Month: September 2015

Porn Addiction Study and the DSM – 5 Debate over Whether to Include Hypersexuality.

Russell J Stambaugh PhD DST CSSP6 Comments
This blog has repeatedly commented on the problems of diagnosing ‘sex addiction’ and hypersexuality.  See “Arrival of the Death Star,” “Out of the Shadows,” “Umbra,” and “Ken Zucker, PhD and Michael First, MD’s DSM – 5 Plenary at AASECT” on this blog for additional discussion of this issue. To summarize those problems briefly:
  
       1)      Disagreement exists on how ‘too much sex’ might be recognized behaviorally, a      requirement needed for reliability,
       2)      The model postulating that ‘sex addiction’ might be similar to chemical addictions      might not be valid,
       3)      If the criteria for too much sex cannot be objectively operationalized, psychiatry might be discredit for making illnesses of ordinary behaviors, thereby loosing legitimacy and
       4)      If the diagnosis is intrinsically stigmatizing, the costs of labeling need to be proven to be offset by medical benefits of treatment that require that disadvantage, otherwise alternate means need to be used where the cost benefit is superior.
       5)      Additional obstacles to ‘sex addiction’ treatments include the legitimating of past addicts as paraprofessional therapists.  This biases such treatment by making acceptance of the label ‘addict’ a quantification to do treatment, and makes that acceptance an integral part of treatment for clients. 
       6)      While there can be little objection to self-labeling in chemical addictions where the behavior of taking drugs for recreational purposes is illegal, it is objectionable to advocate complete abstinence for otherwise healthy sexual behaviors,
       7)      This labeling problem becomes particularly problematic when social prejudices and religious attitudes contest with the scientific criteria for defining sexual behaviors that are in social dispute such as homosexuality, variant gender expression, BDSM and polyamory.

All of which might seem to be a damning case, but sex addiction practitioners have five crucial advantages which perpetuate use of their terms and ideology:

      1)      The public has already come to accept the term ‘sex addiction’.  Its wide use and recognition make it an effective marketing tool.
      2)      Because psychiatry has weak construct validity, sex addiction therapies that make clients feel better cannot easily be removed from the professional cant,
      3)      The biological mechanisms that underlie all perceptions of pleasure have neurological similarities, and it is quite difficult to conduct research that identifies whether these mechanisms are causes or effects.  The scientific jury is still largely out as to whether effective neurological agents might not be developed to treat excessive or unwanted sexual behavior, and their is big money at stake, and
      4)      The therapeutic techniques of ‘sex addiction’ therapies and less stigmatizing treatments overlap considerably.
      5)      Psychiatry, psychotherapy, and religious ideologists all have some vested interest in showing that they have explanatory power in understanding problems of sexual behavior above and beyond the client’ self-definition.  After all, if we do not know something special, why should anyone expect us to offer special relief for their discomforts.

J. Grubb et al from Case Western Reserve University recently showed that belief one had a porn addiction was more strongly associated with a variety of problem symptoms than the extent of actual porn use.  In a series of careful studies, Grubbs replicated his findings and used a design that allowed for imputing causality.  The end results; moralistic religious attitudes and belief that one is a porn addict cause more depression, anger and anxiety than the degree of porn actual use.  The adoption of the label does seem to cause the negative feelings.

This Grubb study was not bullet proof.  One might argue that the porn addiction attitudinal measure, Grubb used, the CUIC, is not the best measure of that condition, and that it not the best operationalization of the concept. It does have a high degree of face validity in assessing whether a respondent is troubled by their porn use. The subjects were self-selected to participate, with a high degree of porn use, and these conclusions might only be valid among relatively frequent porn users, and that people troubled by their porn use might be over represented in such a sample.  That would tend to justify conclusions about people coming into therapy with complaints, but not for the general population.  However, these arguments might all be true and the study’s conclusions still be valid.  Criticisms and all, the study has certainly shown that for some populations, the label is worse than the underlying behavior it attempts to describe in causing subjective distress.

Aside from the evaluation of what intellectual substance might underlie ‘porn addiction’ ideology, the study presented in this thread also elucidates a critical problem that led to the decision not to include hypersexuality in the DSM – 5.

If the frequency of sexual activity is unrelated to negative psychological symptoms, but the holding of an idea or a social label is, different raters will have a hard time agreeing on the threshold for a diagnoses more reliably than by simply asking the client’s opinion.  M.Foucault had no trouble recognizing the philosophical obstacles to professionalizing any conversation about sexuality in which the client is a more authoritative source of information than the professionals.  To be a persuasive demonstration of the superiority of professional opinion, the precision of a diagnosis needs to stem from special professional expertise.
 
Note also how similar this argument about the possible harm in the idea of ‘porn addiction’ is in structure to Moser’s and Kleinplatz’s arguments about paraphilia in the DSMs.  Since DSM – IV, we have operated under a two part diagnostic system.  Part 1 determines whether a behavior is weird: sadistic, masochistic, or centered on a child, or transvestic for example.  These are all pretty easy to code as different from hetero-normative sexuality and different from each other, thus meeting the reliability criteria well. But Moser and Klienplatz have argued that these behaviors don’t have a great deal in common beyond social stigma, and the concept that all paraphilias are somehow alike is culturally biased, not scientific.  Part 2 assesses either work and life disruption, or subjective dissatisfaction by the client.  It is this second part that is problematical in the view of Foucault cited above.  While some raters can be trained to objectify work or life disruption using criteria like divorce, legal trouble, job loss, etc., the degree of life dissatisfaction remains primarily within the domain of the client’s internal and subjective experience.
  
Thus the reliability for paraphilia as research criteria depends heavily on the culturally biased and stigmatized dimensions that can be coded consistently to overcome the ambiguity and subjectivity of client complaints.

As an advocate for better mental health treatment on this list, I have a duty to expose any psychotherapeutic practice that labels variant (non-heteronormative) behavior as pathological on its face.  That is pretty obvious in those that label homosexual, consensually non-monogamous, or consensual BDSM behaviors as pathological or addicted by definition.  But that is exactly what the DSM – IV and 5 systems do if they go beyond subjective client distress.

