A Useful Way Anyone Can Assess Problematic Sexual Behavior

May 2023 note: I've just created a short (11 minute) Powerpoint video that explains the key elements of my approach which may be useful if you are more of a visual learner.  Also I just published a more extended summary review of the "PSB Framework."\

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As I’ve noted elsewhere on this site I’ve been an Atlanta CSAT (Certified Sex Addiction Therapist (CSAT) for many years. This means that I am extensively trained in a specific form of assistance for people who have repeatedly failed in their efforts to stop engaging in sexual behavior that violates their commitments and values. This sex addiction model is a powerful tool for understanding and changing behavior and lives that has helped many people. 

However, impaired self-control (whether it's called 'sex addiction', 'compulsive sexual behavior' or 'out-of-control sexual behavor') is only one of many causes of repeated sexual deception and other chronically problematic sexual behavior patterns.  There are times when diminished control  is not necessarily the right, best or only explanation for a person's behavior. When I look back over the many professional articles I’ve written I can clearly see how I was working my way toward resolving a dilemma that had vexed and splintered the sexual health field for years. 

What something is called influences what we do about it, and this field of sexual healthcare gets hamstrung by language that is either imprecise or associated with specific theories that are not universally accepted.  What has been lacking is basic agreement about the essential characteristics that make any pattern of sexual behavior problematic that is both broad enough to apply to every human being and adaptable to each person's unique journey.  For years I felt like I was working to solve an important and elusive puzzle.

The result of all this deliberation was that in 2017 I published an article in the journal Sexual Addiction & Compulsivity titled “A Framework for Categorizing Chronically Problematic Sexual Behavior”. As the title suggests this brief article describes five separate categories of what can generically be termed “problematic sexual behavior”. These categories are: 

• Sexual behavior that conflicts with a person’s commitments. 
• Sexual behavior that conflicts with a person’s values. 
• Sexual behavior that conflicts with a person’s self-control. 
• Sexual behavior that consistently results in negative consequences.
• Sexual behavior that does not protect others from harm. 

These five categories yield five basic conversational questions to determine what exactly makes a sexual behavior pattern problematic for an individual. These five questions are: 

• Are you keeping your promises? (Commitment violations) 
• Are you ok with what you are doing? (Values conflicts) 
• Are you in control of your behavior? (Diminished self-control) 
• Is everything ok? (Negative consequences) 
• Are you protecting others? (Lack of responsible sexual behavior) 

This simple framework has many important qualities: 

• Since this framework is not tied to any specific theory it can be used by professionals who utilize different theories and work in different settings. It provides a common categorical language anyone can use and understand across theoretical and ideological perspectives.
• These questions can be universally applied across sexual, cultural, religious and moral identities, orientations and beliefs. Two people may engage in the same sexual behavior and answer completely differently to these five questions, making it very adaptable to many different populations.
• The framework avoids labels which tends to reduce defensiveness and improve a person's willingness for practical self-assessment.
• These five categories combine subjective, objective, and principled perspectives to yield a mylti-dimensional assessment for ready goal formulation.
• Combinations of categories can potentially reveal nuanced subtypes of what can be collectively considered problematic sexual behavior. 
• The framework distinguishes 'problematic' behavior from 'pathological' behavior.  It does not require a diagnosis to motivate behavior change and it recognizes that sexual problems don't always need sexual solutions. 
• It avoids the trap of focusing on the frequency or type of sexual behaviors since the diversity of human sexual expression is so vast that what's ok in one setting can be a problem in another. 
• This framework removes the requirement of diminished sexual self-control for a person to receive codified assistance. Under classic sex addiction models (also ‘sexual compulsion' and 'out-of-control sexual behavior' models) a person without loss of control is not eligible to receive the benefits of that knowledge base. This leads some people to either (a) continue painful life struggles involving thier sexual behavior patterns or (b) become mislabeled in order to engage the assistance model. This framework replaces the gatekeeping function of diminished sexual self-control with five independent and co-equal determinants of service access, thus bringing existing and emerging assistance models to a much wider population. 
• These categories are consistent with universal definitions of sexual health applicable to everyone.

This framework has proven very beneficial to the clients in my Atlanta counseling practice. It is the reason I can successfully run my many therapy groups that bring together people regardless of whether or not they self-identify as sex or porn addicts. This brings more people together in a common cause of working for the same sexual health goals and narrows the distance between addicts and non-addicts, which benefits everybody.

The overall reception of this framework for categorizing chronically problematic sexual behavior has been very positive. The journal in which it appeared awarded it Article of the Year.  This framework serves as the first module of the “Advanced Topics in Problematic Sexual Behavior” certificate training that is offered by the Society for the Advancement of Sexual Health (SASH) to mental health professionals. SASH even created a helpful poster of the five questions (see above) and bestowed me the honor of the 2019 Carnes Award “for his pioneering work in the treatment of problematic sexual behaviors".  I’ve published another article showing the utility of this framework in evaluating novel sexual behavior patterns and every day I find the approach valuable in my work with clients in my Atlanta counseling practice.

Still, the influence of this framework remains modest.  The journal in which it appeared is not widely circulated, so it will take some time for the potential benefits of this framework to roll out and make themselves evident, if they do.  I feel pretty confident it will continue to find useful applications and a widened audience since it's easy-to-understand, adaptable to a wide variety of settings, doesn't pathologize and is capable of both containing existing theories and assistance models and promoting the development of new ones.

I hope this brief overview of my approach to assessing the various categories of problematic sexual behavior has been helpful in providing a basic understanding of this innovative and useful framework.  Feel free to contact me if you'd like to discuss it further.

**Note (May 20, 2023): I just published a more extended summary review of the PSB Framework.**

(Print version available as attachment)