“Two country people were fishing in a river. As they fished and talked, they saw a child floating down the river dangerously close to the rushing waterfall. Fearing the child would drown, one of them jumped in the river and brought the child safely to the bank. But soon there was another child floating down the river, then another, and another. Soon the river was filled with children all heading toward the whitewater and waterfall.
Both of them rushed to save as many children as they could, but there were too many children, they would never be able to save them all. One of the two jumped out of the river and started running upstream along the bank. The other yelled “hey where are you going? we need to save these children.” The first yelled back “I’m going upstream to stop whomever is throwing them in.”
– Prevention Parable
For three decades the voices of #MeToo have echoed off the walls of my psychotherapy office. What a long overdue and welcome relief to hear them resound at long last, even be believed in the larger world outside. Gratified and hopeful though I am that the issues of exploitation, abuse and sexual injustice are getting wide mass and mainstream attention, I find myself thinking more deeply about its causes and prevention. Policy and punishment appear to be beginning and changing, and much more is needed than that, to interrupt a pandemic that is daily proving to be even more ubiquitous than we may have thought. I am interested in adding to our responses the major categories of education and treatment for perpetrators and all boys and men; and locating sexual health in all of its ramifications as a public health issue for all children and adults in our country. I for one, am old enough to remember the “false memory” movement where victims and their therapists were blamed and villainized for “fabricating” stories and symptoms of sexual trauma, attempting to drive it back into darkness and silence. We must all work hard to keep that from happening again, and prevent this devastating reality from slipping back under its cloak of denial into hiddenness and complicity.
A new perspective is emerging in the larger sexuality field. There is a budding movement to redefine the concept of sexual health from one that is value, moral, culture and pathology laden, toward a more thoughtful and subjective criterion that emphasizes consent, pleasure and self-regulation.
As awareness grows, we see the beginnings of progress toward changing attitudes, policy, and education about gender, power, sexual harassment and abuse. That is heartening. However, while the #MeToo movement shines a much-needed spotlight on gender and power inequality, it is also an aspect of a far more complex web of problems. By looking a little wider, at more of the issues in play, casting a wider net may garner a better shot at success. Awareness of exploitation and abuse of women and children is imperative, as are sanctions and consequences for perpetrators and sexual opportunists of all kinds. I propose that we also guard against solutions that are too simple, or become a contest that further divides men and women. Perhaps this pandemic of out of control sexual behavior, reflects a cultural crisis involving sexual health, that we may have a public health crisis on our hands. As in yet another parable, of the blind men and the elephant, viewing the parts in isolation, does not convey an accurate enough big picture, and will certainly fall far short of our goals. We need to sort and study in depth the various issues, integrate them, and then put the mosaic together. While with certainty for many men who exploit, abuse and intimidate women, sanction and punishment are the only appropriate response, I also see a fundamental imperative to put sexual education and sexual health through the lifespan on the national public health agenda.
Still, however, sexuality in the larger world, and even in the relatively progressive Bay Area, continues to be sensationalized, commodified, pathologized, mystified and globally titillating, with there being a poverty of information. Although it has become routine to see advertising for sex enhancing medications and other products, most people have a limited understanding of what is sexually realistic or “normal.” I am repeatedly dismayed by clients’ reports that the oncologist treating their cancers; the psychiatrists treating their depression; even their couples’ therapists do not educate, inform them, or do not inquire about sexual function and satisfaction. Because their helpers do not initiate the dialog, they conclude either that it is wrong to ask, or that they are simply supposed to know.
My career began in the 1980’s when the Women’s Movement had recently given voice to violence against women and children. My work with sexually traumatized women took me down an unexpectedly winding road. Realizing how difficult a relationship was for my clients, I became a busy couples therapist, then sex therapist. Sexuality was so difficult for so many of these traumatized women, that it became a focus of my attention and my work.