Given these findings by Grubb et al, suggesting that even where the client reports high subjective distress, the poison may well lie in the label and stigma, not the behavior.  I would suggest this evaluation should be a top priority of evaluation on any variant behavior that enters the consulting room. 
Furthermore, labeling and stigma are the prime suspects in guilty and ashamed clients whose behavior is highly consensual. In most cases, a therapeutic goal of overcoming the stigma will be justified.  It is a disadvantage for many such clients to start with an authoriatative-sounding diagnosis.

Personality disorder is the likely characteristic of persons whose variant behavior harms others while the client reports low subjective distress.  Behavioral control, empathy for others, and accepting painful labels are likely therapeutic goals.
 
Many problems of life functioning are partner relational problems or failure to find community that are best solved by counseling about how to find and use community resources, or how to handle conflict in the relationship.

None of these require a paraphilia diagnosis from the DSM -5, and none require a hypersexuality or ‘sex addiction’ diagnosis that isn’t even in the manual.


Resources:

Grubb, J, Stauner N, Exeline J, et al. Perceived Addiction to Internet Pornography and Psychological Distress:  Examining Relationships Concurrently Over Time Psychology of Addictive Behaviors. 2015

Moser, C and Kleinplatz, P DSM-IV-TR and the Paraphilias Journal of Psychology and Human Sexuality 02/2006; 17(3-4)

Kleinplatz, P and Moser, C Politics versus Science Journal of Psychology and Human Sexuality02/2006; 17 (3-4)

C Moser When is an Unusual Behavior a Mental Disorder? Archives of Sexual Behavior 11/208; 38(3): 323-5

Shindel, A and Moser, C Why are the Paraphilias Mental Disorders? Journal of Sexual Medicine 11/2010; 8(3):927-9

Moser, C Hypersexual Disorder:  Searching for Clarity Sexual Addiction and Compulsivity 01/2013; 20

Moser C A Rejoinder to Carpenter and Krueger:  It is about Clarity and Consistency Sexual Addiction and Compulsivity01/2013

Moser C Hypersexual Disorder: Just More Muddled Thinking Archives of Sexual Behavior 10/2010; 40(2)

Foucault, M (1979) History of Sexuality, Volume 1: An Introduction London: Allen Lane

Copyright Russell J Stambaugh Ann Arbor, MI September, 2015

What if You Get Squicked?

Russell J Stambaugh PhD DST CSSP1 Comment

Like everything on this blog, context matters.  So if you find yourself acutely uncomfortable with a client’s material, what you do depends on when, where, and how it comes up.  Some of these suggestions will not be helpful in all contexts.  Some even contradict each other.  Apologies to Mies van der Rohe, who didn’t first say ‘The devil and God are both in the details.’

Safety first, yours and theirs.  Insofar as you can, do not back away from the material, and do not ask for details that you are not ready to hear and/or the client seems unready to discuss.   You need the client to be able to observe their own responses, and for you to be listening to how it feels for them.  Consent is critical in BDSM as it is in therapy.  It is legitimate and often necessary to question the client about their consent when you reaction comes from ambiguity about whether they have agreed to whatever is disturbing you.

Ask yourself why you or the client are so offended.  If the behavior violates your core values, or you are unwilling to do the work in understanding it in the client’s terms, maybe you need to refer the client out to someone who can.  If the discomfort is primarily the client’s, then it may be resolved through therapeutic discussion.  While the typical condition of human existence may involve some ambivalence, acute and intolerable ambivalence is a proper subject of treatment.  Raw, unprocessed and out of control feelings do not advance the therapeutic process, and are signs that it may be premature to discuss disturbing material.

Give yourself permission to have your own feelings and do not rush to judge them a sign of inadequacy as a therapist.  In order to use your own feelings in therapy, you must first have them and recognize them.  Resolving countertransference is often a powerful resource in therapeutic change.  It is often uncomfortable.  Freud thought resolving transference was what therapy is all about, and countertransference was often how transference was first recognized.  Even if you think your response is excessive, recognizing your feelings is the first step that can eventually lead to acting on them in ways that serve your client.  If you have a strong therapeutic alliance with your client, any mistake you make is likely to be a point of learning for both of you, rather than ruin the treatment, if you deal with it honestly and directly.

Ask yourself if understanding and discussing the squicked material is essential to the treatment goals.  Often a client’s kink is not central to the goals of therapy.  If your client complains they are deeply troubled by their desire, obviously the details of their fantasies and actions are essential to understand.  If they went to an event one time and had a bad reaction, you could be doing yourself and the client a favor to let the client vent as they need to, and return as soon as you can to the primary contract for treatment.  And if you do not understand the relevance on any material, squicked or not, ask your client what connections they see.  If neither of you see the relevance, let it go.  One sure characteristic of treatment is that if you gloss over important issues, they will come up again, so if it is important, you are likely to get another good chance to discuss it.

Get more information.  This holds the promise of helping you clarify why you are uncomfortable, and possible increasing your understanding in ways that make your reaction more manageable.  The question is often where to get good information.  Be careful of using sources like porn and fantasy sites, where there is a strong stylistic tendency to exaggerate for effect.  On-line sources – yes, I realize Elephant in the Hot Tub is one of those – vary in their objectivity and reliability.  Different Loving 2ed by Brame, Brame and Jacobs is a reliable resource for starters.  Look also at reliable sources on edge play.  It is wise when doing this work to have colleagues whose opinions you trust.  Sometimes professional listservs and forums can be helpful.  Triangulate information from multiple sources, and don’t simply cherry pick the information that suits your preconceptions.  Do not take a poll on social media, or inadvertently out your client with specific information, even without names attached.  Often edgy practices are rare or singular events, and public discussion creates the impression that people are being outed and confidentiality violated.

If you have such contacts, ask others in the kink community about how similar material is treated there.  In this, you are not looking for advice, but trying to understand the context, contracting, consent, and community reactions to it.  Kink communities differ, have their own micro-cultures and house rules, and are not unfailingly accepting or nonjudgmental.  But understanding uncomfortable behavior in the likely context of the kink community can help you frame your own reaction, and perhaps, the client’s.

Know your strengths and limits.  That knowledge is crucial in deciding which of the strategies listed here are most applicable to any specific case.  In the Goode Olde Days, therapists had 5 years of psychoanalysis to deepen their self-understanding. That was good, but by no means a perfect assurance of self-knowledge. Nowadays you can practically get licensed by reading a few good books.  Self-knowledge is fragile, but is also the best defense.

