I don’t mind. I love the work and feel like spreading the word about it is kind of my ministry. But I notice that after talking about SPT with people, especially would-be clients, they still seem confused or even misheard important components of what I have said. Sometimes I wonder if people are so blown away that this is a real thing that it spirals them into some kind of dissociated state where they can’t hear me— like an astronaut floating away in space.

I also think that me calling myself a sex worker is confusing. I am, but, you’re obviously all confused by it. So here is an analog that I think is clarifying:

If you want to have a great meal, you can go to a restaurant, or you can go to a cooking class. The restaurant provides a service, the cooking class provides an education. Give a man a fish, teach a man to fish– you get the idea.

Most ‘gratification-based’ or ‘traditional’ sex work (these are terms I made up) are like going to a restaurant. You pick your price point and desired experience, you get what you order, you sit back and relax. Surrogate partner therapy is like going to a cooking class– you’re learning skills, it’s safe to fail, and if it goes well you leave knowing how to make cacio e pepe at home. Both are great, and neither is better than the other—they’re just different.

Why am I telling you this? Well, because I often have clients who think I’m not fucking them fast enough. Some get angry, some have meltdowns, some try to manipulate me and/or the therapist. So I started writing, trying my best to really address the issue of client urgency in the work— why I’m not fucking my clients as fast as they want me to, basically. Here’s what I came up with: explaining again what SPT is and how it works, outlining a general arc of the work its minimum time commitment. I then talk a bit about contraindications to the work, and presentations who should expect it to take longer. Finally I talk specifically about client urgency and when it requires termination or referral, clarify presentations that are not a good fit for SPT (and those that are), and conclude with some thoughts on whorephobia. But also I kinda talk about whorephobia throughout, because I think its a major component of client urgency.

I mainly wrote this for me as a way to process, but I expect some version of it will be required for potential clients going forward and thought maybe ya’ll would want to read it too. xx

Okay, so how does Surrogate Partner Therapy work?

Surrogates use experiential education to help clients learn how to be in relationships. The curriculum of SPT is a series of exercises that emphasize interpersonal communication, emotional awareness, co-regulation, sensuality, and potentially erotic-level skills. Though the skills are important, the most important part of the work of SPT is the relationship between the surrogate and client. It can be helpful to remember that surrogate partners were created so that unpartnered clients could attend couples therapy, where these skills were originally taught. For this reason emotional safety and trust must be established between the surrogate and client in order to advance through the work.

The surrogate is highly trained to teach these skills and to attune to and assess for the client’s relational roadblocks. The work of surrogate partner therapy is psychotherapeutic in nature and thus necessitates the involvement of a mental health professional, such as a psychologist or psychotherapist. The surrogate is a co-clinician who brings their authentic self (tempered with compassionate generosity of course) to the therapeutic relationship– their perspectives on the client’s behavior, resistance, affect, or physiology reveal things the psychotherapist would never witness, given the boundaries of their therapeutic relationship. For this reason, it’s extremely important that the therapist respects the surrogate’s contributions and has taken additional training to help them unpack any bias or whorephobia they might have.

After every session with the surrogate, the client meets with their therapist to process what came up for them during or after their session with the surrogate. After both sessions, the therapist and surrogate share notes with one another on the case to ensure the client is held and progressing appropriately.

How long does it take?

Most clients do not arrive at SPT until after years, and sometimes decades, of frustration and loneliness. By the time they get to me there is usually some level of desperation on their part: they want to solve their problem, and they’d prefer to solve it ASAP. To be clear, I also want to solve their problem. But in order to do so, I need them to trust me. Some of the exercises are silly, we’re going to spend a lot of time talking about our feelings– there are no shortcuts. This is why I emphasize over and over again that surrogate partner therapy is therapy. It takes time and involves a lot of processing– and for this reason it is best suited for people who are willing to introspect and try out new things. Clients who are primarily concerned with satiating their erotic hunger are going to be extremely frustrated by the pace of the work. These potential clients are better suited to working with a traditional sex worker (I’ll be publishing an e-book about how to do this soon, so make sure you’re subscribed).

Here is a very basic breakdown of the progression of the work we do in SPT:

Phase One: Nurturing

Diagnostics & Assessment

Building Rapport

Foundational Skill Building: emotional, somatic, and sensorial awareness

Navigating Consent

Core Relaxation Tools

Phase Two: Sensual

Body Image Work

Intermediate Consent Exercises

Increasing Sensuality & Non-Erotic Intimacy

Sex Education

Self & Other Discovery: Body mapping

*Dating Practice

Phase Three: Erotic

Mutuality

Advanced Skills

Eroticism

*Trouble shooting certain sexual dysfunctions

* = if relevant to client’s presentation

Contraindications related to timing and progression of the work

The above breakdown, which does not account for any potential deviations, would take around 50 hours in total to complete (this is an estimate for me based on my work with previous clients). This does not include the client’s one-on-one therapy sessions (which are to take place between each of our sessions), nor does it include consultation with the client’s therapist. It also doesn’t include triadic sessions with myself, the therapist, and the client. Triadics are mandated when goals change or complete, when we progress to a new phase of the work, or there is an impasse between any two people in the triad.

Clients do not automatically progress through the phases of the work. Some phases are more challenging for certain presentations and may require that the work extends beyond the original anticipated timelines. Just like any relationship, there is a lot that can come up that may surprise us.

Some examples:

1. For clients with attachment trauma, or who have difficulty mentalizing/emphasizing with others, the first part of the work may need to be extended until true rapport and relational safety is built between the client and surrogate. Alexithymia may also slow down the work.

2. For clients navigating body dysmorphia or gender dysphoria, we may need to extend in the second part of the work, which involves non-erotic nudity. Emotional regulation is foundational to progression, so we will move at the pace of the client’s nervous system, should dysregulation present.

3. Phase three may need to be extended for clients navigating sexual dysfunction, to give us extra time to integrate and embody the work, including practicing navigating failure by playing with it intentionally.

4. Clients with sexual trauma, especially childhood sexual trauma, can expect the overall pace of the work to be significantly longer (usually several years).

In general, the more goals or presentations the client has, the longer the work will take.

Client Urgency and Termination

When a client present with urgency it is usually because they want to get to the erotic level as quickly as possible. The emotion of urgency is in itself not a problem, pretty much all clients present with some level of urgency. However, when client urgency manifests in undermining the surrogate’s boundaries, expertise, or personhood, a triadic meeting will need to occur to gain clarity and decide the next indicated action for the group.

1. If the triadic meeting reveals that the client’s erotic hunger is their primary motivation for entering SPT and then rushing the process, termination and referral to a traditional sex worker may be indicated.

2. If the triadic meeting reveals the client cannot stay regulated in the face of surrogate boundaries, then the client lacks the necessary emotional maturity to do the work of SPT at this time. A referral to a DBT program may be appropriate.

3. If the triadic meeting reveals that the client is incapable or unwilling to mentalizing with the surrogate, either due to whorephobia or an empathy deficiency, the work should be terminated out of respect for the surrogate’s safety.

The surrogate, therapist, and client must all be on board as a group in order for the work to advance. SPT is not a series of exercises one completes as quickly as possible in order to “get to” have sex with the surrogate. Therapists need to educate their clients that it is in their best interest to move at a pace that allows them to integrate and metabolize the work, and that buy-in from all three members of the triad is necessary for progression.

Clients who are not a good fit for SPT (non-exhaustive):

• Clients with sociopathy, untreated borderline tendencies, or other cluster b presentations

• Clients in active addiction

• Clients who are unable to self-regulate

• Clients who struggle to mentalize/empathize with others

• Clients who are financially unstable or housing insecure

• Clients with untreated rejection sensitivity dysphoria

• Clients who are primarily looking to satiate erotic hunger

• Clients who would otherwise be labeled ‘high acuity’

• Clients without a therapeutic component to their presentation

Clients who are a good fit for SPT (also non-exhaustive):

• Clients with sexual dysfunction as a result of a psychological issue (e.g.. erectile dysfunction or rapid ejaculation due to anxiety)

• Clients returning to dating after a long period of abstinence (e.g. coming out later in life, gender transition, widows/widowers)

• Clients with SA/CSA trauma who have done trauma-specific therapy and are stable

• Clients with little-to-no interpersonal relational experience (commonly called ‘late-in-life-virgins’)

Concluding thoughts: On whorephobia

The work of surrogate partner therapy, just like the work of any relationship, is profoundly confronting. It is also beautiful and life changing. It requires generosity on the part of the surrogate, and this generosity necessitates that her insights, expertise, agency, and safety are valued by both the client and therapist. When either the therapist or client dehumanizes the surrogate, she is no longer safe to give generously or authentically, and the work becomes debased and corrupted. If she were to continue progressing in this dynamic, it would degrade both herself and the work in general. For this reason, remaining vigilant against any potential whorephobia in the treatment room is of the utmost importance: the therapist must take the surrogate’s flagging of it seriously. If she does not, the surrogate is left with no choice but to terminate the therapy, which can be disastrous for clients who may already have attachment issues and an ebbing level of hope.

In my early 20’s I broke up with a guy by telling him, “when we have sex, it feels like you’re masturbating in my pussy.” He was shocked. My friends thought it was hilarious. I shrugged: I didn’t have a more elegant way of explaining it– but I knew there was a difference between a man fucking me and a man using my body to jerk himself off.

Years later, I started working in the sexuality space. Many of my male clients come to me with presentations (such as erectile dysfunction) that have developed as a result of “dysfunctional” masturbation patterns1. I resolve this in part by having them reorient to masturbation practices that are more replicable to penetrative sex (oral, anal, or vaginal). As a result, in my work, I speak a lot to the differences between solo versus partnered sex, from both a physiological and psychological perspective.

Most of my male clients masturbate using internet pornography, specifically watching videos of other people in staged coitus, to enhance their solo practice. Even though my client is watching humans, his experience with those humans is non-interactive– the people fucking on his computer screen are an object of gratification fulfillment for him2. Men watching porn are generally focused exclusively on their own internal experience; there is no inter-psychic element (meaning relational), only intra-psychic (meaning within the self). There is nothing wrong with the intrapsychic sexual experience of masturbation– the problem is when men try to make partnered sex replicate masturbation.

Partnered sex is fundamentally different from masturbation, especially for humans, so much so that its wired into our biology. We have evolved to have intercourse mostly face-to-face, with our extraordinarily large, white-rimmed, and expressive eyes facing one another. We are designed to pick up every subtle cue in each other’s faces– in fact, it’s literally how our brains develop . Unlike solo sex, partnered sex is a self-other dynamic– we are confronted with the self-hood of the other during relational sex. We notice when our partner’s face expresses pleasure, displeasure, boredom, excitement– and we react to it, as we are designed to do as social animals who are wired for connection. Interpersonal intimacy is in many ways more confrontational than independent intimacy, and requires a level of psychic maturity to withstand the additional social and logistical demands.

Diametrically opposed to this would be using another person’s body for our own satisfaction, without regard for their inner experience. This is how a young child interacts with his mother: he sees her breast as an object of his gratification, not as part of a separate human with needs, desires, etc. This ‘infant narcissism’ is developmentally appropriate, as the brain simply isn’t developed enough at this point to comprehend the idea of another’s personhood. As the child grows into an adult and his brain develops, he begins to understand that his mother, as well as all other people, have their own personhood, feelings, and self. Under the right circumstances, the child develops empathy and matures into an adult who is interested in the inner world of other people, and seeks to engage in relationships with others based in mutual care.

I need not tell you this doesn’t always work out as intended. The most recent example of the societal failure to create men who see women as people was revealed by CNN in their expose of the “Zzz” forum on a now-defunct website called motherless.com. To review: in said forum, men coached and collaborated with other men to drug their wives unconscious and then rape them.

What does this have to do with my ex boyfriend (whose name I can’t even remember) or masturbation coaching?

Because the men in the Zzz forum were drugging their wives in an attempt to make partnered sex more like masturbation. In rendering their spouses unconscious, these men got the pleasure of a woman’s physical body (inarguably superior to one’s hand), while shirking all of the social or relational responsibility that her consciousness would require. They have rendered their wives expressionless, needless, and without an inner world reflected on her face. These husbands reverted back to the obligation-less-ness of the infant: in the way the mother is reduced to the disembodied breast, the wife is reduced to the disembodied vagina. Through anesthetizing her, he need not be distracted by an expression or gesture that could shatter the intrapsychic experience he prefers– the psychic experience of masturbation, but while using the body of another person.

I have often said many men don’t actually like women– they like fucking and cumming. The “Zzz” forum is a perfect example of this– these men resorted to sociopathic criminality in order to access an asocial sexual experience— that is the degree to which they dislike witnessing the personhood of their wives.

