Monday, December 31, 2007

Exercise 4: Life timeline.

The goal of this exercise is to translate the material from the sex history into a visual format to help understand how your sexual behaviors have occurred across time. Complete the following exercise attempting to be as thorough as possible. You might need to devise a code to fit everything into the timeline. (It might also be helpful to tape a few pieces of paper together to make a larger piece.) Across the left hand edge of the page, draw a vertical line. The vertical line should be numbered –5 to +5. At the center of the vertical line, draw a horizontal line going the length of the page. The horizontal line reflects your age across time. Take the responses to the sex history questions and list the events along the horizontal line roughly reflecting your age at the time of the event. In addition to the behaviors identified in your sexual history, plot the following life events on the time line.

1) Meeting a best friend.

2) Having a crush.

3) Age when you hit puberty.

4) Your first time of masturbation.

5) Age when you can first remember being attracted to another person

6) Your first kiss/ first date

7) Age of your first orgasm.

8) Age when you first had sex (however you define that)

a. With a girl

b. With a guy

9) Age when you had your first relationship

10) Age at relationship changes (new relationship, divorce, break-up, marriage)

11) Age at life changes (move, new job, sobriety, first child, illness, death of a loved one).

12) Any other relevant critical incidents in your life. A critical incident is any event, “large” or “small” that has meaning in your life. An example might be when you self-identified as “gay.”

13) With additional color pens or pencils, track other relevant behaviors. This might include tracking spending behaviors, drug or alcohol behaviors, gambling, etc. A later assignment will ask you to reflect on other behaviors that correlate to your sexual behavior.

14) Next, with additional color pens or pencils track additional life events such as depression/mood, stress, marital satisfaction, job satisfaction, or other important events in your life. Below is a simplified example to illustrate how to complete a timeline.

By charting these events, it may be possible to discover simple and/or complex patterns to an individual’s sexual behavior. In the example below, I graphed mood, anxiety, job satisfaction and sexual satisfaction. Reviewing the chart, there appears to be a relationship between mood and frequency of sexual functioning. While it is possible to see a relationship, it is not possible to determine cause and effect. In this case, the mood may lead to sexual acting out; alternatively, sexual acting might be an attempt to feel better; another alternative is that the person feels depressed because of the sexual acting out. Because of the graph, we get a sense of the relationship. Therapy is a process of exploring and understanding the relationship.

Friday, December 14, 2007

Exercise 3: Compulsive "Acting Out" Cycle

The acting out cycle is a framework to explain how people “act out” their compulsive behaviors. The entire treatment is connected to this cycle. The key to changing the cycle is first recognizing the feeling triggers, high risk settings, and thinking,” identifying “active and passive” ways of acting out, and the perceived payoffs. We will review each of these concepts in subsequent exercises. But for now, a brief review is provided to help you develop an initial understanding.

Expanding upon the cycle:


Set ups are often easily recognized. Most people who struggle with sexual compulsivity can identify various feelings before they act out. For the sake of simplicity, I have reduced the types of set-ups to three: Emotional Triggers, Thinking Errors, and High Risk Situations. An example of a feeling trigger can help explain the concept. A person feels depressed, so he or she makes a call to the phone line which leads to a sexual encounter. The feeling identified in this example, depression, precedes the acting out incident. In the same example, a thinking error that might be present includes the thought “I’ll only make a phone call, it isn’t a big deal. I won’t hook-up afterwards.” The high risk situation in the example includes making a call to the phone line. As you move through the treatment process, you will start to identify additional setups that increase the risk for acting out. In the end, you’ll probably be able to identify ten to fifteen setups of each type.

Acting Out

The acting out phase of the cycle is often recognized as the sexual behavior (for example, I had sex with this person; I watched some porn). What you will recognize is that the sexual behavior is only one type of acting out. In the field of chemical addition, there is a term used called “cross-addiction.” I have worked with clients who have stopped their chemical use, but then their sexual behavior gets out of control. Once both the sexual behavior and chemical use are under control, it isn’t surprising to see another issue develop such as eating disorders, compulsive spending, and or gambling behaviors. The key to understanding the cycle is that the sexual behavior is only an expression of the cycle; you need to gain a better understanding of all the different ways you may act out. In recognizing the range of behaviors, you can then address the real problem: the cycle and avoid a band-aid approach to sexual health. As we move through the process, you will discover passive ways of acting out are as important as active ways of acting out. For example, I’ve worked with clients who will withdraw from conflict because of fear. This will result in the person feeling resentful which is a set up for explosive anger (another type of acting out).