Get quality supervision from someone who knows about the scary practices that are vexing you.  That does not necessarily mean falling back on an old supervisor who is a fantastic clinician, helped in your training, but knows nothing about kink.  It is generally unwise to try to clinic such cases on listservs where just anyone can chime in, both for reasons of confidentiality, and for reasons that people unfamiliar with such material are at risk of being made uncomfortable too, and may simply and unintentionally reflect widespread social prejudices.  That may mean cultivating professional relationships ahead of time with people who have a wide familiarity with outliers among the populations you treat.

If you think your own reaction violates your core values, or reflects incomplete work on your part, by all means return to psychotherapy.  Being made uncomfortable by someone’s material is ultimately a problem you can walk away from.  Be made uncomfortable with your own material is not.

Discuss your discomfort with an experienced and open client. This is their work too, and to the extent that they can cooperate in understanding together what your discomfort means, the client is an important resource.  Ultimately, you are responsible for your feelings, but when they are a reflection of the client’s conflicts, showing the client you are comfortable with discussing your own discomfort can be good role modeling, and help them achieve important insight.  When you lack a trusting relationship and good working alliance, discussing your own discomfort can be disruptive and drive away a client.  It is wise to out-refer to someone better able to help.  If a client is gaming you in a way that feels manipulative, make sure that you take steps to ensure your own safety.  BDSM edge play, that is play that is known to be more dangerous and transgressive in the kink community, is mostly unsafe to discuss with severely personality disordered clients and clients with weak observing egos.

Therapy is a great way to fight social problems and social injustice in the world.  But it operates under ethical guidelines that put the client first.  Perhaps you can bring your own reaction into balance better by confronting some of the root problems that make you uncomfortable through teaching, advocacy, or direct social action and philanthropy better than through your psychotherapy with any one client.  This is a special subset of my final suggestion:

Make sure that you are adequately supported in the clinical work you are doing.  This may include your primary and secondary relationships, your institutional setting, your fees, office, training and other aspects of the context of doing treatment.  It may include proper organizational affiliations, and friends who do similar work.  And it includes collecting referrals and biblioresources that support the psychotherapy you are doing.  All of these factors make it easier to understand intense and/or unexpected client materials if they suddenly arise and help you use them to better serve your clients.

That is a starter list, but it is far from exhaustive.  Perhaps you can think of good coping strategies or additional resources I have left out.  By all means, include them in the comments section.

Resources:

Finkelhor, D., Araji, S., Baron, L., Browne, A. Peters, S. D. & Wyatt, G. E. A Sourcebook on Child Sexual Abuse. Thousand Oaks, CA, US: Sage Publications, Inc (1986). 276 p.

Richters, J., De Visser, R. O., Rissel, C. E., Grulich, A. E., & Smith, A. (2008). Demographic and psychosocial features of participants in bondage and discipline, “Sadomasochism” or Dominance and Submission (BDSM): Data from a National Survey. The journal of sexual medicine, 5(7), 1660–1668.

Andreas A.J. Wismeijer PhD, Marcel A.L.M. van Assen PhD: Psychological Characteristics of BDSM Practitioners. The Journal of Sexual Medicine, Volume 10, Issue 8, pages 1943–1952, August 2013.

Patricia A. Cross PhD and Kim Matheson PhD in the book “Sadomasochism: Powerful Pleasures” (2006), published simultaneously as the Journal of Homosexuality, Vol. 50, Nos. 2/3.)

“Psychotherapeutic Issues with “Kinky” Clients: Yours and Their’s” by Margie Nichols, PhD in Sadomasochism:  Powerful Pleasures ed. P Klienplatz and C. Moser (2006) published simultaneously as the Journal of Homosexuality, Vol. 50, Nos. 2/3.)

2015 Russell J Stambaugh, Ann Arbor, Michigan. All rights reserved.

The Squick and the Dead: Intense Countertransference and BDSM

Russell J Stambaugh PhD DST CSSP

Margie Nichols, PhD

One of the best academic papers ever written on BDSM and therapy is “Psychotherapeutic Issues with “Kinky” Clients: Yours and Their’s” by Margie Nichols, PhD in Sadomasochism:  Powerful Pleasures ed. P Klienplatz and C. Moser (2006).  In all therapies, it is important to understand your client’s feelings about you, including ‘neurotic’ or at least unrealistic or preconceived ideas about you as a person and therapist:  transference, and your similar ideas about them; countertransference.  Dr. Nichols specially warned about countertransference in this paper.  She was aware then that many therapists had no direct experience with kinky clients, and a few case studies and personal prejudices often constituted all the background therapists had for undertaking this work.
 
While the situation is a little better now, it is premature to conclude that this problem is solved when TASHRA can go to the American Psychological Association’s annual meeting and count 50 attendees out of the 50,000 psychologists in attendance as good session attendance.  Still, I have to feel that if you have found this blog, you are showing more interest and sophistication about treating kink than the vast majority of mental health providers.  That does not mean that you will never encounter a kinky story that brings up powerful negative feelings for you.

‘Studies in Hysteria’ 1885, Freud and Breur, a seminal document in the beginnings of talk therapy
There are myriad sources of countertransference.  When Sigmund Freud first recognized it 130 years ago in response to his Viennese hysterics falling in love with him, he kind of liked it.  It is not so bad having all these passionate but repressed women idolizing him.  He thought it neurotic to over-respond to this idealization, and so originally, transference came to mean any unrealistic feeling a therapist might have in response to the client.  Over time, however, clinical experience and criticism of psychotherapy suggest that there are two kinds of transference:  Feelings engendered by the particular client’s relation to the therapist, I term this ‘induced countertransference.’  My example from Freud’s work on hysteria is an example of induced counter transference.  Although Freud many mistakes as a theorist, one mistake he did not make was believing that he was just an especially lovable fellow because of all that pressured female adoration.  Insight oriented psychotherapy began when Freud searched for some systematic reason why his patients all displayed this symptom rather than crediting himself.