I have learned in my work with men that many are terrorized by the idea of being witnessed by a woman while being unimpressive. Their greatest fear is to fail, or even worse, to be seen failing. This is especially true during sex, where we have cultural norms that men ‘do’ sex to women, and are thus expected to be naturally skilled leaders in the bedroom somehow, without any tutelage, instruction, or even basic sexual education. I have seen this performance anxiety manifest into sexual dysfunction, as well as total avoidance of women all together, and in extreme cases mutating into a hatred of women and even violent misogyny.

The choice to drug ones wife unconscious and rape her may seem extreme, but I would argue it exists along a spectrum of male discomfort with female personhood; an unwillingness to mentalize or empathize with women in general. Perhaps this spectrum begins with being unable to ask a woman a single question on a date, and moves along to being unwilling to contribute to the domestic labor of sharing a home unless asked directly to do so. The spectrum may progress to passivity around getting tested for STIs, weaponized incompetence in general, playing devil’s advocate when you hear that a man you know has been accused of sexual harm. At the further end of the spectrum we get to rape, family annihilation, and school shootings (in no particular order). The expression may increase in its extremeness, but the root cause is the same: the centering of the male-self and his feelings and desires, while simultaneously reducing women to objects that either gratify or impede him, instead of as human beings with their own personhood.

I found out years later that a girl I knew ended up dating that guy I broke up with for masturbating in my pussy. She told me he gave her a mix CD, and when we went over the tracklist, we discovered it contained the exact same songs in the exact same order he had given to me as well. We couldn’t stop laughing at the on-brand-ness of it all. How could a man who was incapable of seeing women as people think we were anything but interchangeable with one another?

Corey’s first appearance in my IG DMs was in response to a story post where I was wearing a respirator: it was our part of the city’s turn to be ravaged by fire. When he messaged me he was bleary eyed, having been in the mutual aid trenches for days, getting masks, water, and supplies to his neighbors in Altadena. In my preferred trauma response, I fled east and didn’t stop driving, as is my super power. His initial message was one of commiseration and solidarity in what at the time felt like a crisis that might never end– a blur of survival and chaos. From there he made himself a cozy spot in my inbox, regularly responding to my various shit posts and selfies.

June 24th, 2025

I posted something about attempting to date again on my stories, reminding my audience (then of probably 1500 people) that I am a bottom and to not waste my time with any fake top bullshit. He responded promptly. I let him know that I don’t really date cis men, but let him know I was flattered, and appreciated how he came correct about it. He thanked me for my clarity. He continued to be in my DMs, occasionally sending reels or memes he thought I might appreciate, responding to various posts. He was funny and kind and engaged, but never lascivious, and respected the boundary I had set.

June 11th, 2026

A year and a half after Corey’s original outreach, I returned home from a very traumatic work trip that would send me into a month-long existential crisis. I knew part of what would help me feel like myself again was having sex with someone other than the client I had traveled to New York with; that a new experience would help me to re-baseline and stop ruminating on that bad interaction. As is commonly known: “the best way to get over someone is to get under someone else”.

Even though I identify as a queer woman and haven’t had sex with a cis man outside of work since I was in a similar situation during covid, I was willing to make compromises given the circumstances. As many other queer women know, cis men tend to be a less complicated endeavor and in a pinch can scratch an itch. I spent the next few days rummaging through my mental rolodex of men I thought might be willing to fuck me.

June 13th

After staring at the walls for two days in a state of traumatized dissociation, I messaged Corey on IG.

I found his confusion earnest and charming.

He showed up a few nights later carrying a big bouquet of peonies and roses, flowers I had told him were my favorites. This level of effort was endearing, as we had previously determined we would be casual– but casual doesn’t necessitate being callous or disrespectful, and I liked that nuance– it felt honoring, old school– the kind of shit that in queer company I am often embarrassed to admit I like.

I kept giggling at his physical presence– Who designed such an unnecessarily large animal and who let it into my tiny apartment? I know straight women like this sort of thing, but to me being over six feet tall feels bordering on ridiculous, like when you go to an all you can eat restaurant and things turn from indulgent to camp somewhere between the third and fifth plate.

I was shocked by our compatibility. He was happy to lead, but wasn’t bossy. He attuned well to me and asked for eye contact several times which I thought was both erotic and ingenuous. I was so used to being with women I literally forgot about penis-in-vagina intercourse until he reminded me, after I had exhausted his hand, that we had further recourse.

June 15th

Corey texts me, letting me know he might need to discontinue our rendezvous, as it was likely he would develop feelings for me. I was disappointed, but I had no interest in hurting him, and asked him to let me know what he decided.

July 3rd

As I often do for the fourth of July, I was looking to get out of my neighborhood. The residents in my area loved to set off fireworks in their backyards well into the morning, and I was sure to have the sleep of a combat veteran. I booked a hotel downtown, assuming less backyard pyrotechnics since there were no backyards.

Corey met me at the hotel bar, again with flowers. I bought him dinner, again shocked by his size and also what it required in volume of food in order to satiate him. We didn’t discuss the decision making that allowed him to see me again. I decided he had gotten right with his god about it, and truth be told, I didn’t want to ask any questions that might impede me getting what I wanted. Upon reflection it’s a bit weird to me that I didn’t ask myself why I was soliciting round two: I chalked it up to a good first match and the allure of a hotel room.

This time, he stayed the night. In the king bed, his back turned away from me, having fallen asleep instantly and breathing heavy in the dark as men do, I noticed a strange feeling. Or an absence of feeling, maybe–. I wasn’t gripping on until I could be alone again. I didn’t mind him being in my space. I even kind of liked him being there.

July 4th

Perhaps it’s the exhibitionist in me (a hold over from my stripping days), but one of my favorite things to do in early dating is go to a coffee shop together the morning after. There’s something hyper-intimate about public breakfast, the smell of sleep still lingering on you, the formality of public life with all its social rules having not quite permeated your uncaffeinated brain. You may be too comfortable, too cozy, just on the edge of inappropriate, moving a few knots slower than the rest of the world.

Breakfast in the hotel lobby together is another level. Corey wanted to sit on the same side of the booth as me; I shot it down. Where my heart is a little wary, his is open. I like that about him. An anime convention was in town and shrinking adolescents in obscure cosplay and cheap fluorescent wigs wove in and around us as we talked about our childhoods in New England. We idled long after the waitstaff cleared our plates.

I saw him off. He had been having car trouble and was borrowing a friend’s vintage diesel Mercedes. Explaining how to turn it on to the valet took a few minutes. We held each other as if slow dancing on the sidewalk, both shocked to eventually see the boat make it around the corner. I kissed him goodbye like a wife sending her husband off to work, an homage to how we had both been raised, like two kids playing house, and I went back to my room alone.

Immediately it felt like something was off. I couldn’t quite name or identify what I felt. It was as if something was missing. I was cold and couldn’t get warm. The room was too quiet, too sterile. Usually when I have a guest I can’t wait for them to leave. I am someone who loves to be alone, who cherishes her quiet solitude, who can be alone with her books and thoughts for days. But suddenly, I felt the opposite. Did I …miss him? How could I miss him? I barely knew him.

Even worse, I was having the sort of stereotypically intrusive thoughts one gets after a solid date: visions of what it would be like to be his wife, to be pregnant, to have a house together in Connecticut. To waddle around carrying the weight of his too-big children. These weren’t fantasies, they were attacks– visions running up on me in an alley, someone violently drawing the curtains back in a dark room. In the stark and assaulting light I was confronted with the idea that perhaps it’s not that I never wanted these things, it’s that I didn’t believe they were possible for me.

When I had dated men previously I had weighed these possible futures and struggled to see how I could honor my ambition with the sacrifice required to be a wife and mother. None of those previous partners, I knew, would step up in a way that would shoulder the burden– not for the pleasure of raising children or building a life together; and certainly not out of respect for my work. And so I had forgone wanting those things.

And yet. I couldn’t help but see Corey and I on the couch in our living room, playfighting and laughing. Him calling me annoyed because the grocery store was out of something. Shooting each other horrified glances while some mutual family member embarrassed us at Thanksgiving. Fantasies of the mundane. The daily intimacies of a life lived together. His sweetness had shattered something in me.

I was so embarrassed to want these things at all, or even worse, to want them too late, just before the buzzer of my reproductive viability sounded. I was convinced I must be having a psychotic break because also I’m fucking GAY. That whole thing that bisexual people say about “being attracted to a person”, which I had previously found SO obnoxious, started to make sense. What I felt transcended attraction. What I felt with Corey was calm. Ease. Not sitting by the pool with a cocktail ease, but reading the paper in silence together ease. I saw our whole lives together playing out like a movie, even the life I would most likely live beyond him one day when I inevitably survived him, after decades together.

I think of the cliches married people like to tell their single friends: “if they’re the one, there’s nothing you can do to push them away”, or “when you know you know”. I still don’t know. But it is in my nature to be skeptical. I like to lift rocks and count bugs, read footnotes. I tell Corey I’m scared. He asks why. I try to explain. He doesn’t understand, but he listens and nods, with his ever-insistent eye contact. We hold hands and walk forward together anyway.

*Name changed to protect my reply guys (he hates this pseudonym by the way)

This is a paper I wrote for a class on relational abuse in graduate school. Some of my IG followers and lay people in general are often surprised that therapy is not generally considered an effective tool to resolve abusive behavior. I took this opportunity to learn more about WHY that is, and my take away is that there are several different conceptualizations of Intimate Partner Violence— and that some people in the field of psychology are unwilling to accept their limitations, as well as dealing with some unexamined internalized misogyny. This is pretty niche but perhaps it will help someone. xx

One of the reasons I decided to get my masters degree in psychology was to further understand and make sense of abusive behavior. I have been certified as a Restorative Circle facilitator for a few years now, and have previously worked in accountability and as a consent educator. I have noticed there seems to be a misunderstanding or fantasy among the public that psychotherapy can ‘cure’ or ‘fix’ an abuser and make them not abusive anymore. One could argue that I have fallen into this thought-trap myself even by pursuing this degree. Many lay people are unaware that not only is psychotherapy not a good treatment for abuse, it is actually contraindicated in couples where certain types of intimate partner violence is occurring. In this essay I explore why couples therapy is inappropriate in dyads where abuse is present, differentiate between different types of abuse, and discuss the perspective that couples therapy may be appropriate in certain instances of relational violence.

It was established on the first day of our two-day Domestic Violence workshop that couples therapy is contraindicated for patients where intimate partner violence is present, but we didn’t have time to go into depth as to why this is. In order to understand this, we must start but remembering the primary purpose of psychotherapy is to treat mental illness. As outlined in the DSM since the 3rd edition, the current definition of mental illness or mental disorder in the DSM-5-TR is defined as “a clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior” (American Psychiatric Association, 2022). One could perhaps conceptualize the abuse of a domestic partner as a problem of emotional regulation and/or behavior, but in my research, holes in this perspective were illuminated. Couples therapy in particular is meant to treat relational dissatisfaction, but as will be discussed later, in couples where abuse is occurring, treating couples may not only be ineffectual but could even be damaging to the person in the dyad who is being abused.

Another important point of consideration is that the definition of abuse is often subjective. The APA dictionary defines it as, “interactions in which one person behaves in a cruel, violent, demeaning, or invasive manner toward another person or an animal. The term most commonly implies physical mistreatment but also encompasses sexual and psychological (emotional) mistreatment.” (American Psychological Association, n.d.) Specifically when we are discussing intimate partner violence, it’s worth noting that we are talking about patterns of abuse, and that the abuse is specifically designed to effectuate control of another person or persons by the abuser (as discussed in the next section). This differentiates it from violence occurring outside a domestic partnership, as well as bilateral and rare instances of mutual aggression that does not result in injury for either party (which I will discuss later in this paper).

As I often do when exploring a new research topic, I like to start with the public facing literature to conceptualize the topic and then use scientific journal articles to either substantiate or refute it. One of the most popular books on the subject of domestic violence is Why Does He Do That? Inside the minds of angry and controlling men. (Bancroft, 2003). The book is written by Lundy Bancroft, a man who at the time had been running groups for men who had self-reported abusing their partners and then later were court-mandated for that reason. I first heard of the book in a casual discussion with a friend who was finishing her Masters in Psychology at USC at the time. Despite the fact that Bancroft is not himself a psychologist, and the text is written for a popular audience, it had still been assigned to her as reading in a clinical, graduate-level course. I was surprised by this at the time, thinking that she would be reading more empirically researched works. But in looking for such a text myself when writing this paper, I also came up short. It’s a bit of a catch-22 that the major criticism of Bancroft’s work is that it is not scientifically researched; and yet no real book on the why of domestic violence that is written from a psychological or psychotherapeutic standpoint and backed up with quantitative research exists that I could find.

