“Sex Addiction” & Sex Offending: A Growing and Dangerous Relationship

1. “Sex Addiction” & Sex Offending: A Growing and Dangerous Relationship Samantha Smithstein, Psy.D. Elizabeth Corsale, MA, MFT Pathways Institute for Impulse Control CCOSO, San Diego, May 2010 www.pathwaysinstitute.net

2. Overview • Historical Overview • Diagnostic Considerations • Sex Addiction and Sex Offending: the Interface • Case Examples • Treatment Needs: Sexually Compulsive versus Paraphilic & Antisocial Offenders • Case Examples Revisited/Discussion • Special Populations: Women, Juveniles, Partners, Cultural Differences • Questions/Discussion www.pathwaysinstitute.net

3. (Very) Brief History of Sex Offender Treatment • Until mid-1980s : civil commitment programs, prisons, and outpatient clinics scattered around the country. • Psychodynamic and client-centered • Relapse prevention adapted from Marlatt for alcoholics (Pithers, Marques, Gibat, & Marlatt, 1983). • Adopted nationally in 1984; still used today with few modifications (Laws, Hudson, & Ward, 2000) • Medication and Behavioral/aversion Therapy www.pathwaysinstitute.net

4. History of Sexual Addiction • The sexual act itself is not the problem. • The problem is when the behavior becomes unmanageable in an individuals life. • Loss of Control • Example: • A person who views legal pornography from time to time versus • A person who can’t have sex without pornography ever and it creates serious intimacy problems with their partner. • Think: social drinkers versus alcoholics. www.pathwaysinstitute.net

5. History of Sex Addiction, cont. • Nymphomania – morbid uncontrollable sexual desire. • Example: Scarlet Women or Floosies • Previously in the DMS • Satyriasis – abnormally intense sexual desire in men. • Example: Don Juan’s or Playboys • Both are in the ICD-10 www.pathwaysinstitute.net

6. History of Sex Addiction, cont. • 1905 Freud – 3 Essays on the Theory of Sex • Sex Drive • Sexual fantasy as emotional problem (neurosis) • 1948 Alfred Kinsey –The Kinsey Report • Survey of all kinds of sexual behaviors • 1960 -1970’s –Sexual Revolution • The Pill • Increase in Premarital Sex • Stonewall Riots • 1977 – Sex Addicts Anonymous Founded • 1979 – Sex and Love Addicts Anonymous Founded www.pathwaysinstitute.net

7. Sex Addiction History, cont. • 1980 – Patrick Carnes • Writes Don’t Call it Love • “The Cows Out of The Barn” (Internet) • Inpatient/outpatient sex addiction treatment programs • 1984 – Michel Foucault • Sex is not an automatic force (drive) • Sex is an intellectual construct • 1990’s Internet Revolution • 1990 – 2000 • Impulse Disorder • Obsessive Compulsive Disorder • Anxiety Disorder • 2010 – Hypersexuality www.pathwaysinstitute.net

8. Diagnosing “Sexual Addiction” • Sex addiction as Impulse Control Disorder • Inability to resist a drive, impulse or temptation to perform a harmful act to the person or others. • Feels an increase of tension and/or arousal prior • Experiences gratification, pleasure or relief at the time. • Often relief is short-lived; many feel guilt, shame or regret. • Compare to Kleptomania or Pathological Gambling www.pathwaysinstitute.net

9. Diagnosing “Sexual Addiction” continued • Sex addiction as Substance Dependence • Three (or more) of the following; 12-month period:  (1) Tolerance (2) Withdrawal (3) Larger amounts or over a longer period than intended  (4) Persistent desire or unsuccessful efforts to cut down or control www.pathwaysinstitute.net

10. Diagnosing “Sexual Addiction” continued • Substance Dependence, cont. (5) Time spent to obtain access, use, or recover   (6) Important activities given up or reduced (7) Continued despite knowledge of having problem likely to have been caused or exacerbated by it www.pathwaysinstitute.net

11. Diagnosing “Sexual Addiction” continued • DSM5: Sex addiction as Sexual Disorder (Hypersexual Disorder) • A.    At least six months, sexual fantasies, urges, and behavior plus 4 out of 5: (1)  Time consumed (2)   In response to dysphoric mood states. (3)   In response to stressful life events. (4)   Unsuccessful efforts to control or reduce. (5)   Disregarding risk for harm to self or others. www.pathwaysinstitute.net

