and abilities, experiences and epistemologies, and that studying them from the viewpoint of a therapist might be systematically different from being a participant, let alone an ardent enthusiast.  Kinky folk themselves might have had no small difficulties agreeing on a PR campaign!  Not only are the worlds of kink and therapy differing in many of their underlying assumptions, but language, goals, and expectations are often not shared.  In my discussion of consent, I contrasted the sexual freedom and sexual health agendas, and found areas of commonality.  In the last 4 posts, I have explored the differing epistemologies within the psychotherapy community regarding the field’s diagnostic manual. There is clearly plenty of disagreement about how we therapists know health when we see it, how we know sexual freedom when we see it, and when we think those two values are aligned.

Perhaps Saxe was a bit pessimistic.  He was a great lover of rail travel, and following a head injury, he struggled with depression.  In the Jain version of this parable, the six blind men visit the elephant in their various ways, and return to tell the king of their experiences.  The king affirms how they are right in their own ways; that the elephant is all these things and more.  The Jain version ends in harmony and peace rather than cacophony.
As it is with the elephant, so it is with the parable!  We will next turn to thinkers who believe that social reality is all about synthesis.

Sunday, May 26, 2013


You don't know the power...

The darkest sides, the umbra, of the shadows associated with sex addiction are twofold.  Despite the lack of inclusion of ‘hypersexuality’ as a diagnoses in DSM-5, a fairly large number of people find themselves craving sex, love, and relationships in ways they are cause for acute ambivalence, and socially undesirable behavior.  Somehow, both the kink community and the therapist community need to offer understanding and support to these efforts to have less sex and less craving.  Suffice it to say, not all sex is healthy or satisfyingly desired.  Some is self-destructive and criminal.

It shouldn’t surprise us that a concept of addiction that is based on neurophysiological accommodation to exogenous substances—drugs, in other words--doesn’t create unified behavioral criteria for psychiatrists who insist on repeatability and reproducibility to code a diagnosis.  Neither sex, love nor relationships are drugs, Bryan Ferry notwithstanding.  They are not even the same concept, psychologically or physiologically.  Addiction may be an excellent metaphor, but the analogy breaks down at some key points.  Perhaps the resistance Carnes, et al., are facing in trying to gain increased acceptance is appropriately scientific literal-mindedness.  A better life can often be achieved for addicts who get completely clean from alcohol or heroin addiction.  Some would be willing to trade the peace of a sex-free life for freedom from shame and excessive cravings for sex.  Fewer, perhaps, would so readily dispense with love.  And there are points in the typical natural history of relationships when craving is typical, and when love and sex are so similar as to be clinically indistinguishable.  This is a serious classification problem because the sex addiction theoretical model doesn’t fit observed behavior very well.

Limited metaphor
But there is strong evidence that our bodies’ and brains’ natural production of hormones and neurotransmitters underlie romantic craving, sexual desire, and healthy relationship behaviors.  The analogy may be imperfect, but even scientists and clinicians who are not persuaded by the sex addiction metaphor think we are looking in the right neighborhood. 
In 1983, an heir to the Upjohn fortune, plead guilty to first degree criminal sexual conduct with his 14 year old step daughter and 13 year old son.  Facing life imprisonment, he plead guilty in exchange for experimental injection of Depo-Provera, a powerful androgen-agonist that flatlines testosterone production in men.  Ironically, the drug was manufactured at that time by the company securing his personal fortune.  Famous sex researcher John Money had been the first to suggest, in 1966, that the basic chemical compound in Depo-Provera might be used to control deviant sexual urges.  In fact, it does a pretty fair job of controlling non-deviant sexual urges too. 

Depo-Provera's primary use is as a contraceptive.  To reduce sex desire in men, 4 shots per year are needed.
The effects of blood level of testosterone in men are somewhat complicated.  If a man has a normal level of testosterone, his sexual desire is likely to be normal too.  More testosterone doesn’t raise sex desire, but can increase muscle formation and some secondary sexual characteristics, but these potential benefits come with serious risks, including androgen-induced psychosis.  These are among the reasons why steroid use is illegal in many sports, and a relatively dangerous practice.  Decreased testosterone, however, can definitely decrease sex desire.  This is a serious risk for anyone who has side effects from uro-genital forms of cancer where the testes may be affected by radiation, or need to be removed completely.  Depo-Provera had been approved in some states as a less expensive and potentially effective alternative to incarceration for sexual offenders.  Eventually, the Upjohn heir decided chemical castration was not such a great idea, and joined the prosecutor in suing to overturn his plea, and the Michigan Supreme Court ordered re-sentencing on the grounds that Michigan had no legal provisions supporting experimental chemical castration.  But physicians and mental health professionals who argue the importance of underlying hormones in sexual function are on solid scientific ground.  The idea of chemical castration as an inexpensive treatment for pedophilia continues to resurface periodically, much to the abhorrence of civil libertarians.

