Challenges in the Field of Compulsive Sexual Behavior (2004)
By Bill Herring, LCSW
(This is an article originally published in "Sexual Addiction & Compulsivity: The Journal of Treatment and Prevention", Volume 11, Numbers 1-2, January-June 2004, pages 35-42). It presents an analysis of key variables in the developmental growth of the field of sex addiction treatment. After 15 years in print the ideas and language are a bit dated in places but I basically stand by what I wrote. -- Bill, 2019)
It is a great honor to be invited to share my thoughts on the direction of our field. As chair of the NCSAC conference committee for the last several years I have been blessed with a unique opportunity to help guide the growth of our profession. I'm also especially proud to have served as guest editor of this journal when it published the first collection of articles dedicated to the crucial relationship between compulsive sexual behavior and HIV (Volume 8, No. 2). I was a witness to the historic "DSM conference" in Nashville in 2001 that brought so many leaders of various fields together to lay the groundwork for an organized effort to attain inclusion in Diagnostic and Statistical Manual of Mental Disorders. Now, as I step off of the NCSAC board of directors, I relish this opportunity to share the perspective I have gained through these experiences.
We are now 20 years along the road to understanding why some people persistently lose sexual self-control even in the face of adverse consequences. (Throughout this article I will use a wide variety of terms to describe this syndrome in order to highlight the variety of ways in which it can be described and to avoid privileging one theoretical perspective over another.) Along with self-help movements, this field of study has brought life-changing benefits to untold thousands of people, and yet its importance remains effectively lost to the larger culture. Millions of people who are unable to shepherd their sexual impulses are blind to how our knowledge base is relevant to their lives. Because obsessive sexual objectification contributes to so many individual and social dilemmas of our times, we must not settle for anything less than the integration of this topic into the fundamental cultural perspective of contemporary society. In order to insure that this occurs to any meaningful degree over the next 20 years, we must keep some important conceptual and organizational challenges in front of us.
America demonstrates a powerful reluctance to recognize the concept of unrestrained desire, even as it consumes rather than nurtures, divides rather than integrates, and isolates rather than connects. Our rapacious cultural environment is not conducive to reasoned discussion about the concept of compulsive sexual behavior. Adding to this dilemma is the fact that a wide range of individuals, organizations, ideas and values converge around the issue of sex addiction. A robust philosophical foundation for integrating such a rich diversity of viewpoints is necessary if this field of study hopes to be representational of, and therefore relevant to, the larger culture. For all the good work we have done, we have yet to create a sufficient venue for the different perspectives described in this article to interact meaningfully with each other.
More expertise on this complex form of human sexual behavior exists than ever before, including this professional journal which has now been in publication for over a decade. NCSAC, as the primary organizational structure supporting this field of study, is consistently expanding membership and conference attendance. Inquiries continue to increase from the media, from other organizations, and especially from people seeking help for themselves or those they know. If such growth proceeds over the next 20 years then this field will stay very busy indeed.
Yet this journal escapes the notice of too many libraries and index services. Only a few folks representing public health, sexual offender treatment and the clergy attend our conferences. Because of a lack of endowments and grants, NCSAC's revenue barely covers its operating expenses. The ubiquitous sexual shame of our culture prevents people from supporting this field to an extent that is sufficient to either its need or their interest. Integrated assessment, referral and treatment services for this sexual disorder are scarce, and education and prevention efforts are almost nonexistent. From this perspective, continued incremental growth over the next 20 years will insure that this topic will primarily remain the interest of those who suffer from it and their network of care providers. This is not good enough.
The point bears repeating that our field of study interests or impacts a great many different kinds of individuals, ideas and values, for a variety of reasons and whether they know it or not. Only a few of the following groups are adequately represented in our membership and conferences:
- the mental health fields,
- addiction medicine,
- the sex therapy and sex education communities,
- medical and public health providers,
- sexual offender and victim specialists,
- morality-based groups,
- gay rights activists,
- the business community,
- the sex industry and
- the people who personally experience compulsive sexual behavior.
