Tuesday, August 26, 2008

Becoming Open and Honest

A common theme apparent across many clinical settings is the struggle with being open and honest to the important people in your life. I consistently see how people avoid talking with others, disclosing their sex history, or reaching out to others to help break the isolation, fear and shame. In the 12-step tradition, there is a saying "Our secrets keep us sick." As a treatment approach, anything you're not able to talk about is the treatment issue you need to be talking about.

The treatment assignment is to identify the major issues you are keeping secret. I recently asked one client to list the top 25 secrets he hasn't revealed. The assignment scared him, but by the end realized that the isolation he feared didn't come about.

Given the level of struggle with becoming open and honest, I'm interested in hearing from readers about what they found helpful in starting the process of breaking secrets.


Monday, August 18, 2008

Online Community Talking about Sexual Health: An ending opens a new door.

All of the material in this blog (previous to this date) has been used in the development of a workbook addressing sexual health issues to facilitate recovery for individuals experiencing sexual compulsivity. The purpose of the blog was two-fold. First, clients were provided the information quicker than waiting for the workbook to be completed. (The initial content was written over a period of one year.) Second, the blog held me accountable. I was responsible to others to get something done regularly. An embarrassing reality is that this workbook was started in 2005. Without the accountability created by the blog, I simply languished in moving forward.

After completing the workbook, the purpose of the blog is now a place for individuals to engage in an ongoing conversation regarding the material, the workbook, or general questions. Too many people are too isolated and have no place to engage in these conversations. For the safety of all, all posts are moderated. And all posts will be made anonymous unless you give me explicit permission to use your name.

Sunday, August 17, 2008

Body Image

1. In general, I like how my body looks.

2. I like the look of my genitals.

3. I feel I am too thin.

4. I like how my breast/chest looks.

5. R. I am uncomfortable with several parts of my body.

6. It is important for me to make my body look good.

7. I have had cosmetic surgery to change my looks.

8. Overall, I feel my body is attractive.

9. FOR MEN: I like the size of my penis. FOR WOMEN: I like the size of my breasts.

10. R. I want to look more masculine.

11. R. I want to look more feminine.

12. R. I feel I am overweight.

Score 1 point for each no to questions 1-4, 6-9.

Score 1 point for each yes to questions 5, 10-12.

The higher the score, the bigger the concern with body image issues.

A component of sexual health is body image. This involves challenging the notion of one narrow standard of beauty and encouraging self-acceptance. Sexual health requires a development of a realistic positive body image. The necessary work in moving toward sexual health suggests that this is a major issue for all people and may be the last issue resolved according to professions who treat eating disorders. Body image incorporates so many parts of our perceptions, internal messages, external messages, and feelings that it is difficult to address.

Culturally what is considered beautiful changes across time and circumstances. The key to addressing body image is that it is COMPLETELY cultural. The objectification of women has been occurring for a while; recent developments have started the objectification of men as well. Given the cultural emphasis on unrealistic images of the body, the negative messages both genders face are tremendous. The impact of sexually explicit material also raises concerns in the role it has in shaping a person’s view of their body.

While a lot of people struggle with cultural body, there is a mental health diagnosis that reflects significant body image issues. Body dysmorphic disorder is characterized by constantly compare your appearance with others, possibly refusing to let your picture be taken, or are extremely self-conscious in photos, keep checking a certain body part that you think is flawed (e.g., your nose or belly) as well as measure the flaw frequently, feeling anxious and self-conscious around other people, calling yourself names, completing plastic surgery, and often dissatisfaction with the results of plastic surgery,

Developing a Healthy Body Image

Here are some guidelines (Adapted from BodyLove: Learning to Like Our Looks and Ourselves, Rita Freeman, Ph.D.) that can help you work toward a positive body image:

1. Listen to your body. Eat when you are hungry.

2 .Be realistic about the size you are likely to be based on your genetic and environmental history.

3. Exercise regularly in an enjoyable way, regardless of size.

4. Expect normal weekly and monthly changes in weight and shape

5. Work towards self acceptance and self forgiveness- be gentle with yourself.

6. Ask for support and encouragement from friends and family when life is stressful.

7. Decide how you wish to spend your energy -- pursuing the "perfect body image" or enjoying family, friends, school and, most importantly, life.

One assignment I will sometimes give clients is to list 100 negative messages they say about themselves, their body, or hear from the culture. The reason I do this is to help the client become aware of the negative self talk. You can’t change what you don’t recognize. Next, for each negative message, I have them review and investigate the source of the message. Was it TV, family, culture, sexual minority culture? Finally I encourage them to identify positive messages to balance the negative messages.

Examine your sexual history. How has messages regarding body image impacted your sexual behavior. What behaviors have you done or not done in response to the messages? How do you feel about your body now? Describe a realistic and healthy body image.

Assertive Communication

In the process of moving toward sexual health, it is important to develop assertiveness communication skills. Not only is this relevant to expressing thoughts and feelings but it is relevant to sexual expression. It is important to communicate with your partners what you like and need sexually. At first, this style of communication may feel artificial. It should be seen as a template and helpful tool. It is not the only way to communicate, but it is a start. There are many formulas that can be helpful in learning assertive communication. The formula I like has three parts. “I feel __________Because __________I need ___________.”

I’ve expanded this to include

I think/I feel ______(state your thought or feeling) ____

Because _______(explain what triggered the thought or feeling)______

I need/want/would like _____( express the request) ________

I expanded the formula because it allows for robust application. For example, I will often ask people what they are present to. This is my way of asking “what’s going on inside.” It may be a thought, a feeling, a memory, or trigger, connected to the current moment. The “because” is a simple explanation of the moment. It should be “short” and “sweet” and explicitly connected to the moment. Finally, it is important to explain the request. The key is to be clear, specific and measurable. Note that the expansion reflects the distinctions between “needs,” “wants” and “likes.” Too often we confuse the level of importance by our language. Someone might say, I “need” a cell phone, but the reality a need is a basic requirement. I need food, or I need to be treated with respect or I need you to stop touching me etc. To be accurate, the term that should be used is “I want” or “I would like” a cell phone.

