Ethical Considerations in Treating Sex
Addiction in the Digital Age
Deborah Schiller, LPC, CSAT-S, CMAT-S
Program Director, Gratitude Sex Addiction Program
Objectives
1.
Participants will learn ethical considerations to keep in mind
when working with clients who struggle with compulsive
sexual behaviors.
2.
Participants will be able to identify indicators that a client
with problematic sexual behaviors may be struggling with an
addiction.
3.
Participants will have an expanded knowledge of ways to talk
about sexual health issues with their clients.
4.
Participants will learn how to share with their clients a
reliable internet based self-evaluation for sex addiction.
5.
Participants will be exposed to ways their clients may be
looking for love and/or sex on the internet.
© 2015 Pine Grove
Ethical Standards
• Ethical Standards are mandatory in nature
• A moral code to do the “right thing”
• Enforceable rules of conduct to which the professional
must adhere
• Ethics Code Examples
– National Association of Social Workers (NASW)
– American Psychological Association (APA)
– National Counseling Association (NCA)
– American Psychiatric Association (APA)
– National Substance Abuse Certifications
– American Society of Addiction Medicine (ASAM)
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Professionalism
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Society needs and wants professionals to exist
Society must feel and see trustworthiness
Professional status is given in trust by society
Professionalism: both individuals and groups
4
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Principles of Ethical
Decisions
• Any decision concerning a professional boundary
can be evaluated based on the ethical premises of:
– Autonomy
– Beneficence
– Non-Malfeasance
– Fidelity
– Justice
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Autonomy
• Will it foster client independence?
• Does it serve the patient’s interest?
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Beneficence and Non-Malfeasance
• To do “good”
• To do no harm
• To safeguard the welfare
and rights of clients
• Conflicts of interest
are resolved in a
responsible fashion
• These principles guard against personal, financial, social,
organizational, or political factors that might lead an
individual to misuse their influence.
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Fidelity and Justice
Fidelity -- the degree to which it reflects what was
promised and is true to the articulated goals of the
professional service
Justice -- avoidance of unjust practices
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Tell Clients the Truth “UP FRONT”
• Inform prospective clients about the limits you intend to
impose on confidentiality
• Explain any roles or potential conflicts of interest that
might affect confidentiality
• Obtain informed client’s consent to accept limits as a
condition of receiving services
• Reopen the conversation if/when patient’s
circumstances or your intentions change
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“People are lonely. The network is seductive. But if
we are always on, we may deny ourselves the
rewards of solitude.”
“Technology doesn’t just do things for us. It does
things to us, changing not just what we do but who
we are.”
Sherry Turkle, Alone Together: Why We Expect More from Technology and Less
from Each Other
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Addiction is a Brain Disease
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Chemical Addictions
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Process Addictions
Much like compulsive gambling, hoarding,
exercising, work, and spending.
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How are Process Addictions and
Chemical Addictions alike?
 Numb feelings in order
to escape painful parts
of life
 Mood altering
experience
 Becomes most
important need
 Used to avoid intimacy
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What is Sex Addiction?
A compulsive behavior that completely dominates
the addict's life. Sexual addicts make sex a priority
more important than family, friends, and work.
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What is Sex Addiction?
Sex becomes the organizing principle of an addicts'
life. They are willing to sacrifice what they
cherish most in order to preserve and continue
their unhealthy behavior.
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Criterion for Sex Addiction
1. Recurrent failure to resist
sexual impulses
in order to
engage in
specific
sexual behaviors
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Criterion for Sex Addiction
2. Frequently engaging in those behaviors to
a greater extent, or over a longer period
of time than intended
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Criterion for Sex Addiction
3. Long-standing desire, or a history of
unsuccessful efforts to stop, reduce, or
control those behaviors
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Criterion for Sex Addiction
4. Excessive amounts of time spent in
obtaining sex, being sexual or recovering
from sexual experiences
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Criterion for Sex Addiction
5. Obsession with preparing for sexual
activities
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Criterion for Sex Addiction
6. Frequently engaging in sexual behavior at
times when expected to fulfill
occupational, academic, domestic or social
obligations
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Criterion for Sex Addiction
7. Continuation of the sexual behavior despite
knowing it has caused or exacerbated
persistent or recurrent social, financial,
psychological, or physical problems
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Criterion for Sex Addiction
8. The need to increase the intensity,
frequency, number, or risk level of sexual
behaviors in order to achieve the desired
effect;
or diminished effect with continued
behaviors at the same level of intensity,
frequency, number, or risk
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Criterion for Sex Addiction
9. Giving up or limiting social, occupational,
or recreational activities because of the
behavior
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Criterion for Sex Addiction
10. Becoming upset, anxious, restless, or
irritable if unable to engage in the sexual
behavior
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Sexual Addiction Screening Tests
• Therapist Resources:
• www.recoveryzone.com
• www.sexhelp.com
• www.iitap.com
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Sexual Addiction Screening Test (SAST-R) Free
Partner Sexuality Survey (PSS) $6.50
Sexual Addiction Risk Assessment (SARA) $29.95
PATHOS Worksheet
• Certified Sex Addiction Therapist Administered:
– Sexual Dependency Inventory (SDI)
– Post-Traumatic Stress Index (PTSI-R)
– Money and Work Adaptive Styles Index (MAWASI)
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Cybersex Defined:
• The use of any electronic device to carry
out activities or fantasy for sexual or
romantic pleasure.