Bancroft’s main argument in his book, qualitatively linked to his background in working with abusive men, is that abuse is not a mental illness and therefore cannot be treated by psychotherapy. Although many in the public assume that someone’s abusive behavior is a result of mental illness (check tik tok and the enormous popularity of so-called ‘narcissistic abuse’ content), Bancroft refutes this using what we in the field refer to as trait vs. state (Geiser et al., 2017). In this concept, the latter is a temporary experience or episode that may symptomatically resemble a mental illness, for example a period of sadness following the death of a loved one; as opposed to the former, which indicates a stable or mostly static pattern, such as major depressive disorder, which because of its enduring nature would be considered a mental illness. Bancroft conceptualizes that because the abusive partner only treats certain people (i.e., his partner) abusively, his behavior cannot be seen as a personality trait, and therefore cannot be conceptualized as a mental illness. The abusive partner, for example, may fly off the handle in a rage in response to a request by his partner, but he is able to stay calm when his boss makes requests of him, for example. This indicates that his abusive behavior is not a disorder beyond his ability to control, but is strategically, or at the very least, deliberately employed. The true narcissist, who has personality disorder characterized by an unsubstantiated entitlement to special treatment and a lack of empathy for others (American Psychiatric Association, 2022), behaves narcissistically with everyone, not just his partner. Bancroft emphatically states that, “no psychological test can distinguish an abusive man from a respectful one” (Bancroft, 2003, p. 216), meaning that though abusive behavior may present alongside mental illness, being abusive in itself is not itself a mental health diagnosis. Therefore, from Bancroft’s perspective, we cannot treat abusive behavior with mental health treatments such as psychotherapy.

Despite Bancroft’s contention, not all agree with his perspective, and they substantiate their perspective by delineating more specifically the ‘types’ of intimate partner violence that Bancroft views singularly. One such scholar is Michael P. Johnson, a professor emeritus of sociology and women’s studies at Pennsylvania State University. He conceptualizes different classifications of violence that include, in descending severity: Intimate Terrorism, Violent Resistance, and Situational Couple Violence (Johnson, 2012). While the first type concerns violence as a method of control (its description is most in alignment with Bancroft’s description of abuse), and the second type is a response to the first, Johnson posits that a third type of intimate partner violence exists that is not related to control. Instead, Situation Couple Violence is usually in response to a specific circumstance, typically the same things that bring most couples into relational therapy: money, child rearing, relationship status, or substance abuse issues. Johnson suggests that this specific type of intimate partner violence’s “root cause lies in chronic sources of stress and conflict in the couple’s life… sometimes it lies in the psychological problems of one member of the couple, such as alcohol abuse problems or anger management problems. At times the problem has less to do with one individual and more to do with how the couple communicates.” (Johnson, 2012, pp. 60-61) This differs greatly from Johnson’s conceptualization of Domestic Terrorism, which like Bancroft’s conceptualization of abuse, is a strategy of control. Instead, SPV occurs because partners do not have the skills of conflict management, communication, or anger management.

As therapists, whether or not we can be helpful to a couple is worth weighing against the potential harms caused by treatment, in accordance with our oath of nonmaleficence. In the instance of SPV, while psychoeducation is within our wheelhouse, it is up to the therapist’s discretion to decide if they are capable of teaching these skills. It’s worth noting that there are people who specialize in groups that teach anger management and communication skills, which may be a better fit for these clients than psychotherapy, if that is truly what they need to improve. Perhaps the therapist could keep seeing the couple concurrently, or after that skill-based treatment was completed. Though Situational Couple Violence is less likely than Intimate Terrorism to result in severe physical or psychological injury, the risk of homicide and/or post-traumatic stress syndrome are still significantly higher than in non-violent couples (Johnson 2012, pp. 43-47). For this reason it is important for therapists to honestly evaluate their abilities and refer out to specialists in this area where appropriate.

Although it was made clear in class that therapy is contraindicated in instances of intimate partner violence, the fact remains that many therapists continue to treat couples where violence is present. A popular textbook for graduate level psychology students, Clinical Handbook of Couple Therapy, which is assigned for our required class on that subject at Antioch, has an entire chapter devoted to the treatment of so-called “partner aggression” (Leblow & Snyder, 2023). The chapter makes a clear distinction, similar to Johnson, that there is a scale among types of intimate partner violence, though they separate it as either mild-to-moderate or moderate-to severe partner aggression (the former being a slap or push, and the latter resulting in injury). The authors argue that in instances of moderate-to-severe violence, “conjoint interventions” should be forgone (Leblow & Snyder, 2023, p. 8). However, the authors take issue with the “gender-specific treatment groups” that Bancroft suggests as best referrals for male perpetrators of intimate partner violence, stating that they “have shown limited effectiveness, with high recidivism”. Instead, they argue that by not working with the couple specifically, the violent partner misses out on learning dyad-specific tools to better handle conflict in the forum in which they occur: the relationship of the couple (Leblow & Snyder, 2023, p. 392).

The problem with this perspective is two fold: first, it assumes that the self-reports of clients are accurate, when in the case of IPV we should assume the opposite. Perpetrators of intimate partner violence, despite their justifications, generally know that their behavior is frowned upon. As a result, they may be incentivised to downplay the severity of their abuse. Additionally, victims fear retaliation from their abusers should they disclose the abuse. This fear of retaliation makes the victim of abuse likely to downplay or minimize what is happening in their self-report, at least until they are certain they can trust the therapist. A level of hesitation or non-disclosure from clients in general is to be expected in the beginning of a therapeutic relationship, as rapport and trust in the therapist are built over time. However, in the case of intimate partner violence, time is one of our most important interventions, as violence tends to escalate over time (Boxall & Lawler, 2021).

If therapists cannot always rely on client self-report, how then can they effectively discern which couples are appropriate for treatment? The answer lies in proper screening. Screening questionnaires designed to assess for the presence of intimate partner violence include: HITS, The WAST/WAST-SF, The PVS, The AAS (for pregnant women specifically) (Rabin et al., 2009). These scripts were originally developed for use in healthcare settings (Paterno & Draughon, 2016). Screenings should be brief and conducted with each partner separately (Hogan, J. N., 2022). They can be implemented formally or informally. If the data resulting from the clinician’s chosen assessment indicates the presence of more than mild aggression, best practice is to terminate couples therapy and refer clients to individual therapy instead. If assessments are not indicative of intimate partner violence, and yet an instance of more than mild violence occurs over the course of therapy, it is suggested the clinician “conducts a supplemental crisis management session focused on preventing further violence.” (Leblow & Snyder, 2023, p. 395) If a second instance of violence occurs, the therapist should then terminate couples therapy. As is part of our due diligence, if a clinician must terminate therapy, it is best practice to ensure clients leave with referrals. In the case of intimate partner violence, it would be best to meet with each party individually to discuss referrals and termination to prevent possible retaliation.

Beyond Bancroft’s conceptualization that therapy is ineffective in instances of abusive behavior (which stems from his background in non-therapeutic settings), in the field of psychotherapy it is also understood that therapy may be an inappropriate treatment when IPV is present. This is because the nature of abuse is in opposition to the goals of couples therapy, which include: negotiation, mutual empathy and responsibility for problems, and fostering attachment (Leblow & Snyder, 2023, p. 7). The underlying assumptions of these goals are equality, respect, and a level of safety for both parties. In the case of intimate terrorism, the equality and respect necessary for negotiation and empathy is simply not present. One must be careful as well to attempt to guide partners to understand where they are both responsible for conflict in instances of abuse, as this could actually be victim blaming. “The tried-and-true counseling method of talking through clients’ life scenarios, behaviors and choices while asking questions such as “What could you have done differently?” or “What would you want to change if this happens again?” can be hurtful because a counselor may inadvertently be placing the responsibility for the abuse on the victim instead of on the abuser” (Bray, 2019). Additionally, the goal of ‘fostering attachment’ in couples therapy could be very harmful for victims of abuse. It would be more helpful instead to assist victims with safety planning, building self-esteem, and directing toward social resources. Couples therapy works best when the client is the relationship between the two individuals present. If a relationship is overshadowed by control and abuse, as in the case of intimate terrorism or moderate-to-severe aggression; couples therapy can be harmful.

That being said, it is still extremely important for therapists to be educated on intimate partner violence, should it arise in their casework. This is not only because of the potential for harm caused to the clients should they not get appropriate treatment, but also because statistically, “partner aggression is more common among couples who seek therapy” (Lebow & Snyder, 2023, pp. 391–412). One study showed that half of the couples seeking relational therapy reported physical violence and over two-thirds reported psychological violence. Its important for early career clinicians to understand that couples therapy is not only contraindicated for clients whose relationships exhibit signs of moderate-to-severe abuse, but that couples who are navigating IPV are more likely to seek relational therapy. In order to prepare for this, therapists must use good screening tools, have contingency plans for what to do should abuse or violence present during treatment, and have well-thought out referrals and resources for clients who are inappropriate for couples treatment.

In researching this topic I noticed a few things came up for me, mainly how systemic patriarchy is woven into the field of psychotherapy and creates blind spots when it comes to the best course of action for treating intimate partner violence. I was especially horrified by the suggestion that couples should stay in relational therapy because the abuser can only improve if they get to practice skills in a relational format (Lebow & Snyder, 2023). To be frank, I don’t think victims owe their abusers a forum in which they can get well, especially when statistically, the victim’s life is at stake. When we look at the gender discrepancies in who dies from intimate partner violence (Smith, 2022), it is overwhelmingly women being abused by a male partner. The idea that statistically women owe men healing is offensive to me, especially when we can’t even as a society agree that the state owes women safety from abuse, as evidenced by the fact that reporting the abuse of adult women is not mandated by mental health professionals. This double standard speaks to an unchecked bias that women are obligated to serve healing, support, and help men; as if men are ultimately the main characters in therapy, society, and the world. I reject this completely. As a clinician, if I must choose, I would prefer to give the world an alive woman than a redeemed man, and I think it’s absolutely wild that that’s a contentious take. In general, this speaks to a larger conflict between my two primary sources: Bancroft, who is against therapy as a treatment of abuse and conceptualizes all relational violence as abuse; versus Leblow & Snyder, who suggest that intimate partner violence is a spectrum, and that couples therapy is appropriate and even preferable to other treatments in the case of what they call ‘low-level bidirectional IPV’ (where violence does not escalate beyond pushing and slapping and is equally enacted by both partners). I am not certain I agree. My reason is simply in the data: even if the violence is truly bidirectional, in a heterosexual couple, the woman is still much more likely to be killed. Therefore, in continuing to see the couple, instead of referring out to more appropriate and specialized resources, the clinician is ultimately deciding that she is willing to risk her female client’s life in order to serve the couple– and from my perspective I struggle to see how this isn’t an androcentric or even misogynistic choice. I think it’s incredibly important to check to see how our own gender biases come up when we’re doing couples work, specifically who is expected to help make their partner better, and whose life and wellness is prioritized. As for myself, I write this paper from a very privileged place of having not yet been placed in the position of deciding what is best for my clients both as a couple and as individuals. I am quite certain that as a future clinical who is interested in working with couples I will be confronted with this with some regularity. I do believe that there is some nuance beyond Bancroft’s perspective, but I anticipate that in the vast majority of cases, given my Restorative Practices background, my interest will be in helping the victim, rather than the couple– which indicates the case is unsuitable for couples therapy.

References

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.).

American Psychological Association. (n.d.). Abuse. In APA dictionary of psychology. Retrieved February 1st, 2026, from https://dictionary.apa.org/abuse

Bancroft, Lundy. (2003). Why Does He Do That? Inside the minds of angry and controlling men. New York. Berkley Books

Bray, Bethany. (June 2019). Addressing Intimate Partner Violence with Clients. Counseling Today. https://www.counseling.org/publications/counseling-today-magazine/article-archive/article/legacy/addressing-intimate-partner-violence-with-clients

Geiser, C., Götz, T., Preckel, F., & Freund, P. A. (2017). States and Traits: Theories, models, and assessment. European Journal of Psychological Assessment, 33(4), 219–223. https://doi.org/10.1027/1015-5759/a000413

Hayley Boxall, Hayley & Lawler, Siobhan. (2021). How Does Domestic Violence Escalate Over Time? Trends & Issues in Crime and Criminal Justice, 626. 1836-2206. https://www.aic.gov.au/sites/default/files/2021-04/ti626_how _does_domestic_violence_escalate_over_time.pdf

Hogan, Jasara N. (2022) Conducting Couple Therapy via Telehealth: Special considerations for virtual success. Journal of Health Service Psychology. (48). 89–96. https://doi.org/10.1007/s42843-022-00060-x

Johnson, M. P. (2012). A Typology of Domestic Violence: Intimate terrorism, violent resistance, and situational couple violence. Upne. (Johnson 2012)

Leblow, J. L., & Snyder, D. K. (Eds.) (2023). Clinical Handbook of Couple Therapy (6th ed.). The Guilford Press. (Leblow & Snyder, 2023)

Paterno, M. T., & Draughon, J. E. (2016). Screening for Intimate Partner Violence. Journal of midwifery & women’s health, 61(3), 370–375. https://doi.org/10.1111/jmwh.12443

Rabin, R. F., Jennings, J. M., Campbell, J. C., & Bair-Merritt, M. H. (2009). Intimate partner violence screening tools: a systematic review. American journal of preventive medicine, 36(5), 439–445.e4. https://doi.org/10.1016/j.amepre.2009.01.024

Smith, Erica L. Department of Justice. (2022). Female Murder Victims and Victim-Offender Relationship, 2021. Bureau of Justice Statistics. https://bjs.ojp.gov/female-murder-victims-and-victim-offender-relationship-2021#the-percentage-of-females-murdered-by-an-intimate-partner-was-5

Not meant to be an incredible piece of writing, but rather a clarifying overview of the issue, many have asked to see it for that reason. Enjoy and would love your thoughts/reflections in the comments. xx

In the field of psychology, there exists a rift. Those in the profession who operate from the paradigm of sex positivity (Schubert and Pope, 2023, p. 8) often reject the conceptualization of sex addiction outright as a moralistic minefield (American Association of Sex Educators Counselors and Therapists, n.d.). On the other hand, people working in the field of addiction may find some merit in the idea that the neurochemical effects of sexual behavior can become addictive for people with certain predispositions (Caponnetto, P., et al., 2022). In spite of this protestations of the sex positivity camp, the fact remains that the treatment of sex addiction is a booming industry, with over 80 facilities in California alone listed on Psychology Today’s treatment center database. While it would be irresponsible to conflate public interest with scientific merit, it is worth noting that many clients actively seek treatment for and identify with the terminology of sex addiction through psychotherapy, 12-step programs, and both inpatient and outpatient rehabilitation centers, regardless of whether or not sex addiction is a scientifically merited diagnosis.