Franz Bayroz’s (1866-1924) depiction of hysteria.  Apparently he thought it was about sexual fantasy too!
The other type, neurotic countertransference, is caused by many ideas that are not strictly speaking, neurotic, but can certainly be obstacles to understanding your client.  They include our own unmet needs, internalized social stigmatization, our participation in traditional, normative and professional power structures, good and bad prior experiences with marginalization, our own acceptance of kink, sexuality and deviance in ourselves, and our own identities.  Dr. Nichols first source of problem transference is a simple lack of knowledge about BDSM.  Assuming you have been a regular reader of this blog, and have encountered the better resources listed here, you probably have some decent starting BDSM education.  Kinky readers will have some direct experience.  But the world of kink is large and diverse.  A little knowledge, or even quite a lot of it, doesn’t mean that you won’t encounter scary or ugly things you have not known about earlier.  By way of permission to feel uncomfortable sometimes, please recall that people in the BDSM community made up this term ‘squick’ when they and others experienced extreme psychological discomfort at something they learned someone else was doing.

No matter how open-minded and sophisticated you may be about kink, you are going to encounter some uncomfortable feelings, ideas and practices.  To be disgusted by these is to be ‘squicked’.  Partly this is a consequence of the fact that kink is a kind of catch-all term for a wide diversity of practices  Of all those dimensions I identified in ‘Flavors’ and ‘More Flavors’, no single dimension is required for all activities to be considered kinky by insiders or that larger society.  Not everything deviant belongs in kink, and consent is a special boundary.  Frotteurism (rubbing up against unsuspecting people in crowded circumstances), blastophilia (the sexual preference for rape) and pedophilia are not part of BDSM.  But if you associate with the kinky for very long, you are bound to say, “How could anyone who was not pathological ever consent to THAT?”  There is no guarantee that every idea in the kinky canon is healthy, but if you hang around for long, you will at least consider that there is not only more to heaven and earth, but more to health than was dreamt of in your philosophy, Horatio!

David Finkelhor, leading researcher on child physical and sexual abuse.  Another reason to doubt child abuse as a cause of BDSM sex preference:  in the last 2) years, child abuse, and all violent crime, have been headed down cross nationally.  BDSM affiliation has increased during that period.

A symptom of this discomfort with kink is the persistence of the perennial question that I keep fielding in professional meetings about kink and abuse.  “Isn’t it true that most people into kink are physically or sexually abused as children?”  In so far as an idea like this can be dispelled by mere data alone, the best evidence of several good studies is ‘no.’ But such an idea is extraordinarily difficult to disprove by data.  Starting with David Finkelhor’s “Sourcebook on Child Sexual Abuse (1986) just how much sex abuse goes on is highly dependent on how you ask the question and of whom you ask it.  But when you ask everyone the same way, whether in self-selected studies such as P. Cross and K. Matheson, or A. Wismeijer et A. Van Assen. or in well conducted surveys like J Richter et al, people who report engaging in kinky behaviors do not show more evidence of psychopathology on simple global tests of mental health.  Neither do they have higher incidence of past abusive experiences.  Although the best estimates of abuse are quite high in the general population, abuse in the population of sadomasochists is not higher.  There just isn’t any increased of prevalence of prior abuse in the kink community to be explained.  It is obvious from case reports that some people into kink were motivated to adult behaviors by childhood abuse, and that kink is part of their coping strategies for dealing with a part of that history.  Some of those coping strategies work better than others.  So nothing prevents such a person from presenting for treatment with complaint about prior abuse.  Indeed, they are more likely to come in for treatment than people who are fine with their kinks, a likely source of mental health professionals’ longstanding habit of over-pathologizing kinky people.  The people we see are more likely to be unhappy about something.

The Crucifixion by El Greco (1541-1615)  Potentially disturbing religious material
Even where there is no clear historical relationship of abuse, it is impossible for clients to live in a hermetically sealed world devoid of disturbing and even traumatic events.  Religious stories, media and entertainment, and current events are all potential sources of frightening ideas.  A percentage of kinky folk are deliberately ‘playing’ with these events and ideas.  In so far as we as therapists are disturbed by racism, abusive power plays, sex discrimination, violence, severe illness and loss, death itself, and extremes of power imbalance, it is inevitable that we will be tempted to judgment about their manifestation in clients’ sexual behaviors.  Indeed, a strong case can be made that those sexually abused people who are also into kink are more likely than the non-abused to enter into treatment.  So clinicians might be able to say from experienced that lots of kinksters were mistreated in their youth.  We have no good statistics for whether the kinky population of those in therapy and the non-kinky clients have similar rates of abuse, the most direct test of whether clinicians’ perceptions tell us about differential rates of abuse.

The propensity to be squicked by people’s sex interests is partly a reflection of everyone’s permeability to sex negativity and stigmatization in the larger society of which BDSM is a subculture.  While they may be used to such judgment by outsiders, kinksters, too, are tempted to have such judgments in the scene.  Someone’s pain looks too intense, or socialization regarding cleanliness, disease, or risk is too strong, the psychological associations too intense for them not to say “I don’t want any part of that!”  In so far as some people are sexualizing frightening material in order to manage their feelings about it, they might be hard to empathize with for those of us who haven’t mastered that skill.  If we are still afraid and can’t use sexual excitement to master our fear, we are more afraid than they are, even though they may be going to extreme lengths to master their fears.
 
This has several implications for treatment.  The first is that we must check to see if their sense of dysfunction about a kink or practice really matches ours, or whether we are laying our judgments on them.  Margie Nichols said exactly this 9 years ago.  Are they better served by modifying a sexy but ambivalent behavior, or striving to accept it?  How much should outsiders’ opinions count?  Such determinations can become very difficult when clients deliberately make decisions or take risks we as therapists would not take.  But even when clients’ perceptions are gratifyingly similar to our own, our intense reaction to a kink may seduce us to over react to it.

