UNDERSTANDING THE BASICS OF PROBLEMATIC SEXUAL

UNDERSTANDING THE
BASICS OF PROBLEMATIC
SEXUAL BEHAVIOR
The Farley Center at Williamsburg Place, May 2016
Mary Deitch, JD, Psy.D
DISCLOSURES
• I have no financial interests to report.
• I was an employee of Keystone Center ECU
• I was a consultant for VSC
• I am on the Board of SASH and the President elect
• The content of this program, while just an overview, may be disturbing.
OBJECTIVES
• Clinicians will learn the basics around diagnostic issues surrounding problematic sexual
behaviors.
• Clinicians will understand the comorbidity between sexual behaviors, personality disorders, and
substance use disorders.
• Clinicians will learn how to assess for problematic sexual behaviors.
• Clinicians will understand how to treatment plan for these issues.
WHAT ARE WE TALKING ABOUT
• Sexual addiction
• Sexual compulsivity
• Problematic sexual behavior
• Out of control sexual behavior
• Hypersexual disorder
• Impulse Control Disorder (Barth and Kinder)
• Interactive Addiction Disorder (Carnes)
• Paraphilic Disorder
SEXUAL ADDICTION
• Behaviors are engaged in for longer periods of time than intended.
• An effort or desire to cut down or stop the behavior.
• Time is spent to engage in the activity or find a way to engage in the activity or recover from the
activity.
• Important social, occupational, or recreational activities are given up or reduced because of the
behavior.
• Continue to use the behavior despite knowledge of having a persistent physical or psychological
problem.
SEXUAL ADDICTION CONT.
• Recurrent use resulting in failure to fulfill obligations.
• Continued use despite problems.
• Tolerance: Defined by increased amounts of use of behavior or increase in risk.
• Maladaptive pattern of use leading to impairment or distress.
• Withdrawal: This area is least defined in sexual addiction but there is irritability when not able to
engage in the behavior. Frequently depression, anxiety, and physical symptoms are present.
• ASAM now includes sex as an addiction in their definition
SEXUAL COMPULSIVITY
• Behaviors are engaged in to reduce anxiety or internal states
• Behavior feels driven, there is a preoccupation with the fantasy or the behavior that is obsessive in
manner
• Quadland, Coleman
HYPERSEXUAL DISORDER
• Excessive time consumed by sexual fantasies, urges and planning on engaging in sexual
behaviors.
• Repetitive use of these behaviors in response to mood.
• Repetitive engagement in the behaviors in response to stressful life events.
• Attempts to control or reduce the behaviors.
• Disregard for the risk to self or others.
• Impairment in social, occupational or other functioning.
• Not due to other diagnosis.
HYPERSEXUAL DISORDER CONT
• Masturbation
• Pornography
• Sexual Behavior With Consenting Adults
• Cybersex
• Telephone Sex
• Strip Clubs
• Kafka, Reid
OUT OF CONTROL SEXUAL BEHAVIOR
• Not a diagnostic Term
• Characterized by significant problems regulated sexual behavior, thoughts or urges
• Causing negative consequences
• Significant amounts of distress, shame, worry, fear and losses
• The distress does not help regulate the sexual behaviors
• Hopelessness and helplessness
• Braun-Harvey
PARAPHILIC DISORDERS
• “Non-Normative” Sexual Behaviors
• Recurrent
• Intense
• Sexually arousing
• Fantasies, Urges OR Behaviors
• Must rise to the level of disruptive or create victims (victims included in Exhibitionism,
Voyeurism, Sadism, Pedophilia, Frotteurism)
COMMON PARAPHILIAS
• Pedophilia (attraction to non developed minors- do not have to act on the attraction. Only one
without remission specifier)
• Exhibitionism (sexual gratification at exposing oneself to an unsuspecting other- do not need to
agree with the diagnosis the behavior is enough for the diagnosis)
• Voyeurism (sexual gratification at seeing the sexual body parts or sexual activity of an
unsuspecting other- do not need to agree with the diagnosis the behavior is enough, only for 18+)
• Sexual Sadism (sexual gratification at the idea of harming others-if engaged with nonconsenting
other meets diagnosis)
COMMON PARAPHILIAS CONT.