Much of the divergence of opinion regarding the validity of sex addiction as a diagnosis can be reduced to three primary issues: semantics (or a lack of a clear definition or terminology), fear of stigmatizing what is within the normative spectrum of human sexual behavior (a history of the term being conflated with pathologizing non-hegemonic sexual behavior), and a lack of empirical/quantitative evidence to support the addiction model specifically. I begin this essay by exploring the original conceptualization of sex addiction and its faults, followed by subsequent terminology that has arisen since in an attempt to define ego-dystonic habitual sexual behavior, and the shortcomings of these successive terms as well.

What is Sex Addiction?

The concept of sex addiction made its way into the public foray through the work of Dr. Pat Carnes with his book Out of the Shadows (1983). Carnes originally conceptualized sex addiction as a wide umbrella of behaviors, including specific sexual behaviors (such as engaging with sex work or having multiple partners) as well as a general inability to control one’s sexual behaviors, despite resulting loss of relationships, health, or employment.

In response to the publication of Out of the Shadows, professionals in the field of sexuality and psychology were quick to point out the flaws in Carnes’ conceptualization; notably that his work, though promoted as psychology, lacked empirical scientific evidence. For example, one of his screening tools, PATHOS (Carnes, 2012) is a six-question assessment which seems to conflate all sexually dystonic thoughts, feelings, or behaviors with addiction. This is an oversimplification and pathologizing of normative human variance in sexuality, as well as confusing certain cultural mores as universal. Questions such as “Do you hide some of your sexual behavior from others? (Ashamed)”, for example don’t account for cultural expectations around sexual privacy– in America, it is considered quite taboo for family members to express their sexuality around each other for example– children and parents alike hide what is otherwise normative behavior from each other, and this is considered healthy, not indicative of addiction. Another example, “Have you ever sought help for sexual behavior you did not like? (Treatment)”, does not account for client lack of understanding as to what ‘normal’ sexual behavior actually is and conflates all ‘dislike’ as being indicative of pathology when it could be tied to a lack of psycho- or sexual education. Finally, the question: “When you have sex, do you feel depressed afterwards? (Sad)”, doesn’t account for the many potential reasons someone might feel sad after sex, including marital discord, trauma, or dissatisfaction. This is similar to the general and ongoing critique of Carnes’ work, which is that it corrals all dystonic sexual feelings or behaviors under the label of addiction, without accounting for trauma, cultural considerations, lack of client sexual education, or undue shame.

Carnes’ work has also been described as overly moralistic, as it suggests that non-hegemonic behaviors are inherently pathological. For example engaging in sadomasochism, cruising, sex work (as either purchaser or provider), consuming any kind of pornography, or engaging in multiple simultaneous relationships are listed as possible qualifiers in his PATHOS screening (Carnes 2012). Pathologizing these behaviors is directly opposed to the sex positive paradigm and specifically pathologizes the kink, queer, and poly communities; as well as not accounting for economic or disability justice factors in these behaviors. Perhaps even more problematically, Carnes’ assessment includes questions where being sexually abused as a child or experiencing relational abuse indicate the assessed person could be an addict, which is a form of victim blaming.

Perhaps most harmful of all is that equal weight is given to the question “I have been sexual with a minor” as all other questions on the assessment, suggesting that raping a child is of the same degree of pathology as being homosexual or polyamorous. Even more terrifying, by constructing rape as a behavior of addiction, one could then argue that the rapist is suffering from a disease and therefore not entirely culpable for their behavior. Unfortunately, this is a larger problem with using the disease model of addiction to describe all ‘problematic’ sexual behavior, as we have seen many accused in the post #MeToo movement seek sanctuary in sex addiction treatment centers as the first step in their public rehabilitation campaigns, when in fact their problems may have been related to entitlement or sociopathy more so than addiction.

It is important to note that Carnes’ popularity and the backlash it was met with from the field occurred in the midst AIDS crisis, when fear fueled the policing of all non-hegemonic sexual behavior, especially queerness or anything outside of monogamous heterosexual marriage, specifically promiscuity or deviance in any form. Today, the model of sex addiction as conceptualized by Carnes is still widely rejected in most “sex positive” fields of sexology and psychology, including the American Association of Sex Educators, Therapists, and Counselors as noted on their website.

…does not find sufficient empirical evidence to support the classification of sex addiction or porn addiction as a mental health disorder, and 2) does not find the sexual addiction training and treatment methods and educational pedagogies to be adequately informed by accurate human sexuality knowledge. (American Association of Sex Educators, Therapists, and Counselors, n.d.)

Despite the rejection of Carnes’ broad and moralistic model, the fact remains that clients still seek treatment for dystonic sexual urges and behaviors. Many of these presentations are not inherently problematic, and are thus resolved through psychoeducation and divestment from punishing moralist paradigms. However, some clients seek treatment for sexual behaviors which they feel are out of their control and cause them suffering that is similar in many ways to the symptomology of addiction. In response to the rejection of ‘sex addiction’ as terminology, other terms have risen up in the sex positive community to attempt to describe (but not moralistically pathologize) client presentations of dystonic habitual sexual behavior, including Sexual Compulsivity, Hypersexuality, Sexual Impulse Control Disorder, and Process/Behavioral Addictions. While all these terms attempt to describe a larger umbrella of dystonic and repetitive sexual behavior, many fall short. I review these terms below in an attempt to discern which is the most accurate for our clinical common parlance.

Sexually Compulsive Behavior

Many organizations have chosen to avoid the minefield that is the word addiction and instead conceptualize problematic or ego-dystonic sexual behavior within the context of compulsivity. One such organization is the World Health Organization, which has its own equivalent to the DSM (with the inclusion of physical diseases), called the International Classification of Diseases. The latest update to the ICD now includes Sexual Compulsive Behavior Disorder in its 11th edition, as defined by:

…Persistent pattern of failure to control intense, repetitive sexual impulses… becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it….causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement (World Health Organization, 2019).

We see here considerable overlaps with an addiction-based conceptualization, namely: unsuccessful attempts to quit, obsessional thinking, engaging in the behavior despite consequences, desensitization. However, the ICD emphasizes that cultural values around sexuality should be considered when exploring the cause of client distress. This conceptualization is therefore more updated and informed than Carnes’ conceptualization as an umbrella term for ego-dystonic habitual sexual behavior. In this way by using the word compulsive, the ICD focuses on the individual's inability to control their urges or behavior despite distress and consequence, while excluding for the moralistic traps that are characteristic of Carnes' model.

That being said, the choice of the word compulsive is not without its own pitfalls. As noted earlier, the American Psychiatric Association has not included Sexually Compulsive Behavior Disorder in its own diagnostic manual, perhaps due in part to the fact that this conceptualization conflicts with the definition of compulsivity already outlined in its text, defined as behaviors “…that the individual feels driven to perform in response to an obsession or according to rules” and that “…are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event situation” (American Psychiatric Association, 2022, p 265). While it is possible some clients may present with ritualized sexual behavior meant to stop some anticipated occurrence, most important is the caveat in section two: “... these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent…” For the majority of clients who disclose patterns of dystonic sexual behavior or self-describe as ‘addicted’, their repetitive behavior is directly designed to neutralize the preceding feeling (distress or sexual arousal). While the use of the word compulsive is helpful in some ways, it does not account for other aspects of behavior that are better described by the addiction model, despite its shortcomings.

Hypersexuality

Like much of the other language discussed so far, hypersexuality as a diagnosis is both a potentially problematic misnomer, as well as being indicative of a sex-negative paradigm on the part of the clinicians who use it. Reinhart et al., (1997) suggest that what has been clinically considered hypersexual in the past may in fact just be one end of the normative spectrum of human sexual desire and expression. Hypersexuality is more of an outside-in diagnosis, where the clinician makes a judgement on the degree of normativity or deviance in a client's behavior, rather than focusing on the client’s internal experience of their behavior and its consequences, which is more in line with the addiction model. For this reason, many believe that hypersexuality is simply a repackaging of nymphomania, a classifiable disease of the Victorian era (Groneman, 1994), updated to be inclusive of all genders in the contemporary age. Regardless, much like sex addiction, hypersexuality is a broad and un-empirically proven term that clinicians use to describe a wide variety of behaviors, and it is also not found in any diagnostic manuals.

Impulse Control Disorder

Impulse control disorders are categorized along with conduct and disruptive disorders in the Diagnostic and Statistical Manual of Mental Disorders in part as problems where clients have difficulty controlling behaviors that are in opposition to societal norms. (American Psychiatric Association, 2022, p. 521). Interestingly, the diagnosis for kleptomania and pyromania most closely resembles the addiction model, as they are “characterized by poor impulse control related to specific behaviors (fire setting or stealing) that relieve internal tension” (p. 522). Though there is no specification for sexual impulse control disorder, many clients seeking treatment for sex addiction describe an inability to control their behavior, and that they use sex or orgasm to emotionally regulate, despite the behavior often being outside the realm of what is considered socially acceptable. It is worth noting though that this category in the DSM-5-TR also includes disorders of aggression, including Oppositional Defiant Disorder (p. 522) and Conduct Disorder (p. 530), which do not accurately describe the symptomology of dystonic habitual patterns of sexual behavior in any way.

Interestingly, many in the field of psychology consider impulsivity and compulsivity to be opposing ends along a spectrum. Indeed, the fact that ‘problematic’ or ‘out of control’ sexual behavior has been conceptualized form both ends of this spectrum further illustrates how challenging it has been for researchers to conceptualize this presentation into a formal diagnosis.

Behavioral Addictions, Process Addiction, and Non-Substance Addictions

Patrick Carnes’ book on sex addiction was predated by a book called The Pleasure Addicts by Lawrence Hatterer (1980). Hatterer theorized that any number of pleasurable processes could result in what he called process addictions, which are similar to addictions to substances of abuse, but instead a client is addicted to food, television, or sex. This terminology has recently been termed behavioral addiction to generalize addictive patterns to objects or behaviors other than substances of abuse. While the former is perhaps more focused on the ongoing cycle of addiction and the later on the particular manifestations of the addiction, the terms are, for all intents and purposes, synonymous; though behavioral addiction seems to be more popular in the contemporary parlance.

The DSM-5-TR is the first edition of the manual which includes a behavioral addiction in its section “Substance-Related and Addictive Disorders” (American Psychiatric Association, 2022, p. 543). While there are almost 120 pages of the various symptoms of addiction, use, and withdrawal from the various substances of abuse (including alcohol, caffeine, tobacco, opioids, inhalants, and stimulants, for example), the only disorder in the new subsection Non-Substance-Related Disorders listed in this edition is gambling.

It is interesting that “persistent and problematic… behavior leading to clinically significant impairment or distress” (American Psychiatric Association, 2022, p. 660) is understood by the American Psychiatric Association to be a diagnosable disorder when the behavior is gambling, but it does not include other behaviors that evoke the same patterns. The main reason for this is a lack of research, specifically in animal and brain scan studies, even though “there has been growing evidence that other behaviors with positive reinforcing effects may become addictive for predisposed individuals.” (Piquet-Pessô, 2014). This sort of research is expensive, but was funded in the case of gambling disorder specifically by the Bally’s Corporation and other gambling companies (Zeeb et al., 2009). The APA remains open to considering other behavioral addictions, once presented with better evidence to substantiate their inclusion: “the groups of repetitive behaviors, sometimes termed behavioral addictions (with sub category, such as sex, addiction, exercise, addiction, and shopping addiction), are not included because there is insufficient peer reviewed evidence to establish the diagnostic criteria and course descriptions needed to identify these behaviors as mental disorders” (American Psychiatric Association, 2022 p. 543). Perhaps internet pornography companies (such as the charitable arm of Pornhub, Pornhub Cares, which has previously funded medical research) could assist in securing funding for sex addiction research, in the same way Bally’s Corporation has funded research on gambling disorder.

