Sexual Health Blogs


AASECT Summer Institute: Revisiting 'Sex Addiction' (Part 8) with Dr. Susan Stiritz

We interview Dr. Susan Stiritz from the recent AASECT Summer Institute which was titled: Revisiting 'Sex Addiction': Transformative Ways to Address Out of Control Sexual Behavior. Susan co-directed this institue and this post concludes the series. As the only educator at this institute, Dr. Stiritz encourages sex educators to join the conversation and why this is critical. Throughout the interview, Susan discusses how we can take into consideration the artists point of view when thinking about this issue. She discusses how movies and films could help us better understand out of control sexual behavior and a little of AASECT's journey to the formal position statement rejecting "sex addiction" which was just put in place. It's wonderful to hear about this topic from a highly regarded sex educator.

Susan Stiritz is an AASECT Certified Sexuality Educator, who has been teaching sexuality studies for the past twelve years at Washington University in St. Louis. Her research interest, transformative sexuality education, springs from her work, as an antipoverty worker, manager of training and patient education for The St. Louis Family Planning Council, and Women, Gender, and Sexuality Studies faculty member. 

She conducts research on the hook-up culture, noting the difference sex-positive, gender-neutral sexuality education makes. Currently, Susan is Senior Lecturer and Coordinator of Sexuality Studies at the Brown School. She presents workshops and conference papers at AASECT, SSSS, the National Women's Studies Association, and Law and Society.

AASECT Summer Institute: Revisiting 'Sex Addiction' (Part 7) with Michael Vigorito, LMFT, LCPC, CGP

We interview Michael Vigorito, LMFT, LCPC, CGP in this seventh installment from the recent AASECT Summer Institute which was titled: Revisiting 'Sex Addiction': Transformative Ways to Address Out of Control Sexual Behavior. Michael discusses why the group process is important and what we can learn from sexual minority communities. He tells us to put pleasure back into the definition of sexual health and sex education programs and we couldn't agree more.

Michael Vigorito, LMFT, LCPC, CGP is a sexual health psychotherapist, author and consultant.  As a psychotherapist, he provides individual, couples and group psychotherapy for a range of behavioral health concerns.  He co-designed a sexual health assessment and treatment protocol with Douglas Braun-Harvey, which was published in Treating Out of Control Sexual Behavior - Rethinking Sex Addiction (2016).  Mr. Vigorito is a member of the American Group Psychotherapy Association, the Society for the Scientific Study of Sexuality,  the American Association of Sex Educators, Counselors and Therapists and the American Association of Marriage & Family Therapists.

Mr. Vigorito is licensed in the District of Columbia and Virginia as a Marriage & Family Therapist, in Maryland as a Licensed Clinical Professional Counseling and is certified as a Group Psychotherapist through the American Group Psychotherapy Association.

AASECT Rejects the Concept of "Sex Addiction"

Below is an interview with David Ley about the new position statement by the American Association of Sexuality Educators, Counselors, and Therapists (AASECT).


1. Where did the idea of “sex addiction” come from (if not from the medical community, as I understand it)?

Sex addiction is truly a social phenomenon, not a clinical or medical one. It’s important to understand that it largely arose after homosexuality was removed from the Diagnostic and Statistical Manual of the APA, and in response to the AIDS crisis. It’s not by accident that gay and bi men are at three times the risk of being labeled or diagnosed a sex addict. But here’s the thing, I truly believe most sex addiction therapists and writers aren’t bad people – they are trying to help people, people who are in pain and fear because of their sexual urges. In the early 80’s, as these social shifts were going on, traditional medical and mental health people really weren’t talking about sex any longer, and these people who were in pain and scared, found support from addictions therapists who said “we can treat the desire for sex like it’s a craving for drugs or alcohol.” They at least offered support and assistance to people who were terrified.

The problem is that sex isn’t like a drug or alcohol. No one ever died from blue balls, but long-term alcoholics can die if you take away alcohol. At a deeper level, what got glossed over in the zeal to offer support in the form of sex addiction treatment to these individuals, was that their pain and fear was often coming from social and moral struggles with sex. When a gay or bi man is taught to suppress their sexual desires for other men as an addiction, it pathologizes this desire, without ever acknowledging the degree to which the pain emerges from stigma, not the desire itself.