A second implication is there are some problems, some clients, and some practices for which we are not the best professional to deliver treatment.  It is wise, and can be quite uncomfortable to know our own limits.  Particular care needs to be taken when we are tempted to decide that we need to substitute our limits for our clients’.  Even when clients have explicitly contracted with us for this service, it is important to check whether the repeated need to do this is coming from us or from them, and whether it is therapeutically effective to do so.  But there is no shame in admitting that you are too judgmental about sexual health to treat bareback riding (the practice of having unprotected intercourse with partners known to be HIV positive), too disturbed by the Holocaust to treat Nazi play, or too repulsed by America’s history of black slavery to treat race play.  It is not that each of these practices is ‘healthy.’  For some who do them, they are not.  But a therapeutic relationship cannot be achieved by substituting your judgements for the clients without their explicit consent.  Furthermore, social stigma and even law privilege our judgments as therapists relative to those of some kinky practices that such consent is very difficult to obtain freely. 
Some of these factors can be dispelled by data.  I once observed a very heated professional debate about coprophila, in which half of the discussants hotly contested that such behavior was psychopathologically unhealthy by definition because of the risks associated with digestive bacteria getting into other systems.  There is indeed good evidence that some cloacal bacteria can cause UTI’s and vaginal infections, sepsis and even death if they get into the wrong systems.  Other practitioners argued that, despite the real dangers, coprophiles were not getting hospitalized in droves and that fecal play’s real risks were manageable, and the opposing clinicians were selectively reading the data because of conventional social disgust.  While both sides of this argument cited accurate data, it is probably true that only the individual clinicians involved could decide whether their own countertransference was biasing their individual readings of the data.  It is fair to say that if one is hung up on such questions, it is substituting for understanding the client in their own terms.  As a clinician, you do not need to agree with clients’ perceptions, but you must allow yourself to hear them in the clients’ terms.

It is extremely unlikely that most clients will tell you about practices that they imagine might squick you until they have established substantial trust.  That is often the most important meaning of a client bringing in a disturbing story; they trusted you to listen to it empathetically.  Like mayfly infestations that cover lakeside properties with dead bugs, they may be messy and uncomfortable, but they are a sign of a strong therapeutic process.  Mayflies are among the first casualties when water becomes polluted, they don’t spawn in large numbers and make a mess.   Clients usually won’t share stories if they don’t feel safe in treatment.

Not all uncomfortable stories are a positive sign in treatment.  In my personal experience, people who tell you such things very early in treatment are either so unempathetic that they do not recognize your reaction it, or are deliberately manipulating you in some way.  If they lack social skills, thought should be given to autism spectrum and social skills deficits and those effects on their sexuality.  Alternatively, such behavior may reflect ‘acting in’ in the treatment in which they are enacting a sadistic or controlling dynamic with you that is troubling in their relationships outside of treatment, too.
 
This is a huge difference between therapy and BDSM play.  Where enacting scenarios in BDSM can be sexy, fun, and reduce anxiety; all potentially ‘therapeutic’ benefits, they do not necessarily lead to change.  That is generally not a problem in play, where satisfaction is the primary goal and any change is usually secondary. Enacting such dynamics in therapy is generally an obstacle to the therapeutic changes you contract with clients to make, and the hard work, increased anxiety, and withholding of gratification that sometimes are needed for insight and change don’t feel at all pleasant.  This is the basis for many clinical complaints in the history of talking therapy about ‘perversions’ being difficult to treat.  Acting out is thought to substitute for the insight and tolerance of affects and delayed gratification needed for change.  It would do well to remember at such points in treatment that all psychological defenses are also adaptations, sources of both strengths and weaknesses.  Defenses are not such a bad thing.  It is good practice to ask about your clients’ uncomfortable stories, their feelings in sharing them, and their ideas about how you might hear them.  If a client is telling them to make you uncomfortable, it is usually an advantage to surface that in therapy and see what they are accomplishing in doing this.

A gas station infested during a mayfly die off.  Apologies to those squicked by dead insects.
The water quality is good, though!
In order to raise such questions, it is necessary to get comfortable with kinky material first.

Citations for this post included in the following post:  ‘What if you get squicked?’

2015, Russell J Stambaugh, Ann Arbor, MI, All rights reserved.

Wooodhull Sexual Freedom Summit 2015

Russell J Stambaugh PhD DST CSSP
Victoria Woodhull (1838-1927)
Victoria Woodhull was an American adventuress, stock trader, birth control and free love advocate, journalist and suffragette.  Although many are imagining that Hillary Clinton will be our country’s first female candidate for President of the United States, that distinction already belongs to Woodhull, who ran on the Equal Rights Party ticket in 1872.  She obtained no electoral votes.

Ricci Joy Levy, Woodfull Foundation Executive Director
The Woodhull Sexual Freedom alliance was founded in 2003.  Although the Alliance bears no direct connection to Victoria, it does share many of her goals. It has advocated against government repression of sexuality since its foundation.  Since 2009, it has hosted the Sexual Freedom Summit which includes training activities, a ceremony conferring the Vicki Awards for sexual freedom advocacy, and creates community for self-styled sex radicals.  Since its inception it has been ably led by its executive director Ricci Joy Levy.

I chose to attend not because my main theme is sexual freedom, nor because I am self-identified as a ‘sex radical.’  Those are perfectly fine reasons, but the purpose of this blog is improved psychotherapy for kinky and polyamorous clients.  Woodhull is especially prominent in advocating for poly folk, and given the degree of social stigma that attends variant sexual behavior of all kinds, it is simply not possible to promote improvements in the social justice of how we deliver sexual health without some attention to curbing the zeal of government bodies for excessive sexual regulation.  As will be seen in this review, some systems are so ignorant of the needs of sexual minorities, that it is radical just to call for specific information about them to be included in the social conversation.

This year’s Summit was held in Alexandria Virginia, August 13-16.  Your intrepid reporter and his long suffering spouse drove 750 miles in a van with broken AC to attend.  Reportage on those sessions which are relevant to The Elephants purpose will be presented.  Much other activity went on that I will not cover, including an excellent Sexual Attitude Reassessment (SAR) by Patti Britton and Robert Dunlap, and an entire aging consortium from Widener University led by Jane Friedman, and a great session on legal issues in adult entertainment by Lawrence Walters and Luke Lirot.

Harmony, Rebecca and Kait presenting #SFS15.  Photo by Louis Shackelton
Sex Dating, Kink and the ‘C’ Word was presented by Harmony Eichsteadt, Kait Scalisi, and Rebeca Hiles

The ‘C’ word in this presentation was cancer, and this is the first session I have ever attended in which the problems associated with simultaneously being kinky and a cancer survivor were discussed.  From the outset, the presenters made clear that you are a cancer survivor from the moment of diagnosis, not the usual five-year period often used to calculate treatment effectiveness.  Travails presented fell into two main groups:  trouble getting your kink taken seriously by the medical profession, and trouble getting non-professionals to understand what your cancer does and doesn’t mean to potential partners and communities.
Barriers to better treatment for younger and kinky folk included:  the relative paucity of research studies done on teen and young adult cancer patients mean that sexuality and dating implications received little research.  Several stories were told of being unable to get sex discussed with specialists for types of cancer that did not directly impact the reproductive system.  Breast, prostate and uterine cancer specialists may be more open to sex discussion, but do not expect that to include kink.  That means kinky cancer survivors do have to swallow their fears of ignorance and judgment and press for information from potentially uninformed and bewildered professionals.  Treatments for non-reproductive cancer types commonly have hormonal and desire implications.  Some forms of chemo make sex dangerous for partners, and the sexual side effects of some medicines prescribed to deal with treatment side effects are unstudied for their sexual consequences.  Older and younger research subjects are often disinclined to volunteer such information, and doctors don’t ask.
   