Clinical Implications

The debate over whether or not sex addiction is a true pathology is relevant for those of us working in the field of mental health, but especially those of us who work in sexual mental health. As indicated by the APA, sex addiction is only excluded for the time being due to a lack of evidence to mandate its inclusion; meaning, that this could change in subsequent editions of the DSM. It is therefore important for clinicians to remain up to date on this research.

Secondly, given the lack of clarity of language combined with the publics general lack of psycho- and sexual education, clinical inquiry becomes even more important in the therapy room. Many clients may self-report using pathologizing language for what is within the normal spectrum of sexual behavior, or they may interpret their normative behavior as psychologically or physically problematic as a result of moral and cultural paradigms. Clients are not always excellent at self-diagnosing, and for this reason it's important to ask enough questions as a psychotherapist to ensure clarity for the cause of distress, rather than relying on self-diagnosis exclusively, before beginning treatment.

Conclusion

Analyzing the conceptualization of a particular pathology (in this case, dystonic habitual sexual behavior) has been an illuminating process. I have learned about the divergent values of different institutions (the American Psychiatric Association versus the World Health Organization), as well as how the defining of a diagnosis is an ongoing, collective process that is heavily influenced by the zeitgeist of its time.

Furthermore, this research topic has illuminated to me the importance of language. Many institutions refute the existence of sex addiction all together. In my opinion, it's not that sex addiction isn’t a real disorder, it's that the term has been used to explain too-broad a swath of behaviors. Many of these behvaiors have nothing to do with addiction, and many of them are not even psychologically problematic (or if they are, are usually indicative of another pathology altogether which has been previously conceptualized, such as OCD or sociopathy). Though many in the field of sex positive psychology refute sex addiction as a conceptualization entirely, the fact remains that we simply don’t have the neuroimaging or animal studies to prove or disprove sex’s inclusion as a behavioral addiction in the DSM.

That being said, we do have other research that suggests this may be an area worthy further inquiry. Specifically, is well-documented that Parkinson's patients treated with dopamine agonists can develop an increased desire for sex that is coupled with a lack of impulse control. This research includes neuroimages that show the effect of dopamine in the brain when watching sexual imagery– it lights up in many of the same place where drugs of addiction light up (Politis 2013). These studies further indicate a relationship between the brain pathways at play in addiction and the dopaminergic effects of sex and orgasm. It is my hope that more research is done into this subject to truly determine if one can be behaviorally addicted to sex. It would be a shame to allow people who struggle with their own sexual behavior to not receive treatment simply because capital has yet to fund this important and lifesaving research.

Our goal as clinicians and researchers should always be to arrive at clarity and specificity when using diagnostic language. When clients present with dystonic habitual sexual behavior that causes distress, sensitization, and withdrawal, we ought not engage in wars around semantics or culture that move us away from being able to achieve our larger goal: to arrest suffering. Until proper research is funded, as a profession, we must be mindful both to avoid over-pathologizing or dismissing helpful conceptualizations simply due to their challenging origins. Our oath of nonmaleficence mandates it so.

References

American Psychiatric Association. 2022. Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

American Psychiatric Association. n.d.. AASECT Position on Sex Addiction. https://www.aasect.org/position-sex-addiction

Alavi, S. S., Ferdosi, M., Jannatifard, F., Eslami, M., Alaghemandan, H., & Setare, M. 2012. Behavioral Addiction versus Substance Addiction: Correspondence of Psychiatric and Psychological Views. International journal of preventive medicine, 3(4), 290–294.

Berlin, H.A., PhD, Hollander, E. 2008. Understanding the Differences Between Impulsivity and Compulsivity. Psychiatric Times. 25(8). https://www.psychiatrictimes.com/view/understanding-differences-between-impulsivity-and-compulsivity

Carnes, P. 2012. Am I a Sex Addict? https://www.drpatrickcarnes.com/am-i-a-sex-addict

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Research Language and Biases

I would like to acknowledge some issues with language regarding my cited research. Many of the studies I have cited reference “monogamous” prairie voles (Microtus ochrogaster). Monogamy is a social construct and a choice, whereas pair bond formation (be it temporary, long lasting, or life-long) as evidenced by the meta-analysis that follows in this paper, is in part neurobiological (as well as potentially genetic). Where possible, I have omitted the word monogamous and used pair bond in its place.

Additionally, many of the cited studies I have used in my research feature exclusively gender-essentialist terminology in differentiating between sex or gender differences in subjects. As evidenced by other studies not cited in this paper, brains demonstrate plasticity under environmental influence such as hormonal knockdown or hormone replacement therapy. I encourage readers who identify outside the gender binary or with a gender other than the one they were assigned at birth to find what resonates behaviorally for them when reading about sex-specific neurobiology.

Aromantic Inclusion

I would also like to acknowledge that the experience of limerence is not universal. It is estimated that roughly 1% of the population is asexual and/or aromantic (Lund, E. M. et al., 2016) I encourage readers who identify on the ace/aro spectrum to read the following meta-analysis as an insight into the experience of the “other”.

The concept of “falling in love” is pervasive in Western culture: a purported emotional state that is woven into our holidays, economies, literature, and healthcare system. While other states of love, be they maternal, familial, or friendship are also lauded; romantic love rises to the top as a sort of propagandized aspirational state of blissful union. In actuality, the lived experience of early romantic love is not always so pleasant. In fact, it is an altered state of mind that shares many symptomological parallels with psychosis or addiction. In its most severe form, the early passionate love experience is all consuming, and can completely overtake one’s body, brain, and life. In 1979, psychologist and professor Dorothy Tennov published the book Love and Limerence, using case studies to form a symptomology of the dysregulation associated with the experience of early romantic love, for which she coined limerence. This symptomology includes:

“…wide swings of heighted emotion from euphoria to despair, inability to correctly assess the behavior of the Limerent Object (L.O.), catastrophizing, intrusive thoughts, aching in chest, longing, inability to correctly assess the character of the L.O. (“rose colored glasses”), obsessive thoughts, hyperfixation, and a shirking of other responsibilities and relationships. (Tennov, D. 1979, pp 23-24).

Though Tennov’s research is foundational, it doesn’t explore the causes of these symptoms beyond stimulus, only their presentations. In this essay I will explore the neurobiological causes for Tennov’s symptomology using various research on humans, non-human primates, and pair-bonding prairie voles.

To begin, it is important to acknowledge a conflict in paradigm. As I alluded earlier, romantic love is understood culturally to be an emotional state. When one explores the many neurochemical and hormonal functions that facilitate the limerent experience, however, we are forced to acknowledge that falling in love is actually a biological function. Enrique Burunat (2016, 2019) posits that romantic love is a not an emotion, but a physiological need, a cascade of processes unleashed in the brain when prompted by external stimulus, comprised of “impulsive and motivational characteristics”. The primary neurochemicals involved in this limerent cocktail are: Dopamine, Oxytocin, and Vasopressin. In this section I will explore each’s role in the brain’s facilitation of limerence by comparing it with Tennov’s initial qualitative research

The Limerent Cocktail

Dopamine

Dopamine (DA) is a neurotransmitter most commonly associated with reward seeking and arousal (among many other functions). Dopamine is highly concentrated in the VTA and substatia nigra in the midbrain, as well as hypothalamus. Major pathways for dopamine include the nigrostriatal, mesocortical, and mesolimbic.

The mesolimbic pathway recruits dopamine from the ventral tegmental area and transports it to the nucleus accumbens and other limbic structures. Dopamine is highly utliized in the limerent process, specifically in its facilitation of reward pursuit, as evidenced by the research of Ortigue, S., et al. (2010). Using fMRI technology to observe the brain during “passionate love”, researchers measured brain activation against control groups experiencing mother-child love and empathetic non-sexual love. Marked differences presented. Comparatively, “…Passionate love specifically recruits the ventral tegmental area and the caudate nucleus, although maternal love and unconditional love… recruits PAG.” It is worth noting that the PAG (periaqueductal gray) area is associated with sympathy and pain, whereas the caudate nucleus is associated with will: desire and its pursuit (Driscoll; M. E. et al., 2023). Indicating that the experience of limerence, or passionate love, is similar to reward and goal seeking.

Given Tennov’s findings that the limerent experience is characterized in part by “hyperfixation, and a shirking of other responsibilities and relationships” (Tennov, 1979), it is not surprising that, in their meta-analysis of the role of dopamine in romantic love, Xu, X. et al., (2015) discovered that: “Intense romantic love is most commonly reported in the early stages of relationships… as novelty and novelty seeking are often tied to dopamine and dopamine rich regions.”

The role of dopamine in limerence and subsequent early pair bonds formation is so intrinsic that artificial stimulation of D2R receptors in the NAC shell is enough to result in pair bond formation in “monogamous” prairie voles even if they do not engage in mating (Burkett, James P. & Young, Larry J. 2012). In much the same way that dopamine is understood to be tied to reward-pursuit behavior and its presenting single-mindedness, so too is dopamine responsible for the single-minded of limerence, even to the detriment of other obligations.

Oxytocin

In addition to dopamine, oxytocin is also a key component of the limerent cocktail responsible for Tennov’s subjects’ experiences. OT is a neurotransmitter/neuropeptide produced in the hypothalamus. When centrally released, it acts on the hippocampus among other areas (including the cortex, amygdala, and brain stem). Oxytocin is involved in social cognition, empathy, responding to social cues, and social memory.

Specifically, OT is highly correlated with forming social bonds. Oxytocin is released into the bloodstream to initiate lactation in birthing mammals and helps facilitate the chest-feeder to infant bond. Similarly, oxytocin also helps facilitate pair bonds in “monogamous” animals. In prairie voles, who as rodents are very sensitive to smell, “OT modulates sensitivity in the anterior olfactory nucleus, allowing for higher sensitivity to the smell of chosen mate and its storing as a neural representation in the hippocampus” (Blumenthal, S. and Young, Larry 2023), which reinforces individual mate preference through short term memory. This is analogous to how many mammals are able to find their offspring in a crowd based on smell. These presentations of OT indicate that for some species, the mammalian wiring to parent-child bond is not dissimilar from romantic pair bond formation. Additionally, lab interventions show that viral knockdown of oxytocin receptors in the nucleus accumbens manifests as less preferential mating in voles, and when OT is increased in the NAc, more pair bonding and maternal behavior presents. (Burkett, James P. & Young, Larry J., 2012; Andreas Bartels & Semir Zeki, 2004). Finally, oxytocin is released additionally during pro-social touch and during orgasm/ejaculation for both genders (Cera, 2021). This research indicates that oxytocin is essential to attachment bonding, both in parent-child and in pair bonds.

Vasopressin

The third component of the limerent cocktail is Vasopressin (AVP), a neurohormone that is synthesized in the hypothalamus. It is primarily utilized in maintaining blood salinity homeostasis and urination. It also has gender-specific hormonal functions, like oxytocin. In male mammals but not females, it is related to male initiatory sexual behavior. Specifically, in lab settings, knockdown of vasopressin inhibits male sexual behavior, and if administered before cohabitation occurs, will prevent pair bond formation (Blumenthal, S. & Young, L. J., 2023). Additionally, AVP works synergistically with OT and DA to facilitate mate-guarding: aggressive behavior towards adult members of their species other than the established nesting partner. Mate guarding serves a biological purpose, as it ensures reproductive exclusivity and prioritized care to resulting offspring. One could argue mate guarding may be reflective of romantic jealousy in human pair bonding, or the experience of “only having eyes for them” that often presents in limerence.

Areas of De-activation and Inhibition

In addition to the neurochemicals and regions specifically activated during limerent love, there are also noteworthy areas of de-activation, both locationally and chemically. These include the amygdala and the frontal cortex, as well as a drop in serotonin. The subsequent effects of these limerent adaptations are highly correlated with Tennov’s (1979) findings.

Amygdala

The amygdala is a part of the limbic system that is in part responsible for assigning value of stimulus as good or bad, determining threats, and activating a fear response. In a study using brain imaging while subjects viewed attractive faces of the gender of their preference, researchers observed deactivation in the amygdala (Chatterjee, A., 2009). It is fitting then that a characteristic of the limerent experience according to Tennov’s findings is an “inability to correctly assess the behavior of the Limerent Object”. Limerent attraction may inhibit the amygdala function of stimulus analysis as a way to promote pair bonding.