As these therapists then began to define what they thought unhealthy sex was, they based their theories on the select sample who came to them for treatment. Because most sex addiction therapists are themselves self-identified sex addicts in recovery, and they have no training in human sexuality, they base their diagnoses upon their own experiences, and those of the sample of people they see. For example, for a long time, sex addiction theorists have argued that daily sex or masturbation is unhealthy, because that’s a pattern they see in people they treat with sexual behavior problems. Unfortunately, they don’t see the great many people who have daily sex, and experience no problems. This criterion was finally dropped a few years ago, when it was demonstrated that a great many women use nightly masturbation to help them sleep, and that as many as 40% of males go through significant periods in life where they masturbate or have sex daily, all with no problems or consequences.

2. Why is it an issue to oversimplify sexual behavior issues as “sex addiction”? Basically, can you give some examples of harm from using this “diagnosis” versus another diagnosis?

So at this point, we have a wealth of information supporting the very real consequences of the sex addiction diagnosis. For instance, one recent study of sex addicts in treatment showed that 90% had a major mental health disorder such as anxiety or depression, and 60% had a paraphilia, a fetish or a sexual disorder. But, these individuals were receiving treatment for “sex addiction” as opposed to their depression, anxiety or sexual disorder.

Multiple other studies now reveal conclusively that sex addiction is a label rendered overwhelmingly on males (90-95% of sex addicts are males), and half of those males are white, heterosexual, religious (most often Christian and very high rates of Mormon) married males who are middle to upper class in income. This raises two significant issues: 1. Sex addiction is a label applied to diagnose the long-standing sexual privilege held by powerful, privileged males, who are allowed or excused from sexual misbehaviors. 2. There are huge issues here of religion. Religious therapists diagnose sex or porn addiction at far higher rates than secular therapists. Multiple studies now show that the self-identity as a sex/porn addict is predicted by one’s religious values about sex, not actually by frequency of sex. In other words, these folks don’t actually have more sex than others, they feel worse about it. That’s a values conflict, between the sexual values taught in many conservative religious traditions (I’ve seen this in Christians and Muslims for instance) and the sexual opportunities in porn, casual sex, hook-ups, etc., which are available in the modern world. In essence, it’s like the problem of abstinence-only education – we teach kids next to nothing about sex, then are surprised when they struggle with unhealthy sexual behaviors or feel out of control with regards to their sexual desires, because they were never taught to understand or self-manage them. The same is true for a great many people today, raised in highly religious environments, who then encounter the wide world of modern sexuality, and feel overwhelmed by the opportunities available.

In my practice, and that of other clinicians, we see a great many people harmed and confused by the label of sex addict. For instance:

  • 42 year-old male, father of five and a widower, who masturbating to heterosexual porn on a daily basis. Sought treatment for sex addiction because his minister assured him this was unhealthy and an addiction.
  • 56 year-old Catholic male who sought treatment after divorce, because he had been diagnosed as a sex addict for going on craigslist for casual sex, about one time a month. He used protection during these encounters, but felt enormous guilt because they were outside the type of committed, monogamous relationship he had been taught to seek.
  • 33 year-old female who felt she was addicted to fantasies of rape. She had a history of sexual trauma, and sometimes watched porn involving rough sex and fantasized about being raped. In therapy, we identified that her fantasies about rape occurred at times when she was struggling with feelings of low self-worth and needed to “beat herself up.”
  • 18 year old male from a highly religious family, who had just started college and was away from family for first time. Came to me, concerned he was addicted to masturbation. Turned out, he was only masturbating about once a week, but because he’d been taught that any masturbation was immoral and unhealthy and dangerous, he was terrified. He went online, and was diagnosed by sex addiction therapists and online group discussions.

In all of these cases, in research and clinical experiences, the sexual problems are only a symptom, and an indicator, of some other conflict, either in the person, or between the person’s desires and their social or relational context. Some sex addiction therapists agree with this, and say that sex addiction is not about sex. I agree, in part, but I point out that their diagnosis and treatment is unfortunately exclusively focused on controlling sexual behaviors and desires. I see countless people who feel shamed and deeply harmed when their normative, healthy sexual desires (such as daily masturbation) are termed a disease.

