Why the word “addiction” doesn’t fit when talking about sex
Is sex an addiction?
What does the research say about problematic sexual behaviors?
How can we evaluate potential issues with sexual behavior?
The word addiction and the word sex shouldn’t be put together, at least by therapists. It’s used in popular culture often, but 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 health, Dr. Eli Coleman of the University of Minnesota.
In this Podcast:
- There are multiple models to describe problematic sexual behavior
- The addiction model that is quote by many non-clinical people is not the most up to date model
- Some models felt that medication was best used to treat problematic sexual behavior
- Current research does not support that sex can be an addiction
- Current models describe these behaviors as being impulsive/compulsive sexual behavior (ICSB) or out of control sexual behavior (OCSB)
- Dr. Eli Coleman of University of Minnesota (Twin Cities) is an expert in the field and the interviewee on today’s podcast
- Check out their website for resources and information on their 50th Anniversary Celebration Gala https://www.sexualhealth.umn.edu/
Free Treatment Planning Tool www.betsybyler.com/treatmenttool
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 starts the last part of our series about other behaviors that are considered addiction or that have been considered addictions, but haven’t been included in the DSM. For the next two weeks, we’re going to be talking about sex addiction and talking about porn.
When I thought about doing this topic, I had to decide whether I wanted to venture into this space or not. It’s a pretty controversial space because people have really strong feelings about this. Many people feel that there has to be an addiction for sex and porn because of the problems it seems to cause in people’s lives. It is very true that there are people who are very distressed by their own sexual behavior, whether it has to do with actual sexual behavior or if it has to do with porn viewing.
Walking into this space though, can be pretty difficult. There are many researchers, all over the United States, that are doing research on sex and many of them regularly received death threats from anti-porn activists and others who don’t want them to be doing this kind of work.
As therapists, one of the things we found out after grad school was that we didn’t get substance abuse education, Right? The other thing we didn’t get was education about sexuality. Now, some of you may have had the benefit of having better education than a lot of us did. With my experience with different therapists that I’ve worked with over the years, many of us didn’t get very much and we ended talking about sex kind of a lot.
It is such a normal and vital part of people’s lives that we end up discussing it because these problems come up in therapy. The way we talk about sex and issues around sex really does matter, right? The general public may talk about sex as an addiction, and they might use the word addiction and that’s up to them. I really believe that we as therapists have a responsibility to use words very carefully and in the next two podcasts, I’m going to be talking to two researchers who are well-known and well-respected as being experts in the field.
They’re both going to be sharing , that addiction, when it comes to sex and porn viewing are not supported by science. That definition doesn’t hold up. That is not to say that there aren’t issues or that people don’t want to change some of their behaviors around sex. It just means that it’s not scientifically backed up.
Because of that, I want to encourage us not to be using the word addiction. We’re very cautious to not label people as addicts or alcoholics. We leave it to them to determine for the most part. The DSM doesn’t give us a great idea of what disorders there are around sex. It was just two manuals ago that things like homosexuality were listed as disorders. So we can’t really rely on the current state of the DSM to tell us everything, we have to look at the research.
As I thought about going into this topic, I knew that there could be some problems and that people could have some issue with some of the things that I might say or some of the things I might bring forward. But I decided to do it anyway, because I think it’s important.
Now, after these next two topics, we’re going to be heading back to substance use and doing some in-depth discussions on different drugs and their effects.
I think it’s important that we kind of, that we understand a little bit about the different models when it comes to this. When I did the first searches talking about sex addiction, I found a ton of information. It was a huge spectrum. And in the show notes, I’m linking just a bit of the things that I found.
Now as to be expected, there is a wide spectrum of information. Some that would be seen as a really open view that would be on the side of all sexual expression is okay, all the way down to porn and sex being something that is addictive and has to be very carefully watched. I think it’s important that we understand that the addiction model is on the really restrictive end of that spectrum.
