~ March 2021 ~ In the USA there is yet again another storyline showing up the dark side of ‘sex addiction’. A few years ago we had the case of Harvey Weinstein during which the ‘sex addiction’ field received criticisms for being an excuse for sexual offending. Now ‘sex addiction’ seems to be used as an excuse for racism and murder. Although there is a strong religious influence in the USA which makes the ‘sex addiction’ movement strong, the UK is not immune to it either.
Much of the ‘sex addiction’ thinking has permeated the thinking of British psychotherapy. In the USA, many therapists who trained in ‘sex addiction’ and offer such treatments have a primary knowledge in addictionology rather than sexology. Here, in the UK, the treatment of ‘sex addiction’ has been taken up mostly by therapists trained in sex therapy. Does it mean that ‘sex addiction’ treatments offered in the UK are better? Unfortunately, not quite. This is because most of the ‘sex addiction’ thinking has been unchallenged and the theoretical basis has remained heavily centred in addiction.
Most UK therapists have strong desire to be sex-positive; all of us want to do our best for our clients. But there seems to be a lot of confusion between the addiction theories and the science of sexology.
In some ways, the confusion is normal because the field is evolving from a long tradition of anecdotes to a more scientific understanding. The typical process of evolution creates major challenges in re-thinking previously-held beliefs, which can be difficult for both therapists and the public.
The population struggling with sexual compulsivity is a vulnerable population. The intense shame that people feel can make them desperate to find a therapist who will be able to guide them in their recovery. However, how can someone in a distressed state choose the right therapist if we, therapists, are confused about what we’re treating?
Here are some of the common confusions:
1- “Sex addiction’ and compulsive sexual behaviours are the same things”. Wrong. Whilst the DSM-5 has rejected ‘sex addiction’ as a diagnosis, the ICD-11 endorsed the term ‘compulsive sexual behaviour disorder’ (CSBD). The World Health Organisation (WHO) clearly states that CSBD is not an addiction disorder and those two terms should not be used interchangeably.
I also frequently hear: “it doesn’t matter what we call it, if the client calls it an addiction, it is an addiction”. The word ‘addiction’ is part of the popular language (I’m a sex addict, a shopping addict, a chocolate addict). The public can describe their problems whichever way they want, it is not their job to be trained in clinical language, but psychotherapists should stay on the side of science and not perpetuate anecdotal myths. The public often use the word ‘depression’ to mean that they feel low, clinicians don’t take the word lightly and make a proper assessment to determine if clients are indeed clinically depressed or not. The same principle should apply to the assessment of sexual compulsivity.
2- “I’m sex-positive and I recommend 12-steps programmes such as SAA or SLAA”. This is quite an incongruence. SAA and SLAA programmes are sex-negative spaces where there is absolutely no knowledge of sexology, heavily pathologising many normative sexual behaviours, with no understanding of gender, sexuality and relationship diversity. In my opinion, you cannot be both ‘sex positive’ and recommending 12-step programmes. These are incompatible. It is like saying ‘pork meat vegetarian sausage’.
3- “Sex addiction is real”. Well, no. There is now a lot of research done in clinical sexology that confirms ‘sex addiction’ is not a valid diagnosis, yet many will still assess it and treat it with old-fashioned methodologies and addiction-oriented thinking. For example, some therapists may still think that one can become addicted to BDSM, which we now know is not true. Or they may attempt an addiction treatment such as suggesting their clients to avoid sexual stimuli like we would ask an alcoholic to avoid going to the pub. I also often hear: “the science is lacking, there will be proof of ‘sex addiction’ one day”. There is actually plenty of science, including neuroscience, that shows sexual compulsivity is not an addiction. There is plenty of science that confirms pornography is not an addiction either. In fact, amongst the scientific communities such as ESSM (European Society for Sexual Medicine), the term ‘sex addiction’ is rapidly fading away.
4- “Porn addiction is real”. This sounds more like a personal opinion than a clinical opinion. In the absence of endorsed diagnostic criteria for ‘sex addiction’ and ‘porn addiction’, it leaves the therapist’s assessment open to their own bias rather than being guided by their informed clinical opinions. If they don’t like the idea of watching pornography, they can pathologise a client with ‘pornography addiction’ very quickly.
5- “Sex addiction has nothing to do with sex”. This is also incorrect. The underlying causes of sexual compulsivity are multiple and it is not all about sex, but there is a big part that is about sex, and more crucially sexual pleasure as it is one of the components of the exclusion of the CSBD diagnosis according to the ICD-11.
Words matter. Choosing a therapist who isn’t clear about the endorsed clinical terminology may mean that clients will be confused with what kind of treatment they’re actually going to get. Is your therapist truly ‘integrative’ in their approach, or do they mostly rely on addiction-focused behavioural strategies? Is your therapist sex-positive or will they suggest you go to 12-step fellowship programmes? Does your therapist know the latest research in sexology, including pornography, BDSM, kink, fetishes and digisexuality? As a client, it is totally OK to interview your therapist!
Words, labels and diagnosis are powerful. When misused, they can cause harm. I think it is time for clinicians to uphold more clinical excellence and challenge each other in using the right, endorsed terms, to protect the public.