Frontal Cortex

Additionally, the research of Chatterjee, A., et al., (2009) indicates marked deactivation in the frontal cortex during romantic attraction. The frontal cortex is the area responsible for judgement, among other functions. This may account for the experience of seeing one’s desired partner as more idealized than they actually are, or as Tennov (1979) suggested: “inability to correctly assess the character of the L.O. (‘rose colored glasses’).” Similar to the de-activation of the amygdala, it is possible that frontal cortex shut down allows for limerence, pair bond formation, and subsequent mating to occur more easefully.

Serotonin

Perhaps most profoundly, research indicates a drop in serotonin during the early romantic love experience. Serotonin is a neurotransmitter, primarily found in the brain stem. Though its function is not entirely understood, increased serotonin or the inhibition of its uptake receptors is correlated with improved mood for people struggling with depression. SSRIs have been used to treat Obsessive Compulsive Disorder, a diagnosis characterized in part by uncontrollable and recurring thoughts (National Institute of Mental Health, 2023). In a study comparing recently limerent subjects, unmedicated OCD-diagnosed subjects, and a control group:

Subjects who were in the early romantic phase of a love relationship were not different from OCD patients in terms of the density of the platelet 5-HT transporter, which proved to be significantly lower than in the normal controls. This would suggest common neurochemical changes involving the 5-HT system, linked to psychological dimensions shared by the two conditions, perhaps at an ideational level. (Marzazziti, D., et. al., 1999)

This is commensurate with Tennov’s research on limerence, wherein she notes that falling in love is characterized by “obsessive thoughts” and “intrusive thoughts”, which are also symptoms of OCD. Tennov also noted that the limerent experience was characterized by “catastrophizing, aching in chest, longing” (1979), which are often cited as symptoms experienced by those suffering from Major Depression, a disorder also treated with serotonergic drugs.

Though I didn’t observe this correlation explicitly stated in my research, I find it worth noting that a major side effect of SSRI’s is a reduced sex drive or inability to reach orgasm, suggesting that perhaps the limerent drop in serotonin is enacted to facilitate pair bonding through mating drive.

Is Romantic Love a Pathology?

When observing the high levels of neurochemical adaptations that present during limerence and their subsequent effects, it becomes clear that romantic love is an altered brain state. In my research, I found many articles suggesting that the limerent state is inherently pathological: comparing it to psychosis, or addiction. Tennov’s (1979) research does support the idea that limerence is an altered brain state, though she is emphatic in her writing that she does not believe the limerent state to be in itself pathological. Despite this, many have cited her work to argue the opposite, suggesting specifically that romantic love is akin to an addiction or psychosis.

Addiction

There is remarkable overlap between the neurobiology of limerence and the effects of euphoric drugs, specifically in terms of areas of activation. According to the research of Bartels, Andreas & Zeki, Semir, (2000): “…Studies of cocaine- and mu-opioid agonist-induced euphoria have shown increased activity in foci that seem to overlap with all foci activated in our study: …the caudate nucleus and the putamen. This suggests a potentially close neural link between romantic love and euphoric states.” The National Institute on Drug Abuse, in its Cocaine Research Report, implicates the mesolimbic pathway, namely the VTA to the NAc, as the main area of stimulation, which is the same area recruited in early pair bonding. Beyond brain activation sites, the research of Burkett, James P. & Young, Larry J., (2012) correlates the symptomology of substance abuse disorder with romantic love: “When the diagnostic criteria for substance dependence are looked at side-by-side with related phenomena observable in normal human relationships, striking parallels emerge.”

Returning to Tennov’s findings, we are able to draw specific parallels between substance abuse and limerence. The experience of limerence includes: “…inability to correctly assess (the) behavior… obsessive thoughts… hyperfixation…”. As a symptomology, this is remarkably similar to the diagnostic criteria for Substance Abuse Disorder in the DSM-5: “neglecting responsibilities at home, work or school because of substance use…. Continuing to use even when it causes relationship problems. Giving up important or desirable social and recreational activities due to substance use.” (American Psychiatric Association, 2013). This indicates that beyond similar areas of activation and neurotransmitter recruitment, love and addiction share similarities in their symptomology.

Interestingly, there has been much movement in the field of addiction study to promote the inclusion of so-called behavioral addictions in the DSM. These purported addictions include, but are not limited to the internet, food, shopping, sex, and love. There remains much debate in the fields of sexology, psychology, and addiction as to whether or not love addiction is a valid disorder. How can one be addicted to an experience that already so closely replicates, on a neurobiological level, the effect of drugs of addiction?

Earp, B. D., et al., (2017) suggest in their research that love, like any substance or behavior that works on dopaminergic pathways, can be potentially addictive. They challenge the idea that there are “good” or “bad” sources of dopamine, and that instead we must look to an individual’s behavior to classify addiction. “The key determinant for labelling and treatment should be the degree to which the individual is harmed by the love through its deleterious impact on her (sic) well-being”. The research of Earp, B. D., et. al., suggests that romantic love can be addicting, but it is not the experience itself that is problematic, rather the individual’s relationship to, and patterning regarding, the limerent experience.

Similarly, Maglia, M. G. et al., (2023), published a comprehensive meta-analysis of research done on love addiction since the 1990s. In their compiling of data, they find that love addiction can best be described as “those changes that suffocate and suppress the life of these ‘addicted’ subjects and the people who are close to them… we speak of emotional dependence when the partner becomes the center of the world, and a disorganization of the individual’s psychological characteristics and social life slowly follows one another.” Akin to the research of Earp B. D. et al., (2017), Maglia, M. G. et al., (2023) conclude that addiction can only be diagnosed through the consequences resulting, and whether the subject continues to return to the dopamine-producing behavior despite these consequences.

Relatedly, Steve Sussman’s (2012) research attempts to delineate between dysfunctional love behaviors and true love addiction. While many presentations of pathological pair-bonding and pursuit of limerent objects exist; including poor partner choice and anxious attachment; according to Sussman, true love addiction presents as: “acting so as to produce a drug-like induced surge of meso-dopaminergic turnover, one may engage in love addictive processes, which may necessitate periodic changing of romantic partners to best induce such early-stage relationship neurobiological reactions”. I find this delineation to be most helpful. If the normative experience of early pair bonding, be it in prairie voles or humans, recruits the same parts of the brain activated in drugs of addiction, then the behavioral response to this effect is the determining factor insofar as whether one’s behavior can be classified as an addiction. In much the same way one can play blackjack, have an orgasm, or consume a euphoric drug and return to normal life without being classified as an addict; one can only be called a “love addict” when they pursue the altered brain state of limerence in a compulsive manner without regard for the consequences.

Romantic Love as Psychosis

In addition to comparing limerence to addiction, much of the research I encountered suggested that the biological experience of romantic love is in itself a pathology. In fact, many of Tennov’s original findings on the symptoms of limerence do correlate with early-onset psychosis, according to the British Columbia Ministry of Health.

Psychosis describes a mental state characterized by distortion or loss of contact with reality. Positive symptoms of psychosis include delusions, hallucinations and/or thought disorder… Negative symptoms such as poverty of thought or speech, loss of motivation, and restriction in the range of emotional expression can also occur. In addition, there are usually a number of other 'secondary' features, such as sleep disturbance, agitation, behavior changes, social withdrawal and impaired role functioning.

The loss of contact with reality is similar to a limerent subject’s distortion of their limerent object’s character and behavior (Tennov, 1979). But these are simply the result of functional neurobiological processes that ultimate serve a biological imperative. By interpreting a highly idealized view of our potential mating partner and isolating ourselves with them via pair-bonding and mate guarding, we are more likely to raise physically healthy offspring with sound attachment patterning, subsequently furthering our species. In this way, one could argue, limerent love is an evolutionary adaptation that serves any species who have evolved to endure long gestational periods and extended infant dependency.

Romantic love is exalted in our culture and has been for centuries as an irrational, all consuming, alternatingly euphoric and crushing emotional state. To say that love is irrational is a sound assessment, based on the neurobiological affects present. However, limerent love serves an evolutionary and reproductive purpose, and for that reason, must not be conflated as pathology.

References

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Zeki, Semir. (2007). The Neurobiology of Love. FebsPress. https://doi.org/10.1016/j.febslet.2007.03.094

Blumenthal, S. and Young, Larry J. (2023). The Neurobiology of Love and Pair Bonding from Human and Animal Perspectives. Biology.12(6), 844; https://doi.org/10.3390/biology12060844

Burkett, James P. & Young, Larry J. (2012). The Behavioral, Anatomical and Pharmacological Parallels between Social Attachment, Love and Addiction. Psychopharmacology. 224. 1-26. 10.1007/s00213-012-2794-x

Burunat, Enrique. (2016). Love is Not an Emotion. Psychology.7(14). https://doi.org/10.1016/j.mehy.2019.05.011

Burunat, Enrique. (2019). Love is a Physiological Motivation (like Hunger, Thirst, Sleep, or Sex). Medical Hypotheses. Volume 129, August 2019, 109225. https://doi.org/10.1016/j.mehy.2019.05.011

Cera, N., Vargas-Cáceres, S., Oliveira, C., Monteiro, J., Branco, D., Pignatelli, D., Rebelo, S. (2021) How Relevant is the Systemic Oxytocin Concentration for Human Sexual Behavior? A Systematic Review, Sexual Medicine, 9 (4). https://doi.org/10.1016/j.esxm.2021.100370

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This project was a labor of love and I encourage you to skim it if its length freaks you out (it certainly freaked me out writing it). xx

Abstract

Research on the gender-based diagnostic discrepancy for autism has suggested that autism in women and girls is massively underdiagnosed. This has resulted in an explosion in research on autism’s presentation in females in the last few years, much of it oriented around the theory of a Female Autism Phenotype. The FAP posits that autistic girls present with more pro-social behavior and internalized symptomology than do autistic boys, as well as engaging in more camouflaging behaviors (also known as masking). In my experiences as an autistic sex worker, I found that many of my female-presenting coworkers were autistic or suspected they might be autistic. I posit that masking is an autistic skill that allows autistic sex workers to be successful at their profession, as it allows them to more easily embody the work personas they cultivate to succeed in their vocations. I conducted qualitative research through general interviews of high-masking female-presenting autistic sex workers to learn more about their experiences in regards to barriers to diagnosis, what informed their choice to do sex work, and the relationship between masking and persona.

Keywords: Female Autism Phenotype, Autism in Girls and Women, Sex Work

Introduction

Gender discrepancy in autism diagnosis, as well as its causes, is a well-known phenomenon among autistic people and their allies. This bias is upheld by theoretical, clinical, and social constructions of autism as a male neurotype. Gender bias in diagnosis of autism between boys and girls is estimated by various studies to be between 3:1 (Loomes et at., 2017) and 4:1 (CDC). This margin narrows significantly in adulthood, suggesting that many autistic girls are missed for diagnosis until later in life.

A recent theory suggests that autism presents differently in girls and women than it does in men and boys. This idea was originally theorized by Lorna Wing in 1981, but has only recently become an area of concerted research. The theory of a Female Autism Phenotype is characterized by camouflaging or masking (portraying oneself as neurotypical), a stronger interest in social associations, and niche interests related to relational dynamics (Hull, 2020). As a result of their autism being more in line with normative gender performance, many autistic women and girls evade diagnosis.

According to the Center for Disease Control, less than one percent of American women and girls are autistic (2017). When I first read this number, I was shocked by how many autistic women I have known and, as a result, how low that number seems to me. This is due in part to my work history as a sex worker. Far more than one out of every 100 women I worked with in these environs was autistic. In fact, I would say it was rarer for me to meet sex workers who were neurotypical than neurodivergent. Neurodivergence, and autism specifically, is prevalent among workers in the strip clubs where I have worked specifically, and in discussing this phenomenon with colleagues, I discovered it is a correlation that transcends sectors and is common industry-wide.

Sex work is performance: sex workers often develop a persona to use at their jobs. Persona serves many purposes, including attracting one’s ideal customer, as well as allowing for separation of one’s personal and professional life. Often, one’s persona is an exaggeration of the most ‘desirable’ parts of oneself, while excluding the less desirable aspects. By utilizing persona, female-presenting autistic sex workers attempt to more embody the idealized woman of their clients’ imaginations and thus ‘secure the bag’ (earn more money).

Persona is the Greek word for mask. I do not think it a coincidence that masking is the colloquial term used by autistics to describe camouflaging, a key aspect of the Female Autism Phenotype. I believe these behaviors are related, and more specifically, that the skill of masking for autistic women and girls may be a transferrable to masterfully curating ones persona in the sex trades.