• Sexual Masochism (sexual gratification at the idea of being harmed)
• Frotteurism (touching people for the purpose of sexual gratification while making it appear as an
accident)
• Bestiality (engaging in or being sexual aroused by sexual activity with animals) (versus zoophilia)
• Fetishism and/or Partialism- (attraction to non living objects or obsession with nongenital body
parts)
AREAS OF CONSIDERATION FOR
PARAPHILIA
• A client comes to treatment and amongst other behaviors discusses that he enjoys watching his wife have
sexual activity with another person and often fantasizes about this. What types of questions would you need
to ask?
• A client comes to treatment and amongst other behaviors discusses that he enjoys looking into the windows
of his neighbors homes and then masturbates to what he sees. What types of questions would you need to
ask?
• A client states that he has viewed child pornography? What types of questions would you need to ask to
clarify the diagnosis?
• A client is caught in internet chat with a minor. What types of questions would you need to ask to clarify the
diagnosis?
OTHER BEHAVIORS THAT ARE OF NOTE
• clients view web cameras of unsuspecting people for voyeuristic activity
• place cameras in locations where people will be changing or otherwise unclothed
• use web cameras to expose themselves
• watch nudist sites to view children
• watch barely legal pornography
• read erotica about incest
• watch bestiality pornography
• Telephone Scatologia often comorbid with Voyeurism and Exhibitionism
• Alcoholism thought to be highly comorbid with paraphilias generally, specifically sadism and fetishism
SUMMARY
• Sexual addiction is using a sexual behavior to cope despite the consequences. Sexual addiction can take
many forms from masturbation, pornography, affairs, prostitution, exhibitionism, voyeurism, anonymous sex,
and child pornography. Typically, using these behaviors despite it affecting interpersonal, occupational, or
other areas of life. Typically, using these behaviors to a greater degree than intended. Typically, have shame
after or use them despite not wanting to.
• All definitions agree that it is a pattern of behavior that continues despite negative consequences. Many
include to cope with distress or other internal states.
• Must be a pattern, not a short incident of “bad behavior”
• Not an excuse to diagnose, demanding they work
DIAGNOSIS (?)
• Paraphilic Disorder Specified/ Unspecified
• Other Disruptive, Impulse control and Conduct Disorder
• Obsessive Compulsive Disorder
• Bipolar Disorder
• Personality Disorders
• Other Specified Sexual Dysfunction
• Unspecified Sexual Dysfunction
SEX AND TREATMENT FACILITIES
• Why would clients use sex while in treatment?
• What are the red flags for treating providers?
• How would you handle this?
DRUGS AND SEX
• Substance abuse history is common in this population, either clients are co-occurring or switched.
• 40-60% of sexual addicts report substance use disorders
• Alcohol use to help numb before or after sexual behavior (high self monitors, other directed)
• Marijuana use was less common, on the upswing (highest age group 50-59 year olds of a
normative sample, this was also highest group to report “transactional” sex and alcohol use)
• Cocaine and the use of prostitutes
• Meth, “club drugs”, rohypnol and anonymous sex
• Poppers are still an issue
DRUGS AND SEX
• Sex addicts- 40-60% drug or alcohol addicted
• Drug or alcoholics- 10-30% sex addicted
• 12-18% of internet addicts are drug or alcohol addicted
• Those with Cannabis addiction- 4% are internet addicted
• Alcohol with Cannabis use has been related to risky sex
• Drug and Alcoholics high incidence of fearful or preoccupied attachment, needy and fear intimacy. Those
with insecure attachment use maladaptive methods to cope
• One study found that 7% of physicians in treatment for DA had boundary violations (most common was
alcohol and opiate use)
• 20-70% of Drug or Alcohol abuse/dep met criteria for Personality DO
DRUGS AND SEX
• Alcohol use in adolescents is a risk factor for internet addiction
• Of 8th-12th graders, 16% never used alcohol, drugs or sex
• 4% reported drug or alcohol use at recent sex activity
• 2% reported sex for drugs or money
• 1.5% reported heavy marijuana use and high frequency of sex
• Boys using high marijuana and sex were at an increased risk for depression
DRUGS AND SEX
• Sexual behavior during the use of drugs is common and quite frequently risky
• Higher incidence of sexual risky behavior while under the use of stimulants
• One study found that men in DA treatment stated that their drug use and sexual behaviors were
strongly intertwined
• Drug use increases the desire or preoccupation with sex
• Drug users have an expectation that drug use will enhance their sexual interactions and
performance
• Those in DA treatment without a component of reducing risky sexual behavior are more likely to
engage in substance abuse sexual activity, with casual partners and do not enjoy sex as much as
when sober
DRUGS AND SEX CONT
• Gay male math users (and MSM) are more likely to engage in high risk sexual practices at risk for
STI
• Popper use was strongly associated with HIV in MSM. 2x more likely contract HIV. Risk
increased with cocaine and meth. When use poppers and meth, 3x more likely
• Poppers and ecstasy have been related to internet sex seeking
DRUGS AND SEX CONT
• Sexually addicted only versus sexually addicted and drug or alcohol addicted clients, have not
been greatly studied.
