Episode 18
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Why the phrase “addiction to porn” doesn’t fit with the current scientific findings
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What does the research say about problematic sexual behaviors?
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What does research say about pornography?
I see requests online all the time in therapist FB groups about getting help for a client who has an “addiction to porn.” We didn’t get trained that it’s an addiction. There’s a reason for that, it’s not an addiction. That’s what science tells us. Today’s episode is an interview with an expert in the field of sexual science, Dr. Nicole Prause.
In this Podcast:
- Research on sexuality and behaviors related to sex is happening all the time
- Researchers are often targeted, harassed and threatened by people who oppose the work they are doing.
- Research on sexual behavior and pornography viewing does not support seeing these as an addiction or being part of an addictive process
- Problematic sexual behaviors are recognized as being troublesome to people and treatments have been identified.
- Dr. Nicole Prause is a neuroscientist and psychologist from Los Angeles, CA and on the show today.
Helpful Links:
ACT Infographic (mentioned in the interview)-https://twitter.com/NicoleRPrause/status/1344070762341179397
A Pornography Literacy Program for Adolescents | AJPH | Vol. 110 Issue 2
Sex Ed: Teaching Porn Literacy – YouTube
TEDMED – Speaker: Emily F. Rothman
https://www.sexualhealth.umn.edu/
SIECUS: Sex Ed for Social Change
Science Stopped Believing in Porn Addiction. You Should, Too | Psychology Today
Understanding and Managing Compulsive Sexual Behaviors
Research on Compulsive Sexual Behavior | Program in Human Sexuality – University of Minnesota
What Doctors Wish You Knew About Sex Addiction | The Healthy
Why I Am No Longer a Sex Addiction Therapist | Psychology Today
Sorry Harvey Weinstein, sex addiction isn’t real | CBC Radio
Impulsive/Compulsive Sexual Behavior: Assessment and Treatment – Oxford Handbooks
Compulsive Sexual Behavior Inventory | Program in Human Sexuality – University of Minnesota
https://www.drchrisdonaghue.com/
Is Sex Addiction Real? Here’s What Experts Say | Time
Am I a “Sex Addict?” Reflections on Compulsive Sexual Behavior – Ruth Cohn
Free Treatment Planning Tool www.betsybyler.com/treatmenttool
Transcript:
You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective. I’m your host, Betsy Byler, and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and confidence needed to add substance use to their scope of practice. So join me each week as we talk about All Things Substance.
Welcome back this week, we’re going to be talking with Dr. Nicole Prause. She received a PhD in Clinical Science with concentration in statistics and neuroscience in 2007. She’s been on faculty at Idaho State University, University of New Mexico. UCLA in the Department of Psychiatry and more recently an affiliate at University of Pittsburgh, University of Nebraska Lincoln. And she’s worked with the Kinsey Institute, Harvard University.
As you can imagine, doing research requires funding. What Dr. Prause found was that doing research and having different people fund it, they had a lot of stake in what the outcome was going to be. Scientists struggle with that all the time.
Good scientists are interested in what the science says, not in making something support one bias or another. And there are a lot of people who don’t want scientists to be asking the kinds of questions that Dr Prause is asking. And so this led her to create Liberos in 2015, a private research institute and biotechnology company.
She has a number of different research projects underway. Although the pandemic has limited her ability to be in the lab and she’s anxious to get back to her work. Dr. Prause and I were able to have an interview and I am super grateful that she was willing to talk with me and share some of her insights.
There are a number of links in the show notes to different talks that she’s done, whether it’s been a Ted talk on Nova or other podcasts. So if you’re interested in listening to other things that she has done, you can find them easily. This morning. I want to welcome Dr. Prause.
Dr. Prause, thank you so much for being here this morning.
Dr. Prause: [00:02:23] Thanks for covering the topic.
Betsy: [00:02:25] I want to get your opinion on when people use the word addiction when it comes to sex and when it comes to pornography. And I know that this is a huge topic. But this morning, we’re talking to therapists and I think it’s still really common that, that this language is out there.
And I wonder what your response is when you hear people in our field using that terminology.
Dr. Prause: [00:02:49] I think often when they use the term addiction, they probably aren’t using it in the same way. Scientists mean it and words matter in this case, that is addiction means something very specific and influences how we treat.
So it always worries me to hear that because that treatment model is most likely to fail and we have other interventions that we already know help. So it’s frustrating to hear that patients might be being mistreated potentially.
Betsy: [00:03:17] Yeah. So what is the current state of our knowledge about whether or not well we’ll take sex for, for the first part, it being classified as an addiction. What’s current state of the science.
Dr. Prause: [00:03:30] So clearly some people have sex more than they mean to, or in a way that they didn’t tend to. For example, you know, I went out for the night clubbing and I attended to hook up, but I intended to use a condom and then didn’t do that.
And sometimes that’s now getting described as addictive behavior because it’s unsafe, whereas we’ve had many decades of research now, often funded through NIH, through their AIDS program. Describing some of those sexual behaviors as being impulsive and risky, but we didn’t need an addiction framework to understand and help.