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Healthy Computer & Internet Use
• Legitimate dating sites, Flirting
• People with common interests can meet and
perhaps develop deeper relationships
• Couples who live far apart can continue a
healthy sex life (virtual sex, sexual talk)
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Healthy Computer & Internet Use
• Erotica to enhance sex life in a committed
relationship
• Learning about sex, educational sites
• Purchasing sex toys for enhanced pleasure
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Pornography Addiction
• 12% of all websites are porn
• 25% of search engines are porn related
• 35% of all downloads are for sexualized imagery.
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Types of Cybersex Activities:
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Viewing of still pornographic images & videos
Sexting nude photos, videos, and texts
Phone or Skype sexual encounters
Video chat rooms for anonymous cyber
encounters
• Hook-up sites
• Prostitution
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Porn Industry
• More and more digitalized rather than xxx movie
theaters, porn stores
• Business model
• Designed to hook kids
• Designed to pull you in, take you to places you never
intended to go
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Indicators of Problematic Porn Use
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Excessive or late night computer use
Requiring privacy when using the computer
Going to bed at a different time than partner
Private credit card, post office box, locked cell phone,
email or Facebook page
Hyper sexual or lack or sexual interest
Defensive about porn use
Sexualization of others
Isolating
Cybersex Addiction
Screening Test
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Sexual Problems with Porn Use:
• Less interest or ability to be aroused with real partner
• Intrusive thoughts during sex with partner Requiring
partner to engage in acts that are emotionally or
physically uncomfortable
• Sexual behavior becomes riskier
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Sexual Problems with Porn Use
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Living in a bubble; not being fully present for real life sex
Gives up relationships rather than curtail porn use
Neglecting family and friends
Loss of ability to experience emotions
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Problems with Porn Use
• Comparing self and others to individuals viewed in
pornography
• Behaving contrary to one’s values
• Self distain, suicidal thoughts (attempts)
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Problems with Porn Use
• Manipulating and lying to loved ones
• Anxiety and depression
• Falling behind at work
• Irritability
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Virtual Adult-Oriented Sex Games
• Customized fantasy avatars (Second Life, Anime)
• All sexual orientations, fetishes
• Produce individualized porn (scenarios, music, camera
angles, customized body parts)
• In the near future: 3D and touch sensitive for use with
Xbox Kinect and eye tracking technology
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Digitally Available Sexual Activities
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Phone apps, web sites to find casual (perhaps anonymous) sex
Communities that share sexual interests
Chat rooms for romance or sex
Hook-up sites for romance or sex
Fetish sites, Cheater sites, news groups
Viewing/downloading porn photos/videos
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Digitally Available Sexual Activities
• Commercial, professional and amateur porn
• Webcams for mutual masturbation, voyeurism, exhibitionism,
real time sex acts
• Finding sexual massage, escorts, prostituted individuals
• Buying, selling, distributing porn
• Using social media to find arousing photos, potential hook ups
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Predicting the future
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The Orgasmatron
• Woody Allen, Diane Keaton
• Sleeper, 1973
• In real life during trials for a
potential spinal cord
stimulator an implantable
device that stimulates the
pleasure centers of the brain
was discovered. Expensive,
requiring electrodes surgically
inserted near the spine.
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Someday? Personalized Robots!
Will look and behave to your specifications
• Her 2013
• David Levy expert on artificial intelligence predicts that
by 2050 “humans will fall in love with robots, humans
will marry robots, and humans will have sex with robots,
all as ‘normal’ extensions of our feelings of love and
sexual desire.”