“Out of Control Sexual Behavior”
The advent and rise of the Internet brought with it what every “new” technology and medium of communication historically had: it became a vehicle and a new commercial avenue for sex. Pornography in every imaginable and unimaginable iteration appeared, and it became a widely discussed and often sensationalized topic in the world and in the field of sex therapy. It certainly began to show up in my office, with partners or spouses wondering or worrying about what it might mean. Is porn use cheating? Is it patholological or damaging? How much is too much? Due to “Accessibility, Affordability and Anonymity” people could spend inordinate amounts of time watching it and many did. A literature and treatment industry soon mushroomed around pornography in both professional and mass public realms, with little agreement or data supporting it. In my office, I witnessed the pain, suffering, shame, humiliation, confusion anger and despair of couples, where one partner, (in my practice usually male) repeatedly hurt and betrayed a spouse he truly loved. Both were baffled and desperately dismayed that he would not or could not stop. Then I began hearing about other activities: affairs, sex for money, anonymous sex with strangers, empty “hook-ups” and all taking place without explicit agreement between the two who sat in front of me.
“Two Minds”/Split Self
The specifics of the sexual behaviors varied, but the consistent element was what came to be described as a kind of split Self. Essentially the sufferer (or perpetrator) was of two minds: there was a part of the Self that did not want to engage in the behaviors in question, were even repelled and ashamed of them; and another part that irresistibly did. I saw this often in my practice, and it is an experience known to most of us where the warring pull of temptation versus a commitment, value system or priority seem to agonizingly tear the individual apart. The battleground of the two parts in this case was the body and sexual behavior in question, be it infidelity, or some other variation on betrayal. I have seen a broad range. The problem was often less the specific behavior per se, than the drive to repetitively do something in spite of its impact, its consequences and against one’s better judgment. Often these individuals were betraying their own deeply cherished values and morals, and rather shocking themselves. For myself, I struggled and searched for an understanding and an approach that would help both clients and their partners make sense out of what seemed incomprehensible, and maybe even find a way to navigate through it together. No small feat, especially as often the impact on the betrayed partner is many faceted and profound.
2015 brought the seminal work of Doug Braun Harvey, who with his co-author and collaborator Michael Vigorito wrote a groundbreaking book on what they termed Out of Control Sexual Behavior or OCSB. They brought a different lens to the problems of sexual harassment, opportunism, exploitation and abuse, building a coherent and dignified conceptualization, and a treatment approach. The centerpiece of their work is a concise definition of sexual health, which is also its heart and soul.
Sexual health consists of a framework of six essential and non-negotiable principles. Within the frame of those principles, individuals and couples determine for themselves what their sexual activities are to be. For many individuals and couples, these concepts are astonishingly new and they have never thought about them or discussed them. In fact it is remarkable how many couples have barely if at all talked about sex, or their sexual relationship. We live in a world where we are bombarded with sexual stimulation and sexual myth, and information is at a minimum. Doctors and surgeons, prescribing physicians and psychiatrists, teachers and even therapists more often than not fail to speak or educate about sexuality. The majority of clients I have seen over the decades, if they have had any relevant sex education at any time in their early or adult lives, it was pitifully lacking. So I found the six principles to be a surprisingly useful teaching tool.
First and most important of the six principles, is Unambiguous Consent. By unambiguous consent we mean, beyond “No means No!” that unspoken “deals” must be spoken about. If he buys me an expensive dinner, what do I “owe” him? Is it true that revealing attire means “I am available?” Is it “fair” to change my mind? What is the impact of mind altering substances on consent, even if the substance use itself was consensual? And power differentials are a game changer. “What will it cost me if I don’t do what you want?” And “What do I want to do about that?”
Consent is a huge, complex and multidimensional topic, and I view it as a vital component and expression of care and empathy. I teach couples to practice “informed consent” about most anything; as a way that we acknowledge, honor and create equality around differentness. Even something as fundamental as when we discuss any difficult or personal matter, is a point for consensual agreement. In the larger world, consent is complicated by many factors, the most obvious of course, is power.
The other five principles are:
Non-exploitation: This of course means a commitment to being ethical, thoughtful and respectful of the integrity, rights and preferences of all parties to the interaction. It also considers what might be a power inequality between the two parties that could complicate the question of consent. I have also found that as with so many concepts, definitions of what constitutes exploitation, vary widely. Some individuals view pornography and paid sex as categorically exploitative of the sex worker. Others do not. Again, individuals and couples must elaborate and agree on their terms.
Protection from HIV, STI’s and Unwanted Pregnancy: Shared responsibility for safety and equality in all its forms.
Honesty: A commitment to transparency. So often the worst injury in sexual predation and betrayal stems from deceit, of intention, motivation and meaning. I have certainly also seen couples disagree on “lying by omission,” which also needs to be explicitly negotiated.
Shared Values: Sexuality is tied to a vast range of diverse philosophical, moral and religious meaning systems. Gender, exclusivity, sexual frequency, even preferred sexual acts for example, are all personal and subjective, and must be known, negotiated and compatible.
Mutual Pleasure: Not to be forgotten, with the emphasis on mutual.
If the whole world operated on these principles, OCSB as well as the entire #MeToo phenomenon and all its abusers, would pass into grim history.
Beside the Six Principles, the authors detail the problem of “split Self,” of being of two minds, which can result in unwanted sexual behavior, and the emotional and relationship difficulties and disasters that it can bring. Numerous devastating examples of have flooded into my office over the years. Braun Harvey and Vigorito developed an approach consisting of individual, group and couples education and therapy, emphasizing accountability, self regulation and relational integrity. I found their framework to be of great use to me, and many of my struggling and suffering couples.
Self regulation is a concept that is becoming more and more a part of the mental health lexicon as we finally come to better understand the role of the brain and nervous system in human psychology and health. It would seem like a “no brainer” that the brain profoundly shapes the mind, but it has been a long time coming. Self regulation boils down to maintaining balance and control, a fundamental ability that is most noticeable in its absence.
Rules and Regulation
Regulation is the balance between energy and rest, intensity and ease, excitement and calm, sympathetic and parasympathetic: the ability to rev up when appropriate and then settle down. As children we rely on caregivers to oversee or manage these functions. Under the best of circumstances, children are soothed and comforted by parents, their fears and worries are eased, their frustrations and anger tempered or contained by a good parent. As children, we need first to be taught to identify, name and effectively express impulses and feelings. With maturity, we ideally learn to manage our energy, our activation, our impulses, ourselves, to self-regulate. A “regulated” nervous system, is one wherein individuals can control and choose how to behave. Rather than rely on external rules, we ideally become able to trust an internal mechanism of control. Of course none of us do it perfectly. We all have the occasional emotional outburst we regret, the impulse to overspend, the one too many brownies.
The same is true for sexual feelings. Pioneer sexuality educator Betty Dodson teaches that parents’ normalization and acceptance of children’s sexual feelings, and helping them to understand and manage them, are the fundamental building blocks of later sexual health. In the world of sexuality what can feel like a runaway train to an adolescent, becomes manageable to a regulated adult.
In a world where couples rarely talk about sex with each other, let alone their children; and sex education in schools is minimal at best, this is all too rare. However regulation, within a solid sexual health framework, provides a foundation for individuals and couples to thoughtfully, honestly and intentionally evolve and negotiate their arousal and their own erotic palette. That would be a worthy goal.
What Is Wrong With These Men?
Bill Clinton rose out of a matrix of parental alcoholism and violence to become a Rhodes Scholar and Yale Law School graduate. He went on to become the youngest governor in the nation at 32, an age when I was barely emerging from drugs, sex and rock ‘n roll. Elected president in 1992, at just 46, he was arguably the most powerful man in the world, a success story at the pinnacle of success. Why would he risk it all on scandalous, wanton sexual behavior with someone who apparently meant little to him?
Bill Cosby has dominated the sexual predator stage for some years, with one after another of his alleged victims speaking out before his conviction this month on three counts of aggravated indecent assault. But before that downfall, Cosby was also another great American success story. “The Cosby Show” was TV’s biggest hit of the 1980s, earning him the moniker “America’s dad.” He also earned a doctorate in education from the University of Massachusetts, and became a widely followed civil rights activist. Popular, rich and famous; with a beautiful family, he appeared to have it all. Why would someone like this have to drug women to have sex with them? Or why would he want to have sex with unconscious women?
Al Franken, Kevin Spacey, Anthony Weiner, Charlie Rose, Eric Schneiderman, Woody Allen… What is wrong with these men? And how many men, famous or not, powerful or not, “good souls” or “good spouses” or not, are fractured by split selves, and out of control? With the statistic that one in three women are victims of some kind of abuse, harassment, rape and other unwanted sexual attention, it is clear that these men are but a fraction of those who perpetrate.
As a trauma therapist, I have seen the gamut of wildly dysregulated sexuality, from frozenness in seemingly endless sexual impasses, to erotic extremes of every imaginable and unimaginable ilk. I see plenty of “split self” sexuality in the traumatized. Braun Harvey and Vigorito, agree that trauma may be a factor in Out of Control Sexual Behavior some of the time, but certainly not in all cases.
I asked Braun Harvey, “What do you think about this #MeToo phenomenon from an OCSB standpoint?” He replied that sadly, for the most part men do not talk about sexual health, unless they have either been victimized or have themselves already perpetrated. Men’s conversations about sex tend to be limited to what our president referred to as harmless “locker room banter:” competitive, posturing, vapid. Beyond that, even though bombarded with Viagra advertising, most men know very little about what is really “normal” and what other people are doing. Couples commonly don’t talk about sex in any meaningful way. It is time to begin a national discourse about sexual health.
Braun Harvey continued that consent as a concept is largely not broached until it becomes part of a conversation about sexuality, and even then not nearly enough. The broader implications of mutuality, consideration and equality are weak at best in our culture, which was been built largely on the motifs of self-reliance and rugged individualism, not to mention slavery.
Moving Upstream: What More Can We Do?
In 2001 our then Surgeon General, the enlightened David Satcher issued a “Call to Action to Promote Sexual Health and Responsible Sexual Behavior.” Not that different from Braun Harvey’s formulation, it went as far as to place sexual health among both our nation’s values and rights. Education, policy and accessible services must make sexuality as safe, just and dignified, as all other matters of health.
“A major responsibility of the Surgeon General is to provide the best available science based information to the American people to assist in protecting and advancing the health and safety of our Nation,” Satcher’s call proclaimed. “This report represents another effort to meet that responsibility… These challenges can be met but first we must find common ground and reach consensus on some important problems and their possible solutions. It is necessary to appreciate what sexual health is, that it is connected with both physical and mental health, and that it is important throughout the entire lifespan, not just the reproductive years. It is also important to recognize the responsibilities that individuals and communities have in protecting sexual health. The responsibility of well-informed adults as educators and role models for their children cannot be overstated. Issues around sexuality can be difficult to discuss because they are personal and because there is great diversity in how they are perceived and approached. Yet, they greatly impact public health and, thus, it is time to begin that discussion… We need to appreciate the diversity of our culture, engage in mature, thoughtful and respectful discussion, be informed by the science that is available to us, and invest in continued research. This is a call to action. We cannot remain complacent. Doing nothing is unacceptable. Our efforts will not only have an impact on the current health status of our citizens, but will lay a foundation for a healthier society in the future.
Where Did It Go?
Dr. Satcher cited in his 2001 report:
- STDs infect approximately 12 million persons each year
- an estimated 40,000 new HIV infections occur each year
- nearly one-half of pregnancies are unintended
- an estimated 22% of women and 2% of men have been victims of a forced sexual act
- an estimated 104,000 children are victims of sexual abuse each year
A 2007 federal study on abstinence education found that these programs had no impact on the rate of teen sexual abstinence. Rather, teens in states that prescribe abstinence education are actually more likely to become pregnant. 1 in 4 teens in the US receives information about abstinence without receiving any information or instructions about birth control. Among teens aged 18–19, 41% report that they know little or nothing about condoms.
The chilling rates of child sexual exploitation have not changed much. In a 2015 report:
- 37% of American children are reported to Child Protective Services by their 18th birthday (African American children are reported at 54%)
- 1 in 4 girls and 1 in 6 boys will be sexually abused before they turn 18
Clearly it is time to dust off and revisit Dr. Satcher’s call, and resuscitate sex education that will enable boys and men to make sense out of, and speak about confusing sexual feelings; or desires and impulses they don’t know how to manage before they perpetrate. Girls too, besides learning about consent and equality need to learn about what problematic and out of control sexuality look like. In others and in themselves. Identifying a problem and ready access to help that would not be shaming or stigmatized might prevent a lot of damage to self and others. These discussions might begin in the elementary grades.
None of this is in any way intended to let #MeToo offenders off the hook, or excuse sexual harassment, abuse or violence. Quite the opposite. I believe we must continue to make the policy and legal changes that will stop the Harvey Weinsteins, and Larry Nassars (the Physician who abused generations of young gymnasts entrusted to his care,) and protect and prevent children and adults from any unwanted and/or exploitative sexual attention or activity. Parenting classes might expand to include sexuality and sexual health as important parenting responsibilities. And besides making it safe and effective for children and adults to report their experiences, we need sexuality education that covers both wanted and unwanted sexual activity, and the nature of out of control feeling and behavior. Rather than hide and continue it, those afflicted will be able to recognize it; and know that help is available before they do harm, or more harm. And we need to make sure that help is readily available. This means training health care and mental health professionals including school counselors and other key adults at schools, about diagnosis and treatment that are positive, sex positive and effective.
When the infamous pussy grabbing video burst on the scene in 2015, I thought for sure candidate Trump was finished. As a professional, a woman and a civilized human being, I just could not fathom that a man who did and said such a thing could become the president of the United States, there was simply no way he could continue to advance toward the White House after such an affront.
I was shocked and horrified to see how wrong I had been, and that men still impress and amuse each other with “conquests,” and not only in locker rooms. That furor died down. Other shock and horror has followed. And I am concerned about the real change that needs to take hold. I don’t want our cat-eared pussy hats to migrate to the back of the drawer. I don’t want the cries of #MeToo to fade again into silence without the essential response: a response that will include sanctions and reparations for wrong-doing.
The renowned neuroscientist Antonio Damasio, in his most recent book, tracks human evolution back to the earliest bacteria. He posits that it is feeling, the experience that something is “wrong,” something is out of balance with well-being and preservation of the species, that impels the organism to find the correction that will restore health. That, in conjunction with natural selection, brought us from our forebears – those early bacteria that were even without nuclei – to the conscious, complex-brained, and hopefully self-aware beings that we have become. Damasio seeks to create more respect and value for feeling as being fundamental to the advance of healthful life. We need to teach young children to recognize the feelings associated with “good touch” and “secret touch;” older girls to recognize and understand the feeling of unwanted or exploitative attention; and sufferers of dysregulated arousal and sexuality to identify the feeling that something is awry in their bodies. All of this before injury and shame has calcified in these young, and older bodies. It is my fervent hope that we can use the outrage of the #MeToo movement in that direction. This would include parents, teachers, coaches, employers, managers, employees, chefs, bloggers, celebrities, policy makers and of course all health and mental health professionals, all speaking up for sexual health. I guess that is most of us really.
My book “Working with the Developmental Trauma of Childhood Neglect: Using Psychotherapy and Attachment Theory Techniques in Clinical Practice” was published on August 31st. It provides psychotherapists with a multidimensional view of childhood neglect and a practical roadmap for facilitating survivors’ healing.