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By Marty Klein, Ph.D.
Adapted from http://www.SexEd.org/archive/article08.html, and used by permission of Marty Klein, Ph.D.
From the keynote panel presentation at the AASECT annual meeting, May 2, 2002. [note: references to Pat or Eli are to panel participants Pat Carnes & Eli Coleman.]
There is a question that we, as professionals, have all been devoting thousands and thousands and thousands of hours to: How can we conceptualize and evaluate, and diagnose and treat, if necessary, sexual behavior? And how do we do this in a sex-positive way? That’s the question that our profession has been looking at since its inception. It’s the question I was told I needed to look at when I first entered the field –how can we do our work in a sex-positive way? How can we maintain a model of sexual health that is sex-positive?
The media are not our ally in this, the government is not ourally in this, even professions like medicine and psychology are not ourallies in this. And yet we are devoted to this quest. Some people say thatwe are foolish for even trying to do this.
So I think it only makes sense that we should use sexological toolsto examine why it is so difficult to do this. Let’s use our own tools tolook at our own questions.
The sex addiction movement focuses on important issues, and thoseissues deserve sexological attention. Here are some of the things thatthe sex addiction movement has been looking at since the mid-80s: Questionsof lust and desire, the relationship of love and sex, decision-making andimpulse control, guilt and shame, and brain chemistry. Pat, I didn’t knowhow much you were going to talk about that today, but that is yet anotherthing that the sex addiction movement is talking about. These are importantquestions, and they deserve our attention.
But the sex addiction model is based on a group of assumptionsthat most sexologists do not share. The main ones are listed here.
Assumptions of SA model
* sex & sexual desire are dangerous
* there’s one “best” way to express your sexuality
* relationship sex that enhances “intimacy” is best
* imagination has no healthy role in sexuality
* people need to be told what kinds of sex are wrong/bad
* if you feel out of control you are out of control
* laws & norms define sexual health
Based on these assumptions, unfortunately, there are serious limitationsto how the sex addiction movement has answered key sexological questions. As you can see, I think most of the answers generated by the sex addictionmodel are pathology-oriented. They’re clinically incomplete. As Eli wassaying, they don’t include issues of differential diagnosis, they don’talert us to the differences between character disorders, personality disorders,OCD, PTSD, and so on. And they pathologize sexual behavior and impulsesthat are not unhealthy.
The sex addiction movement’s answers are culturally bound; aswe progress through a new century, we’re increasingly aware of culturalissues in sexual behavior, the differences between the way that peoplethink and behave if they were born in Thailand or if they were born inCalifornia, the differences among age groups, differences in the ways thatdifferent people have been raised. Different behavior means different thingswhen different people do it, particularly regarding sexuality.
And finally, a lot of the answers that have been generated bythe sex addiction movement have been exploited politically. We have seenthe ways in which some of these ideas have been used to harm the peoplethat we try to treat, and even to harm the field of sexology. This maynot be the intention of the sex addiction movement, but we need to be honestabout how the ideas of that movement have been used by the government,the media, right-wing activists, and by other people, to harm the fieldof sexology. That’s a reality, whether people like it or not.
The answers generated by the SA model have crucial limitations
* pathology oriented
* pathologize non-problematic behavior
* clinically incomplete
* acontextual–individually & situationally
* culturally bound
* exploited politically
Now, we as professionals, and all clinical professionals, not just sextherapists–marriage counselors, social workers, nurse practitioners–allprofessionals who work with a clinical population have certain requirementsfor their clinical models. Those requirements include: consideration ofphenomenological or subjective context–in other words, how people experiencethemselves is important. Clinical sophistication. What all of us have saidall along, or at least the way that most of us were trained, is that wewant clinical models that emphasize personal agency, the ability to createchange for ourselves. We want our models to value professional expertise,and so they should minimize self-diagnosis. And, finally, political andpublic policy utility: whether you are a therapist in a small office, oryou’re working in an agency, or you’re working in a community, or withfamilies, or whatever, we all want our models of sexuality and sexual healthto be of value in the public policy arena.
What professionals require in a clinical model
* considers phenomenological context
* clinical sophistication, including differential diagnosis
* based in personal agency & responsibility
* cross-cultural insight
* minimizes self-diagnosis
* political & public policy utility
Models of sexual normality, and of course of sexual symptomatology,are constructed. As social scientists, we know that all models are constructed,and that they’re part of a cultural discourse. And so the question is:What is the social context in which sexual normality and sexual symptomsare being constructed today? What is the discourse? Here, in my opinion,is the discourse. These are the features of America’s cultural landscapethat our patients, our colleagues, our legislators, and our media knowas the discourse of sexuality in America today.
Things like the emphasis on victimhood. Things like the increasingmedicalization and biological determinism in sexuality; the increasinglegitimacy of religious concepts and solutions; the increasing politicalcloud of sex negativity. These form the discourse, the cultural contextfor anyone who’s developing models of sexuality today and for anyone whois implementing clinical work. And, of course, there’s the success of 12-stepprograms. That, too, is part of the cultural landscape from which modelsof sexual normality and symptomatology emerge.
