By Ken Howard, LCSW, CST | GayTherapyLA.com / GayCoachingLA.com
Context, Commerce, and Consequences
The concept of “sex addiction” did not arise in a vacuum. In the early 1980s, amid the fear-and-moral-panic atmosphere of the AIDS crisis, sexual behavior (especially gay male sexuality) was widely framed as dangerous or even deadly. Into that climate, Patrick Carnes, PhD, advanced a simple, compelling narrative: sexual behavior that felt “out of control” could be labeled an addiction and treated like substance abuse. That message dovetailed with conservative religious values, promised control and redemption, and—crucially—could be packaged into a cash-pay industry of trainings, workshops, inpatient programs, and proprietary task models that sat largely outside of insurance scrutiny. The result was a sprawling commercial apparatus (IITAP/CSAT (Certified Sex Addiction Therapist) trainings, “gentle path” style programs, intensives) built around a diagnosis the psychiatric field never adopted. Around this time, (October, 1982), the Betty Ford Center was founded, which was an especially elite, expensive, prestigious location for the rich and famous (such as Elizabeth Taylor) to get “clean and sober.” The founding of it by a former First Lady helped to de-stigmatize alcohol and drug recovery, but if “some is good, more is better” on what “addictions” can be treated by high-end, resort-like facilities which can be about clinical recovery but are also about luxury retreats for people who can afford them.
This article blends the historical record with contemporary clinical ethics, and it contrasts the CSAT model with sex-positive, evidence-informed alternatives (e.g., OCSB; the Six Principles of Sexual Health). Throughout, I keep the focus where it belongs: on client autonomy, cultural competence, and outcomes—not moralistic control of the sociologically “controversial” aspects of sex in the generally Puritanical approach to sex that has a long history in the United States.
Patrick Carnes did not coin the term “sex addiction,” but he popularized it through his clinical work and writings in the early 1980s. Since then, the term has been used colloquially in conversation, by standup comics, in sitcom scripts, and even deliberately, defiantly, or tauntingly in porn.
- Carnes authored the first clinical book specifically about sexual addiction, Out of the Shadows: Understanding Sexual Addiction in 1983, introducing the concept to clinical audiences and providing a pseudo-diagnostic model that many therapists adopted, using a home-made “screening tool” (which was not a validated/normed psychological assessment instrument) that provided that almost anyone taking the “test” was pointed in the direction of “sex addiction treatment.”
- He is broadly credited with popularizing the term in therapy and recovery communities, for outpatient psychotherapy practices and in-patient hospital/clinic program, even though earlier usage in pulp and erotic literature dates back to the 1950s.
- Some historians trace the true conceptual origin further back: Lawrence Hatterer, a conservative religious Cornell psychiatrist active in the 1960s and 1970s, described sexual behaviors in addictive terms, particularly pathologizing homosexuality with language like “addictive sexual pattern.” He’s considered by some scholars to be the “real father” of the modern sex addiction concept. So while Patrick Carnes played a pivotal role in formalizing and spreading the notion of “sex addiction” in clinical practice, getting into the talk show media, books, seminars, and the cultural parlance, the term and its underlying ideas existed in various forms before he embraced and defined them professionally.
Over the years, I’ve seen countless gay male clients—some thriving, some struggling—who come through my “virtual door” in search of clarity, healing, and sexual self-acceptance. But one theme I keep encountering, sadly, is the damage left behind by so-called “sex addiction” therapy, especially from therapists credentialed through the CSAT program (Certified Sex Addiction Therapist), a proprietary certification developed by Patrick Carnes.
Let’s be clear from the outset: “Sex Addiction” is not a legitimate medical or psychiatric diagnosis. You won’t find it in the DSM-5. It’s a clinical label rooted more in moral judgment than empirical evidence. And for gay men, it’s especially insidious. Gay men’s stigmatization of their sex has led to discrimination, hate crimes, and even being among the populations targeted for mass extermination in the European Holocaust, where the persecution of gay men continued even after the concentration/death camps were liberated by Allied forces, with the gay men re-incarcerated, when other populations were freed.