While it is typical of many patients, kinky or not, to feel that sex is not the first thing on their minds or to feel too sick to bring it up at some points in their treatment, kinky folk are inclined to prioritize sex highly, and may not fall into that common pattern of avoidance.  The assumption that cancer ends sexual feeling is not always correct and serves as a barrier to discussion.  Specialists are not only undertrained to discuss sex and cancer, but are often compensated and evaluated for other things and lack time for an uncomfortable discussion they may feel ill-informed to conduct.

While undergoing treatment, survivors are just not expected to be experiencing sex desire or dating by the medical community, or the dating public.  Some reported rejection because of their diagnosis, although others found dating partners to be caring and sensitive.  All struggled somewhat against the medicalization of their identities, where being in treatment or in recovery reframed who others thought they are.  Often assumptions about their delicacy were hard to manage.  Try convincing a dominant play partner you do not know well that you are not ‘too fragile’ for your preferred form of sex.

There is a relative paucity of sex information that is specific to kink and cancer.  This is unfortunate in that, if only 2% of the U S population is into some form of kink, half of these can be expected to get cancer, leaving 3 million people without relevant resources.  The presenters run a relatively inactive site on Fetlife, apparently just posting it doesn’t mean people will come.  They reported most success at setting up their own informal support groups within their local kink communities.  Kink Aware Professionals is a resource for primary care physicians, but there are few oncology specialists on it.
 
Whether dealing with doctors or acquaintances, the group agreed that survivors need to be very assertive and take the initiative in dealing with their cancer issues.  Sadly, the expectation is that even specialists will not have gotten training on this.  The best say, ‘I don’t know, and I’ll look into it.’  Then they actually follow through and get back to you.

Dei, Ramien, and Sir Guy presenting #SFS15.  Photo by Louis Shackelton
Black Lives Matter in Porn, Kink and Leather — Black Males, Law Enforcement and Sexual Expression presented by Dei Wise, Sir Guy DeBrownesville, and Ramien Pierre
This panel featured three black dominants who had each been in the scene for 20 years or more. One, Ramien, had won the prestigious International Mister Leather title in 2014.  Dei has won awards from AVN for his work in the porn industry.  Sir Guy was an early member of the Til Eulenspiegel Society, the very first above ground kink social group.   As such, they had been thoughtful and articulate participants in BDSM for a long time before volunteering to present at #SFS15.  Sir Guy had been a NYPD officer for 8 years, and prior racist experiences and a strong sense of what he desired attenuated the experience of isolation in his early years of joining the kink community when there were few other black members.   He did not say, but I also suspect that even when there are other people who are racially similar, some community is formed more around complimentary sexual interest than race.  His enthusiasm for uniform play was already a minority interest in the community, and overcoming isolation was already a frequent experience for him.

Important learning for me was the reflection that white people with fetishes for sex with black partners are an element of community life, but that they represented more of an obstacle that an opportunity for the panelists.  “Not everyone who wants to have sex with you likes blacks very much!’  All three panelists took pains to avoid play with people who they felt objectified them, and they regarded the right play as coming from people who were deeply interested in and accepting of their inner worlds.  Partly, this was an element of risk management.  No one wanted to be outed or harmed by insensitive partners even from the positions of power that dominance afforded.  But play is about emotional connection for the panelists.  Not everyone is ready for that and sometimes race is one of the barriers.

Dei, who had transitioned from submissive to dominant early in his career, was sometimes turned on by risky race play.  “Supreme Court Justices receive a less thorough vetting than my play partners.”  He went on to describe an extreme race play event in which he had viewed that involved a simulated lynching.   All of which left me examining my own values about race and edge play.  I am not alone in this.  Members of the community also have their reluctance.  A Black woman in the audience complained that the onlookers at the lynching constituted the wimpiest lynch mob on record.  None would say the ‘N’ word, which surely would not have been absent from a real lynching.  In order to make it more real for the ‘victim’ she had berated the crowd and exhorted them to be meaner!

It is hard not to imagine that some activities in BDSM constitute attempts at psychological mastery through ‘play’ of powerful, even traumatic social conditions in the larger society.  Uniforms take their meaning from a social context provided by the parent culture.  Racial lynching is an historical fact, although it is unlikely that Dei was old enough to be present at a real one.  Racial prejudice is grist for the mastery mill in American society.  Perhaps one should be uncomfortable with the social conditions that breed race play, even if one has long ago abandoned the myth that we are a colorblind society. 

These uncomfortable realities effect everyone, Blacks and Caucasians, privileged and disadvantaged alike, but they also reflect the conditions in which people pursue their kinks.  If we are sometimes uncomfortable about those kinks, it is always worth remembering they begin from larger social discomforts, and that lacking the same defenses and adaptations that kinky folk employ, we are much more uncomfortable and less excited than they are.  Our neutrality is not always healthier and not always an advantage.
The Family Matters Project:  John D,Emilio, Petter Goselin, Andy Izevon, Nancy Polikoff, Monica Raye Simpson and Ricci J Levy

The conference closed with a presentation on Woodhull’s major initiative; the Family Matters Project.  Superficially, this is about confronting the fact that heteronormative cis-gendered, monogamous family as the dominant ideal family structure in American society.  In fact, the panel’s criticism is more radical, more in the spirit of Victoria Woodhull, and much deeper than that.

The session began with the criticism of Antony Scalia’s conservative reasoning for supporting the extension of marriage rights to gay and lesbian monogamists.  This constitutes privileging of the already privileged; an invitation for gays to embrace a monogamous model that discriminates against those neediest of governmental support.  Even the relatively well-educated poly community is not the most needy cadre of government support.  A more radical approach would abandon sex shaming and economic discrimination against divorced, single, and out of wedlock family styles that affect far more people than polyamory.  These differentially impact the poor and people of color and the family styles they adopt to handle economic hardship and social discrimination.

