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The Fusion of Substance Use & Sex Addiction – Inspiration Series 2.0 Webinar

Dr. Rob Weiss joins us to discuss the fusion of substance use and sex addiction. See the full video and transcription below:

Inspiration Series: The Fusion of Substance Use & Sex Addiction

Keith Arnold: Hello, welcome everybody! Welcome to our fourth and final presentation on our Inspiration Series with Rob, Dr. Rob Weiss – The Fusion of Substance Use and Sex Addiction.

We’ll go over a few things before we get started and hear from Rob, but we’re so, so grateful that you joined us today this month, May. The month of May is Mental Health Awareness Month and obviously we’ve been grappling with a lot – your role, what you do, is so important every day – day in and day out. Many of you are repeaters, in other words you’ve joined us on other webinars and we have some new people who have joined us.

I want to just mention again something I brought up last week called deaths of despair. And that’s the terminology given to people who are dying because of Covid not because of catching the virus but because of the effects – the secondary effects – people dying from overdoses, people dying from suicidal ideation, people – a whole host of issues related to mental health disorders and substance use. So your role – what you do day in day out – is so important like first responders, you are the heroes out there and thank you so much for what you do.

My name is Keith Arnold. I am the Chief Marketing Officer for Gateway Foundation and we have a few things just to go over with you before we get started. First of all, some of you have seen these pictures before. These are, the left-hand picture is, a few of our nurses in Springfield in their Covid outfits. The top right is our Aurora facility and the patients, through gratitude, put those, the signs, out front just to say thank you. They know the stress and the conditions people are under now working. Our treatment centers are open, we are helping people, we are taking all the precautions but yes you know you got to believe some of our staff, know they’re concerned out there but yet they’re there helping people. Just like Beacon House, again the staff wanted to show their appreciation for the staff. Thank you to our staff who are listening. You’re rock stars. You’re our heroes and also obviously everyone else on this webinar.

Few things to go over quickly. There are webinar controls – there’s the orange arrow if you want to get rid of the controls. You just press that button and they disappear. We’ll be stopping and asking for questions periodically so please as you think of questions based on what Rob’s saying just type away in there and then I’ll see them and then Rob, I will interrupt you periodically with the questions.

Dr. Rob Weiss: Would you like to start?

Keith: Oh just in a few minutes. See so some of you are here for CEs. There’s one-and-a-half CEs given out. We’re gonna send you an email after this presentation. Please fill out your evaluation form, send it back and we will send you the certification.

We’d like to thank our sponsors – a Higher Thought Institute, who is providing some of the CEs. They are a premier provider of conferences and webinars dedicated to the behavioral health field.

Gateway Foundation, the largest nonprofit provider of substance use disorder treatment in the country – 14 sites here in Illinois and we’re proud to be representative with the other great treatment centers here in the Illinois area. We offer detox / withdrawal management all the way through outpatient sober living. Our programs are open – inpatient, residential. Our outpatient programs are virtual at this time. We offer specialized programming in LGBTQ, professional program, young men, women and trauma and our alcohol use disorder program.

And Seeking Integrity, Dr. Rob Weiss’s program that he founded in 2017 to focus on sex addiction, pornography addiction and paired substance use disorder. We’re very excited to have Rob today.

I want to say a few words about Rob since Rob and I have history together. He is an amazing man who I very much respect. He’s a clinician and author and international lecturer focused on intimacy disorders including sex addiction, cybersex and relationships. He’s written 10 books. His first book was in 2001 on cybersex with Jennifer Schneider from Tucson, Arizona, where I am from. He is a true thought leader in the field and passionately believes in those suffering from addiction disorders. Dr. Weiss has set up some of the most effective and important programs in the country for men and women suffering from love, sex and relationship addiction issues.

Dr. Rob Weiss from sunny California – it’s so good to see you! Thank you for joining us today!

Rob: My pleasure! Glad to be here!

Keith: So what I am going to do is hand you over the controls.

Rob: Oh I love control.

Keith: Yes, yes you do, there you go…sharing…okay! It’s coming right at you Rob.

Rob: Okay.

Keith: I’ll excuse myself and chime in with questions.

Rob: Yeah please let me know if questions come up and I really would like to do that. Why don’t we get started? So I assume that everyone can see this. Is that correct? Yes?

Keith: Yes!

Rob: So my name is Dr. Rob Weiss as I said…as Keith said and I’ve been licensed as a Social Worker for 25 years and I got my PhD about four years ago in sexology and by the way those of you in your 50s, go get your PhD you’re never too old. I just want to tell you that. A little tired, but never too old, and I’m really glad to speak to you today. My experience has been mostly in the field of what I would call intimacy disorders or early complex attachment disorders which lead to later adult sexual problems, intimacy problems, addictions of all kind, is the work that I’ve been doing for a long time.

And what I wanted to bring you today was a little bit about sex and drugs and maybe even more about using sex in our practices – I don’t mean having it, I mean making use of what sex means to our patients and I don’t know about you but when I went into graduate school, back in the day and it wasn’t, well it was a while ago clearly, but I know that this is still true that there are two area arenas in graduate education where we really kind of miss out, at least at the Masters level, and that is discussing and really understanding the effect of human sexuality on relationships, intimacy and drug and alcohol issues and mental health – all of it. And we also seem to lack a level, a really high level, of discussion about addiction and this as a social worker, I want to tell you the minute I went out in the world and went to a child some kind of you know child welfare or a prison sister situation I was dealing with addiction and incest and sexual violence and there it was.

So this talk is really to maybe just bring a little bit more discussion about sexuality into the work that you do, in a way that might be healthy for you. As a sexologist it has bothered me for a long time that we really don’t look at the whole person when we’re in treatment, when we have someone in therapy or treatment. We say we look at the whole person but I’m not sure we really are and so that’s kind of the topic here.

In order for me to do this talk for you, I’m gonna give you a couple of stories and they’re actually about situations that I’ve been in in the past. They are true stories, all my stories are true and they’re true clinical stories – situations that I have been in that I think are reflective of the problem at hand and so let me just say a few things about sex to begin with. You know I’ve been doing biopsychosocials or evaluations and assessments of new patients for 27 years so we used to do a lot of them in grad school, right? and I have never seen a psychosocial or biopsychosocial evaluation ever that asked about masturbation. I have never seen one that asks about porn. I’ve never seen one that says are you happy with your gender – none of it – and yet how important is sexuality to relationships, intimacy, self-care, dependency, all of it and I really feel like this is a missed opportunity so that is why I’m here today.

Now I want to tell you a couple of stories and this is the first one. Now, one of my former jobs was evaluating the quality of treatment programs when I would sit in on them. I was there to evaluate a program and then give feedback to the company I work for about the effectiveness of that program and what changes I have thought would be useful. And my experience is that, I want to tell you folks, and I think the best way to evaluate any kind of addiction program, and probably most mental health, is by looking at group therapy. It’s in group therapy whether the social bonding happens, where the mutual support of confrontation happens, unless you’ve got extremely mentally ill people, especially if you’re working with addicts, I think that’s where the growth is at. These folks need help with social skills and bonding and intimacy problems and you know, they’ve all grown up with a lot of trauma, and so the challenges of really teaching the women I work with to bond with other women for support, the men that I work with the bond with other men for support, these are the challenges that I face in treatment a lot and they’re very very important.

So I bring you a story – I was evaluating a very high end, very expensive, fancy treatment center – 60, 70 thousand dollar beds – you know that kind of thing and I sat in a group for two weeks because that was my, well actually it was a week, to sit and evaluate and this is what happened. I was working in that group and there was a guy in the group for treatment and it was an addiction group – this was a drug addiction treatment program and he kept saying when he would share in the group “I do coke and hookers” “I do coke and hookers” over and over again.

What the treatment team asked him about that, because I sat in the room, was they said well when did you see these sex workers, these prostitutes, when did you go do this and he said when I was loaded, you know high on cocaine, and the staff asked him, because I was sitting in the group, have you ever had sex with these people when you weren’t high and he said no, I think most of time I was high when I sought out these people. And what I saw in the clinicians who were in that room was a whoo, a big sigh relief, because they knew in their minds that as long as we just talked about the drug issue, if the sex had come out of the drugs, then they didn’t have to talk about sex, and they didn’t want to talk about sex, because they didn’t know anything about sex, they were uncomfortable and so the idea that if this patient has a drug problem and he just had the sex when he was using so if we help him with the using, we’ll get rid of the drug problem was inaccurate. All people who co-, have co-occurring drug and sex problems – meth and sex, coke and sex, heroin and sex – they all have, guess what, sex problems and intimacy problems and you can take the drugs away but they still have those problems and so putting them in treatment just for the drugs or just for the eating disorder without looking at human intimacy and relationships is a problem.