With solid evidence that sexual behavior can be heavily influenced by drugs, it is not surprising that those who treat chemical dependency would seek to help people treat other unwanted intense urges.  But this brings us to the even darker side of this story.  Because of the genesis of the sex addiction movement from Alcoholics Anonymous, it has become the treatment method if choice for religious people who define too much sex in terms of violations of absolutist notions of proper sexuality derived from their interpretations of the Holy Bible.  The community of Christians is very diverse, with many different forms of Biblical interpretation.  The sex addiction movement is home to many of the more socially conservative, absolutist, and fundamentalist beliefs.  These include hostility to Gays, sex outside of marriage, and any form of kinky behavior.  So a professional’s membership in and certification by SASH, the Society for the Advancement of Sexual Health, does not automatically protect consumers from a traditionalist agenda.

Actually, you would think that a Holy Bible which features slavery, crucifixion, and polygamous prophets (all the Old Testament prophets had multiple wives!) would be a poor bulwark against sexual variation.  In fact, I have had patients who attributed their first kinky sexual fantasies to Bible stories.  But the role of such experiences in causing kinks is highly ambiguous.  It is fair to say that if any story, idea, or imagery is in the culture, someone might pick it up, and that the Bible definitely contributes immensely to the Western culture from which modern kink has emerged.  But non–Western societies in Japan, India, and the Moslem world spawned plenty of sexual variation without recourse to Biblical instruction.  And the religious are perfectly correct to point out that the behaviors in the Bible had entirely different contexts, and many different meanings than their modern kinky analogues have.

Indian erotic art at Khajuraho.

Part of the resistance to the sex addiction model comes from people who have seen years of sexual judgments from people of faith, dislike the consequences and feel like they need to resist the judgments of others.  In kink, that may even mean flagrantly provoking the orthodoxy for the thrill of defiance.  But in closing my discussion of sex addiction and the conflict over the DSM I feel constrained by fairness to point out that there are many thoughtful therapists, in SASH or AASECT, who have religious beliefs but do their utmost to keep these from influencing their work with clients who do not share their views.  There are some very fine therapists in SASH. The sex addiction model has helped thousands of patients. In a later post, we will examine some of the component behaviors of successful therapy that 12-step, psychodynamic, and cognitive behavioral approaches have in common. 
I find it reassuring that, in the psychoanalytic model to which I ultimately subscribe, we each have a little darkness in us, and often the sources of our weaknesses are our greatest strengths in a different context.  The trick remains to be open anyway, even when it would feel safer to be closed-minded.  In the end, we are no better served to make sex addiction therapists the Other, than we are to do this to the kinky.

Three Program Notes:

The AAECT 45th Annual Conference convenes at the Miami (FL) Hilton Downtown June 5-9.  There will be some interruption in our regularly scheduled programming here during that convention. 
Thursday evening, 7-8:15; our opening Schiller Plenary will feature Michael First. MD, from the DSM-4TR Committee and Kenneth Zucker, PhD, Chair of the DSM-5 Sexual and Gender Identity and Sexual Disorders Committee.  They will present on the development of DSM-5 with special emphasis on the sexuality sections Ken chaired.

Friday Afternoon, 3:30-4:30; Mollena Williams, kink educator, storyteller extraordinaire, International Ms Leather 2010, and founder of Safewords: a 12-step group for kinky folk in recovery from addictions in the Bay Area will discuss her coming out as a black woman into sexual submission and what that means to the ethics and ethos of pan-sexuality in the BDSM community.

On Saturday morning, 7:45-8:45AM; I will chair the annual face-to-face meeting of the AASECT AltSex Special Interest Group.  There are rumors, patently false, that this meeting was scheduled early to hold down attendance.  Don’t let ‘em get away with it!

More information on SASH and their programs can be found at:

© Russell J Stambaugh, May 2013, Ann Arbor MI, All rights reserved.

Out of the Shadows

Romulans?  What are they doing in here?

A good example of the problems in DSM's use which Foucault's insight explains is the massive electronic database that a consortium of the country's major insurance companies uses to keep track of all medical diagnoses and procedures.  If your insurer ever paid a claim for your care for a hang nail, drug overdose or suicide attempt, the medical procedures used needed to justified as appropriate to your diagnoses, and these diagnosis, cost and procedure data are kept so that the companies can estimate the economic risks associated with your health, and that of all other insured patients.  This central database is presumably a more valid indicator of the actuarial risks insurance companies face than the data from any single company would be since individual company data might be distorted by regional business models, or variations in their clientele. Some regions of the country have different health risks than others, as do different occupations. By associating diagnostic codes with demographic information, insurance companies save money and manage their own risk.  But they also are allowed to use this data to determine if you have a preexisting condition, and increase the costs of your policy.  The Affordable Healthcare Act, aka 'Obama Care', when fully implemented, will prevent limiting coverage for preexisting conditions.  But it will not prevent a diagnostic code from following you for life within the insurance industry, even if you change jobs, jurisdictions or insurers.  Of course, the government has access to the information too and their 'big data' projects could associate it with other information they keep on you.  All of this sounds like bedtime stories for conspiracy theorists.  It has been going on for 20 years, so whether there is any immediate cause for alarm depends on your personal diagnoses and comfort level with them.