Pay offs/Costs

Pay offs refer to the perceived outcome of the behavior. In the example above, the perceived pay off was a relief from the depression. As you can probably recognize, the payoff is usually temporary. Sometimes the perceived payoff leads to the cycle starting all over again. It is important to think strategically in this area. You might not always recognize other payoffs. Yes, the sexual behavior might be pleasurable, but another payoff might be avoiding the fear of being hurt in a relationship, so choosing a casual encounter is also “safe.” Costs are more easily recognized. In behavioral terms, we identify these as “consequences, ” examples include my partner is angry about my behavior; I was arrested; I got drunk.

Relationship between the components.

If you examine the arrows in the cycle, you will see that each is double pointed. The cycle is dynamic, meaning it is always shifting, moving and adapting. The cycle provides feedback to the individual, and the individual adapts as necessary to continue the cycle. This relationship will be reviewed throughout the exercises as well. An acting out encounter may have a consequence (cost) that sets the person up to act out again. Treatment involves working through this cycle and addressing all aspects.

Friday, December 7, 2007

Creating Sexual Health

Integrated into my treatment philosophy is an explicit goal of helping the client clarify his or her appropriate sexual behaviors. Toward this goal, it is important to understand what sexual health is. The definition of sexual health that I liked the most was published by the World Health Organization. They define sexual health as a . . .

“. . . state of physical, emotional, mental and social well-being related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled” (WHO, 2002).

The definition is very complex and represents nearly 30 years of scholarship and development.(For those desiring an understanding o f the history of defining sexual health please see one of the papers that came out of my dissertation [ Edwards & Coleman, 2004]). Sexual health is more a process than a dichotomy answered by a yes or no. As treatment continues, the key is to help the client develop and improve their sexual health. I found another article helpful in framing the process toward sexual health. Robinson et al (2002), provides a model which consists of 10 components which are briefly summarized.

The Ten Components of the Sexual Health Model.

1. Talking About Sex is a cornerstone of the Sexual Health Model. This includes talking about one’s own sexual values, preferences, attractions, history, and behaviors. As you can see, the first exercise is about evaluating your ability to talk about sex.

2. Culture and Sexual Identity are instrumental to understanding one’s sense of sexual self. It is important that individuals examine the impact of their particular cultural heritage on their sexual identities, attitudes, behaviors, and health.

3. Sexual Anatomy and Functioning assumes a basic knowledge, understanding, and acceptance of one’s sexual anatomy, sexual response, and sexual functioning. Sexual health includes freedom from sexual dysfunction and other sexual problems.

4. Sexual Health Care and Safer Sex covers a broad perspective encompasses knowing one’s body, regular self-exams and responding to physical changes with appropriate medical intervention. Examination of one’s safer sex behaviors is critical.

5. Challenges and Barriers to Sexual Health include the major areas of as sexual abuse, substance abuse and compulsive sexual behavior. Other challenges might include sex work, harassment, and discrimination. Treatment must address these areas.

6. Body Image requires challenging the notion of one narrow standard of beauty and encouraging self-acceptance. Sexual health requires a development of a realistic positive body image.

7. Masturbation and Fantasy can be a healthy expression of sexuality. It is important for individuals to clarify their values on masturbation and fantasy. Too often, masturbation and fantasy are linked with shame because of the historical myths associated with sin, illness, and immaturity.

8. Positive Sexuality recognizes that all human beings need to explore their sexuality in order to develop and nurture who they are within a positive and self-affirming environment. Positive sexuality includes appropriate experimentation, sensuality, sexual competence developed through the ability to get and give sexual pleasure and setting sexual boundaries.

9. Intimacy and Relationships. Intimacy can take many forms and is a universal need that people meet through relationships. Sexual health requires knowing which intimacy needs are important for the individual and appropriate ways to meet these needs.

10. Spirituality and sexual health assumes congruence between one’s ethical, spiritual, and moral beliefs and one’s sexual behaviors. Spirituality may or may not include identification with formal religions, but always addresses moral and ethical concerns and deeper values in order to integrate a person’s sexual and spiritual selves.

The exercises and assignments in this blog and in my treatment work are designed to help an individual in their process toward improved sexual health as presented in the sexual health model. The process is extensive, requires significant work and effort. In my opinion, sexual health can be reduced to a process of integrity toward one’s behaviors and one’s values. Hence, the previous conversation on integrity takes one a new level of importance. I cannot define for the individual what is “sexual health.” Only the individual can do so. My commitment is to you express your sexuality with integrity.


Edwards, W. M., & Coleman E. (2004). Defining sexual health: A descriptive overview. Archives of Sexual Behavior, 33(3), 189-195.

Robinson, B. E., Uhl G., Miner, M., Bockting, W. O., Scheltema, K. E., Rosser, B. R. S., & Westover, B. (2002). Evaluation of a sexual health approach to prevent HIV among low income, urban, primarily African American women: Results of a randomized controlled trial. AIDS Education and Prevention, 14(Suppl. A), 81-96.

World Health Organization (2002). Gender and Reproductive Rights, Glossary, Sexual Health,