Each group represents one aspect of the destruction that is caused by the difficulty some people experience regulating their sexual impulses in spite of negative consequences. Each brings to the topic unique expertise, concerns and prejudices. The challenge of this field is to develop much stronger relationships with each of these groups.
It may take another 20 years to get these disparate groups to mutually examine their overlapping interest in the topic of compulsive sexual behavior. Our efforts will begin to bear fruit once the respective journals of each field regularly publish articles on topics related to unrestrained sexuality, especially as literature from one field references another, which almost never happens now. It will also be a good sign when the organizations that represent these groups participate in conferences and other mutual efforts to develop this topic. Only a few of these groups currently demonstrate even the slightest degree of such collaboration with each other. NCSAC board members, advisors and editorial reviewers must begin to include members from each of these groups instead of being comprised almost exclusively of behavioral healthcare providers. These and other similar gains will not only advance the effectiveness of this field but will also promote a sexually healthier culture as all of these professions incorporate a deeper understanding of these concepts in their work.
The tremendous differences between these groups make the ability to simply gather in the same room a formidable developmental task. After all, for some people the goal of sex is procreation, while for others it is a crucible for personal and relational growth or simply an opportunity for a good romp. Pleasures to one are perversions to another. Within NCSAC are people who use religion to support responsible sexual behavior and their colleagues who recoil against the sexual damage caused by the church. There are those who privilege heterosexual marriage and others who champion the morally equivalent right for same-sex couples. Sobriety in one person's approach to compulsive sexual behavior is anorexia to another. Abstinence and harm reduction models feed from different springs. Many people in the field embrace 12-step concepts but the percentage that does not is likely to grow. Which of these different groups doesn't deserve representation within this organization?
Such contrasting values are by no means insurmountable obstacles to the growth of our field, since the only cohesion among these groups that is necessary is a shared interest in the topic of obsessive hypersexual desire. Like the DNA shared by all mammals, any differences between these groups are fundamentally minor. Regardless of any divergent opinions among these groups, nobody argues against reducing child sexual exploitation, unwanted pregnancies, sexual violence, and sexually transmitted diseases. Few speak against habilitative treatment for sex offenders, tolerance for a wide range of sexual expression and a respectful and competent cultural language to discuss these matters. No other criterion for contributing to the field is either necessary or particularly useful.
It is not enough to passively tolerate an increasing diversity of opinion. In order to prevent the development of a narrow theoretical dogma that resists the incorporation of new ideas we must continually and actively invite the full range of issues and interests that relate to this complex topic. Strong conformity of opinion among like-minded adherents of a well-established orthodoxy is an almost inevitable development in the absence of exposure to theories that may initially seem unconventional or counterintuitive. The growth that ultimately matters most requires controversy, and that requires a great deal more diversity than we are accustomed to. By conscientiously involving every group that has a legitimate stake in the topic, we hold the door open to fresh ideas regarding the epidemiological knowledge, etiological understanding and cultural contexts of this complex and challenging sexual desire disorder.
The very fact that a few of the following groups have begun to gather together, however tentatively, in a common mission is an auspicious development and stands as testament to all the good work that has come before. The next 20 years will probably be just enough of a duration to determine if the following aggregation of interests will be able to join together sufficiently to advance the prospect of a sane, safe and sacred sexuality into a wider world.
For all practical purposes this field was born and raised by the behavioral healthcare community, especially the branch that strongly ascribes to 12-step concepts of addiction and recovery. This community contributes a vast knowledge and opinion base about addictions and afflictions and what to do about them, but the concept of out-of-control sexual behavior is too complex a form of human behavior to exist within the province of any one paradigm. Other behavioral health fields have vital expertise to offer. Among other pathological process addictions, for example, the field of compulsive gambling has many lessons to offer from its diagnostically privileged vantage point. The DSM project has the potential to bring together many theoretical schools that have important contributions to make to the contextual richness of this field, although little information about progress in this area has entered the professional literature lately.