Some pitfalls to avoid is the passive approach toward communication. A classic example is “Would you like to . . .” which is often used in place of “I would like. . .” Other dangerous forms to be avoided are “We” statements. Use “I” statements instead. Also, on the other end “You” statements are often more aggressive. “You should . . .” is better replaced “I want” or “I need.”

In applying this to concept to sexual health, being able to assertively express your requests is a significant component of sexual health. Also, setting boundaries and limits become a major related issue as well. In expressing feelings, sexual desires, assertiveness is a major skill. This is only a brief introduction to the concept. If it relevant, please follow-up with your therapist.

Examine your sexual history. How has the lack of assertiveness related to your behaviors? What is the role of thoughts in your ability to be assertive? Often, shame for example, is a belief that I’m not worth anything. If I’m not worth anything, I might be hesitant to ask for what I want and/or need. I may also fail to set limits when someone asks me to do something that I don’t want to do.


The purpose in this topic is to start helping you clarify what your boundaries are. This topic should be seen as a complement to the topics on sexual expression, sexual competency and assertiveness. The concept of boundaries refers to the limits we choose to have in our life. It is the process of defining what is and isn’t acceptable. Boundaries are defined by you and can vary between individuals.

Typically we talk about boundaries are healthy, rigid or blurred. Healthy boundaries are well defined, clearly communicated (see topic on assertiveness) and respectful to self and others. In clarifying healthy boundaries, we each can set the boundary as an expression of our identity. Healthy boundaries can change, but generally are stable across time and situations. Changes in boundaries will occur in response to the unique situations and/or circumstances. The environment, people, our development, and the circumstances can lead to healthy expansion or restriction of a boundary. For example, if I’m tired and lonely, a boundary may be that I won’t have sex. For the sake of the example, once I’m in a relationship, given the same circumstances I may choose to have sex with my partner because of the adult play aspect. While boundaries can change, and flexible, rapid changes in your boundaries and limits is a warning sign.

Two type of unhealthy Boundaries are blurred and rigid boundaries. They represent the opposite extremes on a continuum (with healthy boundaries in the middle). Blurred boundaries are too flexible and too changeable. With blurred boundaries, we tend to let the outside environment or other individuals dictate our beliefs, values and limits. In this situation, we may feel used, violated, exposed, and hurt. Our identity is lost. The other extreme are rigid boundaries. In the introduction to the workbook, I talked about the emphasis on rigorousness. When taken too far, rigorousness can lead to rigid boundaries. Rigid boundaries often appear to be extreme stances as well. In substance abuse treatment, we talk about an all or nothing way of thinking or a take no prisoners mentality. These are two examples of rigid boundaries. The consequences of the rigid boundaries is often isolation, loneliness and judgementalism.

Boundaries can be applied to a number of settings. This brief review is provided to help you think about what your boundaries are.

Physical boundaries

Physical boundaries refer to the space around us. When I worked with children, I talked about the “bubble space” around us which intuitively helps us understand how close I can get to another person. And the concept of a bubble space affirms healthy understanding of the fact that boundaries are flexible. Depending on the circumstances, the size of the bubble space can change. For example, as the number of people in a room increases, we are more comfortable if some sits in the chair next to us as compared to when there are only two people in a room. Depending on the person, the bubble space changes. With friends and family members, our bubble space is smaller versus the amount of space with a stranger.

Emotional and intellectual boundaries

These two types of boundaries essentially reflect your right to your feelings and thoughts. As individuals, we have the right to feel and believe based on values, spirituality, education or any cultural affiliation. More so than physical boundaries, it is our emotional and intellectual boundaries that define our personality and identity. It is these boundaries that form a major basis of sexual health. They key is to examine how your boundaries will shape your sexual behaviors.

Boundary Violations

A boundary violation occurs when someone crosses the boundaries. The reasons for boundary violations are varied. It may be deliberately or accidentally. It may be done to hurt you or help you. Never ending criticism is a major violation. Reading people’s mail or email is another example. Someone telling us what we should feel or think is yet another. The importance of assertive communication helps set and maintain boundaries.

One of the things to highlight are symptoms of unhealthy boundaries as boundaries relate to sexual health. These are but examples, but highlight the impact of unhealthy boundaries.


· When you don’t want sexual contact, but go along with it anyway so the person will like you.

· Saying you want to go on a date but going over to a person’s house.

· Telling someone you like to so a behavior but don’t.

· Saying you want to get together with someone but don’t’

· Using drugs in a sexual setting when you don’t want to.

· Not expressing your sexual desires or preferences with a partner and simply going along with what they want.

· Falling in love with anyone who reaches out to you

· Acting on first sexual impulse when you say you’ll wait for knowing the person first.

· Using sex to express anger or loneliness; being sexual for your partner, not yourself

· Going against personal values or rights to please others

· Not noticing when someone else shows poor boundaries

· Touching a person without asking

· Letting others tell you what you should or should do

· Letting others tell you what is and isn’t healthy sexual behavior.

· Expecting others to automatically know what you want

· Having unsafe sex when you say you wont

Touch/Physical Intimacy

One form of intimacy as described in the Topic on Intimacy is physical intimacy. This expression of intimacy is sometimes referred to as touch intimacy or touch needs. The overlap between sexual intimacy and touch intimacy leads to significant confusion. It is important to ask in any given encounter what my intimacy needs are. And, specifically, what my touch needs are. Perhaps in a particular encounter you may be trying to get your touch needs met rather than sexual needs.