• One study found that SA only clients reported having SA longer than SASUD clients. SASUD
clients reported more treatment history.
• When treated for both, improvements in quality of life and sexual impulsivity were shown.
• SASUD show lower rates overall of sexual compulsivity
OTHER COMORBIDITIES WITH SEX
ADDICTION
• Anxiety disorders
• Mood disorders
• ADHD
• OCD
• Impulse Control Disorders
• Social Anxiety
• PTSD
• Gambling
FOR YOU TO PONDER
• It you are uncomfortable with any topic, don’t do that work!
• Use preventative measures to guard against counselor burn out or PTSD,
• Participate in personal and professional development,
• Recognize and examine own biases,
• Recognize and examine own sexuality, what you have known (and done) will become an issue!
• Be mindful that your own sexual attitudes and beliefs are not being put on the client. Don’t work with
certain populations if you disagree with their version of healthy sexuality.
• Function as a member of an interdisciplinary team
• Have a working definition of sexual health
• Need to be curious! Ask questions!
ASSESSMENT
• SAST –sexhelp.com
• Hypersexual Disorder Questionnaire
• HBI-19 (hypersexual behavior inventory)
• Sexual behavior list
• Pornography consumption inventory
• ECR-R (preoccupied related to affairs, and have sex for affirmation)
• Attachment Style Questionairre
ASSESSMENT CONT
• Shame inventory
• Impulsivity scale
• Self-compassion scale
• Self-monitoring Scale
• MMPI-2
• AASI-3
• Polygraph
PERSONALITY FACTORS
• Lower levels of trust and empathy associated with infidelity as well as being disorganized and
unreliable.
• Higher levels of extraversion and neuroticism associated with promiscuity and risky sex
• Higher levels of psychopathy associated with unprotected sex and paying for sex
• Uncertain of MMPI-2 results as sex addiction is a heterogeneous group. Some evidence for
higher levels of Pd scale, Anxiety. However, can be useful in treatment planning
PERSONALITY FACTORS CONT
• Egocentrism linked to Internet Addiction
• More lonely types spend more time on the internet
• Less conscientious spend more time on the internet
• Higher Novelty seeking is associated with the internet as well as lower harm avoidance
• Impulsivity, Sensation seeking, Aggression, Hostility are correlated with high risk behavior
CLINICAL INTAKE
• Family history
• Substance abuse
• Disordered eating
• Gambling/ debting/ stealing (12-20% of Gambling addicts are Sexually addicted)
• Gaming
• Relationship history
CLINICAL INTAKE CONT
• Treatment history
• Medical history
• Legal history
• Religion/spirituality
• Recovery history
• General Internet use
• History of Violence
CLINICAL SEXUAL INTAKE
• Need to do a complete sexual history
• First time, last time, frequency over time
• Who, what, when, where, why, how
• For all sexual behaviors not just “problematic”
• Where did they learn about sex?
• What were their families attitudes about sex?
SEXUAL BEHAVIORS CONT
• What are their thoughts about sex/sexuality?
• What is their view on their sexual health and satisfaction?
• How often do they have sex with their current partner?
• At the end of the interview- is there anything I have not asked you that I should have? Is there
anything that you were worried I was going to ask you about?
