Last post I discussed some ideas around self exploration and peak experiences that strongly resonate with me. In this post, I’m going to address another issue which is just as equally important to me– harm reduction. What is harm reduction and what application does it have for sexuality in general and sex therapy in particular?

First, let me say that my introduction to the field of sex therapy was in harm reduction, so all of my work is firmly rooted through this lens. Initially I volunteered and then worked in several harm reduction facilities in the city conducting outreach to homeless intravenous (IV) drug users, street prostitutes, and transgendered individuals. For example, I would go into Tomkins Square Park in the village and trade clean needles for old, dirty ones. I always wore an ID badge to make sure I wasn’t arrested. I would go into known prostitution areas and hand out fresh condoms to mitigate the chances of them contacting STDs. If they were ready for help, I’d bring them back to the facility and connect them with a benefits counselor who would assist them with getting sober and finding housing and any other necessities they needed.

According to psychologist Andrew Tatarsky at the Center for Optimal Living, harm reduction is “a philosophy and set of interventions that seek to reduce harmful consequences of substance use and other risky behaviors without requiring abstinence.” Without requiring abstinence? What is that about? I think an important point here, and one that many harm reduction theorists and practitioners would argue, is that abstinence doesn’t work for everyone. Or everyone is not yet ready to embrace abstinence. For some, the behavior is so entrenched as an aspect of their coping that full abstinence would be experienced as tremendously destabilizing.

So, in the absence of full abstinence, how do we keep someone safe while they find a way to deal with their struggles in a way that works for them? This is where harm reduction comes in. One other thing: I think another salient point about harm reduction is that it isn’t necessarily against abstinence. Instead, it views abstinence as just one option, not the only option. So how do I incorporate harm reduction into my work? First, I make sure never to pathologize. Here and here are some other articles I’ve written on the dangers of unnecessarily pathologizing clients.

If a behavior poses no threat or harm to the individual or anyone else, then I think an appropriate first step would be to understand what the behavior means for the individual. Often times, helping someone to remove shame and stigma feels like a tremendous relief and is harm reduction in and of itself. If the behavior does cause harm and feels compulsive or out of the grasp of the individual to control, research (particularly when it comes to sexual behaviors) shows that eradication doesn’t work and suppression just makes it feel more intense.

In that case, I find that a mindfulness-based approach of observing one’s cravings or desires and just taking on an air of curiosity, rather than judgment is a great beginning point to soften the intensity of the urges. Judgment and harsh criticism in particular are often catalysts for intensifying the shame surrounding a thought, feeling, or impulse. Getting an individual to the point where he or she notices when they are being harsh and unkind to themselves (and then practice more self-compassion) is often a pivotal point in the course of treatment.

I wrote about this in this blog post here, but the basic example that I make is of the pink elephant. If I say, “quick, don’t think of a pink elephant,” what are you going to do? Of course– you will think of a pink elephant. Trying to suppress and fight it only makes it worse. If we are constantly trying to stop thinking of a pink elephant, it almost forces us to keep the pink elephant in the forefront of our minds. Instead, if we notice when we think of a pink elephant but don’t really give it too much energy or attention, it will just drift away on its own and feel like much less of an intense presence.

For many, instead of trying to eradicate a sexual desire that may be be dangerous or cause harm, I look for ways that the individual can incorporate this desire but in more appropriate and healthy contexts. So, for example an individual who feels a sexual rush by placing him or herself in dangerous scenarios would benefit from strategies to find means to role play these situations, rather than have them play out in real life. Often a challenge is finding willing role-play partners, in which case I would suggest some resources for the individual to find appropriate community. These are all aspects of harm reduction.

In my mind, harm reduction is the gold standard of care for problematic thoughts, feelings, or behaviors (sexual or otherwise). Sexologist Jack Morin called unsafe sexual desires “troublesome turn-ons,” and I agree with this perspective. In other words, it’s a turn-on that has a time and place and often holds a great deal of importance for the individual. We don’t want to change it, suppress it, or otherwise hammer it away. Instead, we simply want to diminish the most unsafe and harmful aspects of the “troublesome” aspect of the desire. It is not only sex-positive, but ultimately, more humane.