What I’m bringing to you is a more middle ground view; also based on science that we have currently.
For those of you who want some further reading, there’s a really great paper by the man who I’m talking to today, Dr. Eli Coleman. The paper is called An Integrative Biopsychosocial and Sex Positive Model of Understanding and Treatment of Impulsive and Compulsive Sexual Behavior.
In the paper, it talks about the different models and their history. In the early 1980s, one of the earliest models of impulsive compulsive sexual behavior was developed by John Money. He considered these behaviors to be a psychosexual development disorder. He proposed using pharmacological treatment approaches using anti-androgens and outpatient counseling (although the type of counseling wasn’t necessarily defined).
Next came Patrick Carnes who popularized the addiction model using the 12 steps found in Alcoholics Anonymous. His model emphasized the need for treatment, inpatient typically, commitment to a period of sexual abstinence and a spiritual program of recovery
Marty Kafka saw impulsive compulsive sexual behaviors a little bit differently. He talked about sex being an appetitive drive. So it’s a basic appetite. That becomes dysregulated. The sex drive becomes dysregulated as a result of impairments in affect and sexual arousal regulation. Kafka frequently recommended SSRI as a way of moderating that upregulation and downregulation happening in the affect.
More recently studies done by Braun-Harvey talk about this as a sexual health issue. Viewing compulsive and impulse of sexual behaviors as a socio-cultural problem, which they term out of control sexual behaviors or OCSB. This is basically talking about the issues around sexual behaviors coming from intrapersonal conflicts about sexual values.
The last one I’ll talk about is the ICSB, which is impulsive compulsive sexual behaviors. That’s the model that the University of Minnesota Department of Human Sexuality and Dr. Coleman, created. The model views sex as a basic appetitive drive that can become dysregulated. And that there are deficits in self-management and executive functioning, like in an impulse control disorder.
It’s a lot like out of control sexual behaviors, but it does view those sexual behaviors as a clinical problem, or that they could rise to a clinical level. The ICSB sees that there are both biological and psychological issues that contribute to impulsive and compulsive sexual behavior.
So basically our current models, as it comes to research and science, are: Is it a clinical issue or not? Meaning does it rise to a clinical impairment level? And if it is to a clinical level, then how are we going to treat that? What continues to come up is the idea of ‘what is normal (hear the air quotes) sexual expression’, and how do we, as a culture, move past the Victorian attitudes, as it’s often referred to, of our culture.
I got a chance to sit down with Dr. Coleman just before Christmas. His schedule, as you can imagine, is super tight so we didn’t have too much time to talk. But I am really grateful to him for being willing to take a call from someone who is totally not on his radar and willing to sit down and talk with me.
Dr. Coleman is a PhD, professor and director of the program in human sexuality at the University of Minnesota at the Twin Cities. He’s one of the past presidents of the Society for the Scientific Study of Sexuality, the World Professional Association for Transgender Health, the World Association for Sexual Health, the International Academy for Sex Research and the Society for Sex Therapy and Research.
He’s the current chair of the World Professional Association for Transgender Health Standards of Care Revision Committee. He’s one of the founding editors of the International Journal of Transgenderism and the founding and current editor of the International Journal of Sexual Health. He frequently consults with the World Health Organization and the CDC.
Betsy: Dr. Coleman. I want to thank you so much for being here this morning.
Dr. Coleman: I’m happy to be here.
Betsy: I came across your work when I was doing preparation for this podcast. I typically do episodes on substance abuse because as a mental health therapist, I feel like we didn’t get trained quite as well as we could have in grad school about substance use.
And I don’t know that there’s any big conspiracy about why that is, it just isn’t part of what’s required.
Dr. Coleman: No, I, I think it is really interesting. But not only do we not get much on drug and alcohol abuse or dependency, but we receive nothing on sexuality as something so central to one’s identity and relationships.
Betsy: I don’t know why that has never made its way in. I have some guesses. Maybe we could start there. Why don’t you think that our field is still so far behind?