Josh Grubbs of Bowling Green University in OH has done remarkable longitudinal research demonstrating that seeing oneself as a sex/porn addict actually predicts greater life problems, regardless of the frequency of sex or porn. This means that the concept of addiction has gotten inextricably linked now to people’s sexual shame, and has become a damaging self-concept, that teaches people to fear their own sexual desires and needs. This is very sad, and is the unfortunate consequence of allowing sexual morality to blithely intrude into clinical practice.

3. What do you think will be the impact of the AASECT statement? For example, do you see this as having an impact on sex addiction rehab facilities? 

It’s important to recognize that there are two issues here. First, there is the sex addiction industry itself, which is a strange, cult-like group of true believers who treat sex addiction as a faith. These folks feel under attack. They lash out at these efforts to exclude morality from treatment, and they simply don’t understand why people like me are concerned at their lack of knowledge of sexuality or sexual diversity. The great majority of sex addiction therapists have very conservative ideas about what sexual health is, and they will continue to fight to defend their right to judge other peoples’ sexuality. Sadly, their arguments and views often get adopted by conservative politicians who use them to enforce sexual morality on society. As we’ve seen in Utah, where porn addiction was declared a public health crisis, I fully expect we will see sex/porn addiction raised in political dialogues in coming years by a conservative, religious administration.

The sex addiction rehabs are a unique American animal, where people pay thousands of dollars for a treatment that insurance won’t cover, and for which there is no evidence of effectiveness. This is stunning – there’s absolutely NO research showing that sex addiction treatment actually works, or works better than treatment with a regular therapist that your insurance does cover. Those facilities have seen increased struggles of late, as a result of changes in the US healthcare system (Thanks Obama). But, they serve a purpose – where men who get in trouble for sexual behaviors, whether infidelity or the like, can “go away” with the public appearance that they are committed to “getting better.” Unfortunately, these patients are often deeply exploited, leaving treatment owing many thousands of dollars, and usually still struggling with the real psychiatric or social issues.

There’s another group of individuals, diagnosed as sex addicts or sent to sex addiction treatment, where these approaches are grossly inappropriate. Sex offenders, across our country, are being mislabeled as sex addicts, and offered probation as long as they attend sex addiction treatment. This is horrifically unethical and unsupported. There is not a single shred of evidence that one can reduce recidivism by treating pedophilia, or rape, or fetishistic behaviors such as exhibitionism as an addiction. In contrast, there are good, evidence-based treatments for treatment of sexual offending behaviors. It puts our communities at risk that judges, juries, lawyers and victims, don’t understand that these individuals are being sent to a form of treatment that is completely inadequate. I hope that the AASECT statement brings some attention to this.

But, in contrast to the sex addiction industry, there’s also the second issue, and the degree to which the concept of sex addiction has been unthinkingly, uncritically, accepted by modern society and the media. Most people who self-identify as sex addicts do so because they or their spouse read an article or saw a talk show about sex addiction. For years, media has covered sex addiction as though it’s real, despite its lack of credibility or scientific standing. When I first published The Myth of Sex Addiction, I was completely alone. I was horribly and personally attacked by the sex addiction industry true believers, who came after me in awful ways, with threats of lawsuits, death threats and incredible accusations (such as that I was an undiagnosed sex addict in denial). At this point, the belief in sex addiction is an identity issue, not a rational belief.

But now, thousands of members of AASECT have stood up and said that this isn’t good treatment, and there are hundreds and thousands of therapists around the world who feel similarly. In this statement, AASECT joined the American Psychiatric Association which had rejected sex addiction as a diagnosis for forty years. Now, the many people who don’t think sex is an addiction (and never did) have a foundation and backing to push back against this shaming, moralizing concept. Hopefully it changes the media’s approach as well.


How The Concepts of “Sex Addiction” and “Porn Addiction” are Failing Our Clients

Our founder, Heather McPherson, LPC-S, LMFT recently collaborated on a journal article entitled, How The Concepts of “Sex Addiction” and “Porn Addiction” are Failing Our Clients, published in the California Association of Marriage and Family Therapists’ Magazine, The Therapist, in their September/October 2016 issue. Jay Blevins, MFT was instrumental in this research and we appreciate his contribution.