Because individual clinicians; medical doctors and allied healthcare professionals alike, have professional ethical commitments to their individual clients, the insurance and government data requirements create considerable professional conflict for those who treat socially controversial diagnoses.  This came up in HIV/AIDS reporting, and it applies to diagnoses of psychosexual disorders, personality disorders and paraphilic disorders too.  If a doctor interprets his responsibility to ‘first, do no harm.’ strictly, s/he will decline to diagnose conditions that create socially risky consequences for clients.  Many mental health professionals have been doing this with consensual paraphilas for years.  If any other diagnosis fits, paraphilias won’t be mentioned.  There is also considerable debate about what techniques can effectively treat paraphilias, so few patients have been exposed to dangers of not getting reimbursed if they do not get the diagnostic label.  Most insurers decline to cover paraphilias entirely.  

This is all well and good, but more or less defeats any epidemiological research that searches medical records for data on paraphilias.  It is quite likely these are dramatically under-reported in clinical settings, especially private practice, where variant consensual behaviors are most often encountered.  It is time to switch science fiction genres:  this is analogous to Star Trek’s Romulan Cloaking Device.

A Romulan Warbird decloaking
Which brings us to the problem of hypersexuality.  In the DSM-5, hypersexuality is in the glossary but it is not a diagnosis.  Hypersexuality is defined therein as ‘a stronger than usual urge to have sexual activity.’  The literal–minded will immediately find lots of objections to the ambiguous “I’ll know it when I see it” diagnostic approach, but those are precisely the basis for a very large and political debate about what hypersexuality might be and what to call it.  Hypersexuality enjoyed a considerable prospect of making the DSM-5 list of diagnoses earlier in the process before the objections of Dr. Francis and others described in the previous post.  Historically, it has been turned back at the gate of the last 4 DSM revisions all the way back to 1980.  In 1987, it managed a near miss, achieving mention in the Sexual Disorders, Not Otherwise Specified example descriptions of DSM-IIIR.  Martin Kafka, MD, who sat on the Sexual and Gender Identity Disorders Committee that revised DSM-5, forcefully made the case for inclusion in an article in the Archives of Sexual Behavior in 2009, but it was not included in the published edition.

Although this is the sex addiction movement's best seller, AA groups were treating 'sex addiction' for several years before Carnes published the first edition in 1983
All of which is a great disappointment to Patrick Carnes and his adherents, who, following Carnes publication of Out of the Shadows: Understanding Sexual Addiction in 1983, have been treating people who get into difficulties with those stronger than usual urges.  ‘Sex addiction’ ‘compulsive sexual behavior, 'hypersexuality', 'impulsive/compulsive sexual behavior,' and 'problem sexual behavior,' are all terms that have been applied to excessive sexual desire or behavior.  Leaving aside the fact that the neuroscience that sex addiction theorists use to justify their analogy to chemical addictions is very much a work in progress, different professional and consumer constituencies have varied epistemologies for understanding this concept of ‘excessive’ sexual urges.  This is another example where science isn’t strong enough to silence most critics.
In the meantime, hypersexuality is mostly diagnosed as an anxiety disorder.  This effects not only the avoidance of social stigma and makes treatment reimbursement possible, but it masks the prevalence of sex addiction as a separate category of disease, and does not classify the Alcoholics Anonymous treatment methodology of 12-Step programs run by lay group members as a treatment for excessive sexual urges.  The American Psychiatric Association retains professional jurisdiction for licensed mental health professionals in this instance by not legitimizing a diagnosis.  The science suggesting that hypersexuality is an anxiety disorder isn't conclusive either.
All of which leaves sex addiction very much still in the shadows.  With no diagnosis and no data, from a purely epidemiological point of view, it is as if it does not exist!

Cloaked, it looks just like the final frontier

 Out of the Shadows: Understanding Sex Addiction by Patrick Carnes. (Hazelden, 1983) ISBN 978-1-56838-621-8
Kafka, M. P. (2010). "Hypersexual Disorder: A proposed diagnosis for DSM-V" (PDF). Archives of Sexual Behavior 39: 377–400.

© Russell J Stambaugh, May 2013, Ann Arbor MI, All rights reserved