Choosing to do sex work, which is at least stigmatized, if not criminalized, in most parts of the world, is a choice deserving of research in and of itself. Much of the research available on sex work focuses on client experience or originates in the deviance paradigm. What I have discovered in my research is the choice to do sex work for my participants is both a result of interest and skill, as well as a choice based in the need for accommodations not permitted in so-called civilian jobs. Another reason that AFAB autistic women may be prevalent in sex work is because of cultural, institutional, and diagnostic prejudice around what autism looks like; preventing them from diagnosis until adulthood. Additionally, many of the interview subjects alluded to a stigma in their family which gatekept their diagnosis from them. Unlike the experiences of boys who receive diagnosis early, girls were not encouraged to explore their special interests nor receive additional support during school. As a result, while their male peers may be able to join the mainstream workforce with accommodations, many undiagnosed autistic AFAB people may not.

Research Question: Given the prevalence of autism among female presenting SWs, and the fact that many autistic AFAB people evade diagnosis, what are the experiences of camouflaging, masking, and persona for autistic female sex workers and what does this tell us about female autism presentations and the experiences of sex workers in general?

Literature Review

My intention in my senior project is to create a narrative analysis of the experience of autistic sex workers. My first step in this project is to source an explanation for autism’s construction as a male-specific neurotype, as well as to learn more about what prevents women and girls from accessing diagnosis. I will also cite research that explores the relationship between disability and sex work.

Gender Discrepancy in Autism Diagnosis

The discrepancy in Autism diagnosis between boys and girls is well known in both the autistic community, among their allies, and in the field of emerging research. Figures vary, including boys being three to four times more likely than girls to receive diagnosis (Birckhill, R., et al., 2023). This purported discrepancy is additionally supported by the data that many autistic females only receive their diagnosis in adulthood.

The Double Gender Problem

Several theories account for gender discrepancy in autism diagnoses, which can be divided into two categories: at the diagnostic level. bias exists in part because of the way autism is constructed both socially and clinically. Secondly, autism often manifests behaviorally in girls differently than boys. These two factors work in consortium to form what I call the double-gender problem (a nod to the Double Empathy Problem, as coined by Damian Milton in 2012), wherein barriers to diagnosis exist both in the female-specific gendered presentation of autism, as well as the expected presentations of autism which are based in gender bias. In seeking timely research on this subject, I found many articles that used various forms of research to address both aspects of the double gender problem. I will be using the articles below to account for the gender bias in autism diagnosis and substantiate the idea of a double gender problem.

Structural Barriers to Diagnosis

At the structural level, autistic women and girls face barriers to diagnosis through social construction of autism in the media, in the education system, and at the clinical level.

Media

According to the research of Brickhill, R., et al. (2023), mainstream media constructions of autism support a social conception of autism as a specifically male neurotype: “Gendered stereotypes towards autism are also reinforced within the media as stereotypes and stigmas surrounding autism can be strengthened… (examples include) The Curious Incident of the Dog in the Night-Time, Rain Man, The Big Bang Theory and Atypical.” (Brickhill, R., et al., 2023, p. 4). As many laypersons, be it teachers or parents, are the first to advocate for a child’s assessment, public constructions of autism are noteworthy; as they may lead non-clinicians to perceive autism as a ‘boy’s issue’, and thus be less likely to refer girls than boys for assessment.

School

Many autistic children first receive a referral for testing through their schools. This often means that children who express the most unmanageable behavior in the classroom are more likely to be referred for diagnosis. In their meta-analysis, Lockwood Estrin, G., et al. (2021), note that boys are more likely to engage in disruptive behaviors than their girl peers, and that this behavior is more likely to result in a recommendation for assessment by teachers: “…males were more likely to have aggression and hyperactivity and/or attention deficits” (Lockwood Estrin, G., et al., 2021, p. 456).

Clinical

Most perniciously, gender-based autism stereotypes exist at the level of research, assessment, and among clinicians. Much of the original research on autism was on boys, and foundational research such as the Extreme Male Brain Theory and Theory of Mind, though outdated, still informs much of the training provided to clinicians. Brickhill et al. (2023) challenge the clinical construction of autism as biased toward presentations of autism in boys and men, suggesting that “Females are believed to be better able to take other’s perspectives into account. Indeed, theory of mind tasks often reveal a female advantage, as assessed using both behavioral and neural methods of investigation”. In their research, they discovered that subjects that expressed empathy were much less likely to receive an autism diagnosis. Similarly, Lockwood Estrin, et al. (2021) noted that when referred, boys were significantly more likely to receive an autism diagnosis than girls. This is due to clinician and medical provider bias that autism is more common among boys. “Healthcare professionals being reluctant to diagnose a female as autistic and a lack of awareness of ASD in females due to a perceived higher incidence of ASD in males.” (Lockwood Estrin, G., et al., 2021, p. 470). Beyond research and clinician bias, gender bias also exists at the level of testing. Brickhill, et al. conducted original research on the Implicit Association Test (IAT) and the Autism Quotient (AQ) diagnostic tests and concluded that both were biased toward generating a higher likelihood in autism diagnosis for boys than in girls (Brickhill, R., et al., 2023, p. 2).

As a result of biases in the research and assessment level, clinicians demonstrate hesitancy in diagnosing autistic girls. Hamadani et al., (2023) performed qualitative research on both autistic girls and women as well as their parents to better understand their experience of accessing diagnosis and assessment. A pattern emerged of subjects initially receiving diagnoses for symptoms of their autism, and only receiving an autism diagnosis much later. Many of the articles I read found a co-morbidity bias for autistic females specifically, wherein girls and women were diagnosed with “depression, anxiety, obsessive-compulsive disorder, bipolar disorder, eating disorders, and ADHD, among others, prior to being diagnosed with autism.” (Hamdani, Y., et al., p.6). Many of these previous diagnoses were merely manifestations or symptoms of their autism, for which women and girls only received a diagnosis for later in adulthood. Additionally, girls often need to display more behavioral issues in order to access diagnosis, and clinicians tend to be more focused on the quantity of qualifying behaviors rather than the “quality of difficulties, as well as the quantity of presenting symptoms, since females may have a more nuanced clinical presentation.” (Lockwood Estrin, G., et al., 2021, p. 470). This means that women and girls are suffering for long periods of time with misdiagnosis as a result of clinician bias.

The Female Autism Phenotype

In addition to external barriers to diagnosis, autism’s manifestations in women and girls has been historically under researched. In the last few years, however, there has been an interest in the specific manifestation of autism in women and girls centered around the idea of the Female Autism Phenotype, an idea originally researched by Lorna Wing in 1981, who suggested that some girls may be missed for autism diagnosis because they had stronger social and communication skills than their male peers.

Researchers Hull et al., (2020) continue Wing’s theory by suggesting the idea that many autistic women and girls will present with typically reported autistic behavior, but additionally will express more social and relational interest, and are more likely to internalize rather than externalize their problems. Most importantly, autistic women and girls are more likely to engage in a higher level of camouflaging than autistic men and boys (Hull, L., et al., 2020, p. 309). Camouflaging includes suppression of stimming, as well as engaging in mimicry and imitation of neurotypical social behavior in order to better fit in among peers. Because of the skilled implementation of camouflaging, and especially the way it accurately imitates normative gendered behavior, many ‘high-passing’ autistic girls and women are overlooked for diagnosis.

Supporting the idea that many high-masking autistic girls and women are undiagnosed, Belcher et al., (2023) focus their research on “probably autistic women”. They found that these subjects had “higher empathy and general social functioning, and were more likely to have received a diagnosis of Borderline Personality Disorder” (Belcher, H.L., et al., 2023, p. 3118). The authors posit that based on this co-morbidity focus, as well as the higher social skills and camouflaging typical of the Female Autism Phenotype, “Missed autism diagnosis in women is driven by a different presentation of autistic traits than typically shown by men, including less obvious impairments of social functioning and greater internalization of emotional difficulties” (Belcher, H.L., et al., 2023, p. 3119). I anticipate that many of my interview subjects will be self-diagnosed rather than officially diagnosed, as both systemic and financial barriers to assessment abound, especially for marginalized demographics such as sex workers, which is why this research is relevant to substantiate the potential inclusion of ‘probably autistic women’ in my senior project.

Autistic Sex Workers: A Lack of Research

Perhaps unsurprisingly, there exists a dearth of quality empirical research that explores the experiences of female-presenting autistic sex workers. In looking for research on sex work and autism, I found very little. In expanding my research to sex work and neurodivergence specifically and disability in general, the majority of what I found fell into two categories. The first were the experiences of able-bodied workers with disabled clients, and the second, research on the traumatic effects of engaging in sex work that was rooted in paradigms of deviance. I am more interested in worker-constructed perspectives; wherein the choice to engage in sex work is not immediately pathologized and lived experience is centered. I did find two articles that had some relevant information for my subject, but my overall takeaway was that there is a need for more scholarly qualitative research on the experiences of sex workers.

Those of us who have worked in the field of erotic labor or adjacent to it know it to be an occupation wherein disability is common among workers. In her mixed methods analysis, Jones (2022) explores the motivations of disabled and trans sex workers. Jones finds a few overlaps among her subjects. Specifically, her research indicates patterns of flexibility, less conservative workplace culture, and higher rates of pay for less hours worked. “…participants noted that sex work provided the most flexibility relative to other available jobs. Once working in the industry, they felt less exploited, more autonomous, able to honor the needs of their bodies and minds, and reported increased job satisfaction, and in some cases, pleasure.” (Jones, A., 2022). Indeed, many sex work positions are independent contractor, gig-type, or entrepreneurial type work, which allows workers to work in a way that accommodates their disability. As noted by one of Jones’s research participants, “I think for a lot of people with invisible disabilities, sex work is extremely forgiving and allows you to still be able to provide for yourself where traditional employment might [not].” (Jones, A., 2022). Though the question of “why sex work” is often seeped in a pathology or deviance paradigm, the question of why sex work for female-presenting autistic sex workers is perhaps a question both of accommodation and skill leverage.

Beyond scholarly research, there are many public-facing websites geared toward helping professionals and people curious about the psychological impact of erotic labor on sex workers. One such resource I found, Exploring Sexuality and Disability: A Guide for Human Service Professionals from the text Exploring the Intersections of Sex Work and Disability (2023), framed the choice of disabled people to engage in sex work as an economic one based in the gaps of disability programs and the rising costs of living. Additionally, the text suggest that sex work may offer more accommodations than traditional work, as workers with disabilities “may find traditional work schedules and environments incongruent with their daily needs”. Though this text is written for social service professionals, it was one of the only resources I found that wasn’t deeply pathologizing of the choice of disabled people to engage in sex work.

Methodology

For this project, the parameters stipulated qualitative research. While I didn’t have specific quantitative data on the prevalence of autism among female-presenting sex workers, I had substantial informal corroboration based in my own experience and the experiences of colleagues that a correlation was present. While I think a quantitative analysis would be a worthy endeavor, it would be a massive undertaking given the multiple variables involved, including work type, years in the field, full time versus part time status, age, race, location, socio-economic status, legal standing of sex work, and gender. In addition, because there is so little research available on the experiences of autistic sex workers, I was more interested in discovering causal themes through the voices of female presenting autistic sex workers directly. I was open to the possibility that there wouldn’t be overlaps in experience, and anticipated that my interviewees would illuminate gaps in my thinking that I hadn’t considered, which they did.

Methods and Design

I created a digital flyer which was distributed to two sex worker text group chats that I am a part of. A colleague posted my flyer to her sex worker-facing (rather than client-facing) twitter, which resulted in roughly 10 inquiries. I also created a Reel on Instagram calling for participants that included the flyer on my business account, where I am networked with sex therapists, sex workers, and intimacy coordinators. The reel was shared with almost 100 people and viewed by over 2500 unique accounts. I received multiple inquires as a result. Additionally, I directly asked a former colleague because I wanted to include her unique experience as a black woman and stripper specifically. In the reel and on the flyer, I highlighted my own identity as an autistic sex worker, as there is a cultural frustration with research being conducted by people who exist outside our community. Specifically, much policy is created based in research that does not include or accurately represent our voices. As a result, many sex workers cite the quote “nothing about us without us” in regards to participating in research about the filed. Many potential inquires cited that they were put at ease by me ‘outing’ myself in my marketing materials.

As our research was capped at four participants, I responded to all inquiries with the following to ensure potential participants fit the criteria of the study:

In order to qualify for the study please ensure you fit the criteria below.

1. Either an autism diagnosis (official/unofficial from a mental health professional)

-OR-

2. A TOTAL score of over 100 on the CAT-Q Autism assessment: https://embrace-autism.com/cat-q/ (free)

AND

1. Are currently working in Sex Work and have been for over TWO years

(ex: stripping, camming, escorting, pro-domination, adult film performer, sensual massage/Tantra provider, etc.)

-OR-

2. Retired from Sex Work with a career of over five years in sex work.

Respondents were then asked to select a time slot if they fit the criteria. Those who self-qualified through the CAT-Q assessment were asked to share their score with me. All who did so had a score above the average score for autistic females. Those who confirmed a time slot were sent the informed consent form, bill of rights, and confidentiality agreement to sign. Potential participants were also encouraged to sign with their persona name should they not feel comfortable signing their civilian name for their safety. Once I received their signed consent, I scheduled a password protected zoom meeting and sent them the link through encrypted email.

