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.


  1. Trying to communicate in a neutral manner on topics like 'hypersexuality' is more complicated than it looks.

    The APA has basically taken 'a plague on all your houses' approach to the terminology in DSM-5. They cannot be expected to achieve statistical reliability for concepts around which there is so much social disunity. And who really disagrees that the science isn't there regarding whether PSB-based-on-a-lot-of-activity (see, I'm in trouble right away!) is an anxiety symptom, a chemical dependency symptom (its just the chemicals happen to be endogenous), or a behavioral problem with rewards such as might apply to gambling addiction--which they did include. You have to admit that gambling addiction got in cause inter-rater reliability was easy to achieve, rather than the neural pathways are all worked out!

    What I did not say is that APA, and many of their social constituents, don't want to use PSB, with which they are all acquainted thanks to Charles Moser and Peggy Klienplatz, because it doesn't seem either scientific or expert to have the client defining the problem. It seems like just about everyone has a dog of some sort in the fight to prevent that! We are going to have to run PSB up the flagpole quite a few times before much of anyone outside of this list starts saluting (forgive the all too provocative Memorial Day military metaphor.)

  2. Which does provide a fine segue directly to one of the many insects in the ointment: social control. Although I was repeatedly warned, both in life and in training, about the dangers of psychotherapists becoming agents of social control, we keep getting drawn into social control functions anyway. And this name game is not just an epistemology problem as I say in my blog, but a social conflict about what role psychotherapy should play in social control. We must not kid ourselves that when we talk about labeling, deviance, boundaries and limits, and objectification, we are not entering into the social control process. It is not possible to stay completely out, given duty to warn etc. This goes a lot deeper than child custody evaluations, psych reports on the ability to stand trial, and civil commitment proceedings.

    Overlaying that is competing economic interests which are pretty obvious, and I will not belabor them here, except to say that we, and everyone else in the field are actively involved in PR efforts that tread on one another toes all the while we are trying to play nice. SASH is all about operating in the addiction model but changed their name, for clarity, to the Society for the Advancement of Sexual Health. I sometimes wonder to oppose what organization that is struggling mightily for the retreat of sexual health? We in AASECT like to think of ourselves as advancing sexual health, too. But part of the reason this is contentious is that sometimes our values that sexual activity be freely chosen and our desire that it be healthy are in quite a lot of conflict. I am entirely unclear what getting discovered masturbating at work in the face of company policy to the contrary, constitutes healthy sexual expression, and I have no idea if its freely chosen. I only really get to know those things with an open client who actively cooperates with helping me undertsand in therapy, not from a initial behavioral description.

    Which brings us to the clients. I have, on occasion risen in defense of using the client's language where possible, and in the issue of the odious term 'she-male.' many here offered an instructive critique of how that term is actually prejudicial enough that it ought not be repeated. Clients often do things that are transgressive, angry, risky and edgy. They screw others when they 'should' want to share pleasure. They try to get away with looking at porn at work and get too excited to hold back sometimes because it is risky and more exciting. So saying they were discovered masturbating may be about as accurate as saying that the police discovered someone taking money from a bank without permission.

  3. The excellent point Eli (he suggested on the AASECT list that we avoid negative language eg, someone was 'caught' masturbating at work, when 'discovered' would be more neutral) makes is that we not use pejorative language needlessly, and thereby contribute to the labeling piece of the social construction of social control. If I have a vote, here, I cast it for that! It will be an even better trick if I can actually do it.