14 Dec Response to AASECT Position Statement
Recently, The American Association of Sex Educators, Counselors and Therapists (AASECT) released a position statement broadly stating that they did not believe there was enough evidence to accept that problematic sexual behavior and abuse of pornography can be referred to as an addiction. This is hardly a surprise. After all, over the years AASECT has routinely stated that it is important not to pathologize sexuality and that sexuality in all its diversity should be celebrated.
For the most part, this stance has been highly beneficial to both the field and society. Since AASECT was founded in 1967, AASECT has been instrumental in creating acceptance and equality for LGTBQ people and other sexual minorities, including the kink, BDSM, and polyamory populations. Given this long tradition of defending the many forms of human sexual expression from prejudices, it is understandable that AASECT would remain reticent today when viewing problem behaviors involving sex and porn as potentially addictive (therefore potentially pathological).
Interestingly, AASECT’s recent statement is a softening of its long-held stance—a significant deviation from positions taken in the 1980s and 90s when the consistent message was that sex and porn addiction absolutely do not exist. (Typically, AASECT therapists have explained away compulsive sexuality as not being a disorder in and of itself, but rather a symptom of some other psychological issue). Admittedly, this new position may sound the same to many readers, but it is clearly (albeit cleverly and subtly) different (perhaps because the organization recognizes which way the wind is blowing). It says, in part, that AASECT’s members “do not find sufficient empirical evidence to support the classification of sex addiction or porn addiction as a mental health disorder.” So their formal position today is simply, “we need more evidence to agree” rather than “the whole concept is bunk,” as in decades past. Thanks to this neatly hedged language, AASECT’s position can be altered, without losing face, as further evidence accumulates.
Also supporting the idea that AASECT’s position has changed, is the fact that they recently launched a training program designed to help therapists identify and treat “out of control sexual behaviors” which they employ as yet another term to describe compulsive and addictive sexual behavior.
AASECT’s new statement, taken in conjunction with its new training, signifies a clear move toward aligning with the rest of the sexual health field where there is general acceptance that an individual can clearly be out of control with their sexual behaviors and thereby need clinical help to contain them. The primary issue of concern now appears to be that sexual health experts remain in strong disagreement about what language we are going to use to universally define out of control sexual activity. Should it be sexual addiction, sexual compulsivity, compulsive sexual behavior, hypersexuality, hypersexual disorder, out of control sexual behavior, or something else? A recent article on this topic, written by Dr. Patrick Carnes and published in the Journal of Addiction Medicine, compared the most popular nomenclature and theoretical formulations of sexual addiction, finding that whatever name is used to label the problem, the constellation of behaviors used to identify it are incredibly similar. So the controversy and debate really does seem to be more about nomenclature and theory than anything else.
Back in the 1980s and ‘90s, when people whose sexual behaviors were out of control went to a sex therapist for help they often were told that sex addiction didn’t exist. In response, these individuals then turned to the Twelve Step community (Sex Addicts Anonymous or Sex and Love Addicts Anonymous being two such international examples) and a small but a growing number of understanding addiction counselors for help. Typically, these compulsively sexual men and women said they felt “addicted” just like a drug addict. Hence, the term “sex addiction” became the descriptor of choice for most people. And we are now learning that these folks felt addicted for a reason as a growing body of neuroscientific research tells us that the same systems in the brain that are activated with chemical dependency are also in play with compulsive sexual behaviors.
Unfortunately, before this relatively recent research (and a whole lot of other research that supports the concept of sex addiction) came along, the sexual health field splintered—sex therapists, sex addiction treatment specialists, and sex offender specialists—with each group voicing different opinions and taking different approaches to diagnosis and treatment. Over the years, the cross-fertilization of theory and knowledge amongst these groups has been poor, with disgruntled members of each community spurring controversy by disseminating inaccurate information, and attacks on community members that have become quite personal depending more on who is delivering the message, than the facts themselves. Add the additional financial incentives driving all parties in this debate and you have the recipe for a lot of unnecessary intellectual rock throwing.
An additional problem with this fractionalization is a lack of integration of knowledge between groups that could easily learn from each other with everyone benefitting tremendously. For example, the International Institute for Trauma and Addiction Professionals (IITAP) has been criticized for not having enough information about sexual dysfunctions, LGBTQ issues, paraphilia’s, and fetishes. Sex therapists argue that not having this background can be harmful to clients. And they are correct about the fact that, historically speaking, those issues have not been the focus of IITAP’s trainings. In fact, IITAP’s faculty historically has encouraged certified sex addiction therapists (CSATs) to refer sex therapy issues to a qualified sex therapist, and to limit their own practice to their scope of competence (i.e., issues relating to sexual addiction). However, in recent years, IITAP has made huge strides in this area, integrating all forms of sex therapy and acceptance of alternative, non-pathological forms of human sexuality into the curriculum. Thus IITAP now requires all students to receive education toward the healthy treatment of LGBTQ people, those with gender identity and sexual orientation concerns as well as kink, fetishism and the paraphilias. IITAP as a sexual health education provider also has created stringent written ethical policies and contracts with it’s students, in order to prohibit clinicians from harmful practices like reparative therapy or from using the sexual addiction model to try to “eliminate” non-pathological, consensual patterns of healthy sex.