Dr. Coleman: I don’t know. It’s really interesting. You’ve got me thinking about what is this barrier? I don’t know when you went to school. I mean, alcohol and drug use is really just so ubiquitous.
People don’t like to think about limits. We’ve had a hard time really coming to terms with it being really a clinical condition, something in need of treatment gone from seeing it as really kind of a weakness or some sort of moral issue. So that is really interesting, but the, you know, my field is his sexuality and our field has really been so preoccupied with liberating people from Victorian attitudes of sexuality that they have not wanted to talk about limits. We have really experienced that during the HIV epidemic. It was really challenging to talk about limits, restricting people’s liberties, freedoms. It’s very interesting that this is such a taboo area.
Betsy: Well, and you started your research on the eighties. I feel as though maybe we’ve come a little bit of a distance in recent years, but I imagine that in the eighties and nineties, the research and the work you were trying to talk about, couldn’t have been very popular.
Dr. Coleman: But I’ve never taken on necessarily popular issues. And I’ve really always been challenging things from my early work on debunking, the oldest model of homosexuality that’s in the late seventies.
And then I found myself working within the chemical dependency field. Back then, you could not talk about anything other than drugs in treatment. I remember presenting at a conference in Oxford, England, and someone yelling at me that “you’re committing murder”. This is, you’re committing people to death by distracting them talking about sex when they are in treatment for chemical dependency. But even again, in many European countries, a lot of resistance about even chemical dependency treatment.
And I remember training people in chemical dependency in the early eighties. I’ll name it. I mean, we had counselors from Hazleton here in Minnesota who literally had to sneak out and hide the fact that they were going through our training program, because it was absolutely heretical for them to deal with sexuality as part of any kind of treatment or recovery.
Betsy: That is so bizarre for me. I finished my training in ‘03. We didn’t have sexuality as part of the regular coursework. I see what I giant problem that is since I’ve been in chemical dependency work, we talk about sex. Even from Hazelden now, which apparently they were onboard with you guys many years ago because it’s in their literature.
Dr. Coleman: No they came around. I think we had a big impact on the chemical dependency field. Not only here in Minnesota, but through our publications across the country. And so there was finally a recognition and you could talk about it. Even today, you know, people find it hard to talk about their sexuality issues in those groups where people are supposed to be very authentic, very honest.
It’s just a, it’s still sort of a hard area, but it goes to our, our universal discomfort about talking about sexuality in general.
Betsy: It does. So I’ve been a supervisor for the last 12 years and training therapists as they’ve come up. And it has been kind of a joke, but just a comment that no one in grad school told us how much we’d be talking about sex. From working with kids and talking about puberty and talking about changes and normative sexual behavior because nobody’s talking with them.
To whether it’s working with teenagers or with adults or with older adults. We have largely had to figure it out on our own. We just talk about a lot. It’s not standardized still though. I know for myself, I grew up in a, what I consider very British, don’t talk about sex sort of atmosphere. And it took me awhile to just dive in and decide, well, I’m going to talk about this. As I was preparing for doing the series on “addictions” or things that people call addiction, that’s what led me to your work and specifically your work on the sex positive model. Thinking about okay, how do I present this to the listeners?
Because I think that the idea of a sex addiction still persists. I hadn’t heard a lot about people challenging it until I just asked the question in Google one day and there is a ton of work going on. I don’t consider myself necessarily sheltered or naïve. What that tells me is that the therapists, I think that are trying to be as informed as we can, are still missing the information that you and your colleagues are putting out.
I have listeners in the US and the UK and Australia and so I want to make sure I’m presenting things accurately and based on research, not opinion. I wonder if you can talk with me about the addiction model versus the model that you and your colleagues put together on the impulsive and compulsive sexual behaviors and kind of what the main differences are.
