As therapists who strive to help individuals pursue principles of sexual health, we offer this open letter.
We would like to help the LGBTQI community learn how to take responsibility for who they are and their sexual health, but also learn how to challenge professionals who might not be culturally or sexually informed. We both have heard all-too-common examples of shaming – about sex and being gay, internalized homophobia, and lack of self-acceptance.
These factors can lead to engaging in behaviors that lead to the individual being confused, not proud. Over the almost 40 years since the concept of sex addiction was first developed, individuals often have been diagnosed as being sex addicts and treated with the classic sex-addiction model.
Although this approach has been popularized by the media, celebrities, and certain portions of the therapeutic community, you may be surprised to find out that there is no actual diagnosis of sex or p**n addiction in the latest Diagnostic and Statistical Manual of Mental Disorders, the definitive classification manual used by mental health practitioners in the United States. Sex and p**n addiction were intentionally not included due to the lack of research supporting them as a diagnosis. The American Association of Sexuality Educators, Counselors and Therapists (AASECT), the preeminent professional organization focused on sex and sexuality, issued a position statement in 2016 stating that they “do not find sufficient empirical evidence” to support sex addiction as a diagnosis and that sex-addiction treatment models are not “adequately informed by accurate human sexuality knowledge.”
We, as therapists, believe that using the term addiction shuts down the process of understanding sexuality through a non-judgmental perspective. By using the unscientific pejorative language of sex addict, we force the connotations that are tied to substance-related dependence onto that phrase as an identity. We prefer to help a client understand how shame shuts them down and prevents them from being honest. We help clients understand how anxiety, depression, values conflicts, and other issues subtly mingle with sexuality and play out in their relationships. That way, they can have a clearer understanding of themselves, which allows them to keep relationship agreements and have sexual integrity.
We would like to help clients and clinicians stop using act-centered morality to guide them and instead use principle-based, sexologically informed models and knowledge so that they can be authentic in relationships. We believe that using an addiction model prematurely shuts down the evaluation process by which people fully explore their sexuality.
Doug Braun-Harvey and Michael Vigorito have developed and published a model for working with men who experience feelings of being out-of-control in their sexual behavior. Through their work they have applied significant shift to working with the sexual health model components through what they refer to as a “Principle Centered” model. Choosing to shift to the Out of Control Sexual (OCSB) Health model, a model which bases its clinical conceptions on principles is a major shift, which Braun-Harvey and Vigorito (2016) have contributed, allowing a more nuanced understanding and we would portend will allow a more systemic shift to happen in many related professions in the sexual health space.
We, along with many of our colleagues, use a newer approach that is more informed by sexual-health research and more effective when dealing with sexual health and sexual expression. The OCSB sexual-health model is based on the World Health Organization’s definition of sexual health, which is:
A state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. (WHO, 2006a)
The sex-addiction model and the OSCB sexual-health model have important differences:
- The sex-addiction model is an act-centered model, and the sexual health model is principle-based. We use principles that help increase communication and understanding rather than judgment. Braun-Harvey and Vigorito (2016) use principles to help increase communication and understanding rather than judgement and to "avoid the possible misperception that we are privileging sex in romantic relationships" (pp. 46).
- An act-centered model decides that certain behaviors are good or bad for everyone based on a morality determined by someone other than the client. A principle-based model helps clients have a better understanding of their values and how they see being honest and keeping relationship agreements.
- In an act-centered addiction model, if the client is engaging in behaviors judged to be bad, the therapist will exploit the use of shame to attempt to change behaviors or beliefs. A principle-centered sexual-health model helps clients understand their thoughts, urges, and behavior based on the principles of sexual health. The ‘Six Sexual Health Principles’ operationalized by Braun-Harvey and Vigorito (2016) to mitigate proscriptive sociocultural sexual values within the OCSB sexual health model are:
- Protected against sexually transmitted infections, HIV, unintended pregnancy
- Shared values
- Mutual pleasure
We know that shame is not a useful approach to creating sustainable change. Shame is highly correlated with substance abuse/addiction, depression, violence, aggression, bullying, suicide, and eating disorders. Those are not the outcomes we want when attempting to help individuals.
The sexual-health model is driven by the individual’s internal values rather than being based on someone else’s expertise and judgment about an individual’s choices. It doesn’t define anything as inherently good or bad. Instead, it is based on what is individually pleasurable or not and how those choices play out in clients’ relationship agreements with themselves and others. It shifts the focus from “what not to do” to “what you want to create in your life and relationships.”
The OCSB sexual health model invites diversity and uniqueness of individual value systems and principles. Now that our field has a better model from which to work, we can do better work. The shift to helping individuals clarify and embrace their own value system as they develop their own sexual expression allows the individuals to have better skills regarding other principles of sexual health, such as honesty and agreement-keeping. This type of change is more sustainable in the long run.
Valuing someone’s honesty is hard when it challenges our understanding of them, their life and our own belief system. But we have to strive to understand. It’s our duty to be open to diversity and to not assume that everyone should be a mirror image of us or be judged by someone else’s standards. The values and agency of individuals must be respected even as society seeks to create a common set of rules and judgments as a means of controlling sexual expression.
It’s in this space – where the values of others intersect with the values of the individual – that therapists need to be careful not to collude with society, but instead to help individuals clarify their own authenticity in relation to sexual health. The role of the therapist is not to impose the will and morals of society, but rather to help individuals become the people they wish to be.
If you are concerned about issues related to sexual thoughts, urges or behaviors, there are mental health professionals who can help you. Be a smart consumer. Ask questions before choosing a therapist. Talk to more than one professional. Find out whether someone’s approach and personality are a good fit for you. We encourage you to find a therapist who doesn’t attempt to use shame about a subject that already has significant shame created by our society. You deserve to develop your own sexual expression in a way that is consistent with your own principles and values.
Braun-Harvey, Doug., Vigorito, Michael., (2016) Treating Out of Control Sexual Behavior: Rethinking Sex Addiction, New York, NY Springer Publishing