Some speakers outlined the legal basis for just how vague and discriminatory the privileging of family really is.  “It would probably be better if the definition of family wasn’t left to lawyers!” typified the criticism.  For example, some housing laws allude to family but have great trouble defining it.  It is clear that the audience’s preferred methodology, that definitions of family come from the individual heart, was deeply unrealistic about how any such redefinition might be implemented.  After all, the current definitions, lawyerly as they may be, proceeded from heartfelt political will of opposing moralists. The most radical presenters called for abolition of the family as the basis for government benefits for the needy.  The clear solution of the presenters was that government benefits to the needy needed to de-privilege sex shaming and traditional family structure.  Fairer benefits cannot be accomplished by making traditional marriage a protected class.

The Family Matters Panel was able to articulate the ultimate goal of the project:  a de-privileging of traditional family status as the gateway for providing government services.  This would need to go beyond legitimating polyamory or other non-cisgendered, non-hetero-normative family styles.  It would need to end sexual shaming of people’s reproductive, living, and sexual relationships.

Achievement of this goal would have profound impacts on who was responsible for children and their care, who could legally live together in a dwelling, who could take medical responsibility for others, and how child custody was viewed.  Ultimately, it would support genuine equality of widely differing living arrangements.

As to how such a radical change was to be implemented, the panel was at the very earliest stages of any implementation plan.  John D’Emllio, one of this year’s Vicki Award winners, closed with the cogent quote that as gratifying as this goal was, the most radical criticism was a mere exercise in philosophy without a plan for implementation.  Ricci Joy Levy’s plan is clearly to recruit some of the great minds that presented in this session as the backbone of a working group to define what steps towards this goal might look like.

2015 Russell J Stambaugh, Ann Arbor, MI, All Rights Reserved

The Epistemology of Lies

Russell J Stambaugh PhD DST CSSP
One of the stable mysteries in sex research involves the differing percentages of men and women (sorry, but the gender variant are too little studied on this topic, so this essay is going to rely on traditional pronouns) who admit to having sex outside of marriage.  In the early 50’s, Alfred Kinsey estimated that about half of men and a quarter of women admitted to extramarital sex.  In the early 90’s, the Janus report suggested a third of men and a quarter of women had strayed.  In 1994, Laumann, Gagnon, Michael and Michaels reported about twice as many men admitted to straying than women.  While the exact percentages of extramarital affairs varies somewhat over time and with differences in the exact wording of survey items across surveys, this discrepancy holds up.  Neither male on male infidelity, nor questions about the numbers of partners men have relative to women explain the discrepancy.  Neither are all the unfaithful males making up the difference with single women.  The difference is not accounted for by homosexual contacts, or a smaller number of women pairing with a larger number of men. The evolutionary theorists have suggested women stray less because it is more in their advantage to retain male partner to share parenting responsibilities, as men can more easily walk away from parenting duties.  Female infidelity goes up when there is a surplus of men, and down when there is a surplus of women.  Scarcity of partners matters.  Infidelity does appear more common in younger people, and in those nearing the end of middle age, which suggests that child rearing does effect straying, however it is not related to the number of offspring in the United States.  Cross culturally, men do report straying more in societies with relatively more marriageable women, and less in societies with a relative shortage of such women.  It also seems that marital infidelity is more openly admitted among younger respondents in more recent studies.  In 2015, a study reported nearly identical rates of infidelity among males and females for the first time.

So who are all those men having sex with?  The conventional wisdom is that men are inclined to exaggerate their promiscuity, and women to minimize it, apparently even on anonymous sex surveys.  Without a magical or questionably unethical and highly intrusive alternate methodology, this hypothesis is not easily tested.  Clearly women do experience burdens related to child rearing and responsibility that do not evaporate even in societies that support reproductive choice.  Demographics also matter.  So do the socially constructed dimensions of gender roles.  There is no single cause.


This propensity for exaggerating and minimizing extramarital activity on surveys pales in comparison with the analysis of the Ashley Madison core dump by technology author Annalee Newitz and published a week ago on Gizmodo.com.  Annalee describes subjecting the Ashley Madison database of some 22 million men and 5.5 million women to data analysis designed to differentiate users’ behavior by gender.  Looking at data fields recording contact attempts and text messaging through Ashley Madison’s site, Annalee suggested that most of the 22 million users are male, and that only about 10,000 of those who created female profiles ever used them even a single time to contact anyone through the site.  While alternative explanations exist for these observed discrepancies, such as real women creating profiles, then dropping, or some systematic corruption of the Ashley Madison data set, she also found evidence of robotic profile creation and sparse but significant employee complaints about phony profile creation.  Huge numbers of men joined a site with virtually one women for every four men at best on it, yet conversed for extended periods over affairs that could not have happened.  And Ashley Madison perpetrated a fraud of epic proportions, even allowing for their warning that ‘some’ of the profiles on their site were for ‘entertainment only.’  Something is rotten in the state of Ashley Madison.

Newitz’s sex ratio findings make a mockery of warnings from sophisticated observers like Dan Savage that one had best be careful going to the Ashley Madison hack for information about your husband’s fidelity.  The odds might be many thousands to one that, at worst, he may have intended to be unfaithful but failed to find a partner, and more than likely was engaged in pornographic fantasy with little hope of a relationship.   I also warned of this danger of drawing unjustified conclusions from the data in an earlier post.  But I would never have projected a discrepancy between men and women’s behavior this large.  Perhaps I was warned.
Ogi Ogas and Sai Gaddam in their study of Internet porn searches, ‘A Billion Wicked Thoughts:  What the Internet Tells Us about Sexual Relationships,’ presaged this result in their efforts to identify the different on-line behaviors of men and women searching for porn.  This can be easily seen by comparing two charts on the top 5 visual porn sites preferred by male and female searchers presented on page 18 of that book.  The top sites searched by those identified as males totaled about 51M searchers a month.  An entirely different top 5 searches from those identified as female totaled about 3M a month.  That very roughly reflects 6% of the male figure.  Ogas and Gaddam also found about 6% of visual porn searches on American On-Line were from self-identified women.  But most of their data were in the range of 20-30% female use relative to men.  But Ashley Madison, while it had picture profiles, was not visual porn.