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Cyber-Enhanced Sex
• Kiss-Phone measures lip pressure, temperature,
movement and reconstructs this kiss at another KissPhone
• Soon: Tech bed; special fiber sheets and sleepwear allow
partners to feel intimate sensations
• Soon: Contact lenses that change the way a person looks
to the viewer
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Other Customized Pornography
• Eye tracking technology (Pornographers can detect
within a nano-second time spent gazing at a body part or
behavior)
• Muse, iBrain (tracks intra-skull electrical activity …
thoughts become activity)
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Teledildonics
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Warms, lubricates, responds to a partner’s movements
Loved one, performer, stranger, prostituted individual
Virtual oral or manual stimulation
Devices for male or female genitalia
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Differentiating Client Risk Levels
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Casual User
At-Risk User
Addicted User
Offender
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The Casual User
• Intermittent/ occasional
• Driven by curiosity, novelty,
education, or entertainment
• Life stage specific (adolescent,
single, loss)
• Healthy self esteem, lacking
toxic shame
• Stable long term relationships
• Balanced life of work, play,
diet, rest
• Honesty within a committed
relationship
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The At-Risk User
• Secret keeping
• Sacrifices intimacy
• History of other impulse
control problems
• Highly reactive to emotional
stressors
• Challenging primary
relationship
• Struggles with
empathy/narcissistic traits
• Abnormally sensitive, takes
things personally
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The Addicted User
• Lives a double life
• Emotionally distant
• May be abusing
chemicals, food,
other compulsive behaviors
• High levels of anxiety and depression
• No empathy for others, strong narcissistic thoughts and
behaviors
• Loss of personal relationships
• Damaged intimacy within committed relationship
• Childhood or adult trauma often present
• Avoids commitments, does not follow through
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Sexual Addiction or Offending?
• Sexual addiction involves consenting adults or sex
with self.
– Obsessive
– Loss of control
– Negative consequences
• Sexual offending involves nonconsensual forms of
sex involving those who:
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don’t want it
don’t know its happening
are too young to give consent
are mentally handicapped
are having sex forced on them
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ACA- Section H
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Distance Counseling Technology
Separate Personal and Professional
Informed Consent (Limits to confidentiality)
Respect Privacy (Don’t Google Pt.)
Avoid Disclosing Confidential Information
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A brief lapse
can
negatively
impact the
entire
profession
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• Google yourself
• Stress/Burnout
• Privacy settings
• Delete accounts
• Separate Accounts
• Accountability
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Modern Hippocratic Oath
• “I will respect the privacy of my patients,
for their problems are not disclosed to me
that the world may know”
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Cybersex References
• Weiss, Robert & Schneider, Jennifer. Always Turned On.
2015.
• Weiss, Robert. Peyton Place Goes Digital in ‘Men, Women,
and Children.’ Love and Sex in the Digital Age. 2014.
• Weiss, Robert. Cruise Control: Understanding Sex
Addiction in Gay Men. Second Edition. 2013. Maltz, Wendy
& Maltz, Larry. The Porn Trap. 2010.
• Weiss, Robert & Schneider, Jennifer. Untangling the Web.
2006.
• Weiss, Robert & Schneider, Jennifer. Cybersex Exposed.
1999.
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Ethics References
• American Counseling Association (ACA). Code of Ethics, Section H.
Available at http://www.counseling.org/resources/aca-code-ofethics.pdf.
• American Medical Association (AMA). Professionalism in the Use of
Social Media. 2011. Available from http://www.ama-assn.org.
• Basevi, R., Reid, D., and Godbold, R. Ethical Guidelines and the Use of
Social Media and Text Messaging in Health Care: A Review of the
Literature. New Zealand Journal of Physiotherapy, 2014; 42 (2):68-80.
• Carr, Nicohlas. (2011,2010) The Shallows: What the internet is doing to
our brains. New York, NY: WW. Norton & Company, Inc.
• Conaboy, C. For Doctors, Social Media A Tricky Case. The Boston Globe.
April 2011. Available from
http://www.boston.com/lifestyle/health/articles/2011/04/20/for_do
ctors_social_media_a_tricky_case/.
• Cyber-Bullying Statistics. Accessed October 2014. Available from
http://www.cyberbullyhotline.com/.
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• Essary, A.C. The Impact of Social Media and Technology on
Professionalism in Medical Education. The Journal of Physician
Assistant Education, 2011, (22), 4:50-53.