On the other side, many clinicians are expressing worry that people who truly are sexual addicts are harmed by well-meaning sex therapists who without insight or full understanding of these issues discount the problematic nature of these symptoms, thus writing off a client’s compulsive sexual behavior patterns as normal and non-consequential, even suggesting that clients’ issues are related more to their attitude about sex than the sex itself. This stance is clearly harmful to those clients who are getting and sharing STD’s with unwitting partners and/or losing marriages, jobs and educational opportunities due to self-described excessive porn use, online hook-ups and the like. Consider, for instance, the recently published blog from a well-known researcher, and AASECT faculty member that recommended that someone with a porn addiction should go see a sex worker instead of masturbating to porn (since the posting of this article this blog has been removed). From the IITAP educational perspective, such blatant disregard of compulsive behavior can without question be harmful to the client and those close to him or her.
Now, of course, AASECT is offering its first trainings on out of control sexual behavior, thus making significant progress in this area. As with IITAP’s updated training regimen, this is a positive move that will help AASECT’s therapists meet the needs of certain clients.
Unfortunately, when separate professional groups hold vastly different beliefs about the causality, assessment and treatment of the same behavioral problem, confusion, lack of clarity and disagreement can interfere with useful client care. For example, one of the most common criticisms about the sex addiction model is that there is not enough neuroscientific evidence showing that sex can be an addiction. However, there are over twenty studies to this effect! (Sexual Addiction Research Resources)
What this part of the sexology community fails to understand is that addiction research in general is far from nascent, and when the neuroscientific studies supporting sexual addiction are embedded into the larger body of addiction research, the convergence of evidence is much, much stronger. Unfortunately, our mental health training programs across the world, fall short when it comes to education about the neuroscience of addictive disorders. That said, there is a vast robust literature on these areas. And the neuroscientific evidence that has been accrued on sexual and porn addiction falls neatly into the current theoretical formulation of behavioral addiction. This is the data and theory led the DSM committee to finally accepting gambling disorder as a legitimate diagnosis.
It is because of this convergence that the American Society for Addiction Medicine has declared that sex, eating, and other similar reward producing behaviors can all be classified as addictions. In ASAM’s 2011 definition of addiction they write:
Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction also affects neurotransmission and interactions between cortical and hippocampal circuits and brain reward structures, such that the memory of previous exposures to rewards (such as food, sex, alcohol and other drugs) leads to a biological and behavioral engagement in addictive behaviors.
The ASAM definition simply reflected the consensus of brain science about process addictions. The shift in neuroscience was marked by Redish and his colleagues in what is now regarded as a classic in understanding addictive processes, Redish, A. David, Steve Jensen, and Adam Johnson. “A Unified Framework for Addiction: Vulnerabilities in the Decision Process.” Behavioral and Brain Sciences 31.04, 2008. The article is a 94-page meta-review of all the brain science controversies. The author creates a taxonomy that clarifies the many ways the brain becomes addicted including processes like sex. This landmark article echoes Nestler’s Royal Society lecture in 2008, which synthesized the major shifts in understanding of the brain and the world science community acceptance of that.
Here are just a few links that can help provide some education on the neuroscience of addiction:
Dr. Mark Gold, distinguished professor from the University of Florida discusses the neuroscience of addiction, including process addictions such as food and sex…http://www.albertafamilywellness.org/what-we-know/what-is-addiction/
Dr. Valerie Voon, from the University of Cambridge discuss the fMRI study she completed that discusses how pornography addicts have the same changes in the brain as those found in substance use disorders…https://www.iitap.com/blog/2016/12/13/porn-on-the-brain/
For a discussion of how the neurobiology of addiction applies to sex addiction see this Chapter: http://www.sash.net/wp-content/uploads/2016/10/Sexual-Addiction-Chapter-from-Neurobiology-of-Addiction.pdf
Sadly, the media (and therefore the general public) has little understanding of the history, the politics, and the landscape of the sexual health field or the neuroscience of addiction. So after the release of AASECT’s cleverly worded statement last week, the media had a feeding frenzy (as often happens when someone makes a bold sex-related statement), publishing numerous articles and news briefs along the lines of “sex addiction is not a real disorder” and “sex addiction is no longer a legitimate medical disorder.” And rarely were these items tempered by any sort of acknowledgment that AASECT’s is both a minority opinion and that most individual clinicians and professional organizations agree that sex addiction does exist and that the only meaningful disagreement is on what to call it. Meanwhile, people are suffering and struggling with sexual compulsions and addictions, whose reality is being denied, causing them to feel more alone, desperate, and misunderstood than ever.
It is the opinion of the leadership at IITAP, that it is time for the various sexual health organizations to come together in the best interest of our clients—working to legitimize and de-stigmatize this issue, so the people suffering will know there is hope and help. Continuing to propagate myths and to engage in ego-driven infighting will only harm the individuals and families who are struggling. Thus, the time has come for the whole field of sexual health to stand up for the people we are trying to serve instead of propagating turf wars over nomenclature and whose treatment approach is better. It is time to listen and learn from one another instead of drawing lines in the sand.