The female use data as suggested by Newitiz’s analysis of the Ashley Madison user data are so low, it is lower than the likely number of men who joined Ashley Madison pretending to be women to escape the monthly fees.  Joining as another gender might be a barrier to actually meeting, but could facilitate fantasy, checking on the authenticity of others, or even scamming.  It is probably a rational strategy for men who knew from the start that they only wanted to dream about the profiles and weren’t planning to meet anyone.  It is also a lower percentage than the number of 5.5 million women who were kinky, and might have had reasons beyond just wanting a partner who had accepted the necessity an affair in braving the hazards of going on Ashley Madison.  If 1.5% of the women 5.5M women wanted kink, we might have expected 75,000 to 100,000 profiles with contact records, not less than 15,000. 

Finally, I actually know one woman who claimed, long before this fiasco, to have been on Ashley Madison, although she did not share her contact history there with me.    As broad as my circle of friends may be, my profession is somewhat of a lightning rod for sexual discussion of a certain type, the odds aren’t that good that I would know such a woman if there were only 15,000 in the entire country.  But some of my colleagues, also admittedly those most likely to know outliers of this type, claim to know several experienced Ashley Madison users, male and female, who met on-line.  We are, of course, sworn to professional silence about any data we might cull from professional contacts. Suffice it to say, the Gizmodo.com data and my informal reports don’t add up.


Two days ago, however, Newitiz recanted her analysis of the Ashley Madison hacks user fields.  Those empty fields in female profiles didn’t reflect their initiation of contacts with men, but kept data on Ashley Madison’s communications to them.  Ashley Madison was targeting its users with a vigorous program of robotic communications aimed at providing the illusion that sexy women hot for affairs were propositioning them.  The female users’ data fields were empty because with four men on the site or more for every woman, Ashley Madison did not need robotic communication to keep women subscribed to the site.  Only men were charged a monthly re-subscription fee, so Ashley Madison’s robots were focused on men who were looking for female partners.   It is still unknown exactly how many of the female profiles on the site were real women investigating potential affairs.  But it is a fair guess that the absolute upper limit to genuine contacts for heterosexual men was 20-25%, and perhaps way less.  Although Ashley Madison worked pretty much as advertised for women seeking women or men, and for men seeking affairs with men, it was primarily an business model of keeping heterosexual males seeking women strung along paying the monthly fees on a diet of fake profiles and lame propositions programmed by computers with scant possibility of any actual contact.  Most men on the site never had one.

This has a number of alarming implications.  First, how could Ashley Madison, which promised special safety and security to people who wanted to risk breaking social norms, have provided such abysmal service.  Rather than providing good security, they have risked outing tens of millions of people world wide.  Did they ever intend to provide it?  The hack of the company’s internal communications shows an obsession with retaining revenue and customers, not with security.  The site functioned essentially as a gigantic fraud far more deserving of Justice Department attention than Rentboys.com, busted late last week.  For all the good and bad reasons men might have gone on-line seeking extramarital affairs, bilking and hacking them constitute crimes, not condign punishment for social deviance. The Internet world is a very harsh place for people lacking the social skills to protect themselves.  Just when we are confronting men for their social privilege, remember Ashley Madison’s clever hook consisted of robotic invitations like “I’m always up for some kinky chat!”  We are all privileged in some ways, and painfully vulnerable in others.

But that is my original point.  The Ashley Madison hack, like so many other epistemologies, answers only a few questions, raises many new ones, and swirls the murky waters in new ways that obscure some things even as it reveals others.  We are not seeing into the dark hearts of religious conservatives or entitled men in brand new ways that revel unexpected truths.  We are not hearing the death knell of monogamy, but its struggle with changing social contexts.  We are seeing that fantasy is not politically correct because that is not its function.  A lot of guys don’t need the full risks of an affair to get off, and it is worth considering that a whole class of men exists out there which would much prefer the fantasy of an affair to the pleasures and pains of real infidelity.  There might be only modest overlap between the so called ‘cheaters’ on Ashley Madison and men who honestly tell survey researchers that they have had an extramarital affair.

What about Ashley Madison itself?  A number of smart commentators have suggested Ashley Madison might be in for some difficult times in court because the hack reveals that the site’s security promises were ineffective.   The Newitz analysis certainly doesn’t suggest that the site was scrupulous about offering only genuine profiles.  Ashley Madison’s EULA shows genuine foreknowledge that male might experience a dearth of female interest.  What legal vulnerabilities these create will probably be explored.

In the meantime, there are some very clear lessons learned:

Internet security is a functional oxymoron.  You have way less than you think.  Do not do anything here you do not want your worst enemy to know.  Things said on the Internet may have a half life of forever.

People’s reasons for extramarital affairs are very diverse.  They do not reflect simple moral failure or hostility to their spouses, or even proof of a love for the thrillingly illicit.  Someone somewhere has these motivations, but people are not alike simply because we categorize their behavior with the same label.

The immediate corollary is that you don’t know very much about your partner once you find their name in the Ashley Madison hack.  Most men didn’t have affairs, and a good argument could be made that Ashley Madison was a fantasy aid for many, whether they had ever intended to assume the full risks and responsibilities of an actual meeting or not.  Many must have wanted affairs.  Most stayed without getting one.

The moral entrepreneurs who are criticizing the state of American marriage because of this would much prefer to blame people for not following their preferred dogmas.  The evidence of social research suggests dogma is the weakest explanation of why people do and do not stray, and that demographics, social and geographic mobility, and economic changes are more powerful predictors.  Look for lots more ineffective criticism in the future because those genuinely influential factors are growing stronger.

Sex education is hamstrung without media education and affective education.  If we are not going to be cheated by shallow frauds like Ashley Madison, men need to be able to tell the difference between robots inviting them to ever more expensive fantasy sites and conversations with real women.  The bots were not channeling Madame Pompadour and the 18th century courtesans than inhabited salons in the Age of Reason.

Outing people for their sexual conduct is bad.  There is no end here that justifies these means, and the hackers are not heroes, even for exposing Ashley Madison’s corruption.  Two Canadians are alleged to have committed suicide over these disclosures.  I do not know if the hack is the precipitating cause.  But sex shaming is just bullying by privileged means.  If you don’t want people whining about your privilege, use it graciously for genuine good.
2015, Russell J Stambaugh, Ann Arbor, MI. All rights reserved.