• Galletly, C. Crossing Professional Boundaries in Medicine: The Slippery
Slope to Patient Sexual Exploitation. Medical Journal of Australia,
October 2004, (181), 7: 380-383.
• Gross, D. Five Ways Facebook Changed Us, For Better and Worse. CNN.
January 2014. Available from
http://www.cnn.com/2014/01/31/tech/social-media/facebookchanges/.
• Gunnarsson, H.W. Friending Your Enemies, Tweeting Your Trials: Using
Social Media Ethically. Illinois Bar Journal. October 2011, (99) 10:500.
Available at
http://www.isba.org/ibj/2011/10/friendingyourenemiestweetingyou
rtri.
• Guseh, J.S., Brendel, R.W., and Brendel, D.H. Medical Professionalism in
the Age of Online Social Networking. J Med Ethics, 2009; 35:584-586.
© 2015 Pine Grove
• Harvey, C.V., McCoy M.R., and Sneath, B. 10 Tips for Avoiding Ethical
Lapses When Using Social Media. Business Law. Available at
http://www.americanbar.org/publications/blt/2014/01/03_harvey.h
tml.
• Haury, A.C. How To Ruin Your Career Using Twitter and Facebook.
Investopedia. July 25, 2012. Available at
http://www.investopedia.com/financial-edge/0712/social-mediapractices-that-can-get-you-in-trouble-at-work.aspx.
• Huhman, H.R. Six Reasons Social Media Got People Fired. Business
Insider. June 20, 2013. Available at
http://www.businessinsider.com/6-reasons-social-media-got-peoplefired-2013-7.
• Kasten, S.W. Professional Ethics and Social Media. The Boston Bar
Journal. Available at
http://www.bizlit.com/docs/about/articles/documents/socialmediak
asten.pdf.
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• Osman, A., Wardle, A., and Caesar, R. (2102) Online Professionalism and
Facebook-Falling Through the Generation Gap. Medical Teacher. 34:
3549-3556.
• People Kept Complaining This Restaurant Sucked, Look What They
Found Out… July, 21, 2013. Available at
http://themetapicture.com/people-kept-complaining-this-restaurantsucked-look-what-they-found-out/.
• Photographs: Social Media Logos, Various sites through Google. Social
Media Explained, http://themetapicture.com/. Domino’s Pizza Tweets,
www.huffingtonpost.co.ukMagazine, http://www.digitaltrends.com/fe
atures/the-history-of-social-networking/#ixzz3He8yCVv7. Deer and
Man Snapchats, http://www.buzzfeed.com/samstryker/bend-andsnapchat-lol-puns. Homer Simpson, Available at www.behance.net.
Graffiti Tree Hair, www.explosion.com. Banksy, Maid,
www.handbag.com Couple, www.telegraph.co.uk. Balloon,
http://www.pinterest.com/pin/557883472563011185/. Eyes,
Personal Photograph. Cast Away Meme, Jean Jillian,
http://sixstoriesup.com/memes-and-advertising/,
http://hyperspaceit.com/top-social-media-for-2014/,
http://www.teamjimmyjoe.com/2015/04/27-funny-snapchats-youdwished-you-had-sent/, http://www.bitrebels.com/social/10-ways-toexplain-social-media/, www.oldskooldepartment.com
© 2015 Pine Grove
•
• Romero, B. The Death of Conversation: I Photograph People Obsessed
With Their Smartphones Available at
http://www.boredpanda.com/the-death-of-conversation/, including
photographs.
• Sexnology: Technology’s Impact on Sex Addiction. Available at
http://sexualrecovery.com/blog/technology.
• Tariman, J.D. Where to Draw the Line: Professional Boundaries in Social
Networking. ONS Connect, February 2010:25 (2):10-13. Available from
http://www.ncbi.nim.nih.gov/pmc/articles/PMC2891246.\
• Turkle, Sherry. (2011). Alone Together: Why we expect more from
technology and less from each other. New York, NY: Basic Books.
• Videos: If This Video Doesn’t Convince You To Put Down Your Phone,
Nothing Probably Will. http://themetapicture.com/if-this-videodoesnt-convince-you/. Men, Women, and Children Trailer,
http://www.youtube.com/watch?v=zCb8tIQkWfo. Gifs,
http://www.buzzfeed.com/mattbellassai/the-40-greatest-dog-gifs-of2012-6z51. Vine,
http://viralvideochart.unrulymedia.com/vine?id=MIjTE3ZDxa3 .
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