In this topic, the goal is to review healthy touch, and identify how you get these needs met. Some classic social psychology research has suggested that the failure to receive touch can have severe negative health, social and emotional impact on a person. The types of touch exists on a continuum. On the unhealthy end, exploitive touch is manipulative, forced, or unwanted. Nurturing touch is healthy and is expressive of a relationship. Touching someone is one way of reaching out and affirming them or being affirmed. And in fact, unhealthy touch is the opposite. It can be a way to express hurt, anger, or fear. Somewhere in the middle the grey area of touch occurs. In this confusing center are experiences of touch that appears healthy but leaves a person unsure about the intent. It may be the hug that includes a brush against breasts, buttocks or genitalia. Or the kiss that goes on too long. In moving toward sexual health, it is important to recognize healthy and unhealthy touch and to identify ways to get your touch needs met. You may also want to review the topic on sexual exploitation which describes forms of extreme unhealthy touch.

In developing ways to get your touch needs meet, it is also important to be clear about your motivation. In reviewing your sex history, how many times have you engaged in sexual contact when what you were looking for probably simply affirmation through touch? Perhaps there have been times when someone has said “hold” me but the encounter became unexpectedly sexual.

In the modern American Culture, there is a significant cultural barrier to touch. So much of the messages about touch actually sexualizes touch. Two guys holding hands is seen as a gay couple rather than two friend together s as in many Middle Eastern cultures. The misunderstanding of touch raises significant problems regarding sexual harassment claims. I’m not judging any particular claims as right/wrong, but in sexualizing touch, our culture has deprived us of healthy ways to get healthy needs met in appropriate ways.

The cultural fear of touch is often internalized in our lives. As a result, we may misinterpret the messages of another person. There are also gender differences. For many women, touch is culturally encouraged where as for men, touch is discouraged. The typical woman has a better understanding of touch needs than the typical man. This misunderstanding can lead to miscommunication, conflicts, and resentments in both sexual relationships as well as social and emotional relationships.

Relationship Satisfaction

Answer the following questions.

1. Talking about sex with my sexual partner(s) is a satisfying experience.

2. Overall, I feel satisfied about my current sexual relationship(s).

3. I have difficulty finding a sexual partner.

4. I feel my sexual partner(s) avoids talking about sexuality with me.

5. When I have sex with my sexual partner, I feel emotionally close to him or her.

6. Overall, I feel close with my sexual partner(s).

7. I have difficulty keeping a sexual partner.

8. I feel I can express what I like and don’t like sexually.

9. I feel my sexual partner(s) is sensitive to my needs and desires.

10. Some sexual matters are too upsetting to discuss with my partner(s).

Yes responses for questions 3 4, 7 and 10 require long-term follow-up

No responses for 1, 2, 5, 6, 8, 9 require long-term follow-up

Much of the current culture places a sense of happiness within a healthy and fulfilling relationship. Regardless of sexual orientation, long-term personal happiness, health and wellness are correlated with healthy relationships. In fact, you get breaks on your insurance plans if you’re in a committed relationship suggesting that even wealth is correlated with relationship status. Whether you agree or not, our current culture also emphasizes that sexual behavior should occur within a monogamous relationship. In the realm of sexual health, relationship issues are a major factor, both as a target and/or goal of an individual as well as a factor for unhappiness. Too often the same people complaining that they are single are next complaining that they aren’t happy in the relationship.

Addressing relationship satisfaction is a major component of sexual health. Beyond the simple topic of satisfaction, the question of disclosure of sexual compulsivity is a topic reserved for stage 3. In this topic you are encouraged to focus on your level of satisfaction in your current relationship. In scoring the questions, pay attention to the responses that require long-term follow-up. Why did you answer the question the way you did? What are your plans to address these issues raised?

In addition to the above questions, clarify what type of relationship you would like. The typical expectation is that only monogamous relationships are healthy. How much do you agree with this expectation? In fact, there are a multitude of types of relationships. The key to the approach taken in this book is that you be honest, open and responsible for the type of relationship you want. This is where full disclosure is important as well. Are you being honest about what you're looking for and what you are doing?

If you choose an open relationship which is typically defined as a relationship where there exists a primary sexual and emotional partner followed by secondary partners it is important for you and your primary partner to clarify ground rules and expectations. When, where, who, how often, are all some of the questions to be addressed. What are the plans for communicating and coping with fear, jealousy, and insecurity? What are the safer sex rules? One caution is that all partners be open and honest in the conversation. Do not agree to an open relationship if it isn’t consistent with your values. It might be better to end a relationship than agree to a type of relationship that is inconsistent with your values. In the same way, if you want an open relationship clarify what needs aren’t getting met within your primary relationship. It is encouraged that significant reflection occur with your support network to clarify the reasons you want an open relationship. In particular, be careful that you’re simply not trying to get out of the first relationship. If the primary relationship is not healthy, it is important in my opinion to address the issues first. If it should end, do this with integrity versus causing a rift that ends the relationship.

Saturday, August 16, 2008

Sexual Functioning

One of the components of the sexual health model is freedom from problems with sexual functioning. The treatment of dysfunction issues falls generally into two categories, physical issues and mental health issues. The first place of intervention for sexual dysfunction is to obtain a complete medical check-up. If there is a medical condition, no amount of therapy will help address the issue. If the medical issues are identified and resolved and do not appear to be cause of the functioning issues, it is important to seek help to address the additional issues. The causes of sexual dysfunction are varied require an equally number of treatment plans that are beyond the focus here. The goal is to help you possibly identify the issue and respond with plans.

The majority of physical functioning issues include:

Female Dysfunction issues.

Dyspareunia and Vaginismus are issues addressing female genitalia. The causes are varied. A medical review is required to address the cause and treatment. Once medically treated medically, you and your doctor can identify strategies to adjust for the medical issue. While the majority of causes are medical, there may be some psychological issues (such as unresolved abuse issues) that can contribute to the condition.

Male Dysfunction issues.