AASECT Summer Institute: Revisiting 'Sex Addiction' (Part 6) with Ruth Cohn, LMFT, CST

We interview Ruth Cohn, LMFT, CST in this sixth installment from the recent AASECT Summer Institute which was titled: Revisiting 'Sex Addiction': Transformative Ways to Address Out of Control Sexual Behavior. Ruth Cohn shares her approach with treating Out of Control Sexual Behavior in Couple's Therapy. She discusses how to take into account the power dynamics in the relationship. Ruth describes the weekend as "history in the making..."


Ruth Cohn is a Marriage and Family Therapist and AASECT Certified Sex Therapist living in San Francisco, CA. She has specialized in working with trauma survivors and their intimate partners and families since 1987. In 1997 she developed a special interest in working with couples. Largely from her own marriage, she discovered that the intimate partnership takes people to depths in themselves beyond what they can get to any other way. It can also be a vehicle for perhaps the most profound healing imaginable. Inspired, she began to evolve this theory and practice of working with couples who have histories of trauma and neglect.

Ruth is trained in Harville Hendrix’s Imago Relationship Therapy, which is an important component of her work. Because trauma is so much an experience of the nervous system and the entire body, she became an impassioned student of brain science, the body psychotherapies and neurofeedback, which also strongly influence her thinking and practice. She loves working with couples and sustains great hope and optimism about the potential for healing both intimacy and sexuality.

AASECT Summer Institute: Revisiting 'Sex Addiction' (Part 5) with Dr. Eli Coleman

We interview Dr. Eli Coleman in this fifth installment from the recent AASECT Summer Institute which was titled: Revisiting 'Sex Addiction': Transformative Ways to Address Out of Control Sexual Behavior. Dr. Eli Coleman shares the historical perspective about the sex addiction model and explains why we are in such disagreement with the terminology.  He gives us a peak inside the beginning of this transformative weekend.

Eli Coleman, PhD, is director of the Program in Human Sexuality and Chair in Sexual Health at the University of Minnesota. He has written articles and books on a variety of sexual health topics, including compulsive sexual behavior, sexual orientation, and gender dysphoria. He is founding editor of the International Journal of Transgenderism and International Journal of Sexual Healthand past president of the Society for the Scientific Study of Sexuality, World Professional Association for Transgender Health, and International Academy of Sex Research. Coleman has been a sexual health consultant to the World Health Organization and received numerous awards, including the World Association for Sexual Health Gold Medal and Society for Sex Therapy & Research (SSTAR) Masters and Johnson Award. In 2013, he was elected president of SSTAR for a two-year term.


AASECT Summer Institute: Revisiting 'Sex Addiction' (Part 4) with Dr. Neil Cannon

We interview Dr. Neil Cannon in this fourth installment from the recent AASECT Summer Institute which was titled: Revisiting 'Sex Addiction': Transformative Ways to Address Out of Control Sexual Behavior. Dr. Neil Cannon shares his Strengths Based Approach to treating Out of Control Sexual Behavior. He discusses his 11-point worksheet and it's a wonderful resource to use with clients and patients. His Strengths Based Approach is a tremendously helpful tool that can be applied to a multitude of issues. 

Dr. Neil Cannon is a Licensed Marriage & Family Therapist (LMFT), Clinical Fellow of the American Association of Marriage & Family Therapists (AAMFT), and an AASECT Certified Sex Therapist & Supervisor of Sex Therapy. He is also the Immediate Past Chair of the Ethics Advisory Committee for AASECT (2014–2016). Neil can be found teaching and guest lecturing to graduate and post-graduate students of psychology, counseling and social work at many of the leading colleges and universities throughout Colorado, including The University of Denver, The University of Colorado, Regis and Metropolitan State University. In addition to teaching in Colorado, Neil is an instructor at the University of Michigan School of Social Work Sexual Health Certificate Program. The University of Michigan is known in the field of sex therapy for being one of the leading programs in the world for clinicians from around the world who are on a path towards becoming sex therapists. Neil is also a Professor of Marriage & Family Therapy at Denver Family Institute where Neil has been teaching for the past decade. Dr. Neil Cannon is a published author, professional speaker, supervisor, mentor, and nationally recognized expert on sex, intimacy and relationships. 

AASECT Summer Institute: Revisiting 'Sex Addiction' (Part 3) with Dr. Joe Kort

We interview Dr. Joe Kort in this third installment from the recent AASECT Summer Institute which was titled: Revisiting 'Sex Addiction': Transformative Ways to Address Out of Control Sexual Behavior. Dr. Joe Kort gives us an inside look at the Sex Addiction industry and tells us his personal story of trials and tribulations. 