To add a label to something, there needs to be a strong reason to do that. We need to have strong data supporting it. And addiction is a model that requires more criteria be met than almost any other model. It’s a very high bar and sexual behaviors fail in a number of ways to meet some basic addiction criteria.
So to me, I don’t know why we would go for the most extreme claims possible about the sexual behaviors when we already have pretty good models of how a lot of them work, we’ve been studying them for a very long time. And you know, this is not something new is this sometimes presented like, Oh, you know, sex addiction was just discovered like, no, you know, I’ve been looking at unsafe and unintended sexual behaviors for very long time.
And a lot of very well funded studies. I think at this point we have some pretty good ideas of how and why people engage in those frequent behaviors. Currently the American Psychiatric Association does not recognize high-frequency sex as a disorder. In their diagnostic and statistical manual.
And that World Health Organization puts out the International Classification of Diseases are there now in version 11 and they specifically excluded sex addiction. They said that there’s not currently sufficient evidence to support it, but what they did include in their manual was something we’re calling more, a sexual compulsivity problem in the impulsivity section of their manual, which is a whole other different kinds of problems.
I can talk about that. At this point, both the World Health Organization and the APA have rejected sex as fitting a model of addiction.
Betsy: [00:05:47] Which ways does sex fail to meet the criteria for addiction?
Dr. Prause: [00:05:52] So there are a number of criteria for addiction. That one that launched my exposure to the area was my student’s dissertation studying cue reactivity, and key reactivity is sometimes called the biomarker of addiction because it’s so been so well replicated across different substances and even with gambling.
And it’s basically this idea that if you’re having this problem with a substance that is you’re addicted to it. Then when you see an image of it, a cue of it, your brain is going to be more reactive specifically in the late positive potential region, which is a later part of the evoked response potential than those who do not have a problem with that substance or behavior.
And it’s often confusing to people what that cue reactivity is because it’s a difference of differences, which is to say, you know, we can’t just stick an EEG electroencephalography on your head and measure your cue reactivity by just showing you porn. Yeah, we do it in the context of comparisons with neutral stimuli as has been done with all of the previous substance literatures.
So we studied that with the person who published the original cue reactivity study on cocaine. So I felt pretty confident that we had a good team that knew this literature well. And when we publish that, you know, in this case, we we’re using pornography as a model for sex, and we can talk about the good and the bad potentials of that.
But we did not find that there was cue reactivity enhanced in those, those folks. And in fact, I did a study later where we said, okay, you know, addiction should have some tolerance, probably like you should be less reactive to simulate. And what we found is actually people who had more sexual partners were actually more responsive to weaker sexual stimulation, which is exactly the opposite of what you should expect if an addiction model is true.
That is if you’ve had a lot of exposure, quote, unquote to sexual partners, then you should be harder to ramp up. If that follows an addiction model and we actually found the opposite, which is more consistent with someone who’s just sexually responsive or has a high sex drive potentially.
Cue reactivity is one big one. Other people for addictions say that they need to develop withdrawal, which is an interesting one. So if you ask people directly about sex ,people absolutely. Oh yeah. Yeah. I definitely feel withdrawal. And then you say, well, what do you mean by withdrawal? And almost always the symptoms they cite are physical, sometimes psychological, but largely physical.
And there’s never been a study demonstrating any of those effects. And so then we get in this problem where one-on-one with a patient. We don’t want to be disrespectful and say, that’s not true, but if you’re in with a research subject, then it is your job to say, well, you reported this, but I can’t find evidence for it. And I have not yet seen a study that’s actually documented withdrawal effects with sexuality.
There’s also developing tolerance over time, which there are a number of different ways you could see that. So that may be this is getting a little bit more into a porn territory. So important to point out here is there’s very little literature that actually looks at sexual behavior.
And that’s one thing, you know, we have a study that’s on it’s second review. So fingers crossed that we can accept it and I get to share it soon, but we had actual intimate partners come into the laboratory and do stimulation with one another to look at some of these issues, because in all these studies so far trying to comment on sexuality, we’ve been using porn models.
And I think it’s okay for some things, but it also has a lot of problems with that. Porn is not sex. And so at some point we need, if we want to talk about sex and whether it’s sex itself is addictive. Sex is a primary reward in porn as a secondary reward. Those are not the same thing. And we need to actually bring people, humans. into the lab and look at actual sexual stimulation to be able to comment more on those.
So same thing for kind of tolerance. That is if you need more and more sexual partners over time, if you ask people directly, they say, yes, that’s happened, but we haven’t seen it documented in the literature. So there’s a big discrepancy between these folks who I think have been, perhaps they’ve seen it on the internet, perhaps they’ve been shamed by a partner, but they say, you know, you have this thing, this bad thing that makes that you should be shameful about you.
I think if you ask them directly say, Oh yeah, I’m addicted. I have withdrawal tolerance problems. But we really struggled to find evidence for it. And in the case of the sexual behaviors, as compared to porn, sexual behaviors are often lacking any evidence one way or the other porn and we often have evidence against the existence of tolerance or withdrawal.