Male dysfunction issues are typically categorized as impotence problems and (premature and retarded) ejaculation problems. The key is to first get a medical check-up to eliminate physical causes.

Both Male and Female Dysfunction issues. :

Orgasm problems: Problems with achieving orgasms occurs for both men and women, yet are often experienced more often by women. Treatment may or may not be physical and require a medical review. Sometimes, the partners of females need education to assist women in achieving an orgasm.

Low Sexual Desire: Sexual desire changes over time; sometimes a decrease in sexual desire is normal, other times it may be a problem due to medical issues (such as hormone changes) or mental health issues.

Sexual Aversion is when there is an avoidance of sexuality or sexual behavior. More often this is a mental health issues.

Finally, it is important to review how your sexual behavior has changed to cope with sexual functioning concerns. Review your sexual behavior timeline/history, are there any correlation with functioning issues? Have there been changes in your sexual behavior because of functioning concerns (increased masturbation/pornography use b/c of problems with erections). Medication changes/chemical use, depression can all adversely impact your sexual functioning. Are any of these relevant? If sexual functioning concerns are present, what are your plans to address the issues?

Sexual Health and Sexual Behavior/Expression

Throughout history, there have been attempts to define the range of sexually appropriate behavior. Within the Judeo-Christian Tradition, for example, the Holiness code of the early Israelite community was an attempt to define healthy sexual behavior which reflected their values, knowledge and community goals. As a small nomadic people, sexually healthy behavior reflected and emphasized procreation. As a patriarchal society, women were seen as property so most of the holiness code focused on male sexuality. As a society with limited information on current biology, the code attempted to identify sexually healthy behaviors as a function of blood and energy: loss of blood equals loss of energy and reflects a threat for survival. During the time of her period, women were to be avoided. Fast forward two thousand years and we have a Europe dominated by the Romans with a new religion slowly distinguishing itself from the pagan sexualities. Hence anything that reflected the pagan traditions was ultimately rejected. Fast forward another 2000 years, and we have a society that is unlike any previous society with its corresponding attempts toward defining sexual behavior. Our understanding of biology, genetics, and multi-cultural reality results in a variety of definitions of sexual health.

Perhaps the most frustrating aspect of the current debate in the field of sexual compulsivity is the same struggle that has occurred across time and is bound to fail. Many of the past attempts to define sexual health behaviors have emphasized actual sexual acts and condemned the behavior within the context of a religious statement. “This act is unhealthy, it is a sin.” As a result these definitions are culturally and time bound. Too often clients are stuck in the trap of asking the “expert” to define what he or she can do moving forward. Too often clinicians are readily open to defining what is and isn’t healthy based on their world view. These clinicians, in my opinion, fall into the same pitfalls of the historical attempts of defining healthy sexual behavior

In the last twenty-five to thirty years, experts in the field of human sexuality have also attempted to define sexual health. The definition of sexual health used in this book highlights the debate and development. While not reviewed here, the process of defining sexual health has experienced multiple revisions, discussions and bumps along the way. At one point, it was argued that a universal definition was not possible given the diversity of people, sexualities, cultures, and circumstances. The more recent attempts have attempted to facilitate an interaction between the individual and culture by incorporating a dynamic feedback process in clarifying sexually healthy behaviors.

What you won’t find in this book is a list of healthy/unhealthy behaviors. (In my opinion, there probably are very behaviors that are unhealthy. What few unhealthy behaviors are included below.) Rather than a list, my goal is to help you start thinking about the values that shape your life. In identifying these values, your responsibility is to assess the consistency between your values and your behaviors. The discussion below highlights a few critical values that I think are important. I recognize that these reflect my values. They are designed to help you start your conversation for yourself.

Unhealthy Sexual Behaviors

Generally speaking, the consensus among experts in a variety of fields (medicine, mental health, child welfare, and clergy) is that unhealthy sexual behaviors are defined as any behaviors that are exploitive or done without consent. For example, exploitation of children is one of the few universal consistent behaviors that have been condemned across time.

Problems with Identifying Unhealthy Sexual Behavior.

Yet, even this example has some problems. There are grey areas. In modern America, the definition of a child who can give legal consent for sexual contact ranges from ages 14 (Idaho) to 18. Centuries ago, it wasn’t uncommon for a 12-year old girl who just completed puberty (i.e., had a period) to be considered an adult. Today, our collective culture would define this as abuse. Another grey area is questions of exploitation. Many individuals against the pornography industry argue that the material exploits women. These grey areas highlight the ongoing danger and difficulty of universal declarations.

An example sure to raise hackles is the emphasis by a significant group of people in the world which suggests that only sexual behavior focused on procreation within a marriage relationship is the only form of healthy sex. Any sex act that isn’t open to procreation, even within a marriage, is a sin. This approach includes any masturbation and use of pornography as a sin. Some people have modified this approach to emphasize that sex within a marriage relationship is healthy. Others continue to modify this approach that consensual sex within a marriage is healthy recognizing that some traditions emphasize the wife’s religious duty to submit to her husband. Recently, there has been a push within the GLBT community to emphasis monogamy as the only form of healthy sex and the need for marriage rights as a validation of these healthy behaviors. Sadly, where the line of healthy/unhealthy sexual behavior is drawn seems to depend on what side of the line that you fall on. If you’re “outside” the line, you redraw the line to include your sexual behaviors.

Healthy Behaviors

The approach taken in this workbook and highlighted in the recent development of definition of sexual health is to emphasis a dynamic process between the community and the individual. Your values shape what behaviors are healthy for you. However, this is not a free-for all. Part of the process includes disclosure and community conversations via your support network and your prevention plan. This will be discussed below. The rest of this conversation is a process of presenting certain values that may be helpful in defining healthy sexual behaviors. As part of Stage three, you will be asked to identify both values and sexual behaviors that are congruent and reflect your personal definition of sexual health. This topic is designed to help you start that reflection process.