Dr. Kort graduated from Michigan State University with dual majors in Psychology and Social Work. At Wayne State University, he earned his Master's in Social Work (MSW), then a Master’s (MA) in Psychology, and has received his Doctorate (Ph.D.) in Clinical Sexology from the American Academy of Clinical Sexologists (AACS).
More about Dr. Kort:

  • Teaching Faculty at University of Michigan Sexual Health Certificate Program
  • Certified IMAGO Relationship Therapist
  • Board Certified Sexologist
  • Member of the Society for the Advancement of Sexual Health (SASH) 
  • Member of the Academy of Certified Social Workers
  • Member of the National Association of Certified Social Workers
  • Certified AASECT Therapist, Supervisor of Sex Therapy and Member of American Association of Sex Educators, Counselors and Therapists (AASECT)
  • Member of EMDRIA Eye Movement Desensitization and Reprocessing (EMDR) Basic Training
  • Licensed Clinical Social Worker, State of Michigan #6801046330

AASECT Summer Institute: Revisiting 'Sex Addiction' with Dr. David Ley

We interview Dr. David Ley in this second installment from the recent AASECT Summer Institute which was titled: Revisiting 'Sex Addiction': Transformative Ways to Address Out of Control Sexual Behavior. We also had the pleasure of being one of the first ones to read Dr. Ley's upcoming book, Ethical Porn for Dicks, A Man's Guide to Responsible Viewing Pleasure. And, we must say- this is a FANTASTIC guide. We recommend it for anyone with a dick, sure, but also for anyone who has ever been in a relationship or planning to be in one in the future. 

Dr. David Ley is a clinical psychologist in practice in Albuquerque, New Mexico. He earned his Bachelor's degree in Philosophy from Ole Miss, and his Master's and Doctoral degrees in clinical psychology from the University of New Mexico. Dr. Ley is licensed in New Mexico and North Carolina, and has provided clinical and consultative services in numerous other states. He is the Executive Director of New Mexico Solutions, a large outpatient mental health and substance abuse program in Albuquerque, NM.

Dr. Ley has been treating sexuality issues throughout his career. He first began treating perpetrators and victims of sexual abuse, but expanded his approach to include the fostering and promotion of healthy sexuality, and awareness of the wide range of normative sexual behaviors. Insatiable Wives is his first book and won a Silver Medal in the Foreword Magazine Book of the Year contest for 2009. Dr. Ley wrote Insatiable Wives following two years of interviews with couples around the country. His controversial second book, The Myth of Sex Addiction was released in March 2012, challenging the concept of sexual addiction and exploring a different model of male sexuality. The Myth of Sex Addiction triggered a firestorm of debate, allowing people to finally challenge the media hype of this pseudo-disorder. His new book Ethical Porn for Dicks, A Man's Guide to Responsible Viewing Pleasure is due out in Summer/Fall 2016. Dr. Ley may be contacted via email through the Psychology Today website.

AASECT Summer Institute: Revisiting 'Sex Addiction' with Doug Braun-Harvey

One of our founders, Heather McPherson, LMFT, LPC-S recently had the privilege of interviewing some of the brightest minds in the sexual health field. This will be a series of videos with 8 faculty members from the recent AASECT Summer Institute which was titled: Revisiting 'Sex Addiction': Transformative Ways to Address Out of Control Sexual Behavior. 

The first interview is with Doug Braun-Harvey, MFT, CPG, CST, Co-director of the summer institute alongside Susan Stiritz. They accomplished their goal of putting together a wonderful institute!

Since 1993, Doug has been developing and implementing a sexual health based treatment approach for men with out of control sexual behavior (OCSB). His new book “Treating Out of Control Sexual Behavior: Rethinking Sex Addiction”written with co-author Michael Vigorito was published in 2015. 

Mr. Braun-Harvey is Licensed Marriage and Family Therapist, Certified Group Psychotherapist and Certified Sex Therapist. He currently serves as Treasurer of AASECT and is honored, as an alumni of the University of Minnesota, to join their Advisory Board for the Program in Human Sexuality in which he is a founding donor of the Doug Braun-Harvey Fellowship in Compulsive Sexual Behavior. He has been providing individual and group therapy in his San Diego private practice since 1987.