12. Diagnosing “Sexual Addiction” cont. • Hypersexual Disorder, cont. • B.    Personal distress or impairment • C.  Not due to effect of an exogenous substance • Specify if: Masturbation, Pornography, Sexual Behavior With Consenting Adults, Cybersex, Telephone Sex, Strip Clubs, Other • Thoughts/concerns: Sexual Addiction as a “Sexual Disorder” versus impulse or addiction www.pathwaysinstitute.net

13. Sex Addiction & Sex Offending: The Interface • Pre-internet: Treatment programs traditionally designed to address deviance. • Individuals were forced to great lengths to offend. • Compelled by paraphilia • Or extremely antisocial • Sex addicts usually legal (affairs, casual sexual encounters, etc.); the most common illegal means being frequenting prostitutes. www.pathwaysinstitute.net

14. SA & SO Interface, cont. • Post-internet: Explosion of out of control & illegal sexual behavior • Increased tolerance/need for new stimulation leads to widening exploration • Illegal sexual activities increasingly available • Illusion of privacy • Lack of immediate consequence www.pathwaysinstitute.net

15. Police: Burglar uses church equipment to view porn • Second-degree burglary charges have been filed against an Ames man who broke into a church where he allegedly used the institution's electronic equipment to watch pornography. Police allege the 55-year-old man broke into the First Christian Church on Thursday. After gathering items from around the building, he is believed to have gone to the basement to spend the night. • Police summoned to the church Friday by staff, found the man trying to haul away a garbage can filled with food, kitchen utensils, clothes, electronic equipment and a 26-inch flat-screen television. • Police Cmdr. Mike Brennan said the man used the electronic equipment to watch pornographic movies that were found on him when he was arrested. • The man was being held at the Story County Jail in lieu of $10,000 bond. • Information from: The Tribune, www.amestrib.com www.pathwaysinstitute.net

16. SA & SO Interface, cont. • Idea others are doing it too • Many suffering from sexual addiction committing sexual offenses. • Many may not have otherwise www.pathwaysinstitute.net

17. Doctor caught in TV molest sting gets jail • A Piedmont doctor whose 2006 arrest in a police sting was filmed by a television network has been sentenced to two months in jail for attempted child molesting. • Maurice Wolin must register as a sex offender annually for life and will be on probation for three years, Judge Arthur Wick of Sonoma County Superior Court said at a hearing Wednesday. • Wolin, who was then 48, posed online as a 29-year-old man with the screen name "talldreamydoc" and chatted for several days with someone he thought was a 13-year-old girl. • He agreed to meet her in Petaluma for sex and was met instead by an 18-year-old actress from "Dateline NBC," whose cameras rolled as officers arrived, police said. • The sting had been set up by police and NBC, working with an organization called Perverted Justice, whose members pose as young girls and boys on the Internet. Officers arrested 29 people in the joint operation, most of whom pleaded guilty. • Wolin, a cancer researcher, told police he had been "just playing" and hadn't intended to have sex with the girl, according to a transcript provided by his lawyers. But Wolin pleaded no contest to a felony charge in December. • "We hope that the outcome of this case will serve as a deterrent to other Internet child sexual predators who will not know if they are speaking to a child or a police officer when they go online," said District Attorney Stephan Passalacqua. • http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2010/03/12/BAQH1CEBKR.DTL www.pathwaysinstitute.net

18. Examples • Child pornography (when does it become pedophilia?) • Soliciting minor over the internet • Seeking a safe place to be gay • Easy access to hiring prostitutes & escorts www.pathwaysinstitute.net

19. More Examples • Rape pornography (again, paraphilic or no?) • Underage sites with images captured off internet (taken by teens themselves) • Exhibitionism • Voyeurism • Fetishism www.pathwaysinstitute.net

20. Craigslist “Casual Encounters” Anyone have a nice lollipop for me to suck? - w4m - 22 Date: 2010-03-09, 10:38AM You_can have whatever you like. Feeling naughty, I need some Discipline. Get at me. Original URL: http://sfbay.craigslist.org/etc www.pathwaysinstitute.net

21. Transition: Sex Addict to Sex Offender • Escalation of material from legal and “normal” to illegal and “weird” – is it development of tolerance? • The thrill of the (illegal, illicit, forbidden) material rather than arousal to the actual material itself • Escalation of time – spending hours (8, 10, all night or all day), amassing huge collections • Sometimes sexual compulsivity AND Paraphilia combined www.pathwaysinstitute.net