The social context in which “sexual normality” & sexual “symptoms”are being constructed today
* self-help movement
* Oprah & other “therapeutic” talk shows
* emphasis on victimhood
* cultural anxiety about sexual violence
* increasing medicalization of sexuality
* increasing public awareness of non-normative sexual behavior
* increasing legitimacy of religious concepts & solutions
* increasing political clout of sex-negativity
* cultural acceptance & mythologizing of 12-step programs
Now let’s consider the theoretical material that shaped publicconsciousness in America about sexuality after the Second World War anduntil about 1980. This theoretical material came from sexologists–Kinsey,Masters & Johnson, Hite, and Lonnie and Bernie. These people were sexologists,and it was the material they generated that shaped the consciousness ofthe people we work with, as well as our own as professionals.
The theoretical material, however, that has shaped the publicdiscourse about sexuality in the last couple of decades has not come fromsexology. It’s come from a completely different source. Here are threeof the most important books of the last 25 years that have shaped the waythat people think about sexuality, both lay people and professionals. Andhere are some other cultural institutions and forces that, for the last25 years, have been shaping the way that people think about thinking aboutsexuality.
Historical/cultural context from which SA movement emerged
* Women Who Love Too Much
* Men Are From Mars, Women Are From Venus
* The Courage To Heal
* repressed memory movement
* sexual trauma self-help movement
* pharmaceutical industry
* right-wing political activism
* Dworkin/McKinnon anti-porn movement
This is the historical and cultural context from which the sex addictionmovement emerged. It’s not a sexological context as much as it is a narrativeabout fear, danger, powerlessness, and victimization–things like traumaand repressed memory.
If you want to learn about the diagnostic criteria for sexualaddiction, it’s easy to find on the Web. There is, in fact, a Sexual AddictionScreening Test, which Pat developed in the mid-1980s. It’s very popular,it’s well-known and well-respected among a lot of people. The Sexual AddictionScreening Test has 25 questions. Here is a third of the test. We’re toldthat these are the kinds of questions that clinicians can ask patients,or non-patients, to determine whether or not they’re sex addicts. And Iwould like to draw your attention to these and ask if these are the kindsof criteria that you want to use to determine if your patients, or yourmate, or your best friend, or yourself are pathological around sexuality-and,for that matter, are sex addicts.
Sexual Addiction Screening Test criteria (partial list)
* regularly purchase porn or romance novels
* preoccupied w/sexual or romantic thoughts
* feel behavior isn’t normal
* partner complains about your behavior
* worried your behavior will be discovered
* multiple romantic involvements
* use sex or romantic fantasies for escape
* regular participant in S/M
There are inevitable implications for the sex addiction model that comefrom those kinds of diagnostic criteria. They’re different implicationsthan come from, say, Eli’s model or some of the other models that we arecalled upon to evaluate. For example, the sex addiction model inevitablybelieves that eroticism needs to be controlled, and that erotica and commercialsex are dangerous and problematic. Of course, the way that the sex addictionmovement is constituted, it would have to believe that public policy shouldbe focused on controlling sexuality, and in that regard it has been verysuccessful.
And the sex addiction movement inevitably must say that peopleare in danger of losing their ability to make wholesome choices, that peoplecan become addicted, that people can go along and be okay and at some pointsomething can happen-for example, they could consume a lot of pornography–andthey can become addicted. And so people are at risk. So the sexual addictiondiagnostic criteria problematize non-problematic experiences, and as aresult pathologize a majority of people. This is a serious deficiency inthe model.
Inevitable Implications of SA Model
* eroticism needs to be controlled
* erotica & commercial sex are dangerous
* public policy should focus on controlling sex
* people are in danger of losing their ability to make wholesome sexual choices
* “unwholesome” sexual impulses are compulsive
* identifying & preventing sexual pathology is more important than enhancing sexual health
The SA movement exploits people’s fear of their own sexuality,which is one of the major public health problems we have today. Men andwomen are so frightened of their own sexuality that they project this dangeronto other people, and become frightened of those other people’s sexuality.People in America are frightened about their neighbors who are going tonude beaches, or their neighbors who are going to swing clubs. People inAmerica have learned how to be afraid of their neighbor’s sexuality becausethey’ve been encouraged to be afraid of their own sexuality.
And given the way that our culture is so sex-negative, the diagnosticcriteria for sex addiction are culturally syntonic. If you grow up in America,of course you’re concerned about your neighbors finding out about yoursexuality. Of course you have parents who are frightened or ashamed oftheir sexuality. Of course if you use pornography, you’re going to havethe impulse to hide it from your mate. The kinds of things that the sexualaddiction model says reflect problematic behavior are simply common sense–ifyou grow up in a sex-negative culture.
