Out Of Control Sexual Behavior In Women

A Sexual Health-Focused Alternative to the Sex Addiction Model

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Translating the Out of Control Sexual Behavior Treatment Model for Work with Cisgender Women

Abstract:

Currently, there is no agreement within the mental health field on the etiology, diagnosis, or treatment of problematic sexual behavior (PSB) for men or women. The Out of Control Sexual Behavior (OCSB) clinical framework is a flexible and integrative client- centered approach that differs from the more established PSB modalities, which have utilized overly broad sexual symptom assessments and pathologized normal variations in human sexuality. Still, the OCSB framework was created for the treatment of men, and not every aspect of its approach should look the same when used to treat women. In fact, gender-informed clinical assessment and treatment options have historically been limited for women presenting with consensual sexual urges, thoughts, or behaviors that feel out of control for them.

This paper’s intention is twofold: 1) to explore the paucity of both historical and current human sexuality research on women’s sexual health and its impact on the clinical treatment of women’s PSB in general and OCSB specifically; and 2) to help broaden current PSB professional dialogue through defining the OCSB framework, translating it for women, and integrating women’s clinical presentations and sexual experiences into the conversation.

Introduction

In the 1960s, a morning sickness pill offered to pregnant women in a clinical trial was linked to severe birth defects. This tragedy would prompt a second tragedy, the Food and Drug Administration’s resolve to “protect” women and their reproductive systems by excluding women altogether from clinical trials for decades (Dusenbery, 2018, p. 29 & National Institutes of Health, 2020). This decision is just one example in which a lack of understanding around women’s sexual health has led to significant setbacks and gender- imbalanced sexuality research and education. One sweeping governmental policy established by a predominately male medical system contributed to the enduring paucity of research on the normal variations of women’s sexual experiences, reinforcing stereotypes of women’s sexuality in areas such as the right and means to control birth, sexual functioning, appearance and pleasure, and sexual and social value. Reinforcing inaccurate sociocultural norms around human sexuality leads to gendered sexuality research and education, which in turn negatively impacts women’s overall sexual health. Women continue to be proportionally absent from healthcare research, and men’s sexual health remains the “norm” by which to measure women’s sexual health.

The term sexual health itself has long been surrounded by contentious debate. Until medicalized at the 1994 International Conference on Population and Development (Berro Pizzarossa, 2018), sexual health was seen primarily as an extension of family planning and population control and was historically absence-focused. Sexual health meant an absence of STIs, unintended pregnancies, and socially unacceptable sexual urges, thoughts, and behaviors. To be sexually healthy meant conforming with sociocultural norms. Thousands of sexual scientists and educators engaged in post-sexual revolution activism to expand this vision of sexual health. They fought to normalize the sexuality of marginalized populations engaging in consensual sex, a sexuality that didn’t meet the narrow criteria of acceptable sexual expression. In 2002, The World Health Organization (WHO) formally and fundamentally redefined sexual health. The requirements for sexual health shifted from an absence of pathology and deviation of sociocultural norms to a more inclusive framework of pleasurable, respectful, and diverse sexualities.

Consider the following WHO working definition of sexual health born out of the 2002 Geneva Convention:

Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. (WHO, 2002)

This updated definition of sexual health acknowledges every person’s right to freely explore and express their unique sexual self without fear of judgment or constraint. It creates space in the sexual health conversation for differences and acknowledges that healthy sexuality includes pleasure. The WHO’s redefining of sexual health has opened doors to academic support and funding for more inclusive sexuality research. But further expansion of diverse research, training, and advocacy remains a requirement to cultivate and sustain a more balanced sexual health field.

Doug Braun-Harvey and Michael Vigorito’s OCSB framework, grounded in findings from the Pan American Health Organization (PAHO) and WHO 2002 meetings, is a natural extension of the thought expansion required for inclusive PSB clinical treatment. The OCSB framework’s six principles of sexual health — consent, nonexploitation, protection from STIs and unwanted pregnancy, honesty, shared values, and mutual pleasure — prompt a client-centered assessment and sexual health plan that is based on each client’s unique vision of sexual health. This framework considers each person’s multivariate sexual history, vulnerability factors, and clinical presentation — including capacity for self-regulation, attachment regulation, and sexual and erotic conflicts — before assigning appropriate process-change exercises. OCSB’s clinical flexibility differs from long-established PSB clinical models, which have historically prescribed immediate and intensive universal treatment upfront for an assumed sexual pathology.

In their book Out of Control Sexual Behavior: Rethinking Sexual Addiction, Braun- Harvey and Vigorito acknowledge that their model is based on research of, and created for, cisgender men (Braun-Harvey & Vigorito, 2015, p. xvii). They assert that it would be inappropriate for them to presume how this model might look with other clinical populations and their sentiment is appreciated. Indeed, a demographic-specific adaptation of the OCSB model should include the voices of those it seeks to treat and, as such, this paper intends to translate the OCSB model for cisgender women. This work will not presume how the OCSB model should operate with intersex or transgender populations. The word “woman” will be used throughout this paper in reference to cisgender women, those assigned female gender at birth.

Women deserve access to a non-shaming, non-pathologizing PSB framework that more accurately reflects their lived sexual experiences and behaviors. The OCSB framework, with its fundamental grounding in human behavior theory, makes much of its model easily translatable to clinical work with women. However, women’s OCSB treatment must incorporate a deep understanding of both the historical and present-day implicit and explicit sociocultural messages and expectations projected onto and internalized by women.

This adaptation of the OCSB model aims to highlight and normalize each woman’s right to their own unique vision of sexual health. From this base, assessment and treatment can work to alleviate the competing motivations working against their vision. Primary for this paper are 1) to explore the paucity of both historical and current human sexuality research and its impact on women’s sexual health and the clinical treatment of women’s PSB in general and OCSB specifically; and 2) to help broaden current PSB professional dialogue through defining the OCSB framework, translating it for women, and integrating women’s clinical presentations and sexual experiences into the conversation.

Sexual Behavior Becomes Problematic: A History

Christianity began constricting sexuality as it swept through Europe in the Early Middle Ages of 400AD to 1000AD. Europe had no state-imposed law or literacy left at the time to fight the rigid religious narratives of the church (Tannahill, 1982, p. 137) and procreative sex within the context of a heterosexual, marital relationship became the single acceptable sex act. Remnants of this religious-based dogma remained locked in the sexual narrative for millennia. Before understanding germ theory, burgeoning U.S. and European medical fields of the 1800s continued to reinforce this sex-negative narrative, claiming that both disease and death were expected outcomes of variant sexual acts and desires (Deslandes, 1839). Some asserted that masturbation contributed to human suffering and that variation in sexuality signaled human weakness and misery (Kraft- Ebbing, 1894, p. 13). Excessive sex was seen as a disease of both the body and mind (Rush, 1830, p. 163).

This puritanical (male-centric) sexuality lens — with roots going back to the Early Middle Ages — persisted, dominating social, religious, and scientific texts. Periodic protests of gendered and discriminatory sexual medicine appeared through the ages, but no popularly recognized refutation of a church-centered sexuality lens gained traction until the sexual revolution of the 1950s and ’60s (Marecek & Gavey, 2013). When William H. Masters, Virginia E. Johnson, and Alfred Charles Kinsey began conducting extensive research on human sexuality, they began to successfully debunk self-pleasure as a basis for mental and physical deterioration, naming and normalizing diversity in human sexual desire and practice (Kolodny, Johnson, & Masters, 1988, p. 18; & Kinsey, 1998).

A simultaneous, antiquated view of sexuality remained, however, as the American Psychological Association (APA) cemented public opinion of homosexuality, transvestitism, sadism and masochism (S/M), and other “deviant” sexual behaviors as “sociopathic personality disturbances” in its first edition of the Diagnostic and Statistical Manual (DSM) (APA, 1952). And though the APA retreated from their irreparable pathologizing, renaming these behaviors “sexual deviations” in the DSM II, they remained catalogued as personality disorders alongside nonconsensual sexual behaviors (APA, 1968). After further DSM revisions, professional infighting, and protests, the APA quietly removed homosexuality from the DSM III R altogether (APA, 1987). Transvestitism, S/M, and other alternative sexual practices have remained in the DSM as paraphilias to this day (APA, 2013), continuing to explicitly “other” sexual acts and experiences that are nontraditional or non-heteronormative.

Current Theoretical PSB Models and Their Challenges

Most graduate-level counseling programs in the U.S. require one human sexuality class. Some degrees offer no sexual education at all. After covering the basics of genital anatomy and psychosexual disorders, minimal time is left to explore more complex sexual challenges, namely Problematic Sexual Behavior (PSB). This lack of education has been linked to therapists’ discomfort discussing sexuality in client sessions, resulting in unintended negative outcomes for therapy (Harris & Hays, 2008).

Studies indicate that between 1% and 6% of adults in the United States feel that their sexual urges, thoughts, and behaviors are out of control (Kraus et al., 2018). Twenty to 30% of these adults identify as women (Dickenson, Gleason, Coleman, & Miner, 2018). With sexual concerns as the second most reported problem to women’s health care providers in 2017 (Blount, Booth, Webb, & Liles, 2017), an increase in women’s sexuality training is indicated as necessary. These professional trainings would provide both a deeper understanding of and comfort with discussing women’s sexuality in sessions as well as reduce potential for therapist bias of sexual belief systems.

