Why we talk about sex

Individuals entering addiction treatment are usually asked a lot of questions as part of the initial assessment process. Family history, alcohol and drug use, employment and criminal justice involvement are routine data elements used to build a profile of the new client. Many treatment units also seek information about sexual practices, but often limit this information to questions designed to determine the client's risk for sexually transmitted diseases including HIV/AIDS.

For example, federally funded programs that utilize the Government Performance and Results Act (GPRA) data collection instrument ask about the nature of sexual contacts in the past 30 days (i.e., vaginal, oral, or anal), and follow up with additional questions about whether the contacts were unprotected, were with an injection drug user, or were with someone who is HIV-positive or has AIDS.

We know that many individuals entering treatment are conflicted about sexual activities and behaviors in which they have engaged. We also know that shame is a key component in initiating and perpetuating addiction to drugs and alcohol. We are beginning to understand that without addressing problematic sexual behavior and the shame attached, the likelihood of relapse triggered by sexual behavior is high. Despite this linkage, however, traditional treatment procedures tend to avoid the sexual domain.

For example, the Addiction Severity Index (ASI) is perhaps the most widely used questionnaire designed to elicit information from those entering addiction treatment. The ASI includes nearly 200 data elements that cover the medical, employment, drug/alcohol, legal, family and psychiatric domains. Missing are any questions regarding the client's sexual functioning or satisfaction.

Included in the ASI are items of arguably minor significance, such as:

• Have you experienced trouble understanding, concentrating or remembering?

• Have you ever been charged with shoplifting or vandalism?

• With whom do you spend most of your free time?

The ASI's only question about sex asks if the client has been the recipient of forced sexual advances or acts.

Direct approach

At Stepping Stone of San Diego we have learned that addressing sexual behavior and sexual shame are important elements in providing comprehensive addiction treatment and in laying a solid foundation for long-term recovery. Our experience indicates that a thorough understanding of a client's sexual behavior and psychological “comfort” level with that behavior are as important as understanding the client's drug use patterns, psychosocial triggers and significant relationships.

We thus have adopted a “sex positive” approach to treatment, creating a non-judgmental environment in which a client is encouraged to explore sexual desires and behavior with the dual goals of eliminating feelings of shame and reducing activities that place the individual at risk. To this end, each client participates in our Discovering Sexual Health in Recovery (DSHR) program, which is designed to explore connections between addiction and sexual behavior. The 12-week format includes didactic presentations, personal experiential exercises and facilitated process group interactions leading to the following outcomes:

• An understanding of expectations and boundaries while participating in a treatment/recovery program with a sex positive philosophy;

• Heightened self-awareness about the relationship between one's addiction and the role played by sexual behavior and shame in the development and maintenance of problematic drug and/or alcohol use;

• Comprehensive knowledge about human sexual functioning and the ability to assess levels of risk associated with specific behaviors and activities; and

• A relapse prevention plan that specifically addresses each client's sex/risk profile and incorporates both avoidance and compensatory strategies.

The DSHR creates a safe environment in which to explore subjects that have previously engendered feelings of tension, embarrassment and shame. Clients are encouraged to stretch their comfort zone, but ample precautions are taken to monitor on an ongoing basis emotional reactions to difficult disclosures.

Some of the questions that participants are asked to answer in the process of self-assessment are:

• Have your needs driven you to have sex in places or situations or with people you would not normally choose?

• Is it taking more variety and frequency of sexual and romantic activities than previously to bring the same levels of excitement and relief?

• Have you ever been arrested or are you in danger of being arrested because of your practices of voyeurism, exhibitionism, prostitution, sex with minors, indecent phone calls, etc.?

Mike Ortiz is the outpatient manager at Stepping Stone of San Diego and has worked in the addiction treatment field for 17 years. He says, “As a recovering heroin addict, a convict who has been clean for the past 18 years and a survivor of sexual abuse, I know personally how important it is for people to have a safe place to address these issues. One of the most important aspects of Stepping Stone is that we offer a sex positive environment.”

Ortiz continues, “In all my years of working in the treatment field, when the subject of sex or sexual abuse came up it was usually treated as a very taboo, hush-hush subject. It is both my professional and personal opinion that when clients are in extreme desperation and pain in their recovery and ready to disclose the back-breaking issue that might finally help them reach a place of hope, they are often shut down from making these ‘discoveries’ because counselors are uncomfortable with sexual issues. For many clients the sex-addiction link is central and counselors must learn to address it.”

The centrality of sexual shame and high-risk sexual behavior is illustrated in the three composite cases presented below.

Growing up under the influence

Larry grew up in a family where serious drinking was a daily event. All of his sexual activities as a teenager combined drinking with sex. Before entering treatment, Larry realized that all of his sexual encounters had involved alcohol. He believed that without alcohol, other people wouldn't like him or want to have a sexual relationship.

After Larry entered Stepping Stone he began to examine this pattern that had dominated his adult relationships. He realized that he would have to learn the entirely new skill of managing a relationship while sober. He also explored the role of drinking in masking feelings and preventing him from engaging in a healthy relationship. He realized that the desire to be loved and appreciated had become completely entangled with his drinking. Larry's treatment plan involved focusing on the quality of his relationships and gradually learning new intimacy skills that would eventually allow him to have an alcohol-free relationship.

Sex and meth

Paul, a 25-year-old gay male, had been using various drugs since he was a teenager, but methamphetamine had become his predominant drug over the past three years. At intake he stated that he was embarrassed and ashamed of his behavior. Paul described his typical drug-using activities. He would plan for marathon sex sessions-made possible by the use of meth. Paul described the experience of having sex while under the influence of meth as euphoric. He realized that his drug use and his sexual behavior had become inextricably linked. Whenever he thought about using meth, he also planned to have sexual activity, often at a local club or bathhouse. Whenever Paul had sex he felt he needed to use, and he acknowledged that he was generally unable to perform sexually without using.

As Paul's meth use increased, so did the level of risk involved in his sexual behavior, and he frequently had unprotected sex. Paul realized that his life was out of control-not just his drug use, but his relationships and sex life were also self-destructive.

At Stepping Stone Paul attended numerous educational and therapy groups. He recognized that because his drug use and sexual behavior were so closely linked, either behavior could trigger the other. Paul began to see that his sexual behavior was a key feature in his addictive cycle and that if he ever hoped to have a positive relationship, he would have to learn from the ground up how to have a safe and sober sexual relationship. Through role playing and feedback from his fellow residents, Paul learned to be aware of negative sexual triggers and he reduced his dysfunctional behaviors.

I'm home from work-sort of

Brian worked hard every day, then came home and wanted to relax. After a few drinks and smoking marijuana, he would sit and watch television until he fell asleep on the couch. Brian's partner was increasingly vocal that this negative pattern was not acceptable. His partner complained that they always argued and that they never had sex anymore. Brian was placed on medical leave at his job because of his gradually deteriorating work performance.

At Stepping Stone Brian examined the notion that he needed to relax and how he blamed his partner's nagging and complaining for all their arguments. His plan involved re-examining his entire lifestyle. Most importantly, Brian looked at the negative pattern he had established with his partner and the way he was ignoring the quality of their relationship. He committed to working on his communication and relationship skills so that his relationship with his partner would give him something better to do in the evening than drink and smoke pot. He hoped that over time, their sexual interactions would improve as their relationship improved.

Addiction treatment continues to evolve and improve. Addressing sexual health in treatment and recovery might well be one of the final frontiers as we continue to fine-tune our response to addiction and strengthen long-term outcomes.