Article: "A Framework for Categorizing Chronically Problematic Sexual Behavior"

(Note, this article was awarded "Article of the Year" by the publishing company Taylor and Francis, and its ideas serve as the foundational training for the Advanced Topics in Problematic Sexual Behavior (ATPSB) certificate program for healthcare professionals offered by the Society for the Advancement of Sexual Health.)

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Abstract: This article introduces a framework for categorizing chronically problematic sexual behavior.  It identifies patterns of commitment violations, values conflicts, diminished self-control, negative consequences and lack of sexual responsibility as independent categories of chronically problematic sexual behavior.  It recognizes that problematic sexual behavior can be reduced or eliminated by changing either sexual or nonsexual components of a person’s life.  This framework does not use the type or frequency of sexual behavior as an assessment variable.  It neither postulates causes of problematic sexual behavior nor offers techniques for its reduction or elimination.  This framework does not replace any existing theories or assistance models.  Since it is capable of supporting theories representing many different perspectives, it expands the potential for interdisciplinary collaboration to widen the range of options available to more people who want to reduce or eliminate chronically problematic aspects of their sexual behavior.

The gradually increasing use of the phrase “problematic sexual behavior” over the last few years reflects an effort among professionals in various sexuality fields to describe negatively experienced chronic sexual behavior patterns in a way that transcends specific theoretical orientations or treatment methodologies.  However, the phrase “problematic sexual behavior” remains poorly defined and often has seemed to serve essentially as a substitute for “sex addiction”, with little clear distinction beyond that mere stylistic gesture.  This article attempts to correct this lack of clarity by presenting a theory-neutral framework that establishes independent categories of chronically problematic sexual behavior.

This framework does not assess any specific types or frequencies of sexual practices as inherently problematic.  Instead, sexual behavior patterns are considered problematic when they are associated with one or more of the following five categories: ongoing commitment violations, values conflicts, diminished control, negative consequences and violations of sexual responsibility, all of which will be explained below.   These five categories constitute a combination of subjective, objective and principled perspectives that combine to yield a practical understanding of various subtypes of what can be collectively considered problematic sexual behavior.

This framework does not serve to replace any existing models for helping people address chronic sexual behavior difficulties.  Instead it is a way to situate such models within a broader understanding of the constituent elements that combine in various ways to comprise the full range of problematic sexual behavior patterns.  The ability to separately evaluate independent categories of problematic sexual behavior facilitates the development of increasingly specific subtypes of problematic sexual behavior that are outside the parameters of current assistance models. 

As an example, most existing methodologies for addressing problematic sexual behavior require the presence of diminished self-control.  This criterion excludes those who may engage in similar behaviors and experience equally severe negative consequences without this characteristic.  This means that many people who engage in various manifestations of chronically problematic sexual behavior remain outside the scope of most assistance models.  To address this service delivery gap, this framework provides a foundation for developing models to help such people without requiring diagnoses, labels or even the establishment of individual pathology.   Since it provides a conceptual foundation for the creation of assistance protocols for sexual behavior patterns that are problematic but not necessarily pathological, a diagnostic label indicative of individual pathology is not a necessary condition to access formalized professional help in reducing, controlling or eliminating some problematic form of sexual behavior.

This Framework Includes Five Categories of Problematic Sexual Behavior

As stated, this framework does not use the type or frequency of consensual sexual behavior to indicate problematic sexual behavior since this risks pathologizing people for whom that behavior has normative or adaptive meaning, function and outcome. Instead, this framework describes sexual behavior as problematic if it consistently:

• conflicts with a person’s commitments and/or
• conflicts with a person’s values and/or
• conflicts with a person’s self-control and/or
• results in negative consequences and/or
• lacks fundamental protective responsibility

These five categories each yield a question to consider when assessing for any problematic components of a person’s ongoing sexual behavior:

• Commitments -- are you keeping your promises?
• Values -- are you ok with what you are doing?
• Control -- are you in control of yourself?
• Consequences – is everything ok?
• Responsibility – are you protecting others?

Several of these categories of problematic sexual behavior can be reduced or eliminated by changing either sexual or nonsexual aspects of a person’s life.  Here is more detail about the five categories of problematic sexual behavior.

1. Commitment conflicts

Problematic sexual behavior includes recurrent sexual behavior that significantly conflicts with a person’s sexual or nonsexual commitments.  When sexual behavior consistently conflicts with a person’s important commitments that sexual behavior is inherently problematic.  Such conflict can be reduced or eliminated by altering either the sexual behavior and/or the commitment.

While common commitment conflicts related to problematic sexual behavior involve occupational, legal, social or other obligations, a particularly devastating commitment violation involves sexual behavior that occurs without the knowledge or consent of a primary relationship partner. The problematic aspect of this category is therefore not the type or frequency of the actual sexual behavior but rather the secrecy and deception that surrounds it, often driven by some combination of shame, fear and/or the desire to continue the behavior.

2. Values conflicts

Problematic sexual behavior includes recurrent sexual behavior that significantly conflicts with a person’s core values.  When sexual behavior consistently conflicts with a person’s deeply held values that sexual behavior is inherently problematic.  People can reduce or eliminate this conflict by modifying either their sexual behavior and/or their personal value system.   

It’s not news that people tend to have lots of competing values.  Often these opposing values do not cause direct conflict while at other times they represent a moral crisis.  Some values are professed and others and assumed.  Some values are lifelong convictions and some change over time.  Some values don’t require much effort to maintain while others present many challenges to a person’s commitment.  

A common way people manage competing values is by avoiding situations that are likely to bring them into direct conflict.  Sometimes this avoidance is accomplished through reduced self-awareness, such as can occur when a person tries to separate sexual behavior from the painful knowledge of how it conflicts with important values such as honesty, trustworthiness and fidelity.  

