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.

2 comments:

  1. Russell, this is wonderfully written. Great job. Thank you

    ReplyDelete
  2. Several lengthy comments regarding the IITAP response to AASECT's position statement can be found in the next post.

    ReplyDelete