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Home , Anonymous sex, Cybersex, Hypersexuality, Paraphilia, Partialism, Sexual addiction

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 • Sexual compulsivity • Problematic sexual behavior • Out of control sexual behavior • Hypersexual disorder • Control Disorder (Barth and Kinder) • Interactive Addiction Disorder (Carnes) • Paraphilic Disorder

• 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 , , 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

• • • Sexual Behavior With Consenting Adults • • 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, , 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 , , Sadism, , ) COMMON

• 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 ) • Fetishism and/or - (attraction to non living objects or obsession with nongenital body parts) AREAS OF CONSIDERATION FOR

• 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 ? What types of questions would you need to ask to clarify the diagnosis? • A client is caught in 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 about • watch bestiality pornography • Telephone Scatologia often comorbid with Voyeurism and Exhibitionism • 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, , exhibitionism, voyeurism, , 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 • Obsessive Compulsive Disorder • • Personality Disorders • Other Specified • 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 • history is common in this population, either clients are co-occurring or switched. • 40-60% of sexual addicts report substance use disorders • 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) • 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

• 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 were shown. • SASUD show lower rates overall of sexual compulsivity OTHER COMORBIDITIES WITH SEX ADDICTION

• Anxiety disorders • Mood disorders • ADHD • OCD • Impulse Control Disorders • • 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 as well as being disorganized and unreliable. • Higher levels of extraversion and associated with and risky sex • Higher levels of 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/ 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 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 / Swingers clubs Bathhouses Use of or feces for Adult bookstores 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/ 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 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 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, . 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 . • 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 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 [email protected] 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 . 7(5) • Allnutt, S. H., Bradford, J. M. W., Greenberg, D. M., and Curry, S., "Co-Morbidity of Alcoholism and the Paraphilias," Journal of Forensic Sciences, JFSCA, Vol. 41, No.2, March 1996, pp. 234-239. (online) • Bancroft, J., Vukadinovic, Z., (2004). Sexual Addiction, Sexual Compulsivity, Sexual Impulsivity, or What? Toward a Theoretical . Journal of Sex Research 4(3). (Online) 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. Addiction 105(1), 100-108. (online). • Carnes, P., Murray, R., Charpentier, L., (2005). Bargains with Chaos: Sex Addicts and Addiction Interaction Disorder. Sexual Addiction and Compulsivity. 12. • Cooper, A., Griffin-Shelley, E., Delmonio, D., Mathy, R. (2001) Online Sexual Problems, Assessment and Predictive Variables. Sexual Addiction and Compulsivity. 8:267-285 (online) REFERENCES CONT • Garcia, F., Thibaut, F., (2010) Sexual . The American Journal of Drug and Alcohol Abuse. 36. online • Hartman, L., Ho, V., Arbour, S., Hambley, J.M., Lawson, P. (2012). Sexual Addiction and Substance Addiction: Comparing Sexual Addiction treatment Outcomes Among Clients with and Without Comorbid Substance Use Disorders. Sexual Addiction and Compulsivity: The Journal of Treatment and Prevention. 19:4, 284-309. • Holmes, W.C., Foa, E., Sammel M.D., (2005) Men’s Pathways to Risky Sexual Behavior: Role of Co- Occurring Childhood Sexual Abuse, Posttraumatic Disorder, and Depression Histories. Journal of Urban Health, Bulliten of the New York Academy of Medicine. 82(1). Online • Hook ,JP., Hook, JN., Davis D., Worthington, E., Penberthy, J.K., (2010). Measuring Sexual Addiction and Compulsivity, a Critical Review of the Instruments. Journal of Sex and Marital Therapy. 36. 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

• Kafka, M., Hennen. J., (1999). The Paraphilia-Related Disorders: An Empirical Investigation of Nonparaphilic Disorders in Outpatient Males. Journal of Sex and Marital Therapy. 25: 305-319. online

• Kafka, M., Hennen, J. (2002). A DSM-IV Axis I Comorbidity Study of Males (n = 120) With Paraphilias and Paraphilia-Related Disorders. Sexual Abuse: A Journal of Research and Treatment. 14(4).

• Levine, M., Dalrymple, K., Zimmerman, M., (2013). Which Facets of Mindfulness Predict the Presence of Substance Use Disorders in an Outpatient Psychiatric Sample? of Addictive Behaviors. Advance online publication. doi: 10.1037/a0034706 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. • Luoma, J.B., Kohlenberg, B.S.., Hayes, S., Fletcher, L. (2012). Slow and Steady Wins the Race: A Randomized Clinical Trial of Acceptance and Commitment Therapy Targeting Shame in Substance Use Disorders. Journal of Consulting and Clinical Psychology. 80(1) • Motoharu, T., Takihashi, S., Kitamura, M. (2009). Addictive Personality and Problematic Mobile Phone Use. CyberPsychology and Behavior. 12(X). Online • Parsons et al (2010). Explanations for the Origins of Sexual Compulsivity Among Gay and Bisexual Men. Archives of Sexual Behavior. http://rd.springer.com/article/10.1007/s10508-007-9218-8/fulltext.html • Reid, R., Carpenter, B.N. (2009). Exploring Relationships of in Hypersexual Patients Using the MMPI-2. Journal of Sex and Marital Therapy. 35(4). 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 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. 18:301-319. (online) • Skegg. S., Nada-Raja, S., Dickson, N., Paul, C., (2010). Perceived ‘‘Out of Control’’ Sexual Behavior in a Cohort of Young Adults from the Dunedin Multidisciplinary Health and Development Study. Archives of Sexual Behavior. 39:968-978. online. • Michael P. Twohig, Jesse M. Crosby, Acceptance and Commitment Therapy as a Treatment for Problematic Viewing, Behavior Therapy (2010), 10.1016/j.beth.2009.06.002 • Wetterneck, C.T., et al (2012). The Role of Sexual Compulsivity, Impulsivity and Experiential Avoidance in Internet Pornography Use. The Psychology Record. 62.