Another type of values conflict is increasingly being reported by people who engage in extensive viewing of internet pornography and subsequently develop unintended changes in what they experience as sexually arousing.  These changes are problematic when they significantly conflict with a core component of a person’s values, identity or normative assumptions. 

3. Self-control conflicts

Problematic sexual behavior includes recurrent sexual behavior that significantly conflicts with a person’s self-control.   When sexual behavior consistently conflicts with the capacity to exercise sufficient control over one’s choices, that sexual behavior is inherently problematic.

This is the form of problematic sexual behavior that has generated the most models and theories.  It is the basis for models like sex addiction, compulsive sexual behavior, hypersexuality and out-of-control sexual behavior.

4. Negative consequences

This category addresses the reality that sexual behavior may not conflict with a person’s commitments, values or self-control and yet still result in negative consequences.  By any definition a prostitution arrest is a problematic outcome even if it is freely chosen and not incongruent with a person’s values.  The same goes for a person who views internet pornography in a manner that results in unintended erectile dysfunction during partnered sex.  When sexual behavior consistently results in negative consequences that sexual behavior is inherently problematic.

5. Lack of sexual responsibility

This category addresses the reality that sexual behavior patterns may not conflict with a person’s commitments, values or self-control or result in personal negative consequences and yet still be considered problematic due to violation of established principles of sexual health related to responsible sexual behavior.   Problematic sexual behavior includes recurrent sexual behavior that significantly conflicts with the following universal sexual health guidelines:

1. Everybody consents.

2. Everybody is protected.

3. Nobody is exploited.

^” When sexual behavior consistently conflicts with any of these universal principles of sexual responsibility, that sexual behavior is inherently problematic.  By this measure many more people experience consistently problematic aspects of their sexual behavior than are currently receiving benefit from existing assistance models.

This Framework Does Not Postulate Causes of Problematic Sexual Behavior

In addition to not evaluating the type or frequency of sexual behavior, this framework does not postulate any causes of problematic sexual behavior, nor does it offer any techniques for its reduction or elimination.  That’s the function of models and theories, which are described below.  This framework acknowledges that problematic sexual behavior can result from many circumstances:    

• It could represent a form of addiction. 
• It could be a manifestation of a concurrent mental illness (such as a bipolar disorder or narcissistic personality disorder).
• It could be related to other medical conditions (such as hypersexual behavior resulting from Parkinson’s medication).
• It could reflect a person’s core nature (such as a closeted homosexual or bisexual person engaging in same-sex behavior). 
• It could represent a trauma re-enactment.
• It could be a fetish that is troublesome to a person.
• It could represent a relative deficit in a person’s moral code (“it’s ok if nobody knows”).
• It could represent a relative deficit in a person’s reflective and predictive ability (“I never really thought about the consequences”).
• It could represent an undue cultural influence on sexual behavior choices (“Real men need lots of sex”).

These or other factors can contribute to any of the five categories of problematic sexual behavior.  This framework creates the conditions to address each of these possibilities, thus increasing the number of people who are eligible for receiving formalized assistance for the problematic aspects of their sexual behavior.

A Conceptual Framework Differs from a Model or Theory

It is important to understand that this framework for conceptualizing problematic sexual behavior differs from a model or theory.  A conceptual framework refers to a set of concepts and relationships that are proposed as the basis for understanding something being considered.  A framework is the essential perspective for considering an issue. It provides the foundational assumptions that are necessary for the creation of models, which are attempts to describe how the key concepts of the framework are potentially interrelated.   

Models, in turn, are the basis for formulating and testing theories, which are predictions about the best way to manage the relationships between the framework’s key concepts. Theories, in turn, are used to develop methods for achieving these preferred relationships.  Finally, sets of methods form methodologies for achieving desired goals in a manner that is consistent with the theories, models and foundational assumptions supported by the framework.

Differences in frameworks typically lead to differences in assessment, goals, strategies and outcomes.  There will always be ways to understand populations and outcomes beyond the contours of any one theory or model.  When there are few choices there are more ways to fail.  If a healthcare professional utilizes methodologies derived from only one model then anyone not experiencing sufficient benefit is either not doing it right or the model is not an ideal fit.  This framework is therefore useful in supporting the development of expanded models to help more people. By providing an opportunity to develop many different models and theories it will be possible to help a larger number of people than currently are eligible to receive services under models that require the presence of diminished control.

Summary

To review, this framework establishes commitment violations, values conflicts, diminished self-control, negative consequences and inadequate sexual responsibility as independent and equally sufficient determinants of problematic sexual behavior.  

This framework does not consider the frequency or type of sexual behavior.  It postulates no causes nor suggests any solutions for the many various forms of problematic sexual behavior.  It recognizes that problematic sexual behavior can often be reduced or eliminated by changes in either the sexual or nonsexual components of a person’s life.  As a theory-neutral framework it can be utilized to support models and methodologies representing many different perspectives.

This framework does not intend to replace or compete with any current assistance models for helping people reduce or eliminate chronically problematic aspects of their sexual behavior.  Instead it provides a foundation for extending assistance to a wider range of problematic sexual behaviors by increasing options for interdisciplinary and trans-theoretical collaboration and creating a basis for developing assistance model that do not necessitate diminished self-control or even the concept of individual pathology.  This will help more people who want to reduce or eliminate one or more problematic aspects of their sexual behavior

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Note that as of May 20, 2023 I have just publishesd a nore extended summary review of the PSB Framework.

Bill Herring LCSW, CSAT is an Atlanta-based psychotherapist.  In addition to his general private practice he is a noted expert in the field of problematic sexual behavior.