Please look at this chart, which lists behaviors that clinicianssee in our everyday practice. From the sex addiction perspective they areeasily seen as symptoms: Masturbates twice a day–Marty Kafka certainlybelieves that’s sex addiction. Enjoys S/M–that’s a very common indicator,it’s 4% of the Sexual Addiction Screening Test–do you enjoy S/M. Are you’reinterested in non-monogamy; are you married and you cruise public bathrooms;these are the kinds of things that are labeled symptoms of sex addictionby the sex addiction model. However, look at the possible diagnoses thata different kind of clinical sexologist could make. I underline possible,because each one of these is only one possible diagnosis, because diagnosisdepends on the person.
A person who, for example, has extramarital affairs–maybe whatthat’s all about is that they’re having an existential dilemma–they’re50 years old and they’re wondering, ‘is this how I’m going to spend therest of my life?’ A person who enjoys S/M, well, maybe they’re just fine.A person who wants non-monogamy, well, maybe they’re Borderline, or maybethey’re adventurous. I would have to talk to the person. I would have tofind out a lot more about a person before I could say what it means thatthey’re interested in non-monogamy. A person who’s interested in commercialsex–that may be that that person is committed to their marriage, and ratherthan leave their marriage, or even rather than have an affair and takea chance that they’ll fall in love with somebody, they go to a prostituteonce a week. I’m not willing to say that that person is a sex addict, eventhough they feel terribly guilt-ridden about the fact that they’re seeinga prostitute once a week, and they can’t even really afford it, but they’redoing it anyway. I’m not willing, without doing one or several interviews,to say that that person is out of control and is therefore a sex addict.
Evaluating behaviors: sex addiction, something else, or non-problem?
| Possible Dx for clinical sexology | ||
| masturbation twice daily | OK | |
| extramarital affairs | existential dilemma | |
| wants partner sex daily | OK; personality disorder | |
| enjoys s/m | OK | |
| inappropriate come-ons | socially inept; narcissism | |
| exhibitionism | OCD | |
| wants non-monogamy | borderline; adventurous | |
| married, cruises bathrooms | tormented about orientation | |
| fetish behavior | self-aware | |
| commercial sex | committed to marriage; social anxiety | |
| internet porn | depression; dissatisfied with partner sex |
Now here’s a history of sexological diseases. If we look at thelast 150 years, these are conditions that the finest scientific minds oftheir age said were diseases. If you go back to the 1860s, ’70s and ’80s,the finest scientists said that libertinism was a disease–that’s somebodywho’s just too much into sex. If we look at the turn of this century, thefinest medical minds said that masturbating was a serious disease. We’veseen nymphomania as a disease. Carol Groneman’s wonderful book, A BriefHistory of Nymphomania, shows how that diagnosis has been used forthe last 100 years as a form of social control. People who advocated birthcontrol in the 1920s–it was labeled a psychiatric illness if someone wastoo attached to birth control. And we all know that frigidity and homosexualityhave been labeled psychiatric diseases. Sex addiction fits right into thattradition.
History of sexological diseases
* libertine
* masturbator
* nymphomaniac
* birth control advocate
* frigid
* homosexual
* sex addict
America needs a model of sexual health. America is desperate for a modelof sexual health, a model that is clinically complex. Eli, I have to disagreewhen you say let’s call it Syndrome X. I don’t think there’s one syndrome.I think that this stuff is so complicated that we can’t just say thereis a Syndrome X with a bunch of sub-things. I think there are a lot ofsyndromes, and some of them, I don’t think they’re even syndromes, I thinkthey’re real life.
So we need a model of sexual health that is clinically complexand culturally informed. And by culture we don’t just mean what race isa person, we don’t just mean what country was that person born in. Culturalconsiderations are much more subtle, and there are many, many of them.People who are twins are, in their own way, a subculture. People who arein marriages where one of them is 25 and the other is 50 have culturalconsiderations just from being that kind of couples. Now we’ve discoveredthat there’s a subculture of five or six million people in the United Stateswho swing, according to Terry Gould’s wonderful research [The Lifestyle,ed.]. So there are many kinds of cultural groups with sexological considerationsthat we need to know a lot more about.
We need a model of sexual health that does not pathologize a broadrange of eroticism. We need a model that is supportive of adult identity.Being an adult is complicated and it’s scary, and sometimes it’s very difficult,and a lot of people would like to make their sexuality so simple that it’snot scary to be a grownup. And our job is to help people understand thatwhile it is, in fact, scary to be a grownup, we can provide some toolsthat can help them deal with their fear. We don’t have to strip down theirsexuality to take away the darkness, the complexity, the ambiguity, justso people can be more comfortable.
And finally, America needs a model of sexual health that is sex-positive.And that’s the challenge that the sex addiction movement is posing to sexology.They’ve come up with their model. Can we come up with something differentthat’s culturally sensitive and has all those other sex-positive criteria?That’s the challenge that we as a profession face. How are we going torespond to that challenge?