You know, I think the public often hears the debate as you know, are these people lying or are they addicted? And I’m not having that debate. That’s not the discussion that the scientists are having. The discussion we’re having is clearly people are upset about their behaviors in this area. How do we understand those so that we can better help?
Betsy: [00:10:55] So I recall reading that when people who were concerned about their sexual behaviors were questioned that it ended up being a lot of internal conflict based on values, their own personal values, and that there was dissonance. Is that sort of what you’re referring to.?
Dr. Prause: [00:11:13] That’s definitely part of it. So that’s Joshua Grubbs and his team have published a series of studies looking at moral incongruency, I think is what they call it. So this idea that those people who identify again as porn addicted frequently is more what they’re commenting on. So I don’t know about how it generalizes to sex per se, but within pornography, they’re much more likely to have been raised in a conservative, not necessarily religious, but conservative household.
And then addition to that, like, people have looked at people who are receiving inpatient treatment as having sexual compulsion or addiction. And over 50% of these inpatients had a primary diagnosis of depression, for example. So I think yes, part of it is a morals conflict. And I also think a large part of it is misdiagnosis.
That is, they have things we already know about. And rather than treating the depression in those cases, Yeah, I’m really worried that they’re being misdirected to focus on sexuality or pornography. That’s not going to help them when we have great treatments for depression. So I really don’t want to see clients, patients misdirected into these programs for sex or porn addiction. When it seems like they probably shouldn’t be.
Betsy: [00:12:26] And I know there’s some implications or hopeful implications about the nature of sexual behavior and depression that you talked about in a recent interview that I’m going to link in the show notes because I found it really fascinating.
And I don’t want to repeat it here, but for people listening, Dr. Prause did an interview just recently that I’ll, I’ll put a link in the show notes that is talking about a lot of different aspects of her research and projects. So I definitely recommend that you guys go take a look at that. I know that we’re talking, you know, sex and porn get put into the same category when we’re talking about two different things.
Something that you talked about in that interview was that there’s a different brain function happening or there’s, there’s different activity happening when there’s another person versus when someone is individually involved, say in porn or masturbation or something like that. But when there’s another partner that there’s something really different happening. Can you talk about that?
Dr. Prause: [00:13:22] So there is a lot of concern that experience with pornography is going to generalize to the partnered context. So that is, I may see someone who’s so attractive and pornography, or get used to seeing implants or surgical enhancements that I’ll no longer be attracted to my current partner or another possibility that I’m somehow going to wire my brain to pixels.
You see this touted a lot that somehow you can cause yourself to condition to that stimulus. And it’s very unlikely that that can happen because there are a number of differences between pornography and actual sexual stimulation. That means when you are having sex with a partner, it involves very different areas of the brain than pornography does.
So a couple of examples. There are in the dermis of the skin, these really specialized things called C-afferent fibers that are only reactive. When you’re stroking the skin at a very particular frequency, that’s not especially fast or slow and you can’t do it to yourself and a robot can’t do it. Only another human can stimulate this response.
And when those C-afferent fibers are stimulated, they specifically innovate the area of the brain sensitive to social interaction. So, you know, there’s one example of you can watch all the porn you want but we don’t have any evidence that that can stimulate the afferent fibers and it’d be very unlikely to, cause it seems to be a really specific response.
So essentially when you turn to your partner, you’re always going to have a different stimulation that we can possibly get from pornography. Another issue is or difference between those types of stimulation is pornography we consider a secondary reinforcer. So just like money, whereas, you know, if I give you money, that’s all fine and good, but why do I have this money?
It’s because I want to go get something with it. Maybe I would like to have a cake. And so I’m going to go get my chocolate cake with my money. So the cake is the primary reinforcer and the money itself can actually do much for you. It’s a symbol for the reward that you actually want. And porn is a secondary reinforcer also.
That is somewhere around 95% of porn viewing episodes are accompanied by masturbation. So it’s not the porn itself, but the actual sexual stimulation that is the primary reward. And secondary rewards and primary rewards look very different in the brain. You know, it is a cue for it certainly, and it shares some features, but it differs again in this important way.
So there are just a number of different studies that have kind of shown the differences when you’re viewing pornography as compared to masturbation, as compared to partner interactions just seemed to be very different. So I think the likelihood of being able to condition a response to pornography that generalizes to the partner context is pretty challenging.
Betsy: [00:16:11] Yeah. It would be tough to do. There are words that we use in general culture that when you’re talking about science, it’s, it’s not the same thing at all. For instance, when people run around saying so-and-so is so bipolar and right, and we would never say that kind of a thing.
Dr. Prause: [00:16:29] Exactly.
Betsy: [00:16:30] Because bipolar to us is that’s a really serious diagnosis and it has very specific things. I don’t have a count of how many people in a year say that to me when they come into my office. And of course I don’t respond with no, you’re not, you know, I talk about all right so tell me what you mean by that. And, you know and assess.
So I recognize that the words that we’re talking about are really, really important. And as therapists, I think we have a great responsibility to use our words, very cautiously. We all know that there is a power differential and that people trust our words. And so that it really matters what we’re reinforcing, so to speak.
Dr. Prause: [00:17:10] Yeah. Well, I think like people might be surprised too when I have, because I kind of wear both those hats.