Censored Writing!

Our very first Sexceptional Lecturer, Dr. David Ley, wrote a blog for Psychology Today that was removed due to legal threat from some in the Sex Addiction Industry.  Below is a personal note about his original article.

Note by Dr. David Ley:

“The below post was originally published on Psychology Today. However, the International Institute for Trauma & Addiction Professionals (IITAP), and the sex addiction gurus who profit from the Sexual Dependency Inventory (SDI), threatened Psych Today and forced them to take it down. I don’t blame the editors at Psychology Today. Indeed, I had predicted this would happen, and wrote the editors in advance, to warn them that they should anticipate such threats. Unfortunately, groups such as Psychology Today are quite vulnerable to such threats, and the cost/time/energy required to defend themselves against claims of libel, defamation or other such legal bullying.

I wrote this article, not to attack IITAP or any specific individuals. Instead, I wrote it due to my concerns about patient who are vulnerable to exploitation and maltreatment by clinicians using an unsupported instrument in unethical ways. Prior to publishing it, I had the piece reviewed by no fewer than 5 statistical, research and sexuality experts, several of whom have histories of much greater support of sex addiction than do I. It wasn’t an echo chamber review. I wrote it carefully, in as objective a manner as possible. I complied with ethics around test protection, and copyright, and wrote this within specific compliance with Fair Use protocol, in order to ethically criticize a clinical assessment I believe is potentially harmful.

I’m publishing this blog here, and in emails and on the blogs of other colleagues, in interest of sharing this information widely, and challenging the ways in which the sex addiction industry uses threats and intimidation to suppress criticism or challenges to their methods. I myself have been threatened with legal action by the sex addiction industry at least half a dozen times, merely for challenging them and publicly criticizing the validity and harmfulness of their methods. Multiple of my colleagues have also been threatened in similar ways, for daring to criticize the monolithic, cultlike industry of sex addiction therapists. I welcome anyone to republish this on their own blogs or websites, not to promote myself in any way, but so as to increase the chances that a patient mandated to complete the SDI by a sex addiction therapist, has the ability to learn for themselves the limitations of this instrument.

Since I first published this, IITAP has taken down the SDI Manual which was previously publicly available on their website. This has the unfortunate result of making a test which was already less than transparent, even more obscure to outside criticism, and limiting even more the degree to which a potential patient can be informed about this test.


Here is the full article:

The Sexual Dependency Inventory – An Invalid Instrument? 

First published on Psychology Today – Women Who Stray blog of David J. Ley PhD. 9/1/16

Clinical and psychological assessment is a nuanced, and sophisticated area. It’s also a deeply contentious area, with many “pet” assessments which are developed by thought leaders, to evaluate or test their specific theories. Psychological instruments convey a level of science, and therapeutic value, which are sometimes deserved, and other times are used in ways which potentially violate informed consent by patients.

For example – the Myers-Briggs Type Inventory is a test with a great deal of history, often used in business settings and in relationship counseling. But, modern research largely reveals that it is a clinically meaningless and invalid (link is external)test based on antiquated, failed theories. Ethical, informed clinicians no longer use the test, so as not to waste our patient’s time, or to give them the false idea that the test is serving a clear clinical function. The sex addiction treatment industry commonly uses similar outdated and unsupported instruments in ways which pose potentially serious ethical concerns. The Sexual Dependency Inventory (SDI) is one such measure, prominently used by many in the sex addiction industry, despite some alarming weaknesses.

Source: via Wikimedia commons

The Internet is filled with numerous online tests and screening tools which allegedly measure sex addiction. Most of these online tests are free, and appear to work as marketing tools for sex addiction therapists and treatment programs. One however, the Sexual Dependency Inventory-Revised (SDI-R) 4.0, is quite expensive, and commonly used by many sex addiction therapists who sometimes mandate their patients complete the test as a part of treatment. I recently encountered the SDI, in a forensic matter where a therapist had used the SDI 4.0 inappropriately, making custody recommendations on the basis of this test. This case led me to take a closer look at this instrument, which in turn, led to serious concerns about its use in clinical settings. I chose to draft this this post in order to better inform patients who may encounter ill-advised use of the SDI by therapists.

The Sexual Dependency Inventory

The SDI-R 4.0 is described by authors as the only “broadband measure of potentially problematic sexual behaviors and preoccupations…” (Green et al (link is external), p. 127). It is a very long instrument, with over five hundred items, which allegedly assess an extremely wide variety of sexual and relationships issues. I was able to find and download the “SDI R– 4.0 Therapist Manual (link is external)” from IITAP, free on their website and is not identified as restricted or copyrighted. Nevertheless, in keeping with professional ethics regarding test security, I choose not to publish any verbatim items from the test in this article. Quotes used herein are used under Fair Use doctrine, and for the protected purposes of clinical criticism.

The International Institute for Trauma and Addiction Professionals (IITAP) is an organization, founded by Patrick Carnes, PhD. and currently run by his daughter, which established their own training and certification for sex addiction therapists, and offers the SDI-R 4.0 for a substantial fee through their website (link is external). The test is accessed by individuals through an interesting and relatively unique use of “tokens” which are purchased by clinicians, and then distributed to patients by the therapist. It’s apparently up to the clinician to set the fee for the patient to receive a token which allows them access to the test and report of test results. Most clinicians charge their patients between $85 and $250 per test. (This cost range is supported by the websites of various online therapists, as well as internal emails from IITAP staff.)

The Sexual Dependency Inventory – Revised, 4.0 is a muddled instrument which takes a “kitchen-sink” approach to testing, essentially throwing everything in, to see what sticks. It has few scientific publications describing it or its development. A very early (1998) version of the test was briefly evaluated and showed some initial potential value. However, that version was less than a fourth as long as the currently administered test. There have been no further validity evaluations (link is external)of the SDI-R 4.0 or replications of these results. Applying these initial findings from 1998 to the current version is contrary to industry standards: For instance, each time the WAIS (IQ test) is updated, the makers must develop and publish extensive statistical modeling and conversion scores, to allow comparison of the new version to past results. There is no evidence that such comparisons have been conducted or published. Indeed, in much of what is written about the SDI, it is typically quite difficult to determine what version of the test is being described. When there are apparently substantial changes happening across versions, this is a troubling lapse.

The SDI-R 4.0 now includes within it a number of distinct instruments, such as the Sexual Addiction Screening Test (SAST), tests of attachment, assessments of motivation for change, and numerous items and scales which allege to distinguish or identify various sexual preoccupations, predilections and tendencies. The manual offers little information regarding any over-arching theory which ties these various items and tests together, and merely states “The SDI is actually a whole battery of relevant tests organized into one cohesive report.” (page 3 of Manual). Unfortunately, many of these individual tests have limitations and problems themselves and combining them all into a single measure would require research to evaluate the degree to which these instruments may overlap or even conflict, and whether their combined use leads to increased “convergent validity” in assessment and treatment. Moreover, there could be issues with ordering effect wherein responses to some questions impact how an individual responds to subsequent items. No such research is evident in the manual, or published literature.

The SDI relies of course on the disputed, consistently rejected pop psychology concept of sex addiction, as well as makes references to more unique concepts such as “eroticized rage,” “sexual anorexia,” and “intimacy disorders.” These concepts are used heavily in the theories of Patrick Carnes, PhD., but have not been adopted at a broader level in the mental health or addictions industry. They reflect antiquated and stigmatizing psychoanalytic theories. They are not accepted diagnoses or generally supported theories of psychological practice, mental health, or sexual development. It is also unclear how the items and structure for the SDI were deductively generated or developed. A 2015 paper indicated that during a structural analysis of the SDI, some items were retained as “critical items,” despite evidence that they had no statistical value.

The SDI-R 4.0 includes items assessing sexual behaviors related to various sexual subcultures, from the Lesbian, Gay, Bisexual and Transgender communities, to swinging communities, and those who engage in kink-related or BDSM types of behaviors. These varied items, and issues imply that these behaviors are inherently evidence of disturbance in relationship, sexuality or mental health. There is no evidence in the manual, or in published research, that these items have been normed on members of these sexual populations who are not experiencing problems. As a result, it is quite likely that this test will inaccurately assess individuals who are struggling or questioning with their sexual orientation, kink, or interest in nonmonogamy.