1) Generativity. Generativity is the experience that any sexual behaviors makes you alive and energized as part of the experience. In this value, your personal identity is affirmed, created and even expanded. You can walk away from the experience with your head held high. There is a sense of fulfillment and even pride in the experience. While life giving, generativity doesn’t necessarily mean the experience is “great sex” but rather the identity and personhood of those involved is enhanced. Sexual behavior is sometimes referred to as “adult play” suggesting a sense of fun, playfulness, and sense of timelessness. Review the topic “Reasons for having Sex.” The behaviors reflect healthy reasons for having sex.

2) Open and Honest. Healthy sexual behavior is above board, open, and honest. Full consent and awareness are present in the encounters. While you may not talk about the incident because of discretion, you could disclose the activity to your support network. And in the disclosure the support network would be able to conclude that the behavior is consistent with your declared values and prevention plan.

3) Consensual and Mutual. Consent implies that all partners are actively giving permission to engage in the behavior. For consent to be present, this requires appropriate disclosures and considerations. This measure assumes that full disclosure has occurred with your partner, including risks for STIs, pregnancy, relationship status/availability or any number of measures. There is a decidedly lack of manipulation in the experience (i.e., if you love me, you’d have sex with me).

It is important to highlight that in some circumstances, consent is not possible. Children, for example are not able to give consent. Relationships with power differences (for example, student/teacher, boss/employee, therapist/client) are by definition non-consensual. Other circumstances exist where the ability for parties to give consent is questionable including impairment due to mental health issues, chemical use, and/or financial status (prostitution also known as survival sex). Another notion within consent is that all parties need to be aware of the experience, which is why exhibitionism and voyeurism are defined as unhealthy (as well as illegal).

Finally, within the concept of mutuality is the concept of respect for the partner’s boundaries and limits. If consent is removed (i.e, stop, no, I don’t want to), the behavior must stop. Consent can be removed by any person in the experience at any time. The removal of consent does not require a reason; it simply is.

4) Responsibility. As a value, this requires you to fully assert your sexual needs, likes and dislikes. How are you protecting your values? It isn’t up to the other person, rather it is up to you to affirm and do the necessary reflection for the protection and communication of the values.


Review the topic Sex History.” As you look at all the behaviors you may have done, how many of these behaviors are consistent with the values above? If they aren’t, I’d encourage you to remove them from the list of sexually healthy behaviors. Anything that remains would be a candidate for a “healthy behavior.” The last task is to finish the Topic Defining your personal Definition of Sexual Health and Creating your Future. Again review the candidate list of healthy behaviors. Which behaviors remain? Review this list with the support network. What behaviors remain? This is the list of healthy behaviors to be included in your Personal Definition of Sexual Health.

Friday, August 15, 2008

Safer Sex and Sexual Compulsivity

Complete the following questions

1. R. I feel too embarrassed to buy condoms.
2. R. I fear getting HIV/AIDS or a sexually transmitted disease.
3. It is my responsibility to use a condom with my sexual partner(s).
4. I would use condoms if my partner asked me.
5. R. Condoms are embarrassing to use.
6. R. I want information on feeling better about my sexuality.
7. R. I have had anal or vaginal sexual intercourse without a condom in the last 30 days.
8. FOR MEN I gave myself a testicular exam in the last 30 days. FOR WOMEN I gave myself a breast exam in the last 30 days.
9. R. I feel I am at high risk for getting HIV/AIDS or a sexually transmitted disease.
10. R. I worry that I might be infected with a sexually transmitted disease.
11. R. I want information on sexually transmitted diseases.
12. R. I feel ashamed when seeking medical care for sexually transmitted diseases.
13. I feel comfortable when I touch my genitals.
14. R. Condoms make sex less pleasurable.
15. R. I have noticed physical changes on my genitalia in the last 30 days that concern me.
16. My partner would use condoms if I asked him/her.
17. R. I want information on how to practice safer sex.
18. R. I worry that I might be infected with HIV.
[ ] check here if you know you are HIV Positive.
19. R. I want information on HIV/AIDS.
20. I know how to correctly use a condom.
21. R. I engaged in unsafe sexual behavior in the last 30 days.


Score 1 point for each YES for the following: 1-2, 5-7. 9-12, 14-15, 17-19, 21.

Score 1 point for each NO for the following: 3, 4, 8, 13, 16, 20

The higher the score, the increased risk to your overall sexual health and HIV/STD.

The purpose of this topic is to review HIV and Sexually Transmitted Illnesses (STIs) as they relate to your sexual behavior and possibly to the acting out cycle. This topic does not focused on prevention, (see http://www.mnaidsproject.org/ or http://www.cdc.gov/hiv/default.htm) or treatment issues (see http://www.thebody.com/). Together, these three websites cover a range of topics from prevention techniques, resources and responses to commonly asked questions regarding HIV/AIDS. And while prevention and treatment issues are important and are related to sexual health, the goal of this topic is to help you understand how this information shapes your sexual behavior. My experience highlights how the relationship between your identity, thoughts and sexual behavior is multi-directional. To maintain and create sexual health, it is important to understand the thoughts you have about HIV, STIs and sexual behavior.

The questions above reflect research in the relationship between safer sex issues. The questions reflect vectors or concerns that underlie increased risk for HIV transmission. And they reflect areas of focus in your ongoing move toward improved sexual health.

Multidirectional Relationship between Sexual Health and Safer Sex

The relationship between sexual health and safer sex behaviors can be multidirectional. This position reflects that your mood can shape your sexual behavior, and your reaction to that behavior may set you up for the next round of the cycle. “I’m so ashamed of my behavior that my feelings of hopelessness and worthlessness have increased.” The positive part of this reality is that intervening anywhere in the process is a start toward improving sexual health.

Reasons for Unsafe Sex Research.