• Consequences due to sexual behaviors
COMMON SEXUAL BEHAVIORS FOR CHECKLIST
Masturbation
Use of singles ads/singles cites
Masturbation in car
Cyber sex/webcams
Masturbation to the point of injury
Sex with patients/ clients/ parishioners
Sexual obsession/Fantasy
Sex with employers
Pornography in any form
Sex with employees/coworkers
Child Sexual Abuse images (child pornography)
Use of drugs with sex
Romantic Involvements
Use of drugs to obtain sex
Sex outside your primary relationship
Use of sex to obtain drugs
Paying for sex
Sex with animals
Strip Clubs
Group sex/ Swingers clubs
Bathhouses
Use of urination or feces for sexual arousal
Adult bookstores
Phone Sex
Sex in public places
Obscene calls
Anonymous Sex
Dangerous sex (asphyxiation, sadism, masochism)
One Night Stands
Sex with minor
Sex with family members
Exhibitionism
Voyeurism
Cross-dressing
MASTURBATION
• First time, how learned, frequency, thoughts about, last time
• What are the doing while masturbating? Mindful? Fantasizing? Viewing? With partner?
• Where are they?
• Have they ever masturbated to injury?
• Have they ever masturbated in their car? In Public? At work?
EXAMPLE OF QUESTIONS FOR
PORNOGRAPHY USE
• First time
• Last time
• Frequency (both how many times a day/week/month but how many hours)
• What do they view? Who are the people? Age, race, gender, ethnicity. Who are they in the
pornography? What are the people (or non-people as the case may be) doing?
• Where do they watch? (please remember phones and there is still paper).
• Who is around while they watch?
• How do they access it? (e.g. Search terms, pay for, different types of sites)
INTERCOURSE
• First time/Last Time/Frequency?
• Who with? Age, Race, Gender, Frequency (note to ask about sex outside orientation)? How long do they know the
person?
• Pay for? Paid to? “Barter”?
• Protected/unprotected?
• Where?
• Drugs and Alcohol?
• What do they do? What would they like to do?
• How do they find people? (some studies suggest that online sexual encounters are less likely to be protected and
men seeking sex on the internet have higher history of STI’s)).
CLINICAL INTAKE MUSTS
AKA IF YOU DO NOTHING ELSE, PLEASE…
1) Follow up in DA section about if they are engaging in sex/internet use
2) If client has meth, club drug and/or popper abuse must do thorough exam
3) Ask about first consensual/nonconsensual sex
4) Number of hours on the internet
5) Has anyone ever worried or complained about their sexual behavior
6) Have they concealed sexual behavior
TREATMENT PLANNING
• There is no one way to treat a sex addict!
• Presentations are wide and varied
• Its not just about stopping the behaviors
• Group versus Individual
• A few notes
•
•
•
•
•
•
•
Mindfulness
ACT
Trauma Informed Care
CBT/Relapse Prevention
Schema Informed Therapy
Co-Occurring Issues
Motivational Interviewing
TREATMENT PLANNING CONT
• Start with your history
• What are most risky issues right now? Legal, Medical, Substances, Sexually, Family
• What coping mechanisms do they have in place and how to build on that?
• What areas of accountability are needed?
• What are the mental health concerns that need to be addressed and monitored?
• What sexual education has to be done?
• What more “digging” needs to be done in sexual behaviors?
• What Personality Disorder Traits are there?
• What interpersonal skills need to be built?
TREATMENT PLANNING CONT
• What supports are needed (consider 12-step)
• What emotional intelligence work?
• What is the clients shame?
• What trauma/abuse history needs to be addressed?
• What are their sexual health goals?
• What empathy work needs to be done?
• What family/couples work needs to be done? Disclosure?
• What grieving work needs to occur?
• What areas do you need education?
WORKING WITH SPOUSES/PARTNERS
• Most clients had encouragement from loved ones to come to treatment.
• It is very important, yet very difficult, to establish rapport with spouses/partners, without going to far.
• The spouse will need help with education on the disease, recovery, relapse prevention. However you need to
ensure you maintain boundaries.
• Spouses often feel a level of trauma, mistrust, abuse and have resultant symptoms. Be mindful of labeling
them either traumatized or coaddicted/codependant.
• Except in very rare instances, there should be 3 clinicians involved with clear roles, boundaries and systems
in place.
• Boundaries, boundaries, boundaries, boundaries (yours, hers, his and theirs!)
DISCLOSURE
• Disclosure is very important but delicate, spouses/partners are getting informed consent.
• Not the 8th and 9th step, if clients try to avoid using this.