Trailblazing organizations like the American Association of Sexuality Educators, Counselors, and Therapists (AASECT), founded in 1967, and the Society for the Advancement of Sexual Health (SASH), founded in 1987, have spent decades filling in the educational gaps left by academic institutions. As a hub for relevant sexuality and sexual health research, these communities provide learning opportunities for helping professionals who possess a desire to expand their understanding of and compassion for different sexualities. Within these educational communities are different PSB camps. Each has their own theoretical models that frame out proposed symptoms and a recommended course of treatment.

Navigating the conflicting theories and dogma of each of these modalities is no easy task. Braun-Harvey and Vigorito (2015) explore these inconsistencies, acknowledging that without an agreement on what to call, how to define, or how to treat PSB, it’s understandable that no definable etiology has been discovered. “The factors that contribute to sexual behavior problems are diverse and multivariate, and intertwined within a range of sociocultural influences and biopsychological factors” (Braun-Harvey & Vigorito, 2015, p. 24). Currently, there are three prominent PSB theoretical frameworks: 12-Step/Sexual Addiction (SA) (Carnes, 1983), Impulsive/Compulsive Sexual Behavior (ICSB) (Coleman, 2012), and Hypersexuality Disorder (HD) (Kafka, 2009). These three constructs will be explored before delving into the OCSB model. The OCSB model will then be thoroughly examined before highlighting the needed modifications for OCSB work with women. For simplicity’s sake, the umbrella term PSB will be used throughout this paper to reference similar behavior clusters, unless referring to a specific treatment model.

Sexual Addiction

Psychologist Patrick Carnes constructed the Sexual Addiction framework, currently the most widely circulated and cited PSB treatment model, based on his 1983 book Out of the Shadows (Carnes, 1983). Adopting the 12-step, medical-model framework from Alcoholics Anonymous, he draws parallels between the “pathological relationship” a person can have with their out of control sexual feelings, thoughts, and behaviors and the relationship alcoholics and drug addicts have with chemical addiction (Carnes, 1983, p. 14). As with substance addictions, he proposed that SA can be transmitted through environmental conditioning or genetically inherited (Carnes, 1983, p. 6). The International Institute for Trauma and Addiction Professionals (IITAP), founded by Carnes, has created an entire curriculum and certification process around assessing and treating SA, based on the premise that family of origin abandonment and shame lie at the center of this sexual “disorder.” Through an intricately structured task model, patients in group and individual therapy — as well as those participating in 12-step groups — are guided through a “withdrawal” process as they learn to replace old, negative behaviors with new, more helpful ones.

More recently, IITAP faculty member Alexandra Katehakis integrated somatic and relational therapies into Carnes’ SA framework, creating the Psychobiological Approach to Sex Addiction Treatment (PASAT). In Sex Addiction as Affect Regulation (Katehakis, 2016), PASAT asserts that early relational trauma causes a dysregulated interpersonal neurobiology that manifests into addictive sexual behaviors. Her model proposes to heal interpersonal attachment dysregulation through the structured, reparative interpersonal neurobiology received from the PASAT therapeutic relationship. Healing the affect dysregulation reduces addictive sexual behaviors.

While addressing PSB holistically and attending to dysregulated interpersonal neurobiology may be crucial components for reducing problematic sexual behavior, AASECT has made clear that there is not enough empirical evidence to support using the sex or porn addiction labels at this time. They find that these labels unduly pathologize sexuality and are insufficiently educated around human sexuality research (n.d.). Morin (1995) notes that while recovering addicts can completely sever relationships with their substance of choice, people struggling with sexual experiences cannot sever the relationship with their eroticism (p. 258). Other theorists have reframed sexual addiction as problematic sexual behavior based on high sexual desire (Winters, Christoff, & Gorzalka, 2010).

Impulsive/Compulsive Sexual Behavior

Michael Quadland first coined the term compulsive sexual behavior in 1985 to describe out of control sexual thoughts and behaviors (SEICUS, 1986). Eli Coleman further expanded this framework beginning in the 1990s, eventually renaming it impulsive/compulsive sexual behavior (ICSB) to include both the lack of impulse control (unconscious urges and behaviors) as well as obsessive thoughts and compulsive actions (conscious urges and behaviors) (Coleman et al., 2018). ICSB is defined as “the experience of sexual urges, sexually arousing fantasies, and sexual behaviors that are recurrent, intense and cause distressful interference in one’s daily life.” Allowing space for healthy sexual variance, Coleman et al. differentiated two sub-categories of ICSB — paraphilic and non-paraphilic — recognizing that both consensual and nonconsensual sexual acts may have the hallmarks of ICSB but should be assessed and treated differently.

Hypersexual Behavior

In 1997, Martin Kafka categorized PSB as a sexual desire disorder and named it hypersexuality, focusing on “recurrent and intense sexual fantasies, urges, or sexual behaviors” (Kafka, 1997). He claimed that those with hypersexuality have unsuccessfully tried on their own and repeatedly failed to control their sexual thoughts, urges, or behaviors. At the root of this disorder is the motivation to relieve upsetting emotions. As with ICSB, Kafka also distinguished hypersexuality from paraphilic disorders (Kafka, 2009). In 2011, the Hypersexuality Behavior Inventory was created (Reid, Garos, & Carpenter, 2011) to explore various challenges and consequences of hypersexuality in men and this assessment has become a standard practice assessment tool worldwide in helping to identify PSB. There have been multiple clinical studies that argue that high sexual desire may be a more accurate, less pathologizing construct than hypersexuality (Vaughn, R. et al., 2013 & Winters, et. al. 2010).

Summary of Current PSB Models

Certain concepts and tools from the hypersexual, impulsive/compulsive, and sexual addiction frameworks have invaluably benefited the sexual health research and education fields. They have prompted gender and sexuality discussions and sexual health advocacy in family systems and communities all over the world. Concerning, however, is an increase in clients who self-diagnose their sexual behavior based on varying, commercially available sexual disorder assessments from these models, which have a history of pathologizing normal sexual variation. Some clients seek out clinical treatment, having already internalized a sexual pathology, and are prescribed a one-size-fits-all “recovery” protocol that reinforces stigmatization. Each of these PSB medical model theories provides a clear clinical pathway for their clients, which can feel safe in its fixed predictability. However, the primarily male-centric, heteronormative outlook of these models and the rigidity of their curricula can leave many clients believing they are morally broken and powerless to change should their vision of healthy sexuality differ from the mold of the prescribed model.

As it stands, sexual addiction and hypersexuality are not listed in the DSM V. And while compulsive sexual behavior disorder is listed in the ICD 11, it is listed as an impulse control disorder, not a sexual disorder. Winters et al. (2010) note concern that these frameworks “have often been used interchangeably to describe a single set of symptoms, without consideration of potentially disparate clinical implications.” Braun-Harvey and Vigorito (2017) add that the ICSB, SA, and HD theories lump together consensual and nonconsensual sex acts in their assessment and treatment protocols (p. 24). This sets up the potential clinical hazard of a therapist working beyond their scope of practice if they are not already specialized in sexual offending behaviors.

There remains no current consensus on the definition of PSB. And the commonalities between the various PSB research and frameworks outweigh the differences (Samenow, 2013). Dickenson et al. (2018) note that despite these discrepancies, all models appear to agree on the hallmark feature of clients feeling unable to control sexual urges, thoughts, and behaviors, which in turn results in distress and/or impairment in functioning. Though deep divides within the psychological community persist around what to call and how to treat PSB, hope remains that the primary commonality of each theory is a desire to support clients as they move towards their vision of sexual health.

How OCSB Is Different: A Sexual Health Problem

Unlike SA, ICSB, and hypersexual disorder, which consider problematic sexual behavior to be a psychosexual disorder, Braun-Harvey and Vigorito’s OCSB model proposes that PSB is just that: a problem. Adopting Stephen Levine’s (2010) continuum of sexual difficulties, the OCSB assessment differentiates sexual worries from problems from disorders. This model acknowledges and normalizes sexual variation and suggests exploring a fuller sociocultural context before labeling sexual difficulty a pathological disorder. “Until such time that evidence supports the establishment of a sexual disorder, we view OCSB as a problem within the normal range of human sexual expression” (Braun-Harvey & Vigorito, p. 28).

OCSB’s framework does not minimize the painful implications of serious PSB, but it carefully avoids pathologizing consensual sexual differences. Within the OCSB framework, PSB lies on the continuum between more mild, human worries and officially recognized medical and psychiatric disorders. A sexual worry, though minimally disturbing, nonetheless detracts from the pleasure of sexual living (Levine, 2010). An example may be a woman worrying that her vulva appears abnormal or has an unusual smell. Occasional rumination may not reach the level of body dysmorphic disorder (Veal & Daniels, 2012), but it nevertheless keeps this woman from enjoying her experience of oral sex. Sexual disorders, at the other end of the continuum, have the highest potential to disrupt one’s life. They grab the biggest headlines and often get the most clinical focus and research, though they are the least prevalent of all sexual difficulties (Levine, 2010). Examples of sexual disorders include: genito-pelvic pain disorder, orgasmic disorder, and sexual interest/arousal disorder. Sexual health problems fall between worries and disorders. They range from moderate to severe sources of suffering and attract less research due to the complexity of differing sexualities and societal norms. For example, what one culture sees as a problematic thought or behavior, another culture may see as customary (Hall & Graham, 2012, p. 1). A common example of this is the widely varying stances on two persons of the same gender having sex. One culture may view this as a sinful act while another culture sees it as an expression of love. Framing OCSB as a sexual health problem validates the suffering around sexual behavior without adding a psychosexual pathology to it.