22. Case Example 1: Andrew • exposed to rape pornography as a teen • masturbated to it (written material, some photos) almost daily • as young adult, discovered child pornography video • initially was horrified, then sought out written stories (finds it horrifying but forbidden, exciting) • 2X/month compelled to find videos, stops download, hates self, vows not to do it again • masturbates 1-2X per day www.pathwaysinstitute.net

23. Case Example 2: Paul • has viewed pornography compulsively since high school – magazines, to video, to DVD & online • after internet – gradually more extreme • “Max Hardcore” extreme porn • discovered websites with preteen self-made photos • began masturbating to naked photos of girls same age as wife was when she was molested as child • suffers from depression www.pathwaysinstitute.net

24. Case Example 3: Steve • was bullied as child, has speech impediment • has never been interested in S&M with girlfriends • whenever feeling sad, alone, rejected turns to internet • seeks out men who will tell him to do degrading things to himself • sometimes pays • sometimes has done this in more “public” forum online www.pathwaysinstitute.net

25. Treatment Issues: Similarities • Focus on relapse prevention • Triggers: affective states • Healthy lifestyle • Healthy intimacy • Cognitive distortions (about self control, relationships) www.pathwaysinstitute.net

26. Treatment Similarities, cont. • Healthy sexuality • Denial (of problem, of impact) • Secrets and shame • Affect tolerance/management • Prosocial thinking/lifestyle www.pathwaysinstitute.net

27. Treatment Similarities, cont. • Assessment: importance of accurate diagnosis around sexual problem • Attachment & relationship issues • Axis I diagnoses and medication • Axis II diagnoses www.pathwaysinstitute.net

28. Treatment Issues: Difference Sex Addicts Sex Offenders • Arousal to excitement, forbidden • May not ejaculate • Feels compelled, out of control • Denial: may or may not be paraphilic • Arousal to paraphilia • Usually ejaculates • Can be very planned & in control • Denial: about paraphilia www.pathwaysinstitute.net

29. Treatment Issues: Differences Sex Addict Sex Offender • Sexual behavior is compensatory • Self-refer • No hands-on victims; aversion to idea • Typically a “good citizen” • Harm reduction • Sexual behavior is about sex • Legal system refer • Hands-on victims • May be antisocial in multiple ways • Cessation www.pathwaysinstitute.net

30. Treatment Issues Sex Addict Sex Offender • Transference • Sexualization • Being “good” • Trust • Countertransference • Compassion to frustration • Confusion • Secondary trauma • Transference • Authority issues • Shame • Attachment issues • Countertransference • Compassion to revulsion • Secondary trauma www.pathwaysinstitute.net

31. Small Group Discussion: Case Examples Revisited • Is there a paraphilia? • Is there a “sex addiction”? • If there is a sex addiction, what model would you use to diagnose him? • What are the treatment issues? • What would the transference & countertransference might be? • What would your primary treatment approach be? • What are your long-term treatment goals? www.pathwaysinstitute.net

32. Special Populations: Women • Originally small or non-existent in sex offender treatment • Growing population • Some of that due to growing awareness/reporting (child molest/teen “affair”) • Some due to internet: lesbian dating, casual encounters www.pathwaysinstitute.net

33. Special Populations: Juveniles • Also originally small population in sex offender treatment • Growing population • Increase in sexual activity among teens • Increase in sexual promiscuity among teens www.pathwaysinstitute.net

34. Juveniles, cont. • Kids sexually active younger • Exposure to pornography on internet • “Sexting” (child pornography) • Alcohol and sexual activity • Teen girls have whole new venues to act out low self esteem (internet, cell phone) www.pathwaysinstitute.net

35. Special Populations: Partners • Partners become important part of treatment • Huge upheaval in relationship • Unhealthy relationship patterns (“Codependency”) • Re-learning healthy sexuality, communication skills • Trust, boundaries, and who is the “gatekeeper” of behavior www.pathwaysinstitute.net

36. Partners, cont. • Is the partner a sex addict also? • Sex as a power play in relationship • Getting partners into treatment: benefits and challenges www.pathwaysinstitute.net

37. Special Populations: Cultural Differences • To a degree, sex addiction and treatment are culture-bound • Talking about sex in general in different cultures • Distress and life interference are key • Distress and interference with relationship is consideration • Examples: gay male culture, prostitution, age of consent www.pathwaysinstitute.net

38. Questions/Discussion Pathways Institute for Impulse Control San Francisco, CA 415.267.6916 www.pathwaysinstitute.net pathwayshelp@gmail.com Samantha Smithstein, Psy.D. & Elizabeth Corsale, MA, MFT www.pathwaysinstitute.net