The field of HIV prevention has done significant research in why people engage in unsafe sexual behavior. The research has generally suggested a number of themes relevant to sexual health which include Sexual Compulsivity, Mood, Alcohol and Drug Use. In terms of your sexual behavior, reflect on the times you have engaged in unsafe behaviors. What reasons appear to be more relevant for you? These issues need to be addressed in your prevention planning.

Unsafe Sexual Behaviors and Mood.

One of the saddest things in my experience is when I sit across from a person who is negative or a person who is positive when they report that their self-hatred, shame, guilt, depression and/or hopelessness is contributing to their unsafe sexual behaviors. I’ve heard too many times “I wanted to kill myself by getting HIV.” This is a classic example of why sexual health has so many components and highlights the difficulty in moving toward sexual health. In these situations, sexual health requires addressing the underlying mood. In the topics on depression and anxiety, the connection between mood and sexual compulsivity were briefly reviewed. Much of that material applies to safer sex issues: If I believe I’m worthless, and I can only get affirmation through sex, I may do whatever my sexual partner wants to have them stay including the possibility of not following my ground rules for safer-sex. The problem lies in where do you start in the intervention process. This dilemma highlights how treatment for sexual health is so difficult.

Anxiety about HIV and Safer Sex.

Where as a depressed mood can contribute to safer sex, some people experience so much anxiety around HIV that they have simply shut down their sexual expression. The anxiety has led to a paralysis and fear that becomes the focus of the problem. In some of these cases, the anxiety is transformed to ritual masturbation or pornography use that is the manifestation of the acting out cycle. In this example, however, it is the thoughts that create the anxiety about the HIV that precedes the acting out cycle. Another example of the role of anxiety highlights when people are so anxious about HIV that they use alcohol and drugs to self-medicate and reduce the level of anxiety. And while under the influence, they begin to engage in unsafe sexual behavior which creates feelings of shame and guilt ultimately continuing the acting out cycle.


Review your unsafe sexual behavior. Highlight the 4-5 reasons for unsafe sexual behavior that are relevant to you.

Examine the questions above. For each question you scored a point, reflect on the underlying issues and identify plans to address the needs regarding why you scored the point.

Examine your safer safer sex behaviors through the lens of the values you want to shape your life. How consistent are the behaviors and values? If, for example, you value respect, how is self-respect impaired or damaged when you engage in unsafe sex behaviors? How is respect for others diminished when you engage in unsafe sexual behaviors?

What are your plans to address safer sex issues?

Wednesday, August 13, 2008

Fantasy and Sexual Health

1. R. If I fantasize about sex, I will become obsessed about sexual thoughts.

2. R. It is difficult for me to share my sexual fantasies with a sexual partner(s).

3. Sharing a sexual fantasy with a sexual partner(s) enriches my sex life.

4. Sexual fantasy helps me learn about what I like and don’t like sexually.

5. Sharing a sexual fantasy is a good way to get to know what a sexual partner likes.

6. I enjoy fantasizing about sex.

7. R. I feel guilty when I fantasize about sex.

8. I enjoy hearing about my sexual partner’s sexual fantasies.

9. Sexual fantasy helps me express my sexual desires.

10. Sexual fantasy is safe outlet for behavior I choose not to act upon.

Score 1 point for each yes response for questions 3-6, 9-10
Score 1 point for each no response for questions 1,2 and 8
The higher your score, the more comfortable you are with sexual fantasies

Sexualizations and Sexual Fantasies.

The idea of sexual fantasies is a topic that also has many negative societal biases and messages that need to be addressed. To begin with, I make a distinction between a sexualization and a sexual fantasy by using a “3-second rule.” This rule is simply based on clinical experience and not necessarily based on any hard and fast research. Nor does it have to be 3-seconds: it could be 2 or 4 seconds as well. As a clinician, I hold that sexualizations are normal, happen outside our realm of control and are part of the sexual drive. In this approach, sexualizations simply happen. They just are. A sexualization is recognition that someone is attractive to you. Often sexualizations can occur outside of one’s primary sexual partner template. A “straight” man can recognize a handsome guy just as a gay man can recognize a beautiful woman. In these situations, there is simply a recognition of the sexuality and sensuality of another person.

What moves a sexualization to the level of a sexual fantasy is the ongoing thought and/or fixation on a particular person, thought or object. That was how the three second rule was created; it was in response to clients asking for a ruler on when that process switches from a sexualizaiton to a fantasy. Throughout the day, many sexualizations occur. It is how a person responds to the sexualization that raises the issue to be addressed.

Fantasies are normal.

Generally speaking, the reality is that fantasies are simply normal aspects of our sexuality. Everybody has fantasies and daydreams. In and of themselves, fantasies are neutral. To be clear, the key concept in this section is that fantasies are normal and healthy. At the same time, it is important to highlight that some fantasies are risky or unhealthy. The content, frequency, intensity and focus of the fantasy may raise some issues to be addressed. This may require you to address your thoughts about fantasies and to examine the content of the fantasies.

Fantasies can be helpful in understanding ourselves and our sexuality. Through examining our fantasies, we can get a sense of what we find arousing. We can understand our needs and share with our partner and support network. Sometimes we can channel our energy into sexual fantasies to allow a healthy release. Sharing our fantasies is difficult for some people, yet the process of sharing these fantasies can create positive intimacy with the other person. And we can experience fantasies about things we would never choose to act upon.

Misperceptions of fantasies.

In moving toward sexual health, it is important to highlight and clarify misperceptions that exist about fantasies. Having fantasies does not mean you are over-sexed even if you fantasize about sex or think about sex often. Sexual fantasies are thoughts and feelings about sexual behaviors and ideas that we find sexually arousing. Sexual fantasies may represent what turns us on. Sexual fantasies are also a form of self-stimulation. Simply having a fantasy does not mean we have to act on that fantasy. Having a fantasy does not mean that we will automatically follow through with the behavior in the fantasy. Fantasies exist only in thoughts and the subsequent feelings; they are not themselves real. That also means that when we have a fantasy of a negative traumatic event, the fantasy is also real.