Dr. Coleman: So, first of all, the addiction model is alive and well. Many people have programs based upon a 12 step model borrowing from alcohol and drug addiction, which again has happened with every behavioral access. Right. You know, and it made sense. And when I started looking at chemical dependency and sexuality, I almost bought into the idea that we were dealing with some sort of addiction because people were saying “what I do with sex is the same thing as what I did with alcohol and drugs”.
The problem is that the behavior may be out of control. It can be used as a metaphor. The underlying mechanisms that are causing the out of control sexual behavior are vastly different. And to assume when you say sex addiction, you’re really saying that people are addicted to sex. And they’re not, there’s no way that they can be addicted to sex in the same way that people become addicted to alcohol or other substances.
So that is a big problem. And then to take a wholesale adaptation of a model for treating alcohol and drug addiction with all sorts of abstinence approaches and contracts and days sober and all these kinds of things. It’s an inappropriate addiction. I have the highest respect for chemical chemical dependency treatment 12 step approaches for alcohol and drug addiction. It doesn’t really work with impulsive compulsive sexual behavior.
So the big distinction in terms of our model on impulsive compulsive sexual behavior, is it recognizes that the behavior. Even within that, it is driven by a number of very, very complex mechanisms. I use the term impulsive compulsive sexual behavior. I don’t say what it is causing it. It’s just a behavior that is out of control and we need to search what those mechanisms really are and then apply. The most appropriate treatment method for that particular dynamic. And so a lot of it is caused by effect deregulation caused by comorbid psychiatric disorders.
So we’re really addressing that. There’s a strong component of attachment issues. So we use therapeutic approaches to look at their attachments and their difficulty with that. Which oftentimes results and problems of identity and intimacy. I oftentimes see compulsive sexual behavior is basically an identity and intimacy disorder.
And the most important thing. And the best analogy that I talked to my patients about is that it is more similar to an eating disorder. Sex is a basic appetitive drive and it can become dysregulated. So we don’t ask people with eating disorders to stop eating, to go on crazy restrictive diets. No, we teach some about healthy sexual behavior, healthy eating behaviors.
The goal is really not about abstinence or always limiting, but really developing healthy expressions of sexuality, integrating parts of one sexuality into their lives. It’s a very, very different approach. It is sex positive, of recognizing that sex is not the evil. In many cases the problem is that people think that their sex behavior is evil and that causes them to feel that they are evil themselves.
Going back to how we used to classify what we’re now calling compulsive sexual behavior disorder. We used to call it perversion. That was in the diagnostic and statistical manual, which also included masturbation, oral sex and many normative sexual behaviors, but they were all lumped into one, and homosexuality was in there too.
And so we’ve come a long way. The big advance is with the new International Classification of Diseases of the World Health Organization, recognizing Compulsive Sexual Behavior Disorder as a clinical condition. It is placed in the category of impulse control disorders. It’s not placed with alcohol and drug addiction. It’s recognized as something different.
So that’s, I think the main distinction between the two models. Unfortunately, I think a lot of people are confused because sex addiction is a very popular term. It’s easy to, whatever problem that you have, whether you’re shopping too much or you’re eating too much everybody’s calling it an addiction. As a metaphor, Okay. But even then I think it misleads people to thinking, what is the approach for dealing with that issue?
Betsy: I’ve noticed that as well, that what people are referring to as addiction, even in professional circles, I don’t know if it’s that they are thinking about that. The word is very specific, we’re talking brain changes and some things that are happening in addiction that we’re not talking about.
In this instance, it seems as old media, at times, we’re taking some pretty narcissistic behavior and calling it addiction. And it could be that there’s some compulsive sexual behavior going on there as well. I wouldn’t know. It’s like a shorthand that seems to. It’s just unfortunate, like you’ve been saying, cause I think it is perpetuating itself.
Dr. Coleman: That’s a good illustration. Again, the behavior could be really a function, you know, part of a personality disorder. That’s how it’s really expressed. And so you need to really look at how that character structure was really developed and really help clients learn how to really, you know, personality disorders are oftentimes just really kind of learned coping mechanisms, uh, to survive.