In 1992, SDI author Patrick Carnes wrote (link is external)“The giving or receiving of pain, also known as sadomasochism or S&M, is a type of sexually addictive behavior in which pain is associated with sexual pleasure. There is a blatant imbalance of power between the giver and the receiver, although both partners may be consenting. . . . Victims may perceive their feelings towards their torturer as loving, but there is no genuine trust or intimacy when a relationship is based on hurting one another.” This inaccurate and biased perception of BDSM relationships still pervades the SDI.


People who practice BDSM are often stigmatized inappropriately by sex addiction therapists.

Source: Via Wikimedia Commons

Source: Via Wikimedia Commons


The SDI-R 4.0 Manual and test interpretation contains troubling errors regarding sexual disorders, such as this statement: “Dressing and behaving like the other gender with a psychological preference to be the other gender (transvestitism)” (page 35 of manual) actually appears to be describing the issue of transgender or gender dysphoria. Transvestism is a paraphilia related to wearing the opposite gender’s clothing. Similar confusion regarding “cross-dressing” is noted in the manual. Errors such as these in a published clinical test, are troubling and invite a high potential for misinterpretation by both patient and therapist. They suggest a significant lack of awareness of sexological or sexual health treatment in the creation and development of this instrument. Given that it purports to assess and measure paraphilias and sexual behaviors, this is quite troubling.

Another glaring error lies in the marketing and general descriptions of the test, by the therapists who use it. It is frequently described online by clinicians who use it, as having “96.5% accuracy (link is external).” The origin of this misstatement is in the manual, where one subtest, the SAST is described as having been “proven 96.5% accurate in identifying a clinical population.” (page 39, manual). Even this statement about the SAST is disputable, as there is no true “clinical” definition or criterion for such sexual behavior problems, and the SAST is not congruent with the most recent criteria proposed for Hypersexual Disorder. The SAST may be prone to false positives, because of its inclusion of issues related to moral and social attitudes towards sex. The fact that therapists use this statement inaccurately suggests either ignorance or deceptive advertising on their part – either of which are troubling.

Validity testing is a critical component in the development of any psychological test, and is a way to determine if a given test identifies issues that distinguish a clinical population from a nonclinical one. In other words, if there was research showing that the test misidentified a person who is having no problems related to sex, then we would be concerned that this test may more generally mistakenly pathologize normal sexual variations in people. One of the severe weaknesses of the SDI, is its lack of “clinical cutoff scores” which identify problematic users from a normative population. Thus, without these cutoff scores, there is great chance of pathologizing normal behaviors. The SDI has been described (link is external)as limited in its reliance on self-report, with no external validation of confirmation on the patient’s affirmations. Such self-report responses can easily be influenced by feelings of shame and guilt, as opposed to actual clinical issues. As far as I am able to determine, the only validity testing done on the SDI was conducted in 1998, on an early and different version of this test. As a result, we have no current evidence regarding what this instrument actually does.

Based upon the information reviewed and described above, this writer concludes that use of the SDI R 4.0 in clinical or forensic settings is extremely questionable, unless a patient is provided with informed consent regarding the limited validity and reliability of this experimental instrument.  Results and predictions of the SDI-R 4.0 should be regarded with extreme skepticism without other corroborating information, test results or behavioral evidence. The report itself can mislead patients into a belief that the conclusions reflect a scientific or clinical evaluation that is definitive which has the potential to cause psychological harm to those taking the test. The SDI R 4.0 is an internal, “home-grown” instrument, used only within the isolated “cottage industry” of sex addiction treatment. It seems that the test has been created more for a revenue stream for its authors than as a benefit for patients. The absence of the SDI-R 4.0 in generally accepted literature and methods raises significant ethical concerns about therapists administering and charging patients for clinical use of this instrument.

People seeking help for sexual and relationship matters are extremely vulnerable, dealing with intense issues of guilt, shame, fear and isolation. They are eager and desperate for help and reassurance. Such individuals are unfortunately highly disposed to believe and trust based on the appearance of credibility and expertise. In dealing with such problems, clinicians must be extremely careful and thoughtful to educate patients about the limitations of our tools and methods. Therapists currently using the SDI-R 4.0 should undertake a critical evaluation of its role and usefulness in their therapeutic approach. There are numerous free tests available to them, with greater levels of research and support, which are less onerous for their patients, and which stand less likelihood of stigmatizing healthy aspects of sexual diversity.”