Application of the primary thinking error and fantasies.

Morin identified the concept of “core erotic thought” which he used to highlight how our thoughts also shape our sexual fantasies. And by examining our most powerful fantasies, we can gain insight into how we see our basic self. In his work, Erotic Mind, he highlighted how fantasies changed in light of the therapeutic process. Specifically, he highlighted how negative and damaging fantasies slowly decreased as the clients addressed the underlying issues. As they moved toward health, Morin argues that the fantasies changed. The application for this section is to emphasize the importance of not only acknowledging the fantasies, but to study them for insights into your underlying patterns of thinking.

Unhealthy Fantasies.

Occasionally, thoughts of inappropriate or unhealthy sexual behaviors may occur as themes in your fantasies. This is important issue for individuals with a pattern of sexually offending behavior. It is also true for individuals in chemical dependency recovery when the fantasies including drug use and sexual behavior mixed together. To a degree, this is simply normal. How you respond to the unhealthy fantasies when you notice they are occurring is the key step toward sexual health. To the degree that you can, it is important that you stop the fantasy or actively encouraging it. This can be done by changing your environment, talking with your network, etc. It is important that you do not masturbate to these fantasies because you might make them stronger or more frequent. An escalation of unhealthy behaviors may occur if you do not interrupt the fantasy cycle. If you recognize the unhealthy fantasies are increasing either in frequency, intensity or content, it might be a warning sign or high risk behavior. Letting your support system know that you are having unhealthy or risky fantasies can be a part of your prevention plan.

If sexual fantasies are used to avoid and/or escape from reality or are the only form of sexual expression, then I would also express concern. Also, some clients have used fantasies as a form of escape from unpleasant thoughts and feelings. Finally, for some people, particular fantasies can start the acting out cycle. Taken together, these types of fantasies should be avoided. They key is for you to figure out which fantasies are healthy and unhealthy.

Creating Healthy Fantasies

We can use sexual fantasies to move toward sexual health. This can be through harm reduction techniques, as well as positive sexuality. In our fantasies, we can create and clarify our values toward sexuality and toward others. One assignment I provide was listed in the sexual history. Identify three favorite fantasies. I’d encourage you to write these out and be as detailed and specific as possible. As you review the responses to those questions, consider the following questions:

What is the content of the fantasy? Explain the 5 Ws: who, what, when, why, when. As you answer these questions, think about how the content fits in with your components of sexual health. What, if any, risk factors or forms of acting out are present? If they are present, how do you change and/or slowly move the plot line of the fantasy toward something that is healthy for you. In this sense, you can shape the outcome of the fantasy. If this fantasy was to occur, what would you think and feel as a result?

Masturbation and Sexual health

Answer the following questions.

1. I enjoy masturbating.

2. Masturbation is a good way to affirm my sexuality.

3. Masturbation is a good way to help me feel better about myself.

4. R. I believe masturbation is sinful.

5. Masturbation is a healthy way to have sex when I’m horny.

6. Masturbation is a good way to get to know what a sexual partner likes.

7. Masturbation with my sexual partner(s) is a healthy expression of being close to one another.

8. Masturbation is very safe sex.

9. Masturbation is a healthy way to learn about my sexual desires.

10. Masturbation is a positive source of comfort and pleasure.

11. Masturbation is a form of healthy sexual expression.

12. Masturbation can be helpful in overcoming sexual dysfunction.

13. I masturbate to explore my body.

14. R. I masturbate too much.

15. R. I feel guilty when I masturbate.

16. Masturbation is a good way to reduce stress.

17. Masturbation is a good form of birth control.

Score 1 point for each yes response for questions 1-3, 5-13, 16-17

Score 1 point for each no response for questions 4, 14, 15

The higher your score, the more comfortable you are with masturbation

The American Culture has a significant amount of negative beliefs against masturbation. An introductory article that has the basics about the history of masturbation can be found at Wikipedia (http://en.wikipedia.org/wiki/Masturbation). It is not my goal to review this history given it’s availability else. They focus of this post is to examine the role of masturbation in your sexual life. It is also important to help you examine your thoughts and historical messages you have about masturbation and examine how these thoughts help or hinder your sexual health.

The questions above are a good place to start in assessing your views toward masturbation. Review each question again. When you read the question, pay attention to your reaction for each question. For example, when I think about enjoying masturbation, how do I feel (e.g, shame, embarrassed, happy)? What thoughts do I have regarding masturbation (e.g., sin, nothing, angry?)?

Next, review your sex history. The first section of the sex history asked questions about masturbation. As you examine the responses, pay attention to what your historical and current thoughts and feelings have been regarding the experiences of masturbation. How have these thoughts and feelings contributed to acting out? For some people, masturbation is a form of harm reduction reducing the risk of acting out.

Finally, think about the role of masturbation in your definition of sexual health. How might you integrate masturbation as a form of healthy sexual expression? What thoughts and feelings about masturbation must you address to reduce the risk of future acting out? Under what circumstances might masturbatory behaviors might be unhealthy for you? Under what circumstances might masturbatory behaviors might be healthy for you?