How OCSB Works — An Integrative and Flexible Sexual Health Framework

The OCSB framework, with its expanded focus on human behavior and wellness, is an integrative and minimally pathologizing route to client-centered assessment and treatment of problematic sexual behaviors. Within this construct, there is space for the merging and tailoring of various therapeutic theories, clinical assessments, and treatment suggestions, all of which work to pinpoint and support each client’s most pressing needs. This multifaceted pathway considers individual sexual development, sociocultural norms, sexual orientation, gender, race, age, and ability. OCSB treatment appreciates the complexity of PSBs and understands that getting a comprehensive clinical history is crucial for successful treatment.

Braun-Harvey and Vigorito define OCSB as “a sexual health problem of consensual sexual urges, thoughts, or behaviors that feel out of control for the individual” (Braun- Harvey & Vigorito, p. xv). OCSB’s approach does not rely on assigned amounts and durations of clustered or individual sexual behaviors to begin or direct a course of treatment. Instead, the treatment approach is determined by an ongoing assessment of competing motivations, vulnerability factors, ability to self-regulate and regulate oneself with others, and level of sexual and erotic conflict. A tailored clinical picture is created with each client, which includes an individualized sexual health plan that organizes sexual behavior problems within the 6 principles of sexual health: consent, non- exploitation, protection from STIs and unwanted pregnancies, honesty, shared values, and mutual pleasure. The OCSB sexual health plan aims to shift a client’s affective and deliberative system utilizing change-processes (Prochaska & Velicer, 1997) to reduce the competing motivations that lead to the problematic behaviors. With reduced competing motivations and the sexual health plan as an accountability tool, clients begin to regain control over their problematic sexual urges, thoughts, and behaviors.

Competing Motivations in Three Clinical Areas

Adopting the dual-process model for human behavior (Loewenstein, O’Donoghue & Bhatia, 2015), Braun-Harvey and Vigorito see sexual behavior choices as a balancing of deliberative and affective systems, two distinct decision-making processes that can sometimes end up in conflict or competition with one another. The deliberative system utilizes executive functioning areas of the brain, employing higher level activities such as willpower, reality testing, and rationalization, and is focused on longer-term, overarching goals. The affective system, run by more primitive sections of the brain, is focused on short-term goals and can encompass unconscious emotions such as pain, anger, and fear. Haidt (2005) explains that the deliberative system and affective system must work collaboratively to make sound decisions. The affective system, however, evolutionarily predates the deliberative system and, despite deliberative system influence, tends to have initial and prominent weight in decision-making (p. 13). Braun-Harvey and Vigorito claim that these competing motivations are what create the client’s sense of being out of control. While the deliberative system is focused on the broader goal of moving towards a healthy sexuality, the affective system of someone with OCSB hijacks rational decision-making in an effort to avoid negative emotions, which results in harmful sexual thoughts, feelings, and behaviors. Sexual health is linked to one’s capacity to regulate feelings and behavior when internal motivations are at odds with one another (Braun-Harvey & Vigorito, p. 64). OCSB assessment and treatment focus on competing motivations in three clinical areas — self-regulation, attachment regulation, and erotic conflicts — and explore how competing motivations in each of these areas can upset the affective-deliberative balance. The clinical area of self- regulation considers a client’s capacity to regulate their emotions and mood and how this impacts their out-of-control experiences. The attachment regulation area explores how sexual behaviors may be expressions of relationship needs or attachment patterns. Erotic conflicts may include conflict with one’s own eroticism, a partner’s eroticism, fixed arousal patterns, and unusual arousal patterns (Braun-Harvey, 2018).

OCSB Clinical Pathway

Screening

The OCSB clinical model employs a six-criteria screening process for clients entering treatment in an effort to ensure appropriate, effective treatment. The first two screening criteria, motivation for change and sexual consent are exclusionary measures. The OCSB pathway expectation is that change comes from a client’s motivation to live within their individualized vision of sexual health. Because OCSB is a client-centered treatment, having a desire and drive to change problematic sexual behavior is imperative. But OCSB treatment requires that problematic sexual behaviors be consensual. Other PSB models have historically conflated consensual and nonconsensual sexual behaviors both in assessment and treatment (Braun-Harvey &Vigorito, p. 136). As Moser (2011) warns, fusing paraphilic and nonparaphilic sexual behavior risks “medicalizing” criminal acts. This medicalization can be inappropriately harnessed in legal settings to skirt criminal responsibility. Conflating paraphilic and nonparaphilic behavior also increases the risk of therapists working outside of their scope of practice. Persons reporting nonconsensual sexual behaviors during OCSB screenings are referred out to nonconsensual sexual behavior specialists.

The final four screening criteria are grouped into the OCSB sexual health vulnerability factors of physical safety, physical health, mental health, and relationship with drugs and alcohol. These vulnerability factors are monitored throughout treatment, as they may compete against the client’s desire for sexual health. The physical safety criteria are split into two categories: self-harm and relational violence. Is the client at risk for suicide or self-harm? Are they currently stalking or being stalked by a partner, homicidal, or threatened with homicide? Physical health criteria include current medical conditions that may impact a client’s physical ability to work towards sexual health. Examples of this may be newly acquired STIs or long-standing ailments like cancer or heart disease. OCSB therapists refer out to and collaborate with medical professionals and other helping professionals as needed to ensure holistic care. Mental health factors include any psychiatric condition presented when screened for OCSB. A large obstacle in working towards sexual health are co-occurring mental health factors, most commonly Attention Deficit Hyperactivity Disorder, Bi-Polar Disorder, Depression, and Anxiety (Edwards, Delmonico & Griffin, 2011). Psychiatric disorders during OCSB treatment can disrupt a client’s affective-deliberative balance, leading to persistent sexual dysregulation and poor decision making. The final screening criteria is a client’s relationship with drugs and alcohol. OCSB treatment views each person’s relationship with drugs and alcohol as complex and shifting over a lifespan. Braun-Harvey’s book Sexual Health in Recovery (2010) notes that clients entering OCSB treatment with a high risk of substance relapse had double the measured levels of shame as clients without substance struggles (p. 43). In place of the binary, dependent-nondependent screening, OCSB clinicians view a client’s relationship with drugs and alcohol on a continuum of nonuse, use, misuse, abuse, and dependence (Braun-Harvey, 2019). Framing drug and alcohol use as a relationship rather than dependence or non-dependence helps to reduce client defensiveness at the outset of screening.

Assessment

After OCSB screening, and if a client is considered appropriate for treatment, a more in- depth sexual history and clinical assessment is taken. The OCSB assessment is divided into two parts: information gathering and clinical treatment elements. Information gathering consists of the clinical interview, objective measures testing, and professional consults. Treatment elements explore the client’s level of motivation for therapy and readiness to change. It’s from this assessment data that the OCSB unique clinical picture and sexual health plan are created.

Assessment Part I: Information Gathering
Clinical Interview/Subjective Measures
A semi-structured clinical interview is paired with standardized measures to produce both subjective and objective clinical data. It allows for the OCSB therapist to take a flexible guiding and listening role. The clinical interview employs elements of motivational interviewing, such as “collaborative conversation,” which assesses and increases a client’s motivation and commitment to change (Miller & Rollnick, 2012, p. 12). The OCSB approach contrasts with older PSB medical-model theories, which have historically placed therapists in the hierarchical role of collecting symptom data in order to prescribe fixes. The OCSB model considers family of origin, previous intimate relationships, mental health, relationship with drugs and alcohol, medical history, sexual and erotic development, and the sexual behavior problem timeline as interconnected pieces of a client’s subjective history.

Objective Measures

There are several standardized measures given to OCSB clients during the information gathering process in an effort to elicit objective data. The Adverse Childhood Experiences Scale (ACE) explores personal experiences of abuse, neglect, and adverse household incidents from birth to 18 years of age (Felitti et. al, 1998). Following up the ACE measure with the Ace Resilience Score (Aces Too High, 2019) can boost a client’s sense of agency and capacity to bounce back from adversity. The Experiences in Close Relationships-Relationship Structures (ECR-RS) questionnaire measures levels of attachment-related anxiety or depression, which may contribute to problematic behavior. These tools help dig into and flesh out often complex clinical pictures of relational trauma experienced by clients and their link to psychobiological ramifications (Lapides, 2014).

OCSB additionally uses two sexual symptoms and one sexual responses measurement for gathering subjective data on a client’s current sexual functioning. The Sexual Symptom Assessment Scale (SSAS) is a “12-item, self-reported scale designed to assess the change in compulsive sexual behavior symptoms over time” (Raymond et. al, 2007). The OCSB framework does not consider compulsive sexual behavior a psychosexual disorder; however, the SSAS has helped OCSB clients begin tracking frequency and intensity of sexual thoughts, feelings, and behavior and is administered weekly during the assessment. The Hypersexual Behavioral Consequences Scale (HBCS) is an OCSB follow-up measure to the SSAS, and more explicitly explores the negative consequences of sexual behavior (Reid, 2007). The self-discrepancy examples pointed out by this measure help clients identify competing motivations as the therapist develops clinical interventions.

The OCSB assessment heavily considers a client’s individual sexual responses in designing appropriate treatment interventions. For this reason, it utilizes the dual control model of sexual response, which asserts “that sexual arousal and associated behaviors depend on the balance between sexual excitation and sexual inhibition” (Janssen & Bancroft, 2007). Janssen and Bancroft created the Sexual Inhibition and Sexual Excitation Scales (SIS/SES), proposing that “the weighing of excitatory and inhibitory (sexual) processes determines whether or not a sexual response occurs within an individual in a given situation, and at the same time it assumes individual variability in the propensity for these processes.” Information gained from the SIS/SES helps the therapist tailor clinical direction and interventions to meet the needs of each client’s excitatory-inhibitory process.

Professional Consults

OCSB therapists consult with referring mental health and/or medical providers when appropriate. After required permissions are granted, the OCSB therapist gains collateral information and discusses OCSB treatment updates as needed.

Assessment Part II: OCSB Treatment Elements. Change Processes and Frame Processes

Using the transtheoretical model of health behavior change (TMM) during assessment and throughout treatment, OCSB clinicians shift the traditional therapist-client framework from expecting clients to match the demands of a treatment program to tailoring the program to meet each client’s needs. TMM’s stages of change help integrate processes and principles of change from different theoretical models (Prochaska, Norcross & DiClemente, 1994), creating the clinical flexibility required to support clients where they currently are at in recovery. The therapist examines the three main OCSB clinical focus areas — self-regulation, attachment regulation, and sexual and erotic conflicts — using both change processes and frame processes, which work to increase the client’s motivation for change. Change processes are overt or covert activities that help to modify thinking, feeling, and behavior. These processes are dictated by each client’s current level of motivation for therapy, as well as their readiness to change PSB (Sun, Prochaska, Velicer & Laforge, 2007). Frame processes are ways in which the OCSB therapist conceptualizes and sets the therapist-client boundaries and agreements for treatment.

Change Processes
The OCSB assessment focuses on four TMM change processes — consciousness-raising, emotional arousal, self-reevaluation, and social liberation — to help organize and prioritize appropriate clinical interventions. Consciousness-raising occurs throughout the entire assessment and duration of OCSB treatment as both client and therapist explore the client’s many contradictions of actions, values, motivations, and personal histories (Braun-Harvey & Vigorito, 2015, p. 214). This reflection helps clients develop insight around their PSB behavior, oftentimes imparting new awareness of coping skills they’ve instinctively developed to protect them from painful emotions.

As intense emotional arousal often occurs in session, it is named, normalized, and processed. This powerful arousal energy can be harnessed both to increase motivation to change behaviors and build affect tolerance. Connecting painful emotions to PSB consequences in a safe, therapeutic space can shift a client’s competing motivations towards more deliberative-based decision making.

Self-reevaluation often arises out of both consciousness-raising and intense emotional arousal. As clients begin to understand that their core values are in conflict with their sexual behaviors and are provided space to reflect on the impact of these contradictions on their overall self-concept, there comes a reevaluation of problematic behavior choices.

Social liberation change processes occur as the OCSB therapist presents a tone of sexual acceptance and understanding throughout this assessment, offering the PLISSIT model of sex therapy (Annon, 1976). This model — giving permission (P) to feel sexual, limited information (LI) or sexual psychoeducation, specific clinical suggestions (SS) or interventions, and intensive therapy (IT) as needed — invites clients to speak honestly and explore their sexual health concerns and truth. A safe space to sit with the authentic sexual self, sexologically informed knowledge, and non-pathologizing clinical suggestions present clients with an opportunity to integrate healthy sexuality into their broader identity.

Frame Processes

Frame processes are ways in which the OCSB therapist conceptualizes and sets the therapist-client boundaries and agreements for treatment. There are three frame processes: the here and now, transference, and client treatment frame crossing. The here and now intervention gives clients an opportunity to process intense emotional experiences with the therapist as they arise in the moment. For a client who’s feared the full force of their emotions, an opportunity to sit with these feelings in a safe, nonjudgmental space generates potential to increase affect tolerance, both within self and with others, which is a fundamental goal of OCSB. The transference process during assessment provides an early path of relational dynamic exploration and practice. Noting and processing a client’s emotional proximity shift during sessions, a push/pull with the therapist, gives the client an opportunity to evaluate and perhaps change deeply entrenched negative attachment patterns. Client treatment frame crossing is anticipated in OCSB treatment and feels like a client’s push/pull in an effort to shift emotional proximity. Offering to over-pay for sessions, calling the therapist after office hours, and asking personal information are examples of common frame crossings. Entering clients often have a history of crossing personal and professional boundaries. This behavior may be learned from family of origin boundary violations and/or other forms of relational trauma. Frame crossing during assessment and treatment is named and explored. Once the therapeutic frame is rebuilt, the violation is then used to help the client reflect on how similar relational patterns may have or are currently playing out in other areas of their life.

Assessment Summary

At the end of the OCSB assessment, the therapist and client meet to review all completed objective and subjective data. The therapist provides an OCSB assessment summary, which includes clinical impressions of the client’s sexual health and vulnerability factors, as well as the core clinical areas of self-regulation, attachment regulation, and sexual and erotic conflicts. The OCSB therapist informs the client about whether or not OCSB treatment is appropriate at this time and this decision is also processed. If OCSB treatment is indicated, the therapist and client move on to co-create an individualized sexual health plan integrating all of the assessment summary elements.

Treatment: OCSB Unique Client Picture

OCSB’s intention is not merely to help clients cut out specific problematic sexual behaviors, but to also create a long-term, pragmatic vision of sexual health. The three- columned sexual health plan is a clinical tool used to help identify and organize clients’ sexual behavior changes. It’s a living document, a flexible guide towards sexual health. It shifts as needed based on the therapist-client determination of what will be most effective in helping clients manage their competing motivations. The boundaries, ambivalence, and sexual health columns of this exercise take into consideration a client’s assessment summary and are in accordance with the OCSB six principles of sexual health. The six principles of sexual health are explained to the client first, followed by a deeper explanation of the sexual health plan.

Six Principles of Sexual Health

Braun-Harvey and Vigorito’s six principles of sexual health are derived from the findings of the Pan American Health Organization (PAHO) and World Health Organization (WHO) 2000 meeting.

“Responsible sexual behavior is expressed at individual, interpersonal and community levels. It is characterized by autonomy, mutuality, honesty, respectfulness, consent, protection, pursuit of pleasure, and wellness. The person exhibiting responsible sexual behavior does not intend to cause harm, and refrains from exploitation, harassment, manipulation and discrimination.” (World Health Organization, 2000, p. 8).

Including the WHO/PAHO findings in the OCSB principles of sexual health is this model’s attempt to reduce the influence of rigid, sociocultural sexual value systems on sexuality in general and consensual sexual behaviors specifically (Braun-Harvey & Vigorito, 2015, p. 45). OCSB treatment is not predicated on diagnostic criteria and does not assign universal treatment protocols. Each client has the opportunity to create their own sexual health framework and plan. Together, the therapist and client individualize the six principles of sexual health: consent, non-exploitation, protection from STIs and unwanted pregnancies, honesty, shared values, and mutual pleasure, to highlight links between a client’s sexual health plan and their internal motivation, increasing their chances of meeting stated goals.

Six Principles of Sexual Health

1) Consent

Consent for sexual engagement and activity by all parties is a powerful sexual health principle that can increase feelings of safety and pleasure. There are several different approaches to sexual consent, including “No means no,” “Yes means yes” — also known as affirmative consent — and the “sex critical” approach (Papova, 2019, p. 15). The sex critical approach to consent is used in this paper, as it most accurately reflects the multivariate spirit of OCSB treatment. Like other sexual consent models, sex critical consent explores the dynamics of power and privilege in consent negotiation. However, this model views power not only as a top down oppressor-oppressed dynamic, but a nuanced “interaction of multiple forces, all pushing in different directions” (Papova, 2019, p. 20). Factors such as class, race, gender, ability, and sexual orientation create a much more complicated picture of consent and prompt a client to explore what an authentic “yes” looks and feels like. A sex critical approach to consent allows clients to think critically about their true sexual needs and desires, and how they may shift over a lifetime. Betty Martin’s Wheel of Consent is another tool that may be employed in exploring consent as it helps differentiate between serving, taking, allowing, and accepting another person’s physical touch (Martin, n.d.).

2) Nonexploitation

Sexual exploitation is “Any actual or attempted abuse of position of vulnerability, differential power or trust, for sexual purposes, including, but not limited to, profiting monetarily, socially or politically from the sexual exploitation of another” (United Nations, 2017). Capitalizing on a position of power, control, or privilege is compromising someone else’s ability to fully consent to sex. “Sex can be used as a means to exert control or ostracize those who cross gender role norms through overt violence, criticism, rejection, and discrimination” (Goicolea, Torres, Edin & Öhman, 2012). Adhering to the nonexploitation principle means being mindful of and eliminating disparate levels of consent whenever possible.

3) Protection from STIs and Unwanted Pregnancy

This sexual health principle requires that all partners involved in sexual activity have the choice, education, and ability to protect themselves and others from STIs and unwanted pregnancies. All partners must have adequate access to STI testing, medical care, contraceptives, counseling, and accurate sexual and reproductive health information. This principle also considers the right to feel that one has full control over their body. No one should have to live in fear of being subjected to forced “family planning” by partners or families.

4) Honesty

Self-honesty and honesty with others are crucial for effective communication and bolster all of the sexual health principles. Self-honesty means being transparent and truthful around sexual pleasure, experiences, and sexual education. Honesty in relationships varies based upon relational dynamics and is not necessarily synonymous with unlimited candidness (Braun-Harvey & Vigorito, 2015, p. 47). Clients should be able to thoughtfully differentiate between privacy and secrecy. Privacy is choosing what to reveal or not to reveal to a partner. It’s an emotional boundary. Secrecy means hiding something from a partner for fear of the consequences (Senarighi, n.d.).

5) Shared Values

Values are fundamental beliefs and/or guiding principles that dictate behavior. Having shared values with sexual partners helps to further ensure sexual consent through clarifying reasons, standards, and meaning of sexual engagement and activity. Sharing one’s sexual values facilitates clear and honest communication around motivations for sex.

6) Mutual Pleasure

Sexual pleasure is part of overall sexual health and is a natural human right. Mutual pleasure as a sexual health principle highlights the importance of giving and receiving sexual pleasure between sexual partners. It takes into consideration all involved bodies, erotic values, and sensualities.

Three-Column Sexual Health Plan

Once the OCSB sexual health principles are personalized and a full clinical assessment is considered, the therapist and client co-create a three-column sexual health plan (SHP). This action-stage intervention explores a client’s current sexual boundaries, ambivalence, and sexual health. It can be used for both accountability and tracking behavior change and can help clients move toward embodying their vision of sexual health. In common with the 12-step, SAA model’s three-circle plan (SAA Fellowship, 2017, p. 3–16), the SHP is a way to organize and help operationalize sexual behavior change. Both aim to reduce problematic behaviors, but OCSB treatment also focuses on defining and sustaining a life of sexual health and pleasure, while SAA’s primary focus is staying “sexually sober” through abstaining from specific sexual behaviors (SAA Fellowship, n.d.).

Boundaries

The boundaries column of the SHP allows clients to show a clear understanding that certain sexual behaviors have become problematic for the client and are in conflict with their vision of sexual health (Braun-Harvey & Vigorito, 2015, p. 262). As they begin naming these behaviors, the client shows an understanding that they will have to let go of once deeply pleasurable or comforting sexual activities. The OCSB therapist must take caution against getting ahead of the client’s readiness for change when collaborating on what behaviors to place in this column. Pushing the therapist’s agenda may result in a client’s reluctance or inability to change, resulting in therapeutic discord. The therapist should instead elicit sexual behavior change-talk and planning from the client (Arkowitz, Miller & Rollnick, 2015, p. 270). Unlike other PSB models, which require abstention from all problematic behavior early on in treatment, the OCSB model considers it important for clients to set attainable goals they believe they can commit to. Based on readiness for change, they take on behavioral responsibility from a more realistic starting point of healthy sexual standards.

Ambivalence

The SHP ambivalence column is where clients list emotions, situations, feelings, behaviors, and relational interactions that have historically disrupted their affective/deliberative system but which they feel hesitant to change. These disruptions can continue to lead clients to cross stated boundaries in an effort to soothe themselves. OCSB treatment normalizes and welcomes client ambivalence. Problematic behaviors that clients are hesitant to change are processed with an understanding that there can be deep comfort in the familiarity of these behaviors, making them difficult to release. The act of naming that a behavior needs to change isn’t necessarily indicative of what stage of change the client is at. One 2007 study found that 70% of clients seeking hypersexuality treatment had high levels of ambivalence toward changing the very sexual behaviors for which they sought help (Reid, 2007). Allowing clinical space to explore ambivalence provides clients with an opportunity to increase feelings of responsibility and self- efficacy through naming boundaries without committing to premature behavior changes. OCSB uses motivational interviewing (MI) techniques for change-processes (Miller & Rollnick 2012). Treatment remains flexible, allowing for each client to move through the stages of change as they feel ready and capable.

Sexual Health

The sexual health column is a collection of clinical suggestions and interventions informed by the OCSB assessment that helps clients build the regulation skills and healthy attachment they need to improve their sexual, mental, and overall health. OCSB treatment has adapted the action-stage, change-process strategies of counterconditioning, stimulus control, contingency management, and helping relationships (Sun, Prochaska,Velicer, & Laforge, 2007) in order to cultivate strengths and social supports for this shift towards sexual health.

Counterconditioning is used to replace unhealthy sexual and emotional behaviors with new, healthier ones. Giving up PSB coping behaviors without an option for replacement behaviors often ends in a client returning to the coping behaviors should they feel overwhelmed. Sexual behavior countering activities can be physical or emotional and can include physical exercise, relaxation activities, reality testing of distorted thoughts, and practicing assertive communication.

Stimulus Control supports clients who have not yet developed an ability to self-regulate PSB. Environmental control, such as internet filters and avoiding previously frequented sex-related locations, removes additional triggers should intense emotions arise. The purpose of environmental control is not to sexually sanitize a client’s daily life, but to “decrease the spending of unnecessary energy on easily avoided situations to reserve ego- strength for sexual situations that are less avoidable” (Braun-Harvey & Vigorito, 2015, p. 269).

Contingency Management sets up a system of rewards to reinforce the desired behavior change. Rewards can be in-the-moment positive acknowledgement of treatment progress or preplanned rewards after a boundary maintenance goal is achieved (Prochaska & Velicer, 1997).

Helping relationships, whether they are friends, family, clergy, or therapists, are vital to achieving and maintaining sexual health. Sharing the vulnerability of disclosing OCSB and enlisting others for support decreases feelings of isolation and increases the social safety net. If revealing PSB to others feels too premature for a client, indirect social gatherings such as meditation groups or team sports may also work to increase social network and support.

Women’s Sexuality, “Problematic” Behavior, and Implications for the OCSB Model

Exploring how women’s sexuality has been viewed throughout world history is too great a scope for this paper. Instead, attention will be primarily focused on various time periods in Western civilization, particularly within the United States. This exploration will look not only at cultural perspectives on women’s sexuality in general, but also at which sexual behaviors in women have been considered throughout history as OCSB. The aim is to link historical, psychosexual ideologies of women to lingering, present-day gender expectations. Moving forward, a more gender-balanced context for OCSB work in women is needed. Women’s voices in psychological theory and sexuality research will be integrated into the historical summary for this purpose.

As far back as written literature goes, women have sexually declared themselves — and it has been heated. The Greek poet Sappho is a prime example of an ancient woman whose sexual expression was surrounded by contention. She wrote of her own eroticism, as well as her sexual desire for other women. Her work was received by the Greeks as both literary genius and as an abomination to mankind (Tannahill, 1982, p. 99). While Plato positioned Sappho as the “tenth muse” for her writings, other ancients condemned her for wicked sexual practices (Sappho, Lombardo & Warden, 2002). Many critics were more troubled by Sappho’s outspokenness around sexual desire and high sex drive than by her attraction to women (Wilson, 2017). Centuries have passed and the details of Sappho’s life are still distorted to serve the moral or psychological ends of her readers (Chrystal, 2016, p. 109).

The middle ages brought a church-centered piety that would greatly diminish women’s overall social value and limit their ability to engage in any form of sexual expression. Erotic desire and pleasure outside of marriage and procreation was no longer tolerated and was both legally and socially punished (Patton, 1998). This militant sexual dogma dominated Western society for centuries.

Leaping forward to the 1800s, remnants of the old church remained as psychoanalysis and psychiatry began medicalizing gender norms for women. Sexual research from this time examples baseless sexual pathology and gendered theory. Kraft-Ebing (1894) expresses his disregard for a woman’s shifting emotional and physical desires over a lifetime, claiming, “If the past period of sexual life has been satisfactory, if children delight the heart of the aging mother, then she is scarcely conscious of the change of her personality” (p. 13). He describes sexually expressive women as morbid and adds that a “properly developed female mind and body” does not have independent sexual desire or pleasure. Any sexual feelings women do have serve only to incentivize them to marry and procreate. And women who only seek out men for sexual pleasure are abnormal (p. 13). Another psychiatrist, Benjamin Rush (1830), describes one young woman’s same- sex longings as “paroxysms of madness.” He’s puzzled by her occasional resumption of “gay habits” and simultaneous rejection of her religious group (p. 163). Each rare mention of a woman’s sexuality in textbooks or research papers from this time is invariably paired with a panicked male psychiatrist’s voice, clamoring for the necessity to maintain cultural norms.

Until the 1960s, these archaic gender norms remained largely unchallenged (Tiefer, 1991). A woman’s psychological health remained correlated with her capacity as a wife and mother. Sexual apathy, subservience, and a desire for motherhood were seen as “healthy” psychology. Outward expression of erotic desires or the challenging of social norms branded women degenerate, hysterical, and of lower pedigree. In the late 1960s, a panel of women psychoanalytic authorities began challenging the validity of psychological assessments for women (Sherfey, 1973, p. 22). Among other things, they argued that women’s sexual desire and expression should not be pathologized for looking different from that of men on assessments that were created by men for men (The Association for Women in Psychology, 1993). The Committee on Women in Psychology (AWP) and The Association for Women in Psychology (CWP) were formed around this time and began campaigning against systemic sexism and heterosexist policies and practices within the American Psychological Association (APA) (Unger, 2004, p. 9).

The AWP and CWP demonstrate the necessity for a women’s consciousness component in effectively providing therapy for women (Brownmiller, 1999, p. 21). This awareness is especially needed for women struggling with OCSB. In order for a therapist to be able to differentiate between a woman’s potential OCSB, internalized gender stereotyping, and normative sexual behavior, there must first be an understanding of both the historical and present, implicit, and explicit societal expectations of women’s sexuality, and how these expectations may become internalized. A women’s consciousness lens might include questions such as: Does this client pathologize her sexuality simply because it exists? Because she may desire multiple partners? Because she has a high sexual desire and a wide variety of sexual preferences or behaviors? Would these behaviors seem acceptable to her if she were a man? Does she fear her sexuality? (Sipe, personal communication, October 2019). Researcher Wednesday Martin (2018) notes that women often reach out to therapists presuming their sexuality is pathological because it differs from what society has taught them is “normal” (p. 5).

This paper aims to help reset the baseline for what is considered OCSB in women. Throughout history, sexuality research has primarily been designed, conducted, and established by men, with the purpose of helping men. It’s reasonable to assume that there remain gender biases that continue to influence what is considered women’s out of control sexual behavior. To be clear, not all reported OCSB cases in women result from sociocultural imprinting or gendered clinical misreads. Many women unquestionably struggle with out of control sexual feelings, thoughts, and behaviors. It’s critically important, however, to differentiate between OCSB and normal variations of women’s sexuality.

Biologically Based Erotic Differences Between Men and Women?

Gender-based sex hormone differences and their potential implications have been well documented (Blair, M. 2007). This paper’s extensive literature review, however, found consistent, unfounded presumptions throughout history — that men biologically desire and “need” more sex than women, that women have a higher ability to process emotions, and that women prefer emotional intimacy over sex (Cancian, F., 1986; Krafft-Ebing, R., 1894, & Tannahill, R. 1982). Neuroscience has begun to counter this notion with a more nuanced view of gender and sexuality. One study shows that “most brains are comprised of unique ‘mosaics’” of (both male and female) features and “although there are sex/gender differences in the brain, human brains do not belong to one of two distinct categories: male brain/female brain” (Joel, D. et al, 2015). Another study found that within-gender sexual excitation and inhibition variability is much greater than the average differences between genders (Carpenter, D. et al., 2008).

OCSB therapists working with women must understand that women’s sexual excitation and inhibition is multivariate. They should be informed by updated, women-included research to avoid oversimplifying and stereotyping what turns women “on” or “off.” The therapist should also consider potential sociocultural impacts that varying sexual desire levels and eroticism can have on women’s self-perception, as it may influence their levels of excitation and inhibition.

Sociocultural Imprints on Women’s Sexuality and OCSB Implications

Sexual identity develops and shifts throughout a lifetime and is shaped by our sexological ecosystem, or sexual development in relation to other people (Buhler, 2013 p. 52). Sociocultural expectations around women’s sexuality have undoubtedly been a part of the human sexual ecosystem for millennia, impacting how women have felt in and viewed their sexual bodies. Historic, systemic power over a woman’s 1) right and means to control birth, 2) sexual functioning, appearance, and pleasure, and 3) sexual and social value are a few examples of potential impact. For some, sexually accepting peers or supportive communities have shielded harmful influence. For others, family values and social systems have aligned with and perpetuated distorted beliefs.

Power Over Right and Means to Control Birth

a. Pregnancy Prevention and Termination

Attempts at effective birth control date back to 3000 B.C. (Thompson, 2019). The widespread questioning of a woman’s right and means to have children began in the mid- 19th century, when economist Thomas Malthus suggested that “population control” would create a favorable balance between the current human population and the world’s available resources (Malthus, 1798). From the start, reproductive rights legislation has favored governmental (male) leaders’ ideology over prioritizing women’s emotional and physical health. Malthus’s population control theory quickly became adopted worldwide, as it also happened to support burgeoning eugenics programs aimed at ridding society of unwanted minority groups and otherwise “unfit” individuals (DenHoed, 2017).

In the U.S., there have been political and morality-based movements towards limiting birth control, banning abortion and, in some cases, both. The 1873 Comstock Act prohibited selling or distributing “obscene and illicit” materials that could be used for sexual education, contraception, and/or abortion (American Experience, 2018). In 1965, only married couples were granted the right to use birth control and, in 1972, birth control became legal for all U.S. women (Thompson, 2019). There is now, theoretically, universal access to birth control in the U.S. A woman’s true access to birth control, however, remains contingent on where she lives, her distance from a prescribing provider, and her health insurance coverage (if covered). Also, current U.S. laws are reversible and there are efforts present within the U.S. government to further restrict access to reproductive choice. If this occurs, millions of women, “especially women of color and young people wouldn’t be able to afford birth control at all” (Planned Parenthood, n.d.).

The U.S. debate over who holds the power to end a pregnancy has been even more contentious than the fight over who holds the power to prevent one. Outside of the U.S., male family heads continue to have legal authority over girls’ and adult women’s reproductive choices as they are considered responsible for family planning (Boswell, 1998, p. 12). The number of children a woman has, and what sex, becomes a calculated choice in service of retaining or increasing family wealth and success. Across the U.S., there have been confounding and prohibitive laws enacted to stop or deter women and girls from choosing to end a pregnancy (Guttmacher Institute, 2020). Considering the history of abortions in the U.S. and other countries, restricting access to reproductive choice will continue to increase chances for unwanted pregnancies, death from botched abortions, and infanticide (Gold, R., 2020). Infanticide within the U.S., as with other areas of the world, most frequently arises out of external pressures such as fear of punishment, social isolation, and deepening poverty (Oberman, 2004). Should abortion become illegal or more restrictive than it is today, infanticide in the U.S. would most likely significantly increase (Moseson, et al., 2019).

b. Forced Sterilization

Forced sterilization is a nonconsensual, irreversible procedure that ends someone’s ability to reproduce (Woolf, n.d.). Globally, governments and families have imposed forced sterilization on women at different ages for varying reasons, using a broad range of procedure methods. In 1907, the U.S. passed a law allowing state governments the right to sterilize “unwilling and unwitting people” (Krase, 2014). Thirty states adopted this law, claiming that “insane, feeble-minded, dependent, and diseased” people were incapable of controlling their own reproductive abilities. In 1927, Supreme Court Justice Oliver Wendell Holmes wrote, “It is better for all the world, if instead of waiting to execute degenerate offspring for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind… Three generations of imbeciles are enough” (Black, E., 2003). North Carolina, as one example, went on to sterilize 7,600 people. Echoing Malthus’s theory from more than 150 years prior, the 1937 U.S. Law 116 was passed as an attempt to “boost” economic growth in Puerto Rico. A 1965 survey later found that one-third of mothers aged 20–49 had been sterilized, some unaware the procedure was irreversible (Krase, 2014). And as recent as 2013, a report uncovered that the California Department of Corrections and Rehabilitation doctors sterilized nearly 150 female inmates from 2006 to 2010 without authorization (Center for Investigative Reporting & Johnson, 2015). In all of these examples, government power over reproductive health disproportionately impacted working poor women and women of color.

Women and their sexuality are affected by the investment that current social, religious, and political powers have in who decides if a conception leads to a birth, or if reproduction should be allowed at all (Braun-Harvey, personal communication, April 1, 2019). They live with the consequences of reproduction in a very different way than men. Whether or not a woman chooses to use birth control, terminate a pregnancy, or has access to either of these options (or if she is allowed have children) impacts how the woman can view and value her sexuality. With no way to prevent a pregnancy and no way to end one, women do not have full control over their bodies and how they choose to express their sexuality. A women’s OCSB therapist should consider that women can hold trauma in their bodies and sexual self-concept from any potential pregnancy, past pregnancies, or terminated pregnancies. They should be able to hold this difference of a woman living with a uterus and how the potential consequences of conception impact her approach to sexual relationships with regard to competing motivations around self- regulation, attachment regulation, and sexual and erotic conflicts (Braun-Harvey, personal communication, April 1, 2019).

Power Over Sexual Functioning, Appearance, and Pleasure

a. Genital Cutting/Circumcision

Female genital cutting (FGC), also called genital mutilation, “comprises all procedures involving partial or total removal of the female external genitalia or other injury to the female genital organs for non-medical reasons” (End FGM European Network, n.d.). The three main categories of FGC are clitoridectomy, excision, and infibulation, with a fourth category encompassing all other non-medical procedures to the female genitalia. There are no known health benefits to FGC, and there can be serious health consequences. The potential for scarring, cysts, chronic pain, long-term infections, and infertility increases with the severity of the procedure (Stewart & Spencer, 2002, pg. 79). Worldwide organizations have called for an end to FGC, as they consider it a health and human rights violation (Khazan, 2015). However, there are culturally based counterarguments defending FGC as a misunderstood rite of passage. One argument claims that it’s elder women in communities — not patriarchy, as has been widely believed — making FGC decisions. Another argument asserts that everything from the medical costs to the social benefits are fully considered within the communities. However, Western cultures tend to not value traditions they don’t endorse or understand (Khazan, 2015).

In Africa, the Middle East, and Asia, where FGC practice is most concentrated, 200 million girls and women alive today have undergone the procedure (World Health Organization, 2020). Some undergo FGC before the age of 5, and some as infants. FGC is now present in pockets all over the world as more countries become destinations for migrants and refugees who carry this tradition forward (United Nations Children’s Fund, 2016). In the U.S., medical doctors commonly perform FGC on intersex children but present it as “cosmetic surgery,” upholding the gender binary social norm (Human Rights Watch, 2017). One 2012 study estimated that approximately 513,000 women and young girls in the United States were at risk for FGC (Goldberg, et al., 2016), either from cultural or medicalized expectations.

It cannot be assumed that women who have experienced FGC view this event negatively. There may indeed be physical and emotional wounding, but there may also be positive feelings and experiences held from the event.

b. Sexually Explicit Media (Pornography)

Exploring how sexually explicit media (SEM) may impact a woman’s sexuality is a complex task. If she engages with SEM, is it consensual or nonconsensual engagement? Is she producing or consuming the SEM? If she’s viewing it, with what frequency and what are its contents? How long has she been engaged with SEM? How has her sexological ecosystem impacted past and present experiences of anything listed above?

There are conflicting professional opinions on how sexual imagery has impacted women’s sexuality. A wealth of academic sources can be found to support whatever beliefs are held. Consider the following contradiction within a single research study:

“Women described pornography’s contributions to the enhancement of pleasure through solo pleasure, shared viewing with partners, discovering new sexual preferences, and reassurance about body appearance.”

But also:

“Pornography was constructed as interfering with pleasure through its misrepresentation (of bodies, sexual acts, and expression of pleasure), women’s concern for actors’ wellbeing, and its disruption of intimacy” (Ashton, McDonald, & Kirkman, 2019).

The vast majority of sexual imagery in the United States is produced by men for men. (Pornhub, 2018). As a result, a male lens guides the fantasy and the idealization of both men and women’s bodies. With limited factually based sexual literacy available for most young people in the U.S., SEM has become mistaken for sexual education (Ohene, 2019). Young people of all genders are watching SEM, measuring their bodies and sexual behavior against these fantastic idealizations. Current data suggest that SEM usage among women and girls is steadily rising (Pornhub, 2018). SEM is now becoming a reference point for how their genitalia (and the rest of their body) should look, respond, and perform. Progress, however, is being made toward reducing the objectification of women in SEM through increasing SEM literacy in young people. A 2017 study found that the more a young person was provided SEM literacy, the less likely they were to report gendered views (Vandenbosch & Oosten, 2017). There’s also been an increase in SEM created by women for women’s pleasure. “Feminist Porn” features more realistic representations of women’s bodies and sexual responses, works to provide an ethical workspace for all involved, and uses SEM to “counter and complicate dominant representations of gender, sexuality, race, ethnicity, class, ability and age, body type, and other identity markers (Taormino et al., 2013, p. 9).

An OCSB women’s therapist should be able to differentiate between OCSB and normal variation in women’s sexuality, providing accurately informed sexual education as needed. They should possess an awareness of their own cultural and religious biases and be able to hold space for however her experiences are presented. There is an added suffering for women who seek out OCSB support only to be misunderstood and judged negatively. It cannot be assumed that women who participate in consensual sex work or engage with SEM have been traumatized or want to stop participating. They may have been impacted negatively by these experiences, but they also may have enjoyed them. A self-identified “porn addict” may feel that she genuinely cannot stop watching SEM, or she may be presenting with an erotic moral conflict around using SEM. Framing her usage as a pathology in an effort to skirt a religious ethical dilemma as a “porn addict,” she is able to retain her morality because she has taken on this pathology (Braun-Harvey, personal communication, 2018). Or she may enjoy viewing SEM and have a partner or family that believes she is out of control. The OCSB therapist must allow space for and value each woman’s nuanced experience of her sexuality.

Intersectionality: Power Over Sexual and Social Value

A woman’s degree of sexual and social power depends not only on gender difference, but on every one of her identity markers, and can be conceptualized though the qualitative sociological framework of intersectionality. Intersectionality explores the convergence of identity markers that influence how much sexual and social power a person holds. It’s “a lens through which you can see where power comes and collides, where it interlocks and intersects” (Crenshaw, et al.,1996). Each woman holds a unique composition of power (Anderson & Collins, 2015, p. 5), which impacts her right and means to control birth, as well as sexual functioning, appearance, and pleasure.

In the U.S., being assigned male at birth continues to hold more power and social value than being assigned female at birth. Men continue to have influence over the fiscal, social, and sexual value of women though governmental and cultural laws in order to uphold sociocultural order (Ortiz-Ospina & Roser, 2018). A woman raised with implicit and explicit messaging that her social value is determined by others may also come to believe that others get to decide her sexual value. OCSB therapists might consider that a woman’s out of control sexual thoughts, feelings, and behaviors may be, in part, attempts at addressing powerlessness over her sexual agency and social value.

For 200+ years, U.S. institutional dominance over women’s minds and bodies was clearly exampled by the devaluation, objectification, and violation of enslaved African women. In addition to lingering systemic oppression and racial inequities, Black women may struggle with profound self-image concerns. Being trained to believe that lighter skin tone has more social value, or that all Black women should be curvy and are hypersexual (Awad et al., 2015), can impact feelings of self-worth, and OCSB therapists working with a woman of any race or ethnic group should be able to reflect on this gender-race intersection.

The historical disregard for, and avoidance of, disabled women’s sexualities is another example of sociocultural influence over power and value (Sins Invalid, 2019). The history of forced sterilization, institutionalization, and marginalization of disabled women in the U.S. has created still existent barriers to sexual rights, choice, and expression. Assumptions that disabled persons are asexual has led to inadequate sexual education and awareness, and vulnerability to “bad sex” — relationships that are considered to be exploitative and disempowering (Shah, 2020). The intersection of ability and gender for some women with OCSB may present as low self-concept fused with attachment regulation, which can lead to the belief that emotional and physical attachment only come for disabled persons in exchange for sex.

Self-Regulation, Attachment Regulation, and Erotic Conflicts

OCSB assessment and treatment explores how self-regulation, attachment regulation, and erotic conflicts can upset a client’s deliberative-affective balance (Braun-Harvey & Vigorito, p.77). Women with OCSB often report struggles with self-regulating emotions and mood, or affect dysregulation. Faisander, Taylor, and Salisbury (2011) found that adverse childhood experiences were linked to adults with OCSB, reporting that women in particular struggle with higher levels of anxious attachment than men. Consciously or unconsciously, women with OCSB may attempt to circumvent self-regulation by entering into relationships with hopes that a new partner can regulate hard feelings for them. For decades, struggles with interpersonal affect dysregulation have been labeled as love addiction (Mellody, 1992) and, as with the sex addiction “diagnosis,” the label has heaped pathology onto valid needs for emotional and physical connection. Given society’s feminization of the word love (Cancian, 1986) and its historically negative view of women’s emotional experiences and sexual expression, the love addiction epithet simply feeds stereotyping. Diagnostic categories such as hysterical neuroses, histrionic personality disorder, and borderline personality disorder have regularly been a woman’s struggle (North, 2015, and Flanagan & Blashfield, 2003), reinforcing a societal generalization that all women express love only through high emotionality and feelings expression, not physicality and strength (Cancian, 1986). It ignores how women can express love sexually, oversimplifies emotional experiences, and inhibits strengths- building as women work towards shifting their self-regulation patterns. The love addiction symptomology can be more accurately and appropriately framed as insecure attachment and interpersonal affect dysregulation, rather than a sexual and emotional disease.

An understanding of modern attachment theory and interpersonal psychobiology is required to effectively support women processing unhealthy self-regulation and attachment regulation patterns. “Attachment theory is essentially a regulatory theory, and attachment can be defined as the interactive regulation of biological synchronicity between organisms” (Schore, 2000). Bowlby and Ainsworth originated this theory on how people develop and experience emotional bonds over time, specifically naming the emotional impact primary caregivers have on children (Ainsworth, 1979 & Bowlby, 1969). Affect dysregulation is an inability to autoregulate emotions, modify behaviors related to hyperarousal or hypo-arousal, and connect with reason when emotionally triggered (van Dijke, Hopman & Ford, 2018). It often results from chronic childhood mis-attunement and insecure attachment with a primary caregiver (Bureau, Martin & Lyons-Ruth, 2010).

A crucial task for a primary caregiver during the first 18 months of life is to co-regulate the infant’s nervous system via right-brain-to-right-brain attunement — to implicitly teach the child how to regulate their nervous system in a healthy way (Schore, 2001). This caregiver’s right brain attunement must include both the capacity to upregulate (create pleasure) and downregulate (soothe distress) the child. Ideally, over time, the child internalizes the regulatory modeling, learning how to self-regulate, and securely attaches to others. If a caregiver is unable, unavailable, or unwilling to provide this skill, the infant’s nervous system is subjected to “survival mode” of chronic hyperarousal or hypo-arousal and develops trauma expressed as affect dysregulation. As infants with affect dysregulation grow into children, they may start seeking out others for help with soothing intense feelings they cannot tolerate and were not taught to regulate. The struggle of self-regulation shifts to seeking external regulation through relationships. Some of these children, who continue seeking external regulation, become locked in unhealthy attachment regulation. Eventually, they may grow into adults with OCSB, engaging in the relational “dance of emotional proximity as a method to alter their personal feelings” (Braun-Harvey & Vigorito, p. 87). Seeking out emotionally unavailable partners, they expect the impossibility of a partner healing their core attachment wounds. This repetition compulsion of self-harm through sex and relationships (Freud e al. 1975 & van der Kolk, 1989) examples an insecure attachment style, more specifically, an interpersonal (organized or disorganized) psychobiological response to others, imprinted by the primary caregiver long ago (Schore, 2001).

Women with unhealthy attachment regulation can have traumatic sexual histories connected to current erotic conflicts. OCSB therapists must consider the intersectionality of sociocultural imprints on women’s sexuality, internalized gender stereotypes, and sexual orientations/leisure activities (Sprott and Williams, 2019) as these erotic conflicts are processed. A deep-rooted history of pathologizing women’s sexual experiences and expression calls for careful differentiation between pleasurable, consensual erotic play and erotic conflict. Valuing the client’s power and capacity to identify what sexual engagements feel enjoyable, harmful, or out-of-control for her is a hallmark of OCSB’s client-centered model.

Many women entering OCSB therapy continue to seek out partners as external affect regulators. It’s reasonable to assume that some of these women use their sexuality and bodies as a learned “resource” to obtain and secure partners through now well-developed repetition compulsion. During the sexual development of some of these clients, sexual trauma can become fused within their core erotic theme (CET), or “fingerprint” of eroticism. Morin (1995) explains the CET as “an infinite array of storylines, characters, and plot twists (that) can all be inspired by a simple, yet profoundly meaningful dramatic concept” (p. 159). In certain cases, CETs centering around psychological or physical dominance and/or submission can become the crux of what turns a woman on. It’s vital for a therapist treating CETs involving BDSM sexualities and communities to understand BDSM as “a complex set of behaviors that can be expressions of people’s health and impulses to grow or be expressions of people’s brokenness and internal conflict or suffering. One cannot tell by looking from the outside… you have to know what it means to the person” (Ortmann & Sprott, 2015 p. 9). BDSM play is not an indicator of erotic conflict and should only be treated as erotic conflict if that is the client’s lived experience.