Then they become maladaptive. And so it’s really learning those patterns, but they’re very habitual patterns and they are unconscious and those need to be exposed and they need to learn different methods of dealing with it. But it’s always so complex. That could be just one piece. You know, that’s an oversimplification that people have is that all ”sex addicts” are narcissists.
Very few of my patients really meet narcissistic personality disorder. I mean, there is a vulnerable narcissism, which is very different, a self-focus based upon shame, feeling defective and not even having the capacity. Because they’re in such survival mode that they don’t think about the needs of others.
They’re really just trying to survive themselves, but it’s not a lack of capacity for feeling empathy or concern about somebody else. So it’s something very different, but again, that’s the problem with a lot of these words that are thrown about. And no one looks at the complexity.
Betsy: So as you’ve talked about just a few minutes ago, about things, the field considered as perversion, you and your colleagues are suggesting and bringing forth that sex is a normal part of life.
We need to talk about it and we need to not pathologize, but you’re going to step further and suggesting that more things are part of normative sexual experience, then I think sex for procreation, those kinds of things. I think that there are people who are uncomfortable with that. It’s refreshing because you and I know that that is true, that what we hear about in our offices, in our sessions with people is a great deal of shame based around things that they enjoy.
Someone has told them somewhere is wrong, perverse or whatever. I know that there’s some research talking about people’s beliefs and they believe themselves to be having some compulsive behaviors, but it ended up being that they had moral issues inside. Sort of this conflict between what they believe.
Dr. Coleman: You know, that’s what we’re really studying right now is again, Many people, whether it’s just problematic is that they have a conflict of values or there’s some moral in congruence with their behavior and their values or their morals in the, uh, international classification of diseases. It really clearly specifies that you need to rule that out.
That’s not compulsive sexual behavior. That’s moral incongruency and that’s a different issue that needs to be addressed. And we need to separate those things out. That is a big problem, and it’s just ubiquitous. Everyone feels they’re asking themselves, am I normal? And because of the lack of sexuality education in the wide range of sexual expression and things that may be a bit unusual in it itself is, is not necessarily pathological any sexual behavior can be taken to it’s impulsive, compulsive extreme.
And then we have a problem, we have to really help get that regulated in and integrated into their lives.
Betsy: There’s so many things I want to ask you. So I’m rapidly cycling. I want to ask you about out of control sexual behavior versus impulse and compulsive, but we don’t have a ton of time. That’s another term.
Dr. Coleman: I mean, my good friend Harvey, uses the term out of control sexual behavior. Doug was a mentee of mine, so we’re still extremely good friends and colleagues. And I think our models are really very similar. I think probably the main difference that we have is that he wants to call it a problem and doesn’t want to recognize it as a clinical condition.
I think we have to call it a, at some point, things are really psychiatric conditions and are in need of treatment. And he certainly will put people through long periods of treatment. But I think you have to recognize that then it’s, it’s really a clinical condition. I certainly understand the value of not pathologizing and using less pathologizing terminology, like out of control sexual behavior.
And there’s always a continuum, right? Things can get a little out of control and they can be a problem. You can, people will have affairs. They break contracts that they have, and yet they can recognize all that’s a problem and they, and they deal with it. Others, this is really so ingrained or it’s caused by some very deep mechanisms.
And so you have to deal with the anxiety disorder, the depressive disorder, the chemical dependency that may be going on and, uh, address that. And I think Doug certainly agrees with that too. And we’ll refer people for more specialized treatment. I think that that’s the only main difference between our approaches.
So his work is excellent.
Betsy: You know, I went through a training when we were working on normative sexual behaviors for children and it was super uncomfortable for me. But really eye-opening and really changed a lot of my work and my trauma work with kids. And so with adults, I wonder if there are any recommendations you have of what therapists that are coming under your, into your department that you want, you would recommend for them what we should be reading, that we should be doing.