The field of addiction medicine is a distinct domain of expertise that is relevant to the further development of our field. This is the profession that can provide much-needed neurological understanding about the addictive process. The rigorous research standards of the addictionology field can greatly legitimize the concept of sexually addictive behavior to the wider medical and scientific community. Addictionologists, however, have not generally wanted to align themselves with the sexual addiction movement due to concern that this would diminish their standing within the medical field. Because of this, addiction medicine will require the presence of many more controlled studies than have so far taken place in order to devote more attention to this topic.
The field of sex therapy is the obvious "go-to" group on any matter of sexuality. Since this community has a history of privileging a robust rather than a restricted sex drive, the active involvement of sexologists is especially essential to the on-going creation of concepts of sexual compulsivity. Otherwise elements within our field may develop a subtle bias against sexual deviance or even the very concept of sexual desire. Similarly, the related category of sex education is an invaluable profession for incorporating effective teaching models into the field of compulsive sexual behavior. Neither sex addicts nor their traditional resources have as yet shown much competence in the concept of "promotion rather than attraction".
The medical community as a whole does not begin to sufficiently appreciate the relevance of compulsive sexual behavior, even though it deals directly with many of its most obvious medical consequences, such as the transmission of HIV and STDs. Two developments will be necessary to increase the rate of medical referrals, which are currently negligible. One is greater legitimization of this disorder through enhanced scientific rigor, integration with the field of addictionology and achievement of DSM inclusion. The second is the codification of diagnostic and referral protocols that will allow medical practitioners to quickly and effectively screen for this disorder in their assessment process.
The public health field has a great deal to both teach and learn about the risks of hypersexual behavior. Mental health and public health approaches to this sexual syndrome differ in their fundamental goals, concepts, and methodologies. It's not much of a simplification to say that mental health primarily attempts to fix a broken individual, while public health focuses on the needs of a population. Each field complements the other. The public health field has access to many researchers, grant sources and treatment populations that are generally outside the purview of mental health models. For these reasons an unequivocal commitment to furthering both models with equal fervor is necessary.
Professionals and concepts from the field of sexual offender treatment are obviously vital to the issue of compulsive sexual behavior. A criminal justice perspective helps to guard against the possibility that some individuals may attempt to use this disorder to diminish responsibility for their illegal behavior. This community of experts is probably the group currently most sympathetic to NCSAC's mission, due to the significant overlap between the two categories. However, many people in the sexual offender field are not supportive of the sex addiction model. Since an emphasis on personal responsibility is central to both sexual offender and sexual addiction treatment models, each field should continue to incorporate the insights of the other in working with those who sexually exploit others.
The sexual abuse survivor community also has a crucial interest in influencing the further development of this field. Since childhood sexualized trauma and adult sexualized compulsivity are so connected, the participation of people who have been damaged by the sexual desire of others is central to the growth of this concept and organization. This community brings recognition that real people suffer from unrestrained libidinous influences. The heroic and honest voice of the victim-survivor deserves a greater role in the continued growth of this field.
Religious and other morality-based communities also have a strong vested interest in the development of theories of unrestrained sexual desire. Continuing revelations of child sexual abuse within the clergy provide ample evidence of the relevance of this topic to the religious community. Equally important as this crisis of clerical leadership is the growing appreciation across the full religious spectrum of the need to address sexually healthy faith communities by recognizing sexuality as central to humanity and integral to spirituality. This emerging self-reflective clarity within the religious community is more receptive than ever to integrating understanding about compulsive sexual behavior into congregational ministry.