Tuesday, August 12, 2008

Sexually Explicit Material

One of the more controversial issues in the field of sexual addiction, sexual compulsivity and sex offender treatment is the role and use of sexually explicit material. Notice the language: I use sexual explicit material to highlight anything of any sexual content versus the term pornography. Part of the reason for the change in language is to step beyond the conflict and highlight the need to adequately assess the use of ANY sexually explicit material. Pornography is often assumed to be nude magazines or nude videos. In my experience, sexually explicit material is any material you use for any sexual purposes. This can include sexually explicit magazines and videos but can also include what some people would consider benign advertisements such as the classic Sears Catalog of old. The number of clients who report they looked at the bra ads while growing up highlights how a lot of material is sexually explicit without being pornographic. Another example is Sports Illustrated Swim Suit Magazine or Men’s Health. While not pornographic, my experience suggests that this material is used for sexual purposes including but not limited to masturbation and fantasy material. In the topic on the Internet, ease of access to sexually explicit material via computers, cell phones, and other devices simply highlights the importance of addressing how the acting out cycle and sexually explicit material are present in your life.

As you review your sex history and timeline, highlight the types and content of the sexually explicit material. As mentioned, the content can range from pictures, videos, online materials, stories, advertising material, and even art. The “nudes” of classic art can be considered by some clients as sexually explicit material. As a starting point in your personal assessment, start with an extreme conservative definition of sexually explicit material: Any medium with any content that you sexualize or could be sexualized. The key is to help you highlight the degree to which sexual content is present in your life. The level of bombardment is amazing and will probably surprise you once you start this assignment. Next, focus on how much material you explicitly seek out versus simply in your environment.

As you start to increase your awareness of the type and amount of material, start to focus on what is arousing or attractive to you. What themes might be present? Where do your thoughts and fantasies go regarding the material? As you recognize the material, I’d also encourage to highlight any thoughts, feelings or memories that come to mind. Much of what we see as sexually arousing is defined by our culture –such as family, racial, gender, religious, orientation, or national culture -and can change over time. What were the messages you heard while growing up? What are the thoughts you have now?

The role of sexually explicit material in your future is the part of sexually explicit material in your definition of sexual health. The scholarly field is divided. Some clinicians believe that almost any sexually explicit material is unhealthy by definition because it can be misused and can be used to exploit others. Some religious traditions believe that looking or using sexually explicit material is tantamount to infidelity and is therefore a sin (because of the 10 commandments, it is the equivalent of coveting your neighbors wife). Some clinicians find sexually explicit material as neutral and focus on the surrounding context in any given setting about the value of the material in that context. On the other end of the spectrum, clinicians sometimes use sexually explicit material as educational to help couples address sexually functioning issues, and to help facilitate the sharing of sexual thoughts with a partner. And as a final example, other clinicians have no general concerns about pornography and see it as something that simply is.

My approach is a little bit of all of the above. For me, the key is to have you identify your current use of sexually explicit material, review what your values are regarding the material and focus on the role the material has in your cycle. If sexually explicit material sets you up for repeated periods of acting out, then I would suggest that it is not helpful in your case. For other people, sexually explicit material is a form of harm reduction thus reducing the risk of acting out. How do the values you choose to live by in your life shape your use of sexually explicit material. A common theme throughout the book has focused on your definition of sexual health: how does sexually explicit material foster that development. Whatever your choice, the key is to demonstrate integrity between the use of the material and your definition of sexual health.

Monday, August 11, 2008

Internet Use and sexual compulsivity

In my opinion, there is no greater bane for individuals who struggle with sexual compulsivity than the internet. In the nearly 15 years since wide integration into all aspects of our life, the internet has provided easy access for all types of sexual content. The access has only increased the amount of unhealthy behavior and pushed those who struggle with it further from support networks. Cooper in a series of articles focused much of his later research on this topic. One citation is used below, but his work spanned about 8 years. He is easily the “grand daddy” of the internet research and sexuality. One key finding that I find helpful is the metric of how many hours a week are spent using the internet for online activity. His research suggests that 11 hours or more per week is the point that distinguishes those who many have a problem versus those who probably don’t. The number reflects not simply internet use, but specifically internet use for sexual content.

The types of internet use for sexual content is changing at a rapid pace. In the early stages, with dial up the process was primarily pictures downloaded as binary files and reassembled by the user. Now, with readily available high speed access, streaming pornography is present. The rise of internet-capable cell phones highlights the newest expression of how easy it is to access sexual material online. My point isn’t to say this is bad, but too point out how easy an individual with sexual compulsivity struggles with the issue. It is akin to a drug addicting having the drug waved in front of his or her face and being told not to do it. Given the increasing importance of the internet in all aspects of our life (banking, email, news, managing accounts with service agencies, setting up doctor appointments) the problem is only going to intensify.

They types of internet sexual behaviors are too many too list here. As the internet has increased in sophistication, the types of behaviors have adapted. I expect the adaptation to continue as well. I use Cooper’s measure of 11 hours or more per week of online sexual behavior as a metric to suggest further review of the behavior. When you look at your internet use, consider the following behaviors:

  1. Looking at pictures of sexual explicit material
  2. Downloading or viewing streaming pornography material.
  3. Online chatting behavior focusing on sex.
  4. Searching for specific types of material (fetishes)
  5. Reviewing profiles on sex specific connection profiles
  6. Using free websites to set up meetings for sexual sites
  7. Using websites to review which public cruise sites are the focus of police stings.
  8. Using non-sex websites for sexual content (e.g. Craigslist).

Questions to consider:

  1. How many hours a week are you using the internet for online sexual behavior?
  2. Are you using the internet for sexual behaviors where if discovered would create serious consequences (i.e., work)?
  3. Have you attempted to cut back the amount of use and repeatedly used?
  4. Have you attempted to restrict your use through filters or other controls only to circumvent these controls?
  5. What devices have use used to access explicit material (phone, computer, etc?)
  6. How does there internet set up other problematic behaviors (internet to sex to drug use?)

In terms of the acting out cycle, it is important to examine how the internet is both a cause and effect in the cycle. I can be bored, sign online for chat that leads to a sense of desperation, which leads to a hook up. Or, I can get a text message that leads to a hook up and if drugs are present relapse on the chemicals. As a focus of treatment, it is important to identify specific and measurable plans that can facilitate healing. What are your plans?