I know that’s a super broad question, but I just didn’t know if anything, offhand that you had in mind.
Dr. Coleman: No, that’s a good, it’s a very good question. And not only are they thinking things that therapists should be reading, but these are books that they should have on their shelves for parents, for adults, for children, not just the academic books, but all the Am I Normal series by Harris, books for children about sexuality really normative.
The other shout out I would give is to the Guide to Getting It On, I think is a wonderful resource for young adults. But I think it’s probably really written very nicely for anybody too, it’s all based on science and what we know about child sexual development. And adult sexual exploration is very, very, it’s a very excellent book.
There are a number of resources on our website at the Program for Human Sexuality. There are a number of resources, both for professionals and for patients, but we’re not the only place, SIECUS. So many other organizations have really wonderful resources too. But it is really helpful for people to get educated, but also to be ready to give resources to our patients that would be helpful to help normalize and educate them about sexuality and its diversity and understand that.
I think that that’s very important. The other thing I would mention about our website is that we do have a lot of resources about compulsive sexual behavior, which we’re talking about here. I have developed an instrument to assess compulsive sexual behavior. That inventory is available there, how to use it. All of the research that has been done related to assessment and treatment is available there.
So that’s a wonderful resource, our website, and there, you will find that we are celebrating our 50th anniversary of the program, human sexuality, but I want to assure you that I was not there from the beginning.
But I was there. I’ve been there for a long time. And I benefited from the amazing pioneers who started the program and educated me. And we have gone on to educate now over 50 post-doctoral fellows, they’re spread all over the country. So we have a postdoctoral training program, but we are celebrating our 50th year.
We were going to do it this year, but because of COVID. We have postponed it to 2021 and that’s it. It’s going to be a really fun event. And now it’s going to be virtual. So anybody in the country, any of your lists can go to our website and register for that event. It’s going to be really fun. It’s going to be, be fast paced and we’ll celebrate what we have accomplished in our 50 years and advancing.
You know, our goal is revolutionizing the sexual and gender climate of this country. We have done a lot, but we have a lot, we have a lot to still yet to do. And there’s been some backlash we have lost some ground and we’re working to regain that, but we revolutionize that climate through science.
Through understanding and through educating. And we do take that science and we try to educate people in working in public policy and public health about the best science to inform policy treatment and what kind of research that we should be doing. Very happy to be a part of the program for as many years as I have been.
And your listeners might really benefit from going to our website and proofing it and finding resources that they might find helpful.
Betsy: I really appreciate that. And you answered the last question, which was about your measure. Just wanting to know if non specialized therapists. Not specializing working in issues of sexuality, if it’s appropriate for me to be using that measure.
Dr. Coleman: Perfectly fine. Just with the caveat that it is only a screening measure. So should never be used as a definitive way of determining whether people meet the clinical criteria or not. The international classification of diseases has developed a set of criteria that one should really use in clinical interviewing. People could use the scale as a screening instrument to help assess.
Again, always recognize that there’s healthy, there are problematic and then you enter this, that this is a clinical syndrome and problems can oftentimes be resolved by more brief therapeutic approaches or psychoeducation. Don’t always want to assume that things are not able to be resolved by those methods.
But then some people will need some real specialized treatment to address this very complex problem. And when it’s at that level, it’s a, this is not something that is treated in 10 sessions and then it goes away, takes a well-trained clinician to really do, do that work
Betsy: I’m so grateful that you had time for me this morning. I thank you for taking the time. And I hope you have a great holiday.
Dr. Coleman: You too. Wonderful. Take care.
Again, another, thanks to Dr. Coleman for being willing to sit down with me today. Next week, we’re going to be talking to Dr. Nicole Prause who is a neuroscientist and a licensed therapist out of Los Angeles, California. She has been involved in numerous studies and continues to devote her career to studying sexual health. I hope you’ll join me next week when we talk with Dr. Nicole Prause.
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.
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