So anyway, this guy’s in group and he said I’m seeing coke and hookers, coke and hookers and the therapist were like well we’re not going to talk about that and so halfway through the day since I’m sort of the guy who, no I’m sorry – halfway through the week, I’m kind of the guy who speaks sex, you know? So I said to the group leaders, would it be ok if I pull this man aside and talk to him for a little bit? And they said sure, you know, and so I talked him on the side and I asked him that question, the question that no one had asked him and I thought was very obvious to me, I said how many hookers, how many sex workers during the last year and he looked up and he was using his fingers you know and he said about a hundred. So here’s a man in treatment telling us that not only did he use a hundred times last year but he had sex with a hundred different sex workers while he was doing it. Don’t you think that if that road were to be explored, there might be some issues there? There are. I’ll tell you that furthermore, that this treatment center as fancy it was, expensive as it was, did not do any STD testing because they didn’t want to spend the extra money and therefore every addict who walks in was never tested for STDs.

What do you think addicts are out there doing? Do you think they’re just sipping liquor and talking to friends and having this…? No! They’re being wild and crazy out there and I can’t imagine inviting anyone to a treatment program of any kind without testing for STDs in 2020. Seems like, you know, a given to me but more than that this man’s wife was coming for the family week which was at the end of his treatment and I said to the treatment team, how are we going to talk about this? I mean the wife is coming and they said we’re not going to talk about this, we’re not going to bring this up and I thought and said what do you mean, I mean this is clearly a serious issue and they said because he was getting ready to leave, we don’t want to bring this up because this will blow the treatment out of the water. Okay, I mean I thought what were there to treat me just throw all their crappy smelly stuff on the table and pull it apart, but they want to bring this to a neat ending and sex was not where they wanted to talk about it. But folks, this man’s wife was coming for family treatment and she was never told that her husband saw a hundred sex workers in the last year nor does she even know her husband has an STD because no one checked him in treatment.

Can you imagine that woman finding out this information a year later? That it was talked about in treatment and no one ever told her or discussed it with her? Terrifying. So to me the obvious questions are the ones that they were uncomfortable about but they have profound consequences in ways we might not anticipate for our patients, for their families, all of that. So what could we have done differently there? Could we have maybe noticed oh, he keeps talking about these paired issues, we have to pay attention them in a paired way? Um he has a family member, it’s a wife they have kids. He says he has issues with sex, how does that play out? How do we need to explore it? Are there any other ways he’s sexually acting out? He has children in the home. But if we don’t ask and we don’t pursue, we don’t know.

And my experience is in so many environments we just don’t touch these issues, not in our biopsychosocial. We want to talk about sexual trauma, we’ll talk about what happened to someone when they were 16 or 12 or nine all day long, because therapists love to talk about that but here’s an example of what I struggle with. I have a friend of mine who says that when he’s doing talks like this he puts a screen up and on one side he shows a 17-year-old boy who looks really really sad because he’s been molested multiple times and he’s using drugs, and then the other side of the screen there’s a 35 year old man who’s been cheating on his wife and is struggling with drug addiction and you know he’s had five affairs and I say to the therapist, which one of these people would you feel more comfortable working with and all of them say that 17-year-old – he’s in trauma, he’s in pain, I can reach him. Well don’t you realize folks that that 17-year-old is that 35-year-old, 17 or 18 years later, only he’s stuck with the same issues that he was in childhood – the history of abuse and neglect which leads him to be challenged in relationships, which leads him to acting out in various ways but we never asked, we’re only interested it seems in the past and not so much in what is your adult sexual relationship, what are your adult sexual fantasies. We talked about – well I’ll get there…I won’t rant now, we will rant more later.

So I want to tell you another story and this was, again, in my job as an evaluator of addiction treatment programs and this was an insurance-based, not particularly expensive program that I went to and they had mixed groups and it was like a hospital and you know people were there for 30 days on insurance and it wasn’t fancy and there weren’t any horseback riding, you know it just wasn’t like that, but people were getting well nonetheless. And I sat in a group of like five men and three women, which I don’t recommend because I think gender separate treatment is better, absolutely – we’ll talk about that later. But anyway, I was sitting in a group of five men and three women and I spent the whole week and when I’m there I bring up sexual issues as a part of the group. So we had two young women there who were strippers because their boyfriends had gotten them hooked on meth at 17, and at 19 they’re dancing on stages for drugs and their parents are horrified and you know what, so all of that. So we spent the week and I did therapy and I had guys who’ve acted out sexually, I had these women who were dealing with their prostitution issues – it was fruitful.

But at the end of the week, like any good therapist, I went around the group and I said how was this for you, having this guy talk about sex in the room, you know, what was that, was it helpful was that not and interestingly, and this is the reason for this story, I got to the last person in group and this was I would say a 62-year-old lady who didn’t look like most 62-year-old ladies I know because she didn’t dye her hair, she probably didn’t a lot pay attention to how she looks and therefore she looked 62 and maybe even a little older and so when I said to her what was it like for you to be here this week – I mean she was a nice Christian grandma in her 60s and she said you know I feel, really I was starting to feel uncomfortable because I don’t understand why I would need to talk about sex, I mean I’m 62 years old and I’ve been married for 30 years and I’ve grandchildren.

But this woman was in treatment for her third time in the same treatment center for alcoholism and by the way if you’re a treatment expert you don’t want to brag about that – “that person came back to our Center three times” – no no you want them sober and never coming back to your treatment center. But anyway this woman had been back three times for alcohol addiction in her 60s and this is what she said to me, she said you know I don’t understand, I’m a nice Christian grandmother, I never thought I’d have to sit to talk about sex, I never wanted to, I don’t understand why this is in this group but you know, she said, true story, she said I’m beginning to wonder if I as I’ve listened throughout the week if maybe one of the reasons I can’t get sober on alcohol is because my husband probably three days a week makes me look at porn and then has sex with me.

You see no one ever asked this sweet little Christian grandmother about her intimacy and sexual life and there she was on her third round of alcohol treatment and no one had brought up the fact that her husband was making her look at porn and raping her three days a week, but she felt as a good Christian woman she needed to do what her husband said and etc. Thank God I was able to race out to the family therapist before this woman ended up in her fourth round of treatment to say I think there’s a serious problem around sex and intimacy in this relationship, I know she looks like someone who hasn’t had sex in 40 years, but trust me it’s a problem. And why? Why wasn’t that discussed? Is it because she was older? Is it because it’s not in the biosocial? You would look at a young woman who’s wearing a tight skirt and cleavage and say we need to talk about sex but that Grandma over there you don’t think about it? Or the person who says I am having problems with sex and drugs and we only talk about the drugs? That’s only solving half the problem and I would say most often, the underlying problem.

I work sex, I work addiction, I work intimacy and attachment disorders. I can’t tell you probably 30-40% of the thousand people I’ve seen over the last 20 years 25 years had a drug and alcohol problem, resolved that problem but they were miserable because their lives are about keeping sexual secrets and keeping romances and keeping porn and keeping affairs from their partner. So they weren’t really sober, they were still hitting on people and keeping secrets and living a double life – they were sober from alcohol, but their life was still a wreck, they were still not happy, joyous and free and, in fact, their marriage was pretty, pretty piss-poor. So we have to talk about this stuff but I’m not sure we all have a method for talking about it and I’m gonna bring that up in a little bit

Okay, I’m gonna tell you this last story and it’s really actually not a story so much, it’s more thought. You know we have a lot of people walking in now with meth problems and amphetamine problems and you know back in the day, when I was a young man, people would use meth and they would go dancing, they would use speed and they would hang out for three days. Now people use meth and amphetamines and they have sex because now we have, excuse me, viagra and all this wonderful drugs so you could be up for days and up for days. I think you know what I mean. And so now people can go on three-, four-day rants with sex. They can become psychotic, all unconscious, they don’t remember half the things that happened to them and then they come into drug treatment to talk about drugs and their meth use and no one really talks about sex. Well these are, these are people who might have been hanging in a sling for three days, horribly humiliated about what they did when they were high, hate themselves for the sex that they had, feel that they were worthless because of what they did, but no one says tell me about the sex you were having when you were high, tell me about the interaction for you between drugs and sex because for your sex, for your meth addicts, they pair co-occurring drugs and sex and this is one of the things we treat at Seeking Integrity because I’m very interested, and have been for a long time, in the co-occurring issue of drugs and sex. I truly believe that we miss so much in treatment that is not necessary for us to miss and we don’t need, you don’t need to have a PhD in sex to do this kind of work – you simply need to find a comfort level with talking about it and bringing it into treatment.

If you’re working with a chem sex person, alcohol and sex, drug and sex, meth and sex, I have to talk to these patients about sex if I’m going to reduce their likelihood to repeat their behavior. I have to ask about the sex they were having when they’re using, anything they feel uncomfortable about their sexual life, either before or after. I can actually tell you what the etiology is for the many of the male meth addicts is incredible self-hatred around their sexuality. Many of them are deeply homophobic, many of them are deeply transphobic, genderphobic. They have deep religious problems and challenges with their sexuality. They’ve always felt ashamed or unhappy with sex and then they do meth and they feel like a sex god – all of a sudden their fears or anxieties, and so, who wouldn’t want to do something that makes you feel completely sexually free and alive? But without the drugs, they feel inhibited, self-hating…so the cycle makes so much sense. But if you don’t look at the sex piece these people aren’t going to get sober.

And by the way here’s another piece – remember that guy earlier that I talked about who used coke and prostitutes or as he said coke and hookers well, where do you think he gets the coke? He gets it from the sex workers! And so this guy, since we didn’t discuss it with him in treatment, I guess he’s going to go back to the same places that he used to go to have the sex but that’s where the drugs are. So how likely is it that he’s really going to achieve long-term recovery when you haven’t talked about or dealt with that?

I have to talk to these patients about relapse they’ve had on drugs and alcohol-related to sex, about who, what and why and what sexual romantic circumstances might make the difference between sobriety and relapse. We don’t have conversations about this in treatment and let me tell you one more thing, and I’m gonna go into this strongly, this is a really important area for women in treatment, really important, because women are abused more, women are sexually molested more, women have a lot more issues in this area because they are women and how they are treated in our culture and what happens to them and then they, especially because they’re women, do not want to talk about sexuality, do not want to talk about what they did. They have, they have even more shame and yet that not alleviating that making, leaving people feeling like they’re bad people, leaving people feeling like there’s something wrong with them for what they did, as opposed to it’s related to early complex trauma, of course you would do these things you don’t know how to connect with people in a healthy way, you know all the conversations. I want to take people out of sexual shame. I want to take people from feeling badly about themselves to realizing that some things happen to them that left them making really bad decisions about relationships and intimacy in their adult lives but with a lot of support and help they can make it, make different decisions. They’re not gonna learn that if we don’t talk about it.

By the way the meth users, just to say something if you run into the amphetamine users, they have a real challenge in life, because number one, meth is a very difficult drug – one of the most difficult drugs to leave – Several reasons for this. One, if you’re looking for stimulants, go with cocaine, because cocaine, what it does is it sits on the dopamine receptor and it leaves us feeling longing and tremendous pleasure but it doesn’t do it for very long because cocaine is a naturally occurring molecule, it goes right through the brain and out through our, you know out through our kidneys and all that, but meth is not a naturally occurring substance. It is a man-made substance and those meth molecules are huge and as a result they sit on top of the dopamine receptors in the brain until the dopamine receptor dies. And so people who use a lot of meth become become anhedonic, meaning when they’re not on meth that nothing feels good – life doesn’t feel good, friends don’t feel good, sex doesn’t feel good. In fact, many of them will avoid sex after they get sober because it doesn’t feel good to them and so how are you going to teach these people who were hypersexual and now they’re avoiding sex how to find some middle ground for that and not end up using and not end up in places in situation sexually that are problematic. This is I think the work of treatment when a co-occurring issue comes in.

So I absolutely believe that you know if I was running the world and I was running our graduate schools and all of that then I would say that we need to put more personal questions about sexuality relationships into our standard biopsychosocials. I don’t understand. My friends, you’ve done biopsychosocials, you know I ask if I’m doing that I ask about eating, I ask about exercise, I ask about relationships and family, I ask about school, I asked ask work, I ask about finances, I might ask you about your eating, about your self care, about your health – never do I ask about sexuality. It’s as if the area between our belly button and our thighs doesn’t exist in treatment and psychotherapy and yet, how much happens in that little area for our bodies and how much does that affect all of our lives – desire, connection, intimacy, relationship, marriage, all of it crosses the boundaries of sexuality and most often unless the patient brings it up, we don’t. And patients don’t bring this stuff up. They’re already embarrassed, uncomfortable, hating themselves about things they did. If you don’t ask them what kind of sex were you having when you were divorced, what kind of sex were you having when you were using and how do you feel about all those questions, then you leave the shame with them then and, by the way, if you don’t want to talk about it and you don’t ask it but you ask every other question in the world, that patient is going to assume that this is not something we talk about here and they’re not going to bring it up.

I’ll tell you a little story about me. I was teaching for the military. I’ve done a number of trainings to the military because we had something like 25 thousand cases of sexual abuse in the military last year so they have a lot of these issues and I’ve been to a bunch of places to teach but the first place I ever went to teach for the US military was in Germany and I was on a base and this big corporal came up and he was my boss and he was really tall, and he had big epaulets, he scared me haha, and I walked up to him because he was the boss and I said to him you know sir or sergeant or whatever he was, I said colonel or whatever, I’m here all the way from the United States. We have 75 therapists and 50 religious, you know spiritual folks, who are chaplains, so there’s a chaplaincy there and the clinicians and I said to him you know this is one of my first times out, what can I do for you, what what do you really want me to get across these therapists, because I was doing a five-day training on sexual abuse, sexual intimacy, sexual acting out, sexual offending, all of that stuff and he said to me the following, this is true, he said, son, if I can just help you to get these therapists to use the word masturbation, I will have considered you to be a success. I’m spending five days teaching about offending and abuse and gender and and all he wanted, all he wanted, was to make sure that these therapists could speak sex and that they felt comfortable with it, that’s all he wanted, and I understand that it’s going on the military, it’s going on everywhere, and I certainly see it in private practice world.

People – you guys – send your patients to me when they have sexual problems. I don’t know that you fully necessarily evaluated, understand it, decide where to refer, who to refer, all of that. So what I did was, I thought maybe it would be useful to write a few questions down that certainly a treatment center, I think any treatment center, and also I think maybe in your practices, that you might want to ask about sex if you’re doing general intake questions, that would not be so offending that someone would feel like oh my god I don’t want to answer this or why are they asking me this or you know that kind of thing. And so some of those questions are – these are broad questions by the way, these are general questions that we want to ask about sex and romance to clue the listener in – yes, we do talk about this but you know we’re not, we’re not, you know you’re not going to pursue you in a way that feels uncomfortable. So questions like, and I use these all the time, in the last year or so – and we’re looking for time, not let’s say someone was using the last weeks or bipolar, you know manic in the last weeks – so we’re asking over time, over time how are you feeling about your sexual life – my dog is drinking water, I just missed it – How are you feeling about your sexual life? Are you comfortable in your sexual life? Are you uncomfortable in your sexual life? Why or why not? I think that’s a pretty, I think you can ask anybody on an intake question and by the way I want to say one more thing about us asking questions and where we come from. Every time I’ve gone to a patient and said did you feel uncomfortable when that person did the assessment around your sexuality, the only times they said yes is when the therapist was uncomfortable because it is about this, this is a flaw in our system, that we are so uncomfortable or we’re uncomfortable enough asking questions about this, that the patients don’t talk about it and we feel uncomfortable and therefore it gets left out and this isn’t something I think we should be leaving out.

When patients are calling for treatment or an intake, I might say are there any secrets that you have from any anyone around sex or do you have, is there any, can you tell me what they are and why do you keep them. Again, I’m not asking them about really explicit sexual issues. I’m not even asking about orientation or gender. I’m just simply saying, is there anything that you haven’t told anyone and then I’m wondering why are they keeping the secret so it leads down the line of questioning that’s useful for me. Do you have any concerns or as anyone else expressed concerns about your romantic or sexual life in the last year? So your wife, your friends, your boyfriend, someone has said oh what are you doing or I didn’t know you’d looked at that porn? Has anyone, again now we’re saying has anyone on the outside, if they were looking at you, would they have seen anything that disturbed them – a different way of asking the question, but nothing explicit or direct.

And finally, I might say if I had an addict, you know a drug or alcohol addict, do you think there are any connections between your substance use disorder and your romantic or sexual life. And let me tell you, where I find this the most, in women. Women with trauma and sexual abuse, who sexually act out, have profound relationships between their substance use and their sexual acting out. They’re going to bars and getting picked up, they’re on tinder getting picked up, they’re having sex with the mailman. I mean, they have issues but they’ll only talk, certainly to a man, about the substance use problem and only in a detailed way with a woman, if she’s asking the right questions. And by the way, I want to say this to you treatment center folks, I understand that you’re not set up like I am to ask in-depth questions and go through evaluations around sexuality but you could ask a few questions, you really could. And in addition to that, you know, just normalizing this stuff, helping people feel more comfortable with it or making referrals in treatment or out where it’s appropriate.

So women, women struggle more than I see with men, men for sure with this. Women relapse over a bad relationship, they relapse over love gone lost, they relapse over love gone wrong, they relapse over having the wrong boyfriend, they relapse over their mother-in-laws. Women relapse more often around relationships because women are more relationship relational and that kind of intimacy loss is really profound for them in a different way than it might be for a man. So if you don’t, you know I think it’s really important that we particularly with women, and I’ll give you another thought and we’ll mention this later, the most correlation I’ve seen with co-occurring disorders in women is eating disorders and sex. I see women sexually acting out and then they get miserable with that and they say no more men, no more sex, I’m done with that and then their home on Haagen-Dazs and they gain, you know, all this weight and it goes back and forth. So I would say to you if you’re working with a woman with an in, with a, with an eating disorder, she probably, you really want to ask a lot of questions about intimacy in sex.

So if I had someone in my office, if I was doing a live assessment and I’d introduced myself and we’ve gotten to know each other a little bit, we had a bit of a relationship and now we’re going through the biopsychosocial, I would ask more in-depth questions. So in a biopsychosocial someone live, I’d say do you masturbate, yes or no, and how often? If you use porn, how often do you use it or do you use it at all? If you’re in a relationship, are you monogamous with your partner or do you have other agreements? Understand these questions folks I am, I am flushing out for you, what would be the same kinds of things you might ask about education or eating or family relationships or any of the other things we do on our introductory and assessment evaluations but I’m just doing it for this area of the work because we haven’t, we really don’t include that mostly in this area of the work and as I said when I ask patients these questions they are never uncomfortable, in fact they’re often relieved that someone finally came and asked them about this because they feel so ashamed that they’ve never told anybody.

Here’s a quote from Dr. Patrick Carnes who I had the pleasure of doing some training with back then. Pat would say, you know sexual secrets are the most painful and shameful that we carry and yet they’re the ones we are most, or least likely to tell. So sexual secrets are the most shameful and yet they are indeed the ones we will are least likely to tell. I think that’s a good guide for us as therapists to think about.

So other questions I might ask someone in a biopsychosocial that would be included if we’re doing a biorelational, so actually I like a biopsycho-relational, I want to want to get rid of the social – it’s like social distancing, we’re not socially distancing, we are physically distancing – so may be a biopsycho-relational would be a better way to call this thing because then we’re really looking at the intimacy, relationships and the part of our work that is so important today which is attachment – looking at friendships, work relationships, family. A biopsycho-relational would be much more interesting to me than a biopsychosocial. Take that and run with it please.

So around sex, if I had someone in my office, are you married? And if you’re married have you had any affairs? Were they online affairs or in-person? If you had an affair, does your spouse know? Has anyone, as we said before, in your life expressed recent concern – now we’re out of a year, has anyone expressed recent concern about any aspect of your romantic life? Do you have questions about fetishes or paraphilias or atypical behaviors like BDSM and kink? Doesn’t mean I’m gonna be able to answer them folks, I mean I probably could because I have a PhD in sex, but it you know, this is information to you that oh maybe there’s some things about their sexuality they need to learn more about it or maybe they’re doing it in ways that aren’t helpful for them, you know maybe they’re experiencing harm and BDSM or some of their fetishes are problematic. This is where I’m gonna find out.

Here’s a great question for 2020 that we don’t ask in our evaluations. I love this question. How do you feel about being a man? How do you feel about being a woman? I can only tell you that as one of my family members who’s 14 years old came to me recently and said I don’t like my penis and I want to wear dresses and I’ve been putting on mom’s clothes since I was six and this is a 14-year-old member of my family who plays baseball and is the most butch little kid I’ve ever seen and I thought, right, none of us are untouched by these challenges or changes, none of us, not in psychotherapy and not in our personal lives, therefore it’s essential we included in the work we do, it’s all around us.

Are you comfortable with your sexual orientation? Alright often I run into people who are married and have kids and they’re part of their church but they’re having sex with men and they’re cruising male porn and it’s all a lie, it’s all a secret, and so they don’t even know what their orientation is because they’re doing this with a woman and they’re doing that with men – they have split their intimate lives from their sexual lives and that’s where they end up.

Here’s a great question to ask about sex. Is there anything I might, because I might be concerned, about if I’d observe your romantic life over the last few years, like cheating or addicted behaviors or lying or keeping secrets? Is there anything that I might be upset about if you told me? I think these one two three four five six seven eight nine or ten questions do it, like this is it, if you do this, if you can find your way to this, then you are helping your patients on a profound more level than we do before.

I think the name of this talk has to something or if it isn’t on there I’m going to tell you this is a talk about best practices, this is a talk about doing our work better, doing it more effectively, doing it more holistically and being unafraid to approach things, to learn about things, to take the time to approach things that are so important for us to look a.

Keith, did you have some questions for me?

Keith: Yes, Rob, thank you. So from Tanya Shaw LCSW.

Rob: Hi, Tanya.

Keith: What suggestions can you provide to help clinicians become more comfortable with asking these questions, that’s part one.

Rob: So, I didn’t plan on getting a PhD…why would I? What I went to get was a certification in human sexuality and so I did a one-year class which is basically six hours on a weekend for like ten months or eight months. I just would sit for six hours and go to class and in that class I learned about transgenderism and gender identity and kink and fetishism and all the sort of basics, paraphilias, sexual offending. I got a really broad view of that in a year and I got a certification as a sex therapist or sexologist. I’m pretty sure that, yeah that’s how it works. The PhD was like, okay I’m halfway through I might as well do the rest of it but you know believe me there are schools of sexology. There’s a IICS in Florida, the International Institute for Sexual, sorry for Counselors and Sexual Health. You can look at AASECT, the American Association for Sexual Counselors and Therapists. There’s a lot of organizations that help us grow. I think, you know, sure I wish everyone got a certification, but you know what you can, you can roleplay, you know you can sit with another therapist and say okay I want to ask you about masturbation, okay I want to ask you about porn, you can work on becoming comfortable this just like we teach patients to become comfortable things. I mean you need to learn about a lot about masturbation, but how to ask the question, how to respond to the question that you might do in a group with other therapists, go through these questions, practice, see how it feels, see what people say, ask people to say kind of weird stuff – I’m into squirrels – you know and then see how that goes, but I think that’s how you have to do you have to either educate or dive in with the work or both.

Keith: Awesome, thank you. So what do you seem to notice is the most challenging reasons why clinicians shy away from this?

Rob: We don’t know how to educate it. We are uneducated in the area of human sexuality. We, I had, we had a quarter, I had a quarter UCLA, a quarter and what I learned about was the basic plumbing again and I learned about people who were disabled. I saw films with people who have legs and arms they were able have sex. I didn’t learn anything about incest, rape, you know, child molestation, kink, fetish. I didn’t learn anything about any of that. They did the best they could, but even my educators, they weren’t educators in sexual health, they were kind of using their experience in the field and what they had to talk about. I don’t think we have really solid clear curriculum at a master’s level or above for human sexuality that is required. And by the way this is going backward not forward, because the state of California just said that schools who offer a quarter of sex education, no longer need to provide it. So in California we used to have to take a two-day CEU course in human sexuality to keep our licenses – I thought that was great. Now what’s happened is in California, if the school teaches any coursework, like UCLA teaches a quarter in human sexuality, they don’t ask for it and I’ll tell you this, I am adjunct at UCLA and I’ve taught human sexuality and what I have found is that just to say a few students, if any you guys out under you know under 30 or whatever, you know everything about gender identity, you know everything of a gender fluidity, you know everything about orientation, because these are hot topics right now. I’ve been corrected by so many students when I said the wrong word in the wrong way. I mean, I knew what I meant but you know there they were with their Google – “No, you don’t call it that, you call it this.” However, they don’t know anything about all the rest of the stuff. They don’t know anything about all, they don’t know about offending, paraphilias and the things I think they’re really going to need out there, unless everyone’s going to work with gender fluidity and orientation which I think is highly unlikely then you really need to know about all the rest and that is lacking in our masters level education and if it’s lacking there, it’s not going, we have to go get it later. And I understand, by the way, getting information later, like I had to learn about HIV and I had to take a CU course to get my license. Great, I didn’t expect them to teach you about HIV. I mean that was an issue but it wasn’t a big enough issue to put into our curriculum, but human sexuality? I mean I think that’s the kind of issue that sort of crosses all of our disciplines in at least understanding how to assess and talk about it.

Keith, other questions?

Keith: Yes, so the last part to this question from Tanya. How do you promote this within a clinical team without promoting clinical shame?

Rob: Well, I can tell you that Gateway is going to put this up online on YouTube and if you think what I’m saying is useful to you, you can show it to your treatment team or you could write me,, and I’ll help you find research. By the way, any of you want resources to schools, education, certification, you know any of those things around sexology, just write me at I’ll write you back and I’ll find resources for you but they won’t be in the graduate schools, unfortunately.

Other questions, Keith?

Keith: Yes, from Lauren Ashley Whitaker. I work with teenagers in the substance use field. Should we be asking all the same questions, especially when their parents sometimes don’t want us to address sexual behavior at all?

Rob: Okay, those are two different questions, I think. One is should I be discussing human sexuality with teens and the other question is the parents. I’m writing this down because I’ll forget about it. So question number one, I’m gonna ask you guys. I can’t see you so I’m just gonna ask you to raise your hands to yourself at home because I would do this in an audience. How many of you have children under the, between the ages of 15 and 18 at home? Raise your hand. Now keep your hand up if you think your child is not looking at porn online. I hope you’re putting your hands down because every child in America is looking at porn online. I don’t care how wonderful your home is, how…this is what kids are doing and they’re doing it a lot and they’re sexting. So I already know that there are 17 year olds on Tinder saying they’re 18. I know that there’s 15-year-olds and 12-year-olds looking at porn. Why would I not ask? I have kids who are 15 who are looking at an hour and a half of porn a night and they are failing at school and they’re not building relationships. How can I help them if I can’t talk about that?

And I’ll say this, I don’t think, look a parent may say to me I don’t want you getting into this, I don’t want you to get into that. I’m gonna say to them, you know I’m a licensed clinician and while I really appreciate your feedback, I must evaluate your child in a neutral way, so even though you have feelings and questions, my job is to do a holistic evaluation of your child. Everything will be talked about equally, but we don’t want to miss any areas that might be problematic later. I hope you can trust me to do a good evaluation – that’s my job, that’s what I’ve been educated to do. In other words, the answer the parents is no, I’m sorry, you don’t get to control treatment or evaluation, that’s my job, but I do respect your feelings and I really hope that you’ll like the result. No one gets to control what I do in that room with a patient if I have a license and I know what I’m doing. Parents get to say things and if they’re present there are probably things I wouldn’t bring up but why wouldn’t I talk to kids about stuff they’re already doing?

Would I talk to a 7, 8, 9-year-old about sex? Probably not. I would certainly ask them if there’s anything they’ve seen online that makes them uncomfortable. I’d certainly, you know those kinds of things but prepubescent I would probably have very very general questions, post-pubescent I would be getting much more do you look at porn, if so how often, have you had sex with anyone, if so who, things like that for a 15-year-old I can’t imagine treating them without asking it. And you know what they’re gonna say, no I don’t look porn and no I have no sex, great, that’s that kid. Another one’s going to say I look at porn all the time and I’ve had sex with everyone I can find, that’s another kid. How do you know which one you have if you don’t ask.

The other, so I think I answered both half the questions. I’d be very polite to the parents and tell them unfortunately in my own way, not the way I’m saying it now, unfortunately you’re not really treating biopsychosocial so thank you for the feedback but I need to do my job. And if the parent’s in the room, I would probably ask to see the child privately to finish my assessment. I mean, I got to do my job and if I can’t do my job, I’d probably say to the parents maybe you need to take this child somewhere else.

More questions? or would you like me to keep going?

Keith: One last question from Adrian. Why is sex so intense nowadays? When I was growing up in the 70s and 80s it was not like this.

Rob: And what is this person’s name?

Keith: Adrian.

Rob: So Adrian, maybe we do, we grew up in a different period, you and I, but when I was growing up in the 70s, people were having sex parties, play to retreat was for couples and there were all these couples swinging places that were going on. Times Square was full of strip clubs and porn shops and adult bookstores. I think we grew up in a highly sexualized environment but it was never talked about. Nobody talked about the underworld. Nobody talked about people hooking up. Nobody talked about you know porn. We didn’t talk about that back in the day. We just did it. Maybe you didn’t but I know a lot of people who did. What’s happened now is two things. One, we have so much more permission as a culture to talk about sexuality, because, and you know I don’t know about you, in the 70s but when I learned about sex, this is how I did it – I went into the library, I found a book about sex and I put it inside a dictionary, so everyone is looking at me saw that I was reading the dictionary but really I was learning about sex, because I was terrified than anyone would see that I would want to learn about that. Well today every thirteen-year-old has complete access to an encyclopedic dictionary of all of human sexuality so of course people are talking about it.

There are other things too. If you grew up a little later than me, you grew up with AIDS and AIDS and the 80s were all about safety and not. There was a huge wave of sexual conservatism that came across in the 80s that was against all the sexual permission and against the sexual liberation of the 1960s and 70s so by the 80s we’re in conservatism. I’m 60, if you’re 50, if you’re 50, you missed it. My husband’s in his late 40s, he learned, you know, sex was terrifying to them – don’t do this, don’t do this, people are dying, condoms. So if you grew up during that period, no, you missed the 70s but let me tell you as a gay man, boy was it fun in the 70s. There was no HIV/AIDS and we were as popular as gender fluidity is now. Boy, everybody wanted to hang out with us until AIDS came along.

Any more questions?

Keith: Yeah one last question here and then, I will mention as you were speaking we took a poll to see how many of the clinicians that are listening and viewing your presentation ask their patients about sexual behavior. 75% said yes, 25% said no so just for your knowledge.

Rob: Great! What are you asking? How explicitly do you ask? How comfortable do you feel asking? Whoops, sorry. Would you like some support? You know I do a consultation group once a week. We talk about these issues all the time. It’s free, anybody’s welcome. Again just write me a note because I think you have to be, do this kind of stuff peer to peer and maybe you know I said in role plays and you know I can probably give you a lot of information on how to grow and learn. I think you have to have us around to support you and help you grow.

Keith: Okay last question from Meghan Ristaino. How do I explain to a man that his emotional cheating is sometimes just as strong as a physical affair? He is also an alcoholic. Their goal is to gain trust. Thoughts?

Rob: Yes, I think this man is doing more than having an affair. Any of, most the alcoholics I know who are just having an affair, are also just seeing prostitutes, just leaning on and using porn and just doing a whole bunch of stuff. So remember when an addicts lips are moving they’re lying. So and, as an addict I will own that, so first of all I think there’s more going on than he is saying and then I’m sorry what was the other part of the question?

Keith: Well she is asking about his emotional cheating, so how does she let a man know that emotional cheating is something that is as strong as a physical affair, he’s an alcoholic, their goal, their goal is to gain trust.

Rob: So I’m gonna say some things that might be difficult for you to hear ladies and gentlemen but men and women, we think differently about sex. I didn’t know if you know that but we really really do and I know to the feminists out there like no men and women are the same, we can be the same – no we can’t sorry, I have a penis you don’t, we’re not the same. My brain is built and functions differently than yours, if you’re a woman and I’m a man. And by the way, man trumps gay, man trumps Jew, man trumps PhD. I was a man before I was anything else and I revert to male behavior.

So here’s a thought for you. We’ll get back to your question in a second. I’ve done a lot of Me Too work, doing groups, doing, having therapists come together and talk about it. I’ve been doing a bunch of groups for a year now or longer and what I constantly hear in the Me Too groups is that men don’t quite get it and that men don’t understand it and women are very tortured in many ways by what happens to them out in the world.

Keith, can you repeat the question? I want to get to the underlying part about the man.

Keith: Sure, you know this is about emotional cheating.

Rob: Right, sorry got it. So, what most, I wrote a book for this. It’s called Out of the Doghouse: A Relationship Saving Guide for Men Caught Cheating. Out of the Doghouse: A Relationship Saving Guide for Men Caught Cheating and then we wrote a second one called Out of the Doghouse: A Christian Version for Christian Men Caught Cheating. What these books are is, I have worked with men who cheat for 20-something years and here’s the deal, they don’t think that what they did was that big a deal. Men are capable, because of how we’re built of compartmentalizing sex, all of us. That’s why men go to strip clubs and massage parlors. We can say and it’s true, wow I really got laid with that strip person and that was really great ,it was as good as my workout it was even better than my lunch I have, because that’s about as much meaning as a very casual sexual experience has to most men. It was like eating a good lunch and when we go home to you ladies and we tell you well it was just an essential massage, I mean I had an orgasm but she didn’t mean anything to me, you ladies don’t say oh yeah that’s no big deal. I get it you know, what you ladies say is I thought you loved me, what about a relationship, what about everything we’ve had, what about what I mean to you, what about our kids? So because women see relationships much more holistically than men do and women, as you all know as therapists, have a much bigger picture so what a guy’s going to and this is his thinking, this is why I wrote Doghouse, is men are thinking well this isn’t that much of a big deal, I mean yeah I did this but why wouldn’t she get over it, because we do not experience the same level of trauma around emotional and sexual betrayal that women do.

So a man can have a casual affair and in his mind or whatever is it’s not that big a deal because he knows he loves his spouse, he’s committed to his spouse, this is just what he’s doing over here. But the spouse will say, you can’t just go over there and split your life and a half,you know. We have one marriage or one relationship or…so, women will be much more sensitive and emotionally, you know, have feelings about the sexual acting out, about romantic acting out because it touches on the part of a woman that is the most scary which is the fear of disconnection and losing trust. The woman who is afraid that I’m cheating is, she’s going to be furious about the fact that I cheated but trust me her greater pain will be that she lost trust. Her greater pain is now she doesn’t know if anything we’ve shared is true, if anything we’re going to share is true, she doesn’t know if I have another family out there. Now as a man, I’m gonna say I was honest, I was respectful, I mean other than the affair, I’ve never cheated, I’ve never done anything wrong, I’ve always been here for my family and this female spouse is gonna say really and I’m supposed to believe that because you’re a liar and the man can much more readily say well it’s just that compartmentalised over here it doesn’t matter to me, you’re the one I really love and he believes it, and that may well be true for him but for her it’s very, very different.

And by the way I’m not talking about sex addiction, I’m talking about men who cheat and when I wrote this book Doghouse I had to think about what’s the problem with men who cheat, what do we call them? I mean they’re not depressed, anxious, you know. What is their issue? And I decided the issue for men who cheat is really one of immaturity, one of immaturity and the reason I like immaturity for men, and women who cheat by the way, anybody who cheats on a committed relationship and has not told their partner they’re going to go be sexual someone else or romantic, is cheating, because they’re doing something their partner doesn’t know about it it’s a secret and therefore it is cheating. What partners are devastated by, all of you, is that you lost trust in this person that you thought that above everyone else this man or that woman would have your back and they would never go out in the world and deliberately do something that they know would hurt you but you see when they went to that strip club or they went to that massage parlor which meant nothing to them, probably, to you it meant a huge wound about connection, relationship because really when we go and do that and we cheat on you we’re like the six-year-old kid whose mom has said I don’t want you taking any cookies out of the candy jar and then we sneak in and we take the cookies out and then we try to mix it up so the the jar looks full. We don’t want you to find out.

Lots of men are out there having casual sex. We wouldn’t have so many porn shops, massage parlors and strip clubs unless there were hundreds of thousands of men out there going to them. I doubt all of them are single. I also doubt that most of them tell their spouses and I also think that for a lot of them it doesn’t mean much of anything although if it’s repeated over time, it’s an extraordinary problem for the relationship. It is a problem for the relationship. It is a problem for the partner but the person who’s doing it they don’t really see the problem until they get caught.

Should I go on Keith?

Keith: Thank you, Rob. Yeah, we have one more question but we can save that until a later part in your presentation.

Rob: Great, I’m almost done anyway, I’m getting there.

So I just want to touch on this again about women. I spent a number of years running addiction centers that were dedicated to women and one of the things I think is extraordinarily important and I know I don’t want to shame anyone or judge your programs, but I strongly believe in gender separate treatment.

You know I’ve heard, and when, Keith, when you were working in another institution that had mixed gender, I remember what you said to me. You sir, you said to me, well at this institution where we work we believe that men and women together are real life and we want our treatment organization to be like real life and unfortunately, sorry Keith, I don’t think addiction treatment is anything like real life and I think that what our patients need most is to bond with same gender support that is non-sexual. What my men need is other men to support them, confront them, challenge them. They don’t know to be chasing after any women in it to be of support or connection. Unfortunately all the women I work with have what we call mother hunger, they have mother wounds, and they go to a 12-step meeting and there’s a lovely woman who’s a greeter, you know, she’s standing there with her arms, welcome to this AA meeting, and this woman walks in and she shoves that woman out of the way because there’s a cute guy behind her and she doesn’t realize where her strength is. Her strength is in other women.

Here I’ll tell you something from me and Dr. Stan Cath…sorry I’ll tell you something from me and Dr. Stan Cathkin. He’s one of my favorite clinicians in the area of attachment and he says, and so you can’t blame me for saying this, because I can blame him. He said don’t you realize that in the far, in the most third, fourth world country where they have nothing, there are two women beating clothes on a rock complaining about their men because this is a universal truth. The way you ladies survive us, is with each other. Men are difficult, men lie. We’re problematic, we’re pigheaded, we’re arrogant, we have issues, ego, you know and the old, and and um you know you are you guys are off on the balance for that. So my concern is that a man who’s cheated on well it will be an ego wound. When I work with a man, whether a woman or a man cheated on him, this is what a man says, he says she they cheated on me, what my my my penis wasn’t big enough, we weren’t making enough money, I wasn’t kind enough to you, what is all that about? Me. And that’s what men often come to, it’s like was I not good enough for you? That it’s all about an ego loss.

When a woman experiences cheating, it’s holistic. It’s like what about my family, my church, my kids, the in-laws, Thanksgiving, our home, our vows – it’s a much bigger concept for her because she’s looking at her whole world and saying there’s a major threat here, there’s a fox in the henhouse, and that’s terrifying for her and the biggest issue is loss of trust because every time that man or woman who’s cheated goes out the door that partner’s thinking they must be at it again and that’s why I wrote Out of the Doghouse because men do not understand, universally, how to heal cheating with a woman and they run around they say it’s been six weeks aren’t you over it or I bought you some really nice things and we went away for a few days why don’t you give me a break? And I would say from the spouse’s perspective, well let’s see you cheated on me for nine years but in six weeks I’m supposed to be loving and appreciative and value that you’re not cheating? Screw you. You know? And the guy’s like wow my wife’s just difficult, she won’t, because this is the Mars and Venus thing. So I wrote a book for men to understand what happens when they cheat and what they need to do if they want to restore the relationship and I wrote it to men, for men, in their language but I just want you to know those men do not buy self-help books and I can tell you that as an author of ten of them, women buy self-help books, by far. Women buy 95% of all self-help books which means if you’re someone like me that I have to write a book that women will read and then throw at the men in their lives.

I think I’m gonna go on…When you’re seeing patients, so I’ve worked in this field long enough and studied long enough to know that there are, there are co-occurring issues that can frequently show up in people that have both sex and intimacy and relationship issues appearing with the drug and alcohol or other problem. So when women arrive with an eating disorder, I would ask about her sexual and romantic and intimate history. You may be surprised at what you find and here’s a thought for you – what are our earliest ways of getting our needs met? I would think they have something to do with sensuality and eating, so when people have sex and food problems, I start to think well maybe their injuries are earlier because it was such an early stage that they didn’t, that they struggled with this as opposed to maybe some later you know teen or later childhood issues.

When someone comes in and they are too fat, they’re too thin, they hate their bodies, they want to change it, they’re being obsessive about that, body dysmorphia, they don’t see what we see when they look in the mirror, I would be curious about their sexual life. Some of those people are anorex…they avoid sex, they’re hypo sexual. By the way um there is a word I just almost said it. The word anorexia has been used to talk about people who are no longer having sex, you’re avoiding sex and that comes from Pat Karns and unfortunately I do think that’s a word that really belongs in the eating disorder field. I think that people are hyper sexual or hypo sexual but we don’t have an association for the word anorexia in the true sense in the sexual world. I think that should probably be left out for now.

When people come in with strong narcissistic traits, I know that’s all of our patients, but that is someone who is willing, who’s able to let someone down, use someone else to get what they want and not feel bad about it, they don’t have empathy and people who lack empathy can be healed because narcissists are really good at remorse and you can’t get us for empathy but you can really get us for remorse. So I feel bad about this, I don’t want to do this again, that’s where narcissists are great in treatment, however we also keep a lot of secrets because we do not want you to look at us like that person. And so if someone is pretty arrogant, defensive, you know, if they really show narcissism, I would probably want to ask a lot about their history in sex and relationships.

All of my patients have early complex trauma, even those who were molested or raped at 8 or 10 they had no parents to talk to about it, there was no home to be safe. One of my favorite quotes in trauma work is by John Briere from USC and John Briere says something like, as much as the trauma that occurs to the child affects them, what is equally problematic or what is equally promoted, is going to promote their growth or be negative, is how the family experiences trauma. So if a child has some kind of abuse and they run home to their parents and they feel safe and the parents want to talk all about it and hear about it an endlessly support, I don’t even need know if that child needs therapy, I don’t know, but if the parents don’t want to talk about it, if things are going on the house like alcoholism, drug addiction, sexual issues, and no one’s talking about it. If there’s abuse and neglect, you know, the people I work with and I want to suggest all addicts struggle with early attachment issues. If you decide that you would rather turn to a substance or a behavior when you are struggling emotionally when what healthy people do, clearly, is turn to people for support but you turn away from people and you to turn towards self-soothing with substances and behaviors, that tells me very clearly that you don’t trust people, that you don’t believe that people would want to support you or you’ve not had enough experiences of people supporting you, you learned early in life that you need to take care of your pain on your own and every Atteberry addict I know is needless and want lists would rather eat dirt than ask for help and I think all of those things relate to early attachment, my belief.

I have had patients come into the treatment center with dildos, with porn, with sex toys, and it’s right there in their suitcase next to their jammies and you know when we go through suitcases and stuff, we kind of have to figure that out and ask them why and what are they going to do with it. It might be another issue by the way, if you’re talking about sexuality with someone is, do you have anything that you use? Because fetishism, which is the incorporation of an object into sex, like leather, like lace, like panties, like latex, you know their, I would like to know that. Some people have real shame about that. Some people will call that an addiction and fetishism is not an addiction nor is it something that you can eliminate. The person has to learn to live with their kink, that’s who they are. It’s pretty much fixed by 11, so how do I teach this person who hates themselves and drinks over the fact that they’re into BDSM or they’re into women or men or dressing up as a woman, how do I find that person, how can I bring that person to peace with who they are and what they are, so that they can stop using?

And by the way, my patients , something interesting to say, they will use drugs and alcohol because they are so ashamed of the kind of sex they want to have, that when they’re high it’s easier. Like with meth, when they’re loaded sex is great, when they’re sober they hate sex. I have other patients who were you know hypersexual but they only do that when they’re sober but then they drink or use because they feel so badly about what they went and did out sexually that they then try to drink or use to make themselves feel better, so that either end of someone’s problematic sexual behavior can lie drugs and alcohol.

Sure, has this patient had recent affairs, sexual issues, hookups? You know I don’t know how much you know about apps, but apps are where it’s at. You’re not gonna find people hanging out in bars especially now. I think everybody is pretty familiar with the apps and listen, I have 70-year-old friends and 60-year-old friends that say, come on Rob, how do I date? I mean in this new world, get online, you’ve got to get online. You cannot go to some, you know, country club or or golf club and think you’re going to meet somebody the world just does not work that way anymore and if you’re gonna meet people 90 percent of the time you’re gonna meet them online, no matter what your age. So what are your patients doing online? What are they doing online related to sex?

Another question I would ask, are they looking at porn? Do they have any sex apps? Do they hook up on sex apps? Who do they hook up with? When did they hook up with them? Who knows that they’re hooking up? These are all really important questions that I want to think about when I’m kind of track…want to track how someone’s thinking and behaviors are going out in the world.

And lots of assessment, lots and lots of assessment, around human sexuality for co-occurring triggers, for co-occurring issues and for co-occurring addictions like eating disorders, those kinds of things. In fact I think my next slide…oh it’s one after that.

Gender separate treatment, how many ways can I say yes? Extremely important and by the way if you’re not gender separate, you have some kind of program, please do a women’s group twice a week where women are with women and a female therapist and when I do those groups, well I don’t do them, when I set them up, we have an agenda. We’re going to talk about rape and molestation and abortion and incest and we’re going to talk about those as topics in the women’s group and in the men’s group, you know, we’re going talk about lack of performance, using people for sex when you don’t care about them, molestation or abuse at an early age. Each of these groups need to be gender-separate even if you’re not doing gender-separate treatment people are not going to talk about these issues in front of opposite gender.

Some of you will ask me other way because I’ve had this question, what about gay people? What about men with men? Women with women? And so here’s my answer for you. Most gay men don’t act out in treatment because we would rather not be the guy that the other men are looking at like that guy. I never want to be the guy who’s seen is hitting on all the other guys especially the straight ones because that’s not who I want to be as a gay guy and I don’t want to be gone after for that so I’m not gonna probably hit on a lot of people in treatment as a gay man. Unfortunately, the challenge is honestly with sexual acting out in treatment or much off more often with women, men are sexually acting out in the world more often but in treatment the challenge for women is, I think, that those who have some abuse those who have had profound trauma when they get really close to other women in treatment, they start to sexualize them and then they start to confuse love and sex, you know, attachment, relationships and sexuality and so I think in the women’s programs it’s extremely important to be constantly talking about, you know, at what point might your feelings become something other than you know what matches this relationship. Women are much more fluid in this way and they will move into you know an emotionally needful woman when there are no men around and she’s looking at trauma and she stopped drinking she and she’s got some really good female friends, I can see her turning to them for sex.

Okay and in case you I’ve been around the block lately, a little bit about tech and sex, so very little. There are types something called we call teledildonics, teledildonics, or cyberdildonics, and those are, that means that you’re having remote sex online. So that means I might have something that fits somewhere my penis, you might have something that fits your part of your body or over it whatever that is and when I tap a button that thing squeezes you or touches you and when you tap a button I feel that and we’re thousands of miles away. So we can have sexual experiences that are mutual but only connected by the computer. And then there’s talk that is all what that is technology for remote sex so in teledildonics, tactile sensations are communicated over datalink between participants. Today I can say look ma no hands I’m using bluetooth.

There are adult friend or finder apps so Ashley Madison, Tinder, Grindr, these are not apps to meet a friend, yes sometimes people in remote rural areas might go on one of these sex finder apps to meet a friend because they’re in the way in the middle of nowhere and they want to find another gay person, they want to find another whatever, but in the city or in urban areas and even sub urban areas what these apps are for are hooking up for sex, and they are the easiest simplest way to do it because when I pull up an app I’ve got six or eight women or men and we’re looking for sex right now a hundred feet away from me, a thousand feet away from me, 3,000 feet away and so for me to act out is just so much easier. I can get someone over here and gone or be there in ten minutes you know I don’t have to hang out at a bar all evening trying to hook someone up, hook up with someone and by the way they’re gonna have sex with me if they can coming over, I’m going over there, I mean 90% we’re probably going to do it when I used to walk into a bar and try to pick some up in the 70s, not only do I not you know I didn’t know if they liked me, it was really intimidating, lord knows you might not have sex, you know, rejection, all that’s gone, right because you’re on an app for a reason and you’re gonna find the person you want. Unfortunately, these apps can be for some people, very addictive. Some of you may know that the dating apps can be a little addictive, like you’re running home and think has anyone called me, does anyone like me, does anyone love me, there you are at that dating app every night. You know I kind understand that, but the sex apps are going to lead to repeated problematic behavior and by the way, if you look on the app stores the various Apple or Sony or whatever Android, you’re not going to find anything listed under sex apps. These are listed as, and this is my favorite euphemism in the world, they’re called adult friend finders because you don’t want your 17-year-old on an adult friend finder but they would never say sex app because if they said sex app, people would get very very upset. But trust me these are sex apps and they have only one purpose to geolocate a sex partner within five minutes or an hour wherever you are in the world and they work quite well.

Let’s see oh there’s Ashley. So you know it’s not very hard. I have a profile in there. I’m looking for women, I pull some women up, I see their faces, their profiles, what they’re looking for. Oftentimes, by the way, there’s a lot of online prostitution and sex work here. If a woman says in her profile “I like jewelry, I like vacations, I like fancy apartments,” she’s not telling you she wants a date. And by the way in case you haven’t noticed, street prostitution is pretty much gone. Street drug sales are pretty much gone, because all of that is online now, much safer.

The gay game changer was Grindr, for sure, and I have to say I’m somewhat grateful to this program because if you understand a little bit about gay men, we were forced into the streets for sex, you know, when it was illegal and we were gonna get arrested, when, you know, it wasn’t like we could meet each other in a club, so you know the all of the public sex that went on in the past – the parks, the restrooms, the the you know, all of that stuff really came out of no place to go to connect, and now we have is an easy way for young men to connect with each other and older ones too. They’re not out there in scary places in the middle of the night hooking up except for the ones who are more troubled. They are sitting at home finding somebody and how much safer is that?

And by the way the for the ladies just to say it if I picked you up in a bar in 1985 and you came to my house, you might never be seen again and no one might know where you went, because that’s the way it was, you weren’t as safe as you are now, because if we meet on Tinder, every single keystroke is recorded, you know, it’s all says where I went, where you went, what we’re doing, it’s all in real-time so I’m much safer because anyone who wants to know where I am can find me through my phone. I mean they’re not going to be able to geolocate me but if anyone reviews my phone they’re gonna know where I went, what I did, who I was with and this makes this whole arena actually much safer than picking up a stranger.

Okay and by the way if you feel badly about your sex, about what you did with your app and you’re driving home and you think oh my god what does my spouse gonna feel, there is also you know apps like this. So this is a Catholic Church confession app which is put out by the Catholic Church and all the religions have them and if I guess, in this case if you really badly you can do an examination, do a confession, your prayers and you know before you even go home you’re forgiven. I bring that up as a joke just because pretty much everything is on an app, no matter what you’re looking for.
Okay really quickly, why does, this is, kind of was said earlier, why are we seeing so much more open sex, sexuality, why are we talking so much about sex, and the culture part of it is this. People have more access than ever to every form of sexual behavior. When I was a kid, I had one magazine, two magazines, a video. How many images were there? How long could I get caught up in that before I needed to go buy more porn because men like visual stimulation and we like frequently new visual stimulation. Well now when I sit in from the computer, it’s more like playing craps or blackjack, the dice never end, the cards never end, and I can get much more obsessive about the process.

All human beings hunger for new stimulation which leads to rapid fire Dopamine release. We like that stuff, and of course when you’re online in these situations with porn and apps that pleasure never leaves, that new sense of newness, because there’s this person, that person, this person, they’re saying this and that says that and there’s just so many opportunities. Those younger, younger folks, you know I would say under 35, you don’t really understand what the world was like when we didn’t have access to any sexuality other than a book or a magazine or a video or maybe cable, when anybody who went into a magazine store and bought a porn book was looked at. I mean people looked at you like uff you’re buying that? I think I put my time and my Newsweek on top of my porn book and then put the Atlantic under it, I mean that’s kind of what it was like. We didn’t have the sexual freedoms and we talked about them and we did them but I’m sorry, we or sorry, we did them, we didn’t talk about them and I think that’s where we started, there’s so many things we didn’t talk about in the 70s, we didn’t talk about child abuse, we didn’t talk about domestic violence, we’d never,about a whole bunch of things that we talk about now and our culture’s change as a result of it.

Think about this. In 1978, if I wanted to look at some porn I had to get in my car or get on my bicycle, go to a icky place in a bad part of town, drive in the parking lot, hide my car, walk in. It was icky, it smelled bad, they had a camera, who was gonna see me? I looked in this icky place to buy some magazines and then I went home, and or a video, took it home and half the time I’d have to return the video. What is it like now to get porn? Siri show me some porn – that’s it, so in 2.3 seconds or point niro nanoseconds or whatever it is, I can have immediate access to porn so the immediate accessibility to such intense content that really you don’t have any inhibitions to if you can just look over and over, we, our brains really like that and it’s much more, and think about this also if I want to pick someone up or act out or do something sexually in the past somebody might see me or notice, or but I’ll tell you what Fifty Shades of Grey was one of the best selling porn books ever, and ladies you bought tons of it and I think part of the reason you bought it is because you could buy it on pads and tablets and you could sit anywhere and people think you’re reading the Bible but you’re really reading Fifty Shades of Grey. Imagine 15, 20 years ago, when you had to go in a bookstore, “I’ll take that that that Fifty Shades book,” you just didn’t feel good about that in the store, things have changed.

People with pre-existing social and emotional deficits like teenagers a lot of them these days need to evolve a social skillset that they don’t have in order to be sexual. We’re running into lots of people their early 20s, who have looked at so much porn it’s mind-blowing, but they’ve never had a date, they didn’t get into college, they can’t keep a job because the porn is obsessive for them and believe it or not, we don’t have a diagnosis for it by the way, we only have a compulsive sexual behavior disorder, which is the same basically a sex addiction but porn addiction has not been, porn problems has not been broken out yet although, lord knows, there are tens of thousands of people online looking for help with porn.

Finally, certain behaviors that are legal in the real world are not necessarily legal online so if I was in a parking lot at a mall and malls were open and I exhibited myself you could probably call a security guard or the police but, and they would take me away, but if I’m in a women’s chat group on Zoom who’s talking about, some platform you’re talking about, you know, pre-maternity issues and I show up and I’m showing you my penis, nobody’s gonna arrest me for that. Nobody’s ever gonna find me. So there are behaviors that were offending and illegal in the real world, that are still offending and illegal online but nobody’s gonna find you, nobody’s gonna catch you, and therefore technology’s made it more easy for some people to act this out.

This is my worst nightmare. I’m glad to say that in my programs that I’ve run, if this has happened, I don’t know about it, I don’t want to know about it but what a nightmare. I mean who wants to be the one calling that parent or that husband and saying by the way your wife or husband or son had sex at our treatment center, they may have an STD, they could be pregnant. I mean who wants to have that conversation? Snd and I got to tell you that can end up in the newspapers and then that’s the end of your program.

And I also would say to you those of you in programmatic environments, Me Too is a big deal in our field and I don’t think we’ve talked about it nearly enough. There are a lot of young recovering men in our field who don’t understand the right way to treat a woman and I, or a respectful way to treat a woman, or even some men, and I do think that we have to be very careful with the male staff we hire, to interview them extensively about about all of these issues of sexuality, not about the things you can’t say, but the things that you can, how comfortable you are with this, how would you feel about that, things like that.

I’ve written, as Keith said, ten books so I’m just gonna bring you a couple of them here and my unwieldy slide. Cruise Control was written in 2003 and rewritten in 2013. It is the only book for gay men who are sex addicts. I wrote it for them. Sex addiction 101 and the workbook that goes with it is kind of a basic primer on, or primer or whatever you call that, use that word, on sex addiction. It’s kind of the book to go, “Oh do I have this problem? Yes I do” self identification. Out of the Doghouse was written to, because most of the men I’ve ever met don’t know how to heal a woman when she’s in pain around cheating, and so I wrote a book to teach them exactly what they need to do to heal a wound of cheating and whether they like it or not, that’s what they have to do. And finally I wrote Prodependence last, about two summers ago, and what I’m really proud about that book is that it is the first meaningful alternative to codependence in 35 years and it is becoming an international issue. I have, there are prodependence meetings going on in Asia and Australia. This is a book that’s going to go in academia, so I’m really excited to say that we’re, I’m very motivated to push codependency aside and move on to a much more attachment-based way of looking at families and partners of troubled people.

Finally, I think we’re almost done, oh my god we’re going through that again, hold on, what a silly slide set.

I think, I think that’s it, Keith. I did want to say, I’ll give you a couple of resources and what I’ll do is maybe I’ll get them to you, Keith, so if people want links to support groups to learn more about education, for sexuality they can either write me or or get ahold of Keith and the Gateway folks and I’ll make up a list of resources for you that you can have, like places you can get educated and things you might want to offer your patients and I think that’s about it.

Keith: Awesome, thank you so much, Rob. A couple more questions if you have time.

Rob: We have until 1:30, it’s only about eight minutes.

Keith: Minutes, yes. So how do you avoid bias or judgment in regards to intimacy issues versus lifestyle preferences?

Rob: Great question. There’s two answers to that. Some people have created their lifestyle preferences around pathology, so there are people who are constantly going out and hurting themselves and others and I’m not talking about BDSM, I mean lying, cheating, manipulating, using people for sex, they have all kinds of issues and they really need help with those issues, so what I see the difference, so there are people with preferences, but really what they’re using their preference for, as a as a sort of overview of acting out like a crazy person, however there are other people for whom sex, and that sounds pretty dysfunctional I think, for other people. So let’s say you’re into BDSM or you’re into you know whatever you’re into even if you come into me and you say oh I hate this kink, I hate this fetish, I don’t want to be a homosexual, I feel driven to this, it takes over my life and I feel like it’s an addiction – it’s not an addiction, the way that you keep from pushing back on people’s lifestyles is by understanding what a lifestyle is and what it means to be a gay person, what it means to be a transgender person, what it means to be someone who is into transgender women or transgender men, we have to have that knowledge and then I understand in what ways can that be problematic for people, in what ways can that be helpful for people but I will never pathologize, ever, someone who comes in and they hate themselves for kink, or they hate themselves for orientation, or they hate themselves because they have some kind of fetish, because those are normalizable healthy behaviors, whether we like or not – lots of people don’t – but if you have a kink, if you have kink, it’s not going away, if you’re into men, that’s not going away, if you feel like being a woman, that’s not going away.

So what I am is respectfully curious about how someone’s sexual behavior is affecting their functionality and their feelings about themselves. I don’t have any judgement about people’s sexual behavior, I’ve heard most everything. I haven’t heard anything new in last three years, I do have a PhD in sex, but I can really carefully listen for things that are working for people and things that aren’t, things that are supporting who they’re becoming and things that are working against them and against their life goals and I know the difference between orientation, gender issues and and and just those personal issues around sex as opposed to sexual pathology. You kind of have to know both – what is a fetish versus paraphilia, they’re very similar but a fetish carried out to the point of dysfunction is paraphilia.

So drop me a note. I’ll be glad to help you get support and find some more answers to your question.

Do we have more questions, Keith?

Keith: Another question and that was from Amy MacDonald Wajack. Okay, so in your experience of people who suffer from sex addiction with a co-occurring substance use disorder, what percent, as we as clinicians treat those folks out there you know, what do you see that combination of sex addiction and substance use ?

Rob: I’m not sure what there are several different questions – how many programs treat that specifically, how…

Keith: What percent of patients do you feel fit in both categories, are concurrent, co-occurring?

Rob: Well if I just look at drugs and alcohol, meth aside, about 35 to 40 percent so a little less, a little more than a third of my patients have had pre-existing drug and alcohol issues or have concurrent drug and alcohol issues and they have never looked at the sex, they’ve only looked at drugs and alcohol and so they’re coming in because of the sex.

And then meth is a little bit different because those people relapse so frequently and they need a whole different form of support and and by the way there really are very few treatments and one of the reasons we created Seeking Integrity, and it’s not a plug it’s a reality, is to look at these dual issues because we understand sex so well and we understand addiction so well and how important it is.

Like I had a transgender guy just want to say, he wasn’t transgender, he was into, he was into women who have penises and he was into transgender women who weren’t fully through surgery and the way he did this was, he would go off to a certain part of town and get drunk as crap and even do drugs and be with these women and then he would go home to the rest of his life, but he hated himself so much for what he did that he would drink and party with those people and then keep it a complete secret in the rest of his life. This man was unable, despite several treatments, to get through drug and alcohol treatment because that wasn’t his primary issue. The primary issue was is on his inability to tolerate or accept that which was so arousing to him and he loved that part of his life but he couldn’t imagine integrating it into the rest – his parents, his friends and thus he drank. He will never stop drinking until he is able to resolve that conflict, because it goes to the core of who he is and those are the kinds of issues that disturb me. I am supporting his gender interest but I’m not supporting the way he lives it out because it’s dysfunctional for him and others.

Keith: Thank you, awesome. Well, great. Rob, it’s always great to see you and have you as a presenter, you are a rockstar and a thought leader in this field, you know I admire you and what you’ve done to help people, to help the clinicians out there in terms of their training so that they can help more people, the books you’ve written, thank you.

Rob: So this is volunteer work and I love anytime I have an opportunity to help therapists grow because some of you helped me grow, so thank you to Gateway and thanks for your time. Thanks, Keith.

Keith: Awesome. There are just a few things before we end the webinar. Certificates for your CEs, you will be receiving an evaluation form after this presentation. Please fill out the evaluation form and we will be sending you a certificate that looks like this for 1.5 credits.

I want to put a plug in. This Inspiration Series that we just had twice with Rob – the first session was on prodependence – has been extremely successful. Thank you to all of you for your support. We’ve had a lot of you really participate in all of the webinars we’ve had. We have another series coming up, 2.0, with Dr. Mark Pirtle, who’s speaking on addiction as a chronic stress illness, Colin Ross will be back on trauma attachment dissociation and EMDR, a good friend Sr. Sonnee Weedin on eight ways to wellbeing, and Dr. Allan Berger, who’s affiliated with Beacon House, integrating creativity in the therapeutic process focusing on the left and right hemispheres of the brain.

Once again everyone, thank you so much for being here, thank you for the work that you do. Please be safe, be healthy, continue to help people in need who are struggling. Gateway Foundation is here for you, Beacon House is here for you, Seeking Integrity is here for you. Let us know how we can support you in this time. Thank you so much everybody. Enjoy the rest of your Friday. Thank you, Rob.

Rob: My pleasure.

Keith: Beach this weekend.

Rob: I’ll look at it.

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