• Careful planning and work with the client is needed and many drafts might done.
• Do not rush this process as it will add more issues to the table! It might be tempting but take your time.
• Make sure the disclosure is to your best ability as the clinician a true and honest account. Watch your integrity.
• Make sure to plan for after the process and where will everyone go.
• Work with spouses therapist to ensure the most stability and support in place.
WORKING WITH PARENTS
• Crucial work! Very fine line between support, good parenting and smothering or sponsoring.
• First work with your client to gauge their perspective of what might be useful, beneficial,
supportive.
• Many clients don’t want to nor need to tell their parents about their trauma history or to express
how it was growing up in the household. Some may need to and have to be okay without
validation.
• Have to help the whole system look at the system dysfunction and where to go while honoring the
system’s fears and hurts due to our clients behaviors.
CONTACT INFO FOR
QUESTIONS
Mary Deitch, JD, Psy.D
Deitch Therapy and Consulting
www.deitchtherapyandconsulting.com
mary@deitchtherapyandconsulting.com
610-945-8021
1112 MacDade Blvd
Woodlyn PA 19094
REFERENCES/RESOURCES
• www.sash.net
• www.iitap.com
• Multiple Authors (2010). Findings from the National Survey of Sexual Health and Behavior
(NSSHB) Center for Sexual Health Promotion Indiana University. The Journal of Sexual
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• Allnutt, S. H., Bradford, J. M. W., Greenberg, D. M., and Curry, S., "Co-Morbidity of Alcoholism
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• Bancroft, J., Vukadinovic, Z., (2004). Sexual Addiction, Sexual Compulsivity, Sexual Impulsivity,
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REFERENCES CONT.
• Bowen S., Chawla, N., Marlatt, G.A. Mindfulness Based Relapse Prevention for Addictive Behaviors. (2011)
Guilford Press.
• Braun-Harvey, Douglas. (2010) Sexual Health in Recovery: A Professional Counselors Manual. Springer
Publishing
• Calsyn, DA., Critis-Christoph, P., Hatch-Maillett, MA., Doyle, S., Song, Y., Coyer, S., Pelta, S. (2010).
Reducing Sex under the Influence of Drugs and Alcohol for Patients in Substance Abuse Treatment.
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• Carnes, P., Murray, R., Charpentier, L., (2005). Bargains with Chaos: Sex Addicts and Addiction Interaction
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REFERENCES CONT
• Garcia, F., Thibaut, F., (2010) Sexual Addictions. The American Journal of Drug and Alcohol Abuse. 36.
online
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• Holmes, W.C., Foa, E., Sammel M.D., (2005) Men’s Pathways to Risky Sexual Behavior: Role of CoOccurring Childhood Sexual Abuse, Posttraumatic Stress Disorder, and Depression Histories. Journal of
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REFERENCES CONT.
• Kafka, M. (2009). The DSM Diagnostic Criteria for Paraphilia Not Otherwise Specified. Archives of Sexual
Behavior. Doi: 10.1007/s10508-009-9552-0
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• Kafka, M., Hennen, J. (2002). A DSM-IV Axis I Comorbidity Study of Males (n = 120) With Paraphilias and
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REFERENCES CONT.
• Liau, A., Millett, G., Marks, G., (2006). Meta-analytic Examination of Online Sex Seeking and Sexual Risk
Behavior Among Men who Have Sex with Men. Sexually Transmitted Diseases. 33(9): 576-584. Online.
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CyberPsychology and Behavior. 12(X). Online
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REFERENCES CONT.
• Reid, R., Cyders, M.A., Moghaddan, JF., Fong, T.W., (2014). Psychometric properties of the Barratt
Impulsiveness Scale in patients with gambling disorders, hypersexuality, and methamphetamine dependence.
Addictive Behaviors. 39(11).
• Schmitt, D.P. (2004). The Big Five Related to Risky Sexual Behaviour Across 10 World Regions: Differential
Personality Associations of Sexual Promiscuity and Relationship Infidelity. European Journal of Personality.
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• Michael P. Twohig, Jesse M. Crosby, Acceptance and Commitment Therapy as a Treatment for Problematic
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• Wetterneck, C.T., et al (2012). The Role of Sexual Compulsivity, Impulsivity and Experiential Avoidance in
Internet Pornography Use. The Psychology Record. 62.