Professional and Institutional Rejection of “Sex Addiction”
- DSM-5: After a review of proposals like “hypersexual disorder,” the diagnostic workgroup declined inclusion—citing insufficient validity, risk of moral/cultural bias, and the danger of pathologizing normal sexual variation.
- AASECT: The American Association of Sexuality Educators, Counselors and Therapists’ 2016 position statement rejects “sex addiction”/“porn addiction” as diagnoses and directs clinicians toward sexual-health frameworks and the Six Principles of Sexual Health.
- Clinical implication: Using “addiction” language for consensual sexual behavior absent diagnostic consensus risks mislabeling distress, undermining treatment focus, and reinforcing shame.
Ethical Code Conflicts (AAMFT, CAMFT, NASW)
- AAMFT: (American Association of Marriage and Family Therapists) Requires nondiscrimination and cultural competence; pathologizing consensual non-monogamy and gay sexual norms conflicts with these duties.
- CAMFT: (California Association of Marriage and Family Therapists) Emphasizes evidence-informed practice and avoidance of harm; reliance on contested constructs is ethically precarious.
- NASW: (National Association of Social Workers) Centers client self-determination and the obligation to do no harm; imposing an “addict” identity where no accepted diagnosis exists undermines autonomy.
A Sex-Negative Legacy in a Queer Body
Patrick Carnes promoted the idea of “sex addiction” at a time that coincided with the dawn of the AIDS crisis, when gay male sexuality was stigmatized and associated with not just “moral objection” like before, but now with disease and death. In a darkly comedic moment on her comedy album, “Mud Will Be Flung Tonight”, recorded May 1, 1985, Bette Midler captured the fear of the times in a joke: “If you fuck the wrong person, your arm falls off,” (conflating AIDS with stereotypes about leprosy, another historically stigmatized illness). That joke was considered funny at the time because it hit close to home because it lampooned people’s widespread anxiety – even straight people – about sex and dating in the age of AIDS.
Into that climate stepped Carnes and his followers, ready to “diagnose” and “treat” sexual behavior outside the bounds of heteronormative monogamy as pathological. What began as a puritanical reaction to the sexual revolution of the 60s and 70s quickly metastasized into a multimillion-dollar industry. Entire clinics, retreats, books, conferences, journals, and training programs sprang up, profiting off the shame of men—particularly gay men—who had the audacity to be sexual outside the framework of one-partner-for-life.
AASECT and the Progressive Response
Thankfully, a different movement has emerged. Organizations like AASECT (the American Association of Sexuality Educators, Counselors, and Therapists) have consistently rejected the notion of “sex addiction” as a valid diagnosis. Instead, progressive sex therapy draws on evidence-based, affirming models that honor diversity in desire, relationship structure, and erotic expression.
In Treating Out of Control Sexual Behavior: Rethinking Sex Addiction by Michael Vigorito and Doug Braun-Harvey, the authors offer an alternative: one that examines the context of sexual behavior—trauma, attachment, self-esteem, cultural stigma—without reducing it to addiction language. Their “Out of Control Sexual Behavior” (OCSB) model focuses on harm reduction, sexual health, and collaborative goal-setting, not moralizing or punishment.
David Ley, Ph.D., a leading critic of the sex addiction industry, wrote in his book, The Myth of Sex Addiction that this diagnosis often reflects cultural discomfort with sexual behavior—particularly queer behavior—rather than actual dysfunction. Similarly, Marty Klein, Ph.D., has long argued that the sex addiction model suppresses sexual diversity and creates more shame than it resolves.
The Gay CSAT Problem
Some of the greatest harm comes from within our own ranks. Gay male therapists—sometimes from internalized shame—have become CSATs and adopted the model wholesale. It’s a great compelling strategy for young therapists to get a foothold in the therapy community, and tap into widespread feelings of sexual shame and internalized homophobia to attract affluent gay male professional clients who don’t rely on lower-cost or HMO-based therapy practices.
At various group mental health practices, clients may unknowingly be subjected to “treatment” rooted in heteronormative ideals, where sexual freedom, non-monogamy, kink, or porn use are seen as symptoms of a disease.