Interviews were held over password protected Zoom and recorded to my hard drive. Interviews lasted from 39 minutes to one hour and 15 minutes. The style of the interviews was informal, where I had a list of 15 questions for participants (available in the appendices), but participants were encouraged to share openly on their experiences beyond simply answering the questions directly. It was important to me that participants were encouraged to share openly about their experiences and perspectives, as I anticipated that new information or patterns would arise beyond what I could have anticipated when crafting my set of questions. Transcriptions were created of the interviews, printed out, and reviewed. Notes were taken and coded, sorted into themes, and then collated into a separate word document which was saved into the previously mentioned password protected folder.

A Note on Gender

As this research is framed in the theory of the Female Autism Phenotype, it became necessary to get very clear on what 'female’ meant in terms of the study. As I was mainly interested in persona, the embodied ‘character’ that one plays at work, I chose to limit my participant pool to those who worked in a female persona. I also limited my participant pool to interviewees who were assigned female at birth and raised as girl children. My logic for this is based in a main component of the Female Autism Phenotype, that autistic girls were more likely to evade diagnosis than their boy peers, both because of male-specific paradigms about autism that exist at the diagnostic and social level; as well the theory that autism manifests behaviorally differently for girls than it does for boys, primarily via masking. For this reason, I chose to include AFAB non-binary and transmasculine autistic sex workers in the study, as long as their work persona was female. I chose to exclude autistic transfeminine and AMAB non-binary sex workers from this study, under the assumption that they were socialized and perceived as male in childhood, and therefore more likely to receive a diagnosis or not fit the criteria stipulated in the Female Autism Phenotype. Additionally, transmasculine sex workers who worked in a male persona were excluded, as the purpose of the study was to find parallels between masking and persona while controlling as much as possible for gender as a variable. For this reason I often use the term AFAB (assigned female at birth) to delineate childhood gender assignment or socialization as separate from participants’ gender identity.

Additionally, those interviewed had a clientele of primarily cis men. For this reason, I often use ‘he’ when talking about clients to differentiate from my interviewees who use she or they.

Participants

JJ: A transmasculine independent full-service sex worker who lives in a major city in the central USA. Late 30’s, Caucasian. Has been in the field for over 10 years.

NS: A black cisgender female stripper working in a major metropolitan city in the US. Late 20’s. Has been in the industry for over 10 years.

VD: A Caucasian cisgender woman in her mid-thirties based in the UK. Working as an independent dominatrix for over 10 years.

WF: Caucasian, non-binary, 20’s based in the UK. Primarily does fetish work both online and in-person. Has been in the industry over five years.

Results

Barriers to Diagnosis

As is delineated in research presented to support the Female Autism Phenotype, autistic girls or those socialized as female are subject to multiple intersectional barriers to diagnosis. These include systemic barriers, family biases, and gender biases. These same barriers were evident in the experiences of my interviewees.

Systemic Barriers to Diagnosis

“I was diagnosed with ADHD and that kind of sent me off on thinking that maybe there was something a little bit more going on. So yeah, I haven’t been officially diagnosed with autism, because, as you know, it’s a huge a huge thing to go through all the hoops it get that diagnosis. But my therapist thinks I probably have autism. And I think I probably do.” (JJ)

“The guy (psychological assessor) said I think it would take so long, its like five years being on the (NHS) waiting list. But he was like de facto, like, you’ve got this.” (VD)

Despite each of my participants receiving high scores on the CAT-Q, only one participant had received an official autism diagnosis. Two of the remaining three had an unofficial diagnosis from a therapist or psychologist. In public health systems such as in the UK, extraordinarily long waits for assessment are common. In the US, one can get an assessment more quickly, but it will cost several thousand dollars. Despite this, all of my participants had a history of previous diagnoses besides autism.

“I was always behind everybody else in my class. And don’t learn how to read until I was 8 or 9 and things like that, which I think, you know, I was diagnosed with a learning disability, but I think also that could have been autism.” (JJ)

“I always had, like a cocktail of different things in my mental chart. I technically have a bipolar diagnosis, even though I was never told about that directly. And you know, ADHD was a pretty early on one... But then I found out there was a lot of overlap. And there was a lot like social things with autism that made a lot more sense.” (N S)

“(I got my diagnosis) when I was 30 from the psychiatrist that I got my ADHD diagnosis from. He was like ‘well you’ve got a hundred percent ADHD, but have you thought about the spectrum?” (V D)

“I knew I had ADHD because I was taking medication like Ritalin or Adderall. I was heavily medicated on those since I was like 10 or 12 through maybe like university. I went to speech pathologists. I went to a whole array of child specialists.” (WF)

Each of the four participants shared a similar story of being diagnosed with multiple other disorders before eventually either concluding or suspecting that they might be autistic, or seeking a professional assessment for autism. This is a common experience of female presenting autistic persons, who often receive diagnosis for multiple other issues prior to receiving an autism diagnosis. As such, burnouts and meltdown become BPD, dyspraxia is assumed to be a learning disability, difficulty focusing as a result of overstimulation is diagnosed as ADHD. This is in alignment with the findings of Hamdani et al., wherein many autistic women are diagnosed based on the symptomology of internalizing behaviors of autism, rather than autism itself. I call this the “charm bracelet” of female presenting autism: after collecting enough ‘sort-of-right’ diagnoses, many women turn in their collection of diagnoses for the correct one: autism.

This hesitancy to diagnose women and girls as autistic is multi-layered. As was mentioned previously, the historical construction of autism at both a clinical and social level has been almost exclusively male-focused. This creates a paradigm where either consciously or unconsciously, clinicians are unlikely or unwilling to diagnose girls with autism. Additionally, autistic women and girls present with more subtle symptomology, and specifically are generally less disruptive and more internalizing with their behaviors.

Family Stigma

Stigma or disbelief that girls can be autistic permeates the clinical realm, trickles through society, and even presents in the family. Many of my participants noted their experience with family stigma as a barrier either to diagnosis or accommodation.

“(Parents) don’t necessarily see it that way… even though things are pretty clear, like, you know, quirky or eccentric, or those sorts of things, like my mom does acknowledge that I’m neurodivergent, but she doesn’t—she associates the concept with like a different meaning, so she’s not really super quick to embrace it, because from her perspective, she’s like, there’s nothing wrong with you.” (N S)

“Like 5 years ago, in my mid 20’s, I found out that I had an autism diagnosis because my mother, in a sort of fit of rage, kind of blurted it out. But in the way that she was embarrassed by it and didn’t want me to know… She like didn’t want me to go through like the sort of ‘special help’, but like kind of tried to push me, like being like, ‘oh if you can just like get over it’, get over these hurdles. If you just try to push yourself, basically, and that like getting special treatment was some sort of cop out, in her mind or eyes.” (WF)

Three of four respondents mentioned that their parents either rejected an initial neurodivergent diagnosis or did not disclose their child’s diagnosis to them until adulthood. Two of the four respondents alluded to their parents’ desire to keep them out of segregated education for special needs children. These parents instead felt their children could excel without accommodation if they applied themselves more.

One participant shared about her husband’s experience, who had an autism diagnosis from an early age.

“He was diagnosed when he was a very young child, so his school life was like, he had helpers. He was told to join Mensa as a kid. He had a full scholarship to Cambridge for psychology, you know, he was like ‘the smart autism’.” (VD)

Autistic children who are diagnosed and whose parents embrace their diagnosis are more likely to get the accommodations they need, learn to their abilities, manage their symptoms, and thus thrive later in life, as this participant’s husband did. Instead, autistic girls often struggle without support or accommodation, frequently left to create their own narratives of why they are struggling.

“Math was a thing for me. I just could not do it. But I could speak 5 languages. I read Oscar Wilde when I was 12. So, you think you’re stupid, you think, well, I’m not doing well in school. So, I must be dumb, but then it’s like, if I was dumb, then would I know 5 languages?” (VD)

Currently, special education programs in the US are two-thirds boys (Kirby, A., 2023), which may speak less to a division among genders of accommodation needs, and more to either gender-based stigma of who gets to receive help and who is expected ‘push through’; or the fact that autism’s manifestation in girls is perceived as less of a challenge for the child. This speaks to larger theme of gender bias.

Gender Bias

Autism is a neurotype that can only officially be assessed for by a qualified psychologist. However, social constructions of autism exist that propagandize a singular archetype of autism through the media in the eyes of the public. In America, this archetype is exclusively male, confounding the issue, as autistic women and girls are unlikely to present in the same way as autistic men and boys, and so are unlikely to be assessed.

“Its like the media what people ingest of like it being like, I dunno, Jessie Eisenberg or like the big bang theory or specific way that its portrayed and like they don’t think of like Amelie or some other like, I’d say Greta Gerwig- coded like characters who are like I would say, autistic.” (WF)

“They think you’re like Rainman, they think you’re retarted.” (VD)

Some well-known female characters have been labeled as ‘autism coded’ in autistic circle. These include Cher Horowitz (Clueless, 1995), Beth Harmon (The Queens Gambit, 2020), and Luna Lovegood (Harry Potter and the Order of the Phoenix, 2003). However, none of these characters is called out as autistic or self-declares as such. Some famous people who were socialized female and who have come out about being autistic include Daryl Hannah, Holly Madison, and Hannah Gadsby. It is worth noting that all six of these of these individuals, fictitious or not, are Caucasian. My strong belief is that autistic women and girls benefit from celebrities and characters coming out with their diagnoses, as it allows for the public to construct a more nuanced imagining of what autism can look like.

Participant Experiences with Autism

Despite the many intersectional barriers to assessment and diagnosis that exists for autistic women and girls, my participants were all able to cite multiple experiences regarding sensitivites, that, upon reflection, were clear evidence that they were autistic.

Sensory issues

“So I have a lot of sensitivities. You know, clothing is hard for me. Heat is hard for me. I used to be a very picky eater, and I’ve kind of gotten over that. But I go through phases where I’m a picky eater still.” (JJ)

“When it comes to sensory stuff, I can’t wear nylon tights, or like leggings, really fitted pants are kind of tough for me.” (N S)

“Certain sounds will send me into a rage, like a violent rage… and like, why do I always have like noise cancelling headphones on. Why do I always wear my sunglasses, you know, until it’s literally dark outside, all these things, I don’t know.” (VD)

Participant Experiences with other Autistic People

For many of my participants, experiences with non-autistic people wherein they felt different or overwhelmed were an indicator that they might have a different neurotype than the majority of their peers.

Social Anxiety

“Those panic attacks and anxiety like I feel like the amount of anxiety I was experiencing as a child didn’t make a ton of sense unless something else was going on, you know, and I don’t have something else to point to.” (JJ FS)

“The social anxiety was a big one. Social situations were always really, really anxious.” (N S)

Social Exclusion

“ I’ve gotten kind of just like used to being excluded from stuff, because its like when you’re autistic, you’re just kind of like the different one. And that’s always kind of been the thing is like the different one. When I started to feel excluded I was really really quick to assume that it was just like okay they’re doing what everyone has done. They are getting rid of me because I am, you know, too odd.” (N S)

“For as long as I can remember, like I said, I was always like too weird for the normal kids, but not weird enough for the weird kids, I just kind of always was in limbo…And I just never fit in. I never fit in and as soon as I kind of was myself, all of a sudden, people just wouldn’t like me. Somebody I’d been friends with for years. As soon as I showed like my true self. I’m weird. I’m different. Im, you know, they just get that ‘off’ feeling.” (VD)

“One of the schools that my older sister went to, they didn’t want me to join, because I was stimming and stuff like that.” (WF)

Being ‘Clocked’ as Autistic

Participants also cited experiences with other autistics as being part of why they began to consider the diagnosis for themselves. For those who came to a suspicion on their own, many cited TikTok and other social media as being a place where they saw other autistic people sharing their experiences, noted similarities, and began wondering if they were autistic as well.

Many cited a close relationship with another autistic person as being a catalyst for their research into the possibility that they might be autistic.

“I noticed that all of my friends are autistic, and I thought, oh, well, there might be something to that. Why we all get along so well, you know?” (JJ)

“When he (the doctor) said it I was like ‘no way’, but then I spoke with my husband (who is also autistic), and when I learned about like, you know masking and being overwhelmed and sensory things and stimming, you know I didn’t know what any of that was, and then I was like ‘holy shit’.” (VD)

“…social media kind of giving light to-- especially women-- who have like audhd and different types of autism.” (WF)

“I have a friend who is autistic and she and I went to high school together. At one point she said, ‘do you think we got bullied so much because we were autistic femmes?’, and like we have never talked about being autistic before so I was like…that kind of started me on my journey of discovery.” (NS)

Why Sex Work?

The choice to engage in sex work is influenced by numerous factors, including personal ability and comfort, as well as external variables such as navigating stigma, legality, and safety. Despite the enormity of differences among sex workers, several themes emