Why we talk about sex

June 30, 2009
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A California program allows for frank discussion of the link between sexual and substance-using behaviors

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

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

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

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

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

  • Have you experienced trouble understanding, concentrating or remembering?

  • Have you ever been charged with shoplifting or vandalism?

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

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

Direct approach

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

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

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

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

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

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

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

John de Miranda, EdM

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

William Brock, Psyd


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

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

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

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

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