Psychoeducation around attachment trauma and the affective-deliberative systems, as well as skills-building for increased stimulus control and countering behaviors, work to reduce feelings of helplessness towards entrenched patterns of self-regulation, unhealthy attachment regulation — interpersonal affect dysregulation — and erotic conflicts. The OCSB therapist facilitates a positive sexual and erotic identity development through empathetically listening and normalizing ambivalence as the six principles of sexual health become a foundation for an integrated, healthier sexuality.

OCSB Assessment and Treatment Adaptations for Cisgender Women

Individual vs Group Modality

Braun-Harvey and Vigorito’s path for OCSB treatment with men is concurrent individual and group therapy. The individual therapy “provides clinical management, treatment- planning, and in-depth focus on intrapsychic concerns associated with dysregulated sexual behavior,” while the group therapy “provides in-the-moment relationship events in which members explore defenses and interpersonal patterns and expand relational capacities for intimacy and closeness” (Braun-Harvey & Vigorito, 2015, p. 292). This combination of individual and group treatment is a powerful support for positive emotional and behavior change (Zisi, Gratsani, Leontari & Theodorakis, 2016).

Anecdotally speaking, both in clinical practice and discussions with other researchers, the number of women seeking OCSB treatment is significantly lower than that of men. A 2016 study found four potential barriers for women seeking treatment with problematic sexual behavior: (a) individual barriers, (b) social barriers, © research barriers, and (d) treatment barriers (Dhuffar & Griffiths, 2016). Societal pressure for women to adhere to cultural norms, to meet sexual ideals, and/or hide their sexuality entirely, while men are allowed room to publicly struggle with OCSB, has added to sexual shame for many women. The understandable hesitation to seek needed OCSB support reinforces the challenge in finding women OCSB research subjects. With minimal research data on women’s sexuality, it is difficult to create an accurate baseline — for researchers or the general public — that enables one to compare gender difference in presenting sexual behavior, problematic or otherwise.

Women often enter OCSB treatment not as “sex addicts” but as self-diagnosed “love addicts” (Mellody, 1992) or “codependents” (Beattie, 1992). This may be due to problematic sexual behavior literature and social messaging primarily targeting men, or the gendered construct that women are just “more emotional” than sexual (Cancian, F., 1986). There is a tendency for women OCSB clients to feel more comfortable focusing on the emotional pain of partnerships while minimizing or ignoring how their sexuality may factor into the problem. Clients often acknowledge that the emotion-based labels feel less shameful than naming that they may have a problem with unhealthy sexual behavior.

Given the above-listed blocks around women seeking OCSB treatment, forming and sustaining a group for women identifying with OCSB can be challenging. This does not confirm that the currently low prevalence of women in OCSB is accurate. More thorough clinical assessments must be implemented, and accurate women’s sexual health literature circulated, to help women identify OCSB in women. A modified, singular route of OCSB individual therapy for women can be used until group formation is possible.

In addition to clinical management, treatment planning, and intrapsychic concerns, individual OCSB sessions with women should include the three primary clinical objectives used in OCSB men’s group setting:

1. Help clients maintain their SHPs
2. Improve client self and attachment regulation
3. Facilitate a positive sexual/erotic identity development

Additional Assessments

Creating mental health and sexuality standards and measurements with limited consideration for women leads to assessments that can reinforce gender stereotypes. The struggle to fairly assess women’s mental and sexual health continues. Sari van Anders has stated that, “In almost all areas of research, men are understood to be humans and women are understood as gender or a special case” (Volpe, 2019). Emily Nagoski (2015) reflected concern around using men’s sexuality as a guide to measure women’s sexuality. She noted how a pharmaceutical company once tried (and failed) to create women’s Viagra. Instead of considering gender differences in sexual response, namely potential “sexual brakes” (or sexual inhibition) in women, the company promoted off-label use of this male sexual enhancement drug for women (p. 46). In addition to “Pink Viagra’s” harmful side effects (Agarwal & Baid, 2018), this drug-push encouraged unrealistic expectations of women’s arousal and subsequent self-blame when arousal expectations were not met (Urist, 2014).

New or adapted clinical assessments, created or informed by women researchers, must be used in OCSB treatment with women to help normalize gender differences in sexual experiences.

Nagoski’s (2015) Sexual Temperament Questionnaire (STQ) is used when exploring how the dual control model applies to clients (p. 54). The STQ is an adapted and abbreviated version of The Sexual Excitation/Sexual Inhibition Inventory for Women (SESII-W) created by Graham, Sanders & Milhausen (2006). Graham et al. argued that the original SES/SIS measure (Janssen, Erick, Vorst, Finn & Bancroft, 2002) lacked sufficient consideration of gender differences in women, such as the perception of threat, which may impact level of sexual inhibition. Nagoski asserts that this adaptation is to be taken only as an approximation of one’s internal sexual response system and is an attempt to depathologize the subjective experience of each woman’s “gas and brakes” (p. 53).

The Quirk et. al. (2002) Sexual Function Questionnaire Version 2 SFQ (SFQ-V2) is a 34- item self-report used to gain a multidimensional measure of sexual functioning in women. This client-centered assessment paints a comprehensive picture of each woman’s sexual functioning based on newer developments in research of sexual response and dysfunction. Crossing seven domains of women’s sexual functioning — desire, physical arousal-sensation, physical arousal-lubrication, enjoyment, orgasm, pain, and partner relationship — this measure catches the nuances and potential overlap of functioning that might be conflated with problematic sexual behavior.

The Body Exposure During Sexual Activities Questionnaire (BESAQ) (Cash, Maikkula & Yamamiya, 2004) may be added to the assessment if a woman presents with a clinically significant, negative body image. The BESAQ provides a baseline of how a woman feels in her body. It highlights how sociocultural norms and her sexological ecosystem may have negatively impacted her feelings of desirability and sexual value. For example, the BESAQ provides an opportunity to process internalized body shaming that can occur from a woman not fitting within the white-privilege, heterosexual, and able-bodied normativity ideal of desirability (Sins Invalid, 2019).

Conclusion

Sexuality research and literature has historically depicted women’s sexual variation, expression, and expansion as insane, diseased, amoral, or spiritually bankrupt. Age-old sociocultural and governmental standards have prioritized sexuality research and education conducted by men for men, creating deep-rooted harm to portrayals of women’s sexuality throughout history, and inhibited research is needed to more broadly understand and support women’s sexual health. Cisgender, heterosexual men’s sexual experiences persist as the “norm” by which women’s sexuality is gauged. Inevitable gender differences in sexual desires, thoughts, feelings, and behaviors leave women marginalized. As gendered stereotypes linger in sexuality research and education today, how are therapists, often professionally underdeveloped in sexuality, expected to distinguish between truly out-of-control sexual behavior and normal variations in women’s sexuality? To be clear, not all reported OCSB cases in women result from sociocultural imprinting or gendered, clinical misreads. Many women unquestionably struggle with out of control sexual feelings, thoughts, and behaviors. But a helping professional must be able to spot the difference.

The out of control sexual behavior (OCSB) clinical framework provides a minimally- pathologizing route to treating problematic sexual behavior. Its client-centered, integrative approach examines sexual urges, thoughts, or behaviors that can feel out of control. The OCSB framework does not rely on assigned amounts or durations of clustered symptoms or individual sexual behaviors to begin or direct the course of treatment and does not consider OCSB a psychosexual disorder but, rather, a sexual health problem. This reduces the potential for the further marginalizing of women’s sexuality. It incorporates into its sexual health plan the transtheoretical model of health behavior change and motivational interviewing techniques to support clients wherever they are in the stages-of-change cycle. These techniques help to mitigate competing motivations between the deliberative and affective systems in three distinct clinical areas: self-regulation, attachment regulation, and erotic conflicts. A healthier balance between these two decision-making processes, in turn, helps to reduce out of control feelings around urges, thoughts, and behaviors. OCSB treatment shifts the problematic sexual behavior clinical frame from an empirically unsupported addiction lens to a sexual health problem based in interpersonal, psychobiological affect dysregulation.

Doug Braun-Harvey and Michael Vigorito created the OCSB model for cisgender men, inviting helping professionals to translate it for use with other clinical populations. This paper has attempted to do just that, adapting OCSB treatment for use with cisgender women. It cannot assume how the OCSB model might shift for transgender or intersex clients, as its author’s work with these populations remains limited. This work includes a women’s consciousness lens to more accurately reflect women’s sexual voices and experiences, highlighting both implicit and explicit sociocultural expectations that can become internalized during a women’s psychosexual development via her sexological ecosystem. It explores systemic power over a woman’s 1) right and means to control birth, 2) sexual functioning, appearance, and pleasure, and 3) sexual and social value.

As the sex therapy research and education fields are still grappling to find consensus on etiology, diagnosis, and treatment for OCSB, both in men and women, this paper aims to increase space in the professional dialogue for women’s sexual experiences and voices. Perhaps shifting clinical attention away from specific sex acts and frequencies — which tend to marginalize normal variation in human sexuality — towards qualities of relational attachments can help reduce long-standing gender binaries.

Acknowledgements: There are no financial conflicts or funding sources for this paper.

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Oakland, CA certified sex therapist specializing in women’s sexual health and out of control sexual behavior. jessicalevith.com

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