When I have clients come in who say, you know, I think I’m addicted to sex or, you know, my partner knows I have a pornography addiction. I’d take the same kind of approach. Oh, okay. You know, why, why are they upset about that? What have you tried to help resolve those conflicts that you have?
So with the patients, I absolutely don’t expect them to be using some scientifically accurate language, but clinicians. I would really like it if we could not promote those kinds of errors of thinking. And especially with the addiction language, I get really concerned just because they’re people often understand addictions as something you never recover from. You know, they say, Oh, you’re always in recovery and it’s such a risky die to cast, to present someone with a lifelong diagnosis.
Whereas, you know, there are, I think for example, television viewing is a great example. There are tons of behavioral interventions to reduce television viewing mostly in children, but, and we can absolutely help people behaviorally change. You know, we can get these kids watching less television and in many cases we probably should because it’s associated with weight gain and other unhelpful kind of problems that kids can struggle with. It doesn’t mean that television is addictive. It just means you need to watch less. Let’s help you watch less.
Betsy: [00:18:34] Yeah, I think that’s a helpful comparison. I think that a lot of therapists had standard education. Like most of us did, are very cautious about identifying substance addiction to classify someone as an alcoholic or a drug addict.
But I think this word addiction gets thrown around a little more when it comes to things like sex or porn. I was specifically surprised by some of the research on porn that seems to suggest that it’s not the case rather than for it. And that’s the importance I think of science because we want to know what the science actually says versus just something that is going to confirm our hypothesis or our bias or that kind of thing. As clinicians. I want us to focus on that.
Dr. Prause: [00:19:19] Totally. There has been one study now, actually looking at like clinicians beliefs in these models and found for example, that you may be seeing things or being presented it through a lens that has a particular belief about appropriate relationship structures and appropriate sexual expression, you might not follow science.
So I hope that it supports clinicians also investigating their values and thinking, where did I get this idea? Who talked to me? Just in the same way, we would do a sexual history of clients. You know, where did you learn about sex? What did school teach you? What did your parents talk to you about? To do that kind of assessed self-assessment as well saying, you know, where did I get these messages? Why do I believe right now that this is the case?
Betsy: [00:20:02] Well, and I think that kind of work is important for all of us. If we have to be aware of our bias for whatever it is. I’ve spent time as a supervisor over the years, talking with people about when their belief or bias, intersects, or is in conflict with what a client is presenting and wanting to check in about where is this coming from?
Are you aware? How serious is this? Do you feel like you can set it aside? You know, for instance, let’s take abortion. For instance, when I had a staff member who was very passionately pro-life and had a client who was considering an abortion. And we had a number of conversations about the ethics of her working with her.
And could she set that aside and can she truly be neutral and support the client? Because those are very real. I’m not asking her to set her beliefs aside in the way that it might seem for some people, but her job is to help the client walk along their path and find their truth and their choices, not our idea of what is appropriate and or good.
And I think when it comes to sex and values and culture, like that can be really difficult as I don’t know that all of us were adequately trained or questioned about these things in our training. I talk about how substance use wasn’t something we were trained in, but human sexuality is even less common as a training.
I have had more therapists over the years who have had, haven’t had a single class in human sexuality, but may have had one class in substance use, which is bizarre. And I don’t know what that’s about, but it definitely seems to be the case.
Dr. Prause: [00:21:43] Yeah. So I would like to be sure to point out to folks who might want to be providing services in this area where they feel like they might not be completely competent or know what to do with them and say, well, then, then what do I do?
You know, like these people are still walking in my door and oftentimes with sexuality is kind of unique from other problems in that. Some basic education like psycho ed is often helpful and maybe all that’s needed. And so obviously you want to be as aware of statistics as you can be. If that may be enough to help resolve someone’s concern, but with respect to pornography viewing, there’s also this acceptance and commitment therapy an ACT approach.
That’s been tested to help with distress around porn viewing. And so when you’re talking about values, one thing that’s great about ACT is, you know, if you say. I’m Catholic and I feel my Catholic faith says I can’t watch any porn. You say, okay, so this is a value. It sounds like you have an abstinence value from your faith.
And so you feel like having anything other than zero viewing is going to be distressing for you. Is that right? Just clarifying that, you know, this is not a brain disease, for example, or something that is a moral truth in the world, but rather something that they received and understood from their particular religions perspective, which is fine, but we just need to be explicit about where that value is coming from.
And so this ACT approach is probably familiar to a lot of clinicians who have some ACT training. It’s just applied in the pornography domain. And those who go through ACT ultimately do significantly decrease their viewing of pornography. So if they have that as a goal, that’s something that’s likely to help, but it’s really focused on decreasing the distress around that discrepancy between values around pornography and the behaviors around viewing pornography.
So if you need something to pull off the shelf and say, just tell me what to do ACT to me is the best data that we have at this point to support people who are upset about their porn viewing.
Betsy: [00:23:48] There’s an infographic that you posted on your Twitter that I found helpful and we’ll put a link to about the act work and just had some really neat points.
And so I’m going to post that because I felt like, you know, I think as therapists, we want to try to help people as always, of course. I mean, I know that’s a given. But in these places delving into sexual issues. I think a lot of clinicians feel really ill-equipped, but if we look at sexual behavior, their distress around it, their goals clarifying “well, is this, your value” “is this a value you continue to have?” You know, “what do you want to do about that?” What’s going to help bring you into congruence, more peace with how you’re, between how you’re acting and what your value is and values clarification. But I found that the ACT work and information is really helpful.
Dr. Prause: Great. That’s exactly why I made that with Dr. Cameron Staley, who was a student of mine back in the day, and now his expertise exceeds mine at pornography treatment. And that’s exactly what we’re hoping to do with some of the graphics that we’re starting to put out is to make it easy, like use the research supported intervention that is going to help folks who are upset about these behaviors.
And I’m excited that there’s also a sexual compulsivity treatment that came out last year and I’ve contacted the authors already a couple of times about the manual. They said it was going to be published at the time. It never came out. Now it seems it’s going to be in a different language when it comes out.
So. There may still be a while. We don’t currently have a research supported intervention for sexual compulsivity, but I’m trying to get my hands on it. And when I do I’ll share it.
Betsy: That’s actually what I was going to ask next. It was about compulsivity versus addiction. So I want to understand for myself as well as for listeners, what we’re talking about, because there are a number of models that talk about impulsive and compulsive sexual behaviors.
There’s this balance I think, between. All sexual expression is okay and normal. And we know that there are people who come in, who are significantly distressed and experiencing some consequences from some of their sexual behaviors. And so how do we manage that. So I wonder if you could speak about compulsive sexual behaviors.
Dr. Prause: [00:26:05] Yeah. So in general, I think there are five kinds of prominent models of frequent distressing sexual behaviors, three of which are potential diagnoses, two of which are kind of normal range. And these are the ones to me that we’re trying to figure out which best fits so that the three problematic are kind of this addiction model, which I think has by far the weakest evidence and some good falsification studies already. So I think it’s pretty much out of the running. The other two problem models are compulsivity and impulsivity. And then the two more normal variation models are the values conflict that we already talked about. And then the high sex drive experience.
And so the two remaining problematic models, the compulsivity and impulsivity have one big differentiating feature. So that is compulsions you think of just like obsessive compulsive disorder that is behaviors that are engaged in to reduce negative affect. To me it is the key of a compulsivity disorder.
Whereas impulsivity and impulsivity problems are this feels good right now. So I’ll do it. So it’s more of a draw towards pleasure and the compulsivity is more a reduction of negative emotions often by repetition. So when I think, you know how I want to treat those things, it really depends which one you think is operating.
And so I think our past models of frequent sexual behavior were more based on impulsivity models,. I’m pursuing this behavior because it just feels good. Compulsivity would be more, you know, I don’t even get anything out of this, you know, I don’t feel very good about it. I just maybe to validate myself worth, feel better about myself. I’m seeking out these sexual behaviors and I don’t even kind of like them.
Circuits for compulsivity and impulsivity in the brain are differentiable. You know, these are separate systems. The brain is not that clearly differentiated. So yeah, I want to be clear for those maybe who are, don’t have a neuroscience background, nothing is that clear in their brain.
So I want to, you know, don’t oversell this, but they are substantially different circuits. If someone is having a compulsivity problem with sexuality, I think it needs to be treated differently than if they’re having an impulsivity problem with sexuality. So compulsivity, I would treat in an OCD framework that may be looking at the maintaining behaviors.
You know, what are the beliefs that underlie this need to continue in engaging in this, which is harming your often relationships in some way. Yeah. Your partner is not happy with what you’re doing. So maybe you’re masturbating so often that when I want to have sex with you, you can’t get an erection.
Yeah, we see that clinically sometimes and the person says, Oh God, they’re a sex addict. I said, no, it just sounds like they’re compulsively masturbating. And we need to understand what that is about and how we can find a better balance so that you can have a sex life you want. Or as someone who’s impulsive, that may be more of a cheating issue.
So there’s some evidence that with infidelity, infidelity is strongly predicted by opportunity. That is the person’s ability to conceal the behavior which sounds terrible. But to some extent, that means you, if you’re inclined to cheat on your partner, that if you’re able to, you know, is the biggest predictor of whether you follow through on that desire, which looks pretty impulsive frequently.
And so that’s a whole different kind of problem where you say, man, that it’s so hot. You know, I love that so much. It’s so exciting that if I have the chance I’m going to. That’s impulsive. And I don’t want to treat that as a compulsive problem. So I’m trying to take it kind of all the way from brain down to behavior to say why these differences matter.
These are not small differences to me. They’re huge. You know, it’s do I treat this person who’s engaged in a lot of sexual behavior as having a compulsivity problem or impulsivity problem. They look very different to me, both as a neuroscientist and a clinician.
Betsy: [00:29:55] Yeah, I think that there are very important, those impulsive and compulsive behaviors lumping them together can seem like not a big deal, but knowing that we’re talking about a different intention, different maintaining behaviors, I think that’s a really big deal and a very important conceptualization to make. And so I appreciate the information on that.
Dr. Prause: [00:30:15] So one other thing that could be useful is we do have porn interventions for youth that people should be aware of. If they haven’t yet looked at Emily Rothman’s work, they have published a porn education program that they do trainings for the trainings.
Of course you pay for it, but yeah, she’s a scientist. So this is just out in the world. It’s not a secret, you know, or something that’s super licensed and hard to get. Her team from Boston University has a porn education program that talks frankly with youth about kind of positives and negatives that is, you know, acknowledges that, I believe, you know, obviously look to her for her description, but my understanding is: they want youth to not feel bad about sexual exploration. That often they’re viewing pornography because they’re curious and often for the same reason adults do, for sexual pleasure and masturbation purposes. You know, we often, obviously a very tough topic and you know, talking about child sexuality and child sexual pleasure.
It’s a very difficult thing to talk about, even for clinicians, much less parents. And so her program gives a really nice structure to say, you know, what is it that we need kids to know? So we need them to know that sending an image of themselves to someone else it’s nude or taking an image from someone else is potentially illegal.
And we want to be supportive of their exploration and not shame them sexually, but we also want to make sure they don’t do that in particular. Because it can have consequences they would have no idea existed. I really liked that her program seems to take a really balanced view on, you’re not shaming them for accessing pornographic material, but trying to acknowledge like, yeah, there’s some totally understandable reasons why you might be looking at those things. but here’s some things you might consider. That there are some consequences if you do it in this way. I really, really liked her program and hope more people use it. So if you’re in the dark with what to do with kids, especially with kids and pornography, I think hers is a great program.
Betsy: [00:32:21] I think that’s really helpful. I, one of my specialties is working with teenagers and I have had so many conversations with teenagers about porn, about what they’re watching, how they’re engaging with it and not just, and I think when people think of that, they’re going to think about teenage boys, but it’s absolutely with the girls too. And wanting to support their appropriate exploration of their own sexuality, but it’s a fine line. And I find myself, you know, I’m a parent, my kids are grown now, but having understood the hesitation. We had a training that a colleague of mine did for us on what was appropriate sexual behavior for which stage of development.
And she did this game where we had these sexual behaviors listed, and we had to rank them in red light, yellow light, green light. Right. What’s normal. What’s kind of concerning, but we’re not there yet. And what’s a red light behavior. And I found I had such a conservative view. I had everything in the red light.
This was probably eight years ago when my kids were younger and I was thinking of my own children and going, Oh my gosh. I realized I had such a conservative view of what was normal or appropriate, and it was incredibly eye-opening and helpful. And from a person that I greatly respect who does look at science is aware of biases and whatnot, as much as we all can be.
But I found that even for myself, who I consider myself fairly forward-thinking, liberal minded, but I had some very serious bias about that. And I found that really eye opening and also reaffirming this idea that I have a responsibility to not necessarily share my own conflict and bias that I need to check that at the door and be walking aware.
Right. And that we do that so much in everything else, but with the sex thing, it is different and odd. And I don’t know if that’s limited to the United States, if other countries are further along than we are, because we have such a hard time dealing with talking about sexuality and all that goes around that.
But I appreciate the information about teenagers. We have this discussion a lot as clinicians. At least the clinicians that we, I have worked with, we all end up talking about this stuff kind of a lot.
Dr. Prause: [00:34:53] I have some obvious, at least struggled similarly in the therapy room. And I try and keep my brain on science as best I can. But so I kind of struggled from the other side, sometimes that is there. I have couples come in who’s like, “you know I saw him looking at this woman. I can’t believe he cheated on me”. And I’m like, Oh my God, like there’s only so many percentage of the population that considers that infidelity. I don’t think that’s infidelity at all, but they’re defining it that way.
Okay. Where is that coming from? You just have to bite it. And, you know, I think some people think, Oh, you’re a sex therapist, you’re so liberal. They’re just trying to get everyone to be swingers and no, like I have some of the same struggles. It’s like, I realized that I have a breadth of exposure that’s not typical. And so I also need to reign that in. Absolutely cuts both ways.
Betsy: [00:35:46] Well, and I think that sex therapists, seeing them as legitimate, I think is difficult for some clinicians and they just pretend, like our field as a whole pretends, they don’t exist. The AASECT, I think they’ve done a lovely job validating and promoting professionalism and the importance of talking about these issues.
I mean, sex is central everything; to the survival of our species. And I think they’ve done a lovely job, but I think us as a field in general has not necessarily come along with that. And I think that they’re putting themselves up for criticism, which is crappy for them and brave, I think, as well, to be willing to address these issues because they do come into our therapy rooms all the time. It’s just not something that we, I think, we’re trained to ask about and to manage and deal with.
It is really vital. I have a lot of respect for the work that sex therapists are doing and doing things with just as much professionalism and ethical consideration and science as anything else that we do.
Dr. Prause: [00:36:51] I think you had some similar kinds of experience because even within the scientific domain. So, you know, I’ve always say, I’ve had, twice now, I had the very strange experience. A lot of what I study in the brain is basically emotion neuroscience. So I collaborate a lot with those folks. But a couple of times I was at conferences and saw a talk that I was like, Oh my God, they’re basically working on the same system I am.
This is so cool. And so I’d go to talk to them afterwards. And in two cases, Male scientists, which tend to dominate that area. And they said, Oh, my wife would kill me. I could never study in that area. And I was like, What, why are we talking about your wife? I thought we’re talking about science. And so absolutely even within that, the scientific domain.
And I do think this is changing in large part because we’re forcing them to, or like we’re coming into your journals, whether you like it or not, You have to listen to us. You have pornographic material in your emotion stimuli. You need us, you need to understand what those look like and why they’re changing like that.
So yeah, among sex therapy and also sex science, we definitely have a problem getting people to see that we are part of the emotion neuroscience area. Some have been absolutely wonderful about it. I’ve got great collaborators in that space, but also some are just the same kind of biases and just straight up, you know, they’ll tell you it’s I, I don’t want to work with porn or I would be in trouble at home if I did that.
So it’s really not a scientific approach to understanding the brain and in my mind, but we’re slowly working to change that as well. So we can get more of that good information out and develop more treatments that can be helpful. I hope
Betsy: [00:38:34] So if we were to talk to therapists, okay. Are listening and they’re like “okay, so I get that the word addiction is not helpful and we don’t have science to back it up. Okay. And that impulsion and compulsion are different. And that it’s about people’s distress, the client’s level of distress about their behavior”. What do you wish, or what would you suggest that our colleagues in the therapy realm do to, I guess, be better at this?
I think it would be difficult for the sex therapists to absorb all of the clients who could use some support. And I think that it would be difficult for clients to self-select into see a sex therapist because of some of the connotation. So it really is to the generalist therapist population that we end up talking about something that we haven’t specifically trained in.
So I wonder from your perspective, you know more about what is out there, what would you, if you could sort of suggest or design something for therapists to have more knowledge about or engage in or train in what kinds of ideas would you have?
Dr. Prause: [00:39:50] Yeah, I love that question. So I think for a lot of people that are presenting, especially with problems with pornography, although also sex more generally, is there is so much bad information on basic base rates stuff. By base rates, I just mean how often something occurs in the population. If you can provide accurate sexual information, you may be able to address a great majority of these problems that people come in with because often it’s a misunderstanding. You know, they thought something they were doing was weird or outside the realm of normal, in some sense.
And you know, we already have good data for example, on masturbation, frequency by gender by age. We know kind of what’s within the range of 80% of people or what’s in the range of 95% of people. And so we can say, okay, you know, are you really outside the range of what most people are experiencing? And obviously, you know, you can still be distressed about it.
So it’s not that this is going to be useful for everyone because you do have those people who say, I believe I should never look at porn. That’s my value. And so the psycho-ed is not going to help as much in those situations, but very, very often it’s just a simple bad information, you know, they need good education.
So seeking out those basic statistics so thatyou know, for example the average age of first viewing of pornography for females is around age 17 for males it’s around age 14. And it’s not, you know, age eight and nine is this sometimes touted. I have no idea where that stat came from, but it’s not true.
So just be sure you have good information so you can transfer that information and education. Like that’s probably the most basic. And then there are good interventions for these behaviors already. So most likely, you know, someone’s describing sexual behavior problems to do with frequency issues.
It’s probably a disorder you already know about, so you probably don’t need to make it about sex. Does the person have depression and they help deal with their low mood by distracting themselves with pornography. Porn is great for distraction. It’s very good at getting your attention. And about 15% of people, when we tested in the laboratory who have low mood, their sexual interest actually increases when they have low mood, kind of weird, right?
You don’t normally hear that with depression, but know that that’s a thing that can and does happen. Or if they’re engaging in sexual behaviors that are compulsive. Is that just their way that their OCD is manifesting. Like, do you really need to address the sex per se? Or is this an OCD treatment that you already know how to do and can just apply it to the sexual behavior they’re using?
So you’re going to get another huge cut off of these folks using intervention. So you already know how to do. So just because you hear sex, don’t go into sex mode. Think like, Oh God, what special sex thing is this that I need to pull out? You probably don’t. And the data support that, that overwhelmingly these folks who are getting treatments are specific for sexual behaviors probably shouldn’t be.
And then if you determine like this really does seem to be something that’s specific to pornography or specific to sex, then you’ve got for pornography that great ACT intervention. You probably already have some training in ACT, especially if you’re recently trained and those manuals are accessible.
These are research publications. So the peer review journal articles are widely circulated. We’re working to help get infographics out, to make it even easier to communicate with patients about those options. And then if it’s with pornography, maybe you have that option with kids. Emily Rothman’s porn education program.
And if it’s sexual compulsion, we don’t currently have. This major review just came out of sexual compulsion interventions in a well-respected high impact journal a few months ago. And they said, we have no intervention for this. Like there is no but there has been one that is published in a different language that we are trying to get our hands on to disseminate.
So those are coming but there’s not currently anything great for those. So, it behooves you as a clinician to try and see does this sexual behavior look like it’s part of something I already know. And you know, don’t assume that it’s especially weird.
Betsy: [00:44:15] I think that’s really helpful because I think that when I experienced the same thing in the substance abuse realm, that when somebody gets a substance abuse,mentions it, it’s like we all freeze up a little bit and they’re like, Ope that’s out of scope.
And yeah, I don’t know. Well, you know, it depends. So let’s assess, let’s learn how to move into some of these areas, because in a lot of ways, especially those of us who are kind of community, mental health, not specializing, we kind of have to be all things to all people at times. And in our desire to be as the most ethical therapist as possible, I think sometimes we can limit ourselves when it just takes a little bit of well reasoned perhaps slightly cautious, but still moving forward to see what we can do. So if we don’t have something for compulsive sexual behavior, what are the maintaining behaviors, what’s driving it. What’s underneath it. Just like we would anything else.
Dr. Prause: [00:45:10] Yeah. Behavioral analysis can absolutely be helpful there.
Betsy: [00:45:13] Right. And I think that we though when sex comes up, I think a lot of therapists just sort of like, Whoa, that is not my area. And I want to; I’m not encouraging people to practice out of scope and I’m not encouraging people to just willy nilly, do whatever they want.
I do recall a colleague we consulted about a kid that one of the therapists was seeing and she said, don’t worry about the fact that it’s sexual behavior, treat it like any other behavior modification. Whatever this behavior was it totally cleared up the issue. This therapist who was asking the question was excellent at behavioral modification and it just cleared it up for both of us.
“Oh, Okay. That’s how we’ll do it.” We don’t, and it was kind of eye-opening I think for me and for my supervisee. A lot of the clinicians I know, want to be as effective, ethical, you know, reasoned, measured, all those things. What I don’t want us to do is not help in an area or have to ignore an area that we really could step into.
Dr. Prause: [00:46:15] Yeah. I don’t know who that is, but I love them already.
Betsy: [00:46:19] I really appreciate all of the work that you’re doing. I’m going to put a number of links, like I said, in the show notes. Because I think that this is an area where many of us are looking for someone who is well-respected professional scientific that we can look to and say, all right, what, tell me, what’s out there, what’s happening here.
And that we can inform ourselves. And so I want to support that growth for all of us, you know, in all sorts of areas. I’ve talked about gambling and internet gaming food, and now talking about sex and then porn. I really appreciate you, Dr. Prause being willing to be on a show with me and do this right around the holidays.
I’ve really enjoyed talking with you. And I appreciate all the information and the work you’re doing. I know that it can be a difficult space to step into, and there’s a lot of criticism and I just appreciate your willingness to do that for all of us.
Dr. Prause: [00:47:19] I appreciate the invitation because I am very much wanting bench-to-bedside. You know, if I sit here and publish papers all day long and y’all never hear about it in the clinic, then what have I done? So I appreciate the opportunity.
Betsy: [00:47:32] Well, thank you so much. And I hope you have a great new year.
Dr. Prause: [00:47:35] Thank you, you too.
Again, I’m so grateful to Dr. Prause for being willing to take time to talk with me.
In grad school, we talked about looking at our own beliefs and values and making sure that we’re not presenting those to clients in session. I think that sex is one of the areas that we all have a lot of opinions and that we need to be really aware of what those opinions are and how they influence our attitudes about sex, sexual expression, pornography, and all things involved in the sexual health area.
Talking about sex is something that most people are willing to accept. I think taking a stance on pornography is a totally different issue. I’m not here to take some sort of major stance on pornography. I am here to talk about :what does the science say about it”? There are a lot of issues in the porn industry and the viewing of erotic images is more than 10,000 years old.
This is something that has been a part of culture, as long as there has been culture and it’s going to continue. And the scientists tell us that viewing erotic images is normal sexual expression. One of the studies that really stuck out to me was where they found people who had identified as having an issue with porn and what it ended up being was that they had a lot of internal conflict about their own values around viewing pornography. And it was a lot of cognitive dissonance rather than addictive behaviors.
Remember that with addiction, we’re talking about specific brain changes and functions that are happening. Those haven’t been identified. And in some cases there’s evidence not just not supporting, but against the idea of it being an addiction. It’s a complicated topic.
And at the bottom line, what I’m after is that we as therapists are the safe place for our clients to share all of the things that they struggle with and the things that they’re too afraid and too ashamed to speak of. We create that space. And since a lot of us didn’t get trained in how to work with people in sexual behaviors, and we’re not going to be referring everybody who talks about sex out to a sex therapist. We have to dive in a little bit, check our own opinions, look at the science, and provide a space for people to help them find a place of peace and resolution to what’s going on in their lives.
We’re going to start a new series where I’m going to go through different drugs and their effects short-term and long-term, withdrawal scenarios and other information that I think you might find useful. Hope to see you next week.
If you’re ready to take the next step in addressing your client’s substance use head on over to betsybyler.com/treatment tool. The treatment planning tool I created will help walk you through the process of evaluating your clients use and deciding how and when to intervene. The tool is completely free and will be delivered to your email so that you can use it right away.
Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist, friends, and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know. Just send a message to podcast@betsybyler.com. I’ll see you on next week’s podcast and until then have a great week.
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