The gay rights movement has a profound interest in the development of concepts that attempt to set forth guidelines of normative sexuality. The strong gay-positive sensibility that exists at this organization's core is a cause for celebration. In many ways, gay members of this field have taken the most personal risks of any group, by challenging many of the prevailing norms about sexuality within gay culture. A politicized movement that emphasizes sexual empowerment does not easily embrace members who attempt to define the boundaries of sexual freedom. The active participation of gay rights activists is crucial to help insure that concepts that emerge from this field of study do not unduly pathologize cultural practices.
The business community is slowly acknowledging a relationship with the concept of out-of-control sexual behavior. So far the primary occupations to take notice of this disorder are the various providers of behavioral healthcare services who profit from it. This is further evidence for the need for a widened conceptual framework in order to gain the interest of businesses associated with other fields. The human resources and employee assistance fields are useful in facilitating the integration of sexual compulsivity into the language of workforce productivity. Increased quantification of the economic cost that this disorder imposes on the business community and the continued cultural legitimization of these concepts will help tip the balance sheet toward more informed corporate support.
People who self-identify as sex addicts are a virtually untapped resource for expanding societal acceptance of the concepts that are central to this field. It remains rare for a person to reveal the history of his or her compulsive sexual behavior to the world at large. Consequently, it is hard for those who have not personally experienced the pernicious destruction of unabated sexual appetite to appreciate the human dimension to a topic rife with misperception. Such shame-based silence is difficult to overcome. One by one, as people with a personal history with this topic talk openly about their experiences with members of each of these groups, the misunderstanding that permeates this subject will slowly dissipate.
It is philosophically inescapable that there is a need to integrate the sex industry into these discussions. Those who make a living off our country's sexual appetite have not only a right but also a mandate to assist in the functioning of organizations that support work on this subject. Alcohol and gambling industries willingly contribute to the organizations that support treatment and prevention of irresponsible usage. For this field to not accept assistance from the pornography or professional sex industry, or even to engage in dialogue about the matter serves to reinforce the presence of sexual shame by making sex the enemy rather than its poor usage.
Over time, groups other than the ones described here will be able to both contribute to and benefit from the maturation of this field of study. The field of reproductive health, for example, will provide invaluable assistance in integrating this concept further into existing theories of sexual human rights. The developmental process described in this article is a necessary precondition for this type of widened conceptual linkage to occur.
The number of distinct groups that share a relationship with the concept of compulsive sexual behavior reflects the relevance of this topic to many of the crucial issues of contemporary culture. We must actively seek to include the many intelligent and influential members of these groups in order to expand the range of available dialogues about this topic. Few issues have such potential to invoke the passions and talents of so many diverse caretakers and guardians of the mind, body and soul of society. If there is any other topic that radiates through the entire spectrum of care from mental, physical, and public health providers to legal, spiritual, and cultural experts, advisers and activists, it is HIV. The fact that both involve the culturally taboo topic of poorly managed sexuality reflects the imperative need to carry forward these efforts.
There are enough dimensions of this complex form of human sexual behavior for all of these groups to learn and contribute different lessons as they work with each other. The involvement of these counterbalancing interests will help keep the excesses of any dominant group in check. Groups that successfully integrate the concepts of this field will only gain a deeper understanding of their own missions. The improved sexual culture of overall society that results from such concerted efforts will benefit each group in the same way that boats rise with the tide. Integrating concepts of these groups will not dilute the mission but rather deepen the character of this field.
Developing enough theories, methodologies and resources to accurately assess, appropriately treat and meaningfully prevent compulsive sexual behavior is a Herculean undertaking that requires a deeply nuanced understanding of many dynamic social, psychological and biological forces. All of the individuals and organizations that experience the consequences of unrestrainable sexual desire deserve to participate in the conceptual development of this topic. Such increased collaboration is a necessary precondition for achieving a sufficiently comprehensive appreciation of this challenging field of study. This in turn will enhance the relevance of this topic to many more people than currently benefit from it. These efforts are therefore both philosophically principled and deeply pragmatic and need the assistance of every person dedicated to the advancement of this field. We've only just begun the work that must be done.
