Over the years, I’ve worked with a number of individuals who have presented with out of control or compulsive sexual behaviors. In the past, these folks may have been designated as “sex addicts,” but the field is currently in transition and moving away from this perspective. A number of other models have sprung forth to fill in the void, and I have written about some of them previously. In this article, I will focus on what I feel is the most fundamental shift in the discussion around this issue, which is a move from abstinence only (the addiction model) to harm reduction.
Harm reduction? What is that? In essence, harm reduction is nothing new; it has been a staple of public policy and social programs for years. Indeed, I got my start in the field as a harm reduction outreach worker, going to local parks and other hangouts in and around NYC, exchanging clean needles for dirty ones with intravenous (IV) drug users or providing condoms and other necessities to transgender street sex workers. There are a number of harm reduction centers in many large urban areas around the country, funded both by charities and grants, as overwhelming evidence supports the efficacy of this kind of approach. It is only recently though that harm reduction has entered the psychotherapy office as a foundation for understanding human growth and psychological change. Indeed, I am proud to be at the forefront of this movement, hosting workshops on integrating harm reduction with sex therapy and speaking at major conferences on this issue.
At its root, harm reduction is both humanistic and culturally libertarian. No, I’m not talking about politics and Ron Paul. Let me explain what I mean. One of the most crucial aspects of psychotherapy is to privilege the subjective experience of the client. In other words, my job isn’t to try to convince the client to change his or her views, lifestyle, or beliefs. Rather, my role is to try to understand the client as deeply as possible, to metaphorically place myself in the shoes of the client, and soak in the lived experience and subjective reality of the individual before me. By privileging the autonomy of the individual, rather than using the authority of the psychotherapist to push some specific agenda, harm reduction gives space for this kind of experience to take place. In this way, it is both humanistic (honoring the subjective experience of each individual) and culturally libertarian (honoring the right of the individual to make his or her own choices). From there it is my task to help the client achieve their goals, while honoring the client’s right to live life as they choose, all while minimizing the harm that may come from those choices.
Harm reduction is typically used in drug settings, but I feel it is just as important and appropriate when it comes to sexuality. Here’s why. Tons of research shows over and over again that sexuality is hard-wired and cannot be changed through psychotherapy. In other words, the person with a high sex drive, the individual with “weird” fetishes, the client that doesn’t fit into neatly arranged gender norms, that individual is wired that way and no amount of talking about it will change that. Nor should that be the objective anyway. Therapy that’s aimed at changing sexuality is inherently shaming and moralistic. This is where harm reduction shines, as it doesn’t attempt to change the unchangeable or push an exterior agenda. At its core, a harm reduction approach asks, “How can I help this individual integrate their chosen behaviors into their life in safe ways?” As my friend, fellow sex therapist Doug Braun-Harvey says, we need to protect clients from ourselves by making sure we don’t try to give clients an “erotic-ectomy.”
So fine, we can agree that sex addiction is an inappropriate diagnosis for those who practice nonnormative forms of sexuality. But what about those individuals that are truly out of control– they spend all their money on sex workers, lose their job due to porn usage, and are constantly in legal danger due to high risk behaviors? How does harm reduction help here? For the answer, let’s look a little deeper at the underlying philosophy. If you get a chance take a look at this quick video about addictions, and then rejoin me below the clip:
As this video illustrates, what we typically call an “addiction” is not a physiological dependence at all, but merely a compulsive urge stemming from underlying emotional issues. Indeed, as the video describes, Vietnam war vets who were removed from the source of their mental anguish had very high rates of staying clean and never going back on heroin, while civilians with internal problems kept going in and out of rehab. This is one reason that the sex addiction label is so misleading– it tries to provide a physiological cause for something that is primarily emotional and psychological in nature.
So with this in mind, what of the individual that wants to stop a certain behavior but doesn’t have some alternative or support system in place? In these cases, the abstinence model is not only unhelpful, but even counterproductive. Without implementing a replacement first, “abstinence only” is often doomed to fail, propelling the individual into a further sense of frustration, shame, and futility.
With a harm reduction approach, we don’t discount abstinence, but we also acknowledge that other approaches are just as viable. It’s not a “one size fits all” approach. Most importantly, harm reduction accedes that not everyone is ready to quit. For most, their behavior provides them with some personal benefit, often in the form of self-soothing or maintenance, and if this behavior is removed without replacement they are left to fend for themselves without the very means with which they learned to cope and survive. In other words, harm reduction is humane (and humanistic) because it acknowledges that some individuals need to continue their behavior, albeit safely, while learning additional coping strategies. Indeed, the initial focus is not about prohibition, but rather understanding. Specifically, understanding what this behavior means to the individual, how they can get their needs met in more appropriate ways, and how they can stay safe while this process takes place.
If you are interested in learning more about harm reduction, please consider attending the following events:
Tues Sep 20: A Harm Reduction Approach to Problematic Sexual Behavior, with Dr. Andrew Tatarsky and Dr. Wendy Miller
Fri Sep 23: Society for Sex Therapists and Researchers (SSTAR) Fall Case Conference– Integrating Sex Therapy with Harm Reduction in the Treatment of Out of Control Sexual Behavior, featuring yours truly