Even supposedly gay-affirmative CSATs try to frame gay male sexuality as a “special case,” but still default to some of the same restrictive, judgment-heavy approaches that promote monogamous marriage and child-rearing as the “healthy” endpoint of therapy. That might be fine for some, but it’s far from the only valid or affirming vision of a gay man’s life.
And let’s not forget the disturbing practice in some CSAT programs of using lie detectors to “monitor” progress—an ethically and clinically questionable tactic that turns therapy into surveillance. Where is the trust? Where is the consent? Where is the dignity? If your partner subjects you to a polygraph test to “keep you honest” about where you’ve been and what you’ve done, that’s not a very loving, trusting, compassionate relationship. Love is not like being “on probation” by the justice system after having committed a crime, where someone has “accountability” to their “traumatically betrayed” partner like a criminal has accountability to pay their debt to society.
Self-Help Resources
- Sex-Positive, LGBTQ-Affirmative Therapy
- Approach: Work with a therapist who is trained in sexual health, LGBTQ issues, and non-addiction-based models like Out-of-Control Sexual Behavior (OCSB) or Sexual Health Model frameworks.
- Why it Works: These models address behavior in the context of personal values, consent, safety, emotional needs, and relationship agreements—not arbitrary “sobriety” rules.
- Where to Find:
- AASECT directory (American Association of Sexuality Educators, Counselors, and Therapists)
- LGBTQ+ therapist directories (e.g., Psychology Today filter, Gay Therapy LA, TherapyDen)
- OCSB Model (Doug Braun-Harvey & Michael Vigorito)
- Key Features:
- No “addict” label
- Collaboratively defines what’s “healthy” for you
- Explores triggers, emotional regulation, attachment patterns
- Focus: Helps integrate sexuality with life goals instead of suppressing it; many say “if you try to battle your sexuality, you will lose.”
- Why It’s Better: Research-based, used by many AASECT-certified sex therapists, aligns with principles of harm reduction and sexual diversity.
- Key Features:
- Cognitive Behavioral Therapy (CBT) & ACT
- CBT: Helps identify and change unhelpful thinking patterns that drive compulsive habits.
- ACT (Acceptance & Commitment Therapy): Focuses on aligning actions with values, even in the presence of urges.
- Why It’s Useful: Both are evidence-based for behavioral self-regulation and distress reduction without moral judgment.
- Moral Incongruence Work
- Based on David Ley and Josh Grubbs’s research: Distress about sexual behavior can come from value conflicts, not from the behavior itself.
- Therapy here focuses on:
- Clarifying personal sexual values
- Differentiating between true goals vs. inherited shame
- Reducing guilt that’s based on cultural or religious stigma
- Ley has described how self-identified “sex addicts” don’t necessarily have any “more” sex, or use porn more often or for longer than others, but it’s how they “feel” about it, often in a religious values context.
- Peer Support (Non-12-Step)
- SMART Recovery: Secular, science-based, self-management for imbalanced-feeling behavioral concerns (not “addictions”), adaptable to sexual concerns.
- Men’s Sexual Health Support Groups: Can be therapist-led or peer-led, focusing on sexual skill-building, consent, boundaries, and shame reduction—without abstinence rules. Leather, kink, fetish, and BDSM communities or social groups can be peer-affirmative.
- Self-Help Resources
- Books like:
- The Myth of Sex Addiction – David Ley, PhD
- Sexual Intelligence – Marty Klein, PhD
- Treating Out of Control Sexual Behavior – Braun-Harvey & Vigorito
- Online workshops or courses from AASECT-certified therapists, such as my course on Improving Sexual Confidence for Gay Men.
- Books like:
- Lifestyle & Environmental Adjustments
- Review stress, isolation, relationship satisfaction, and emotional needs.
- Build alternative coping strategies for stressors beyond sex or porn, and identify diverse outlets for connection (gay men’s social groups, sports leagues, book clubs, political organizations, arts groups).
- Adjust porn or app use with mindful scheduling, content choices, and intentional pauses rather than total abstinence.
Our field, with the Modern Therapist, can and must do better. Gay men deserve therapists who are liberators, not enforcers. Let’s stop mistaking shame for healing. Book a free consultation at 310-339-5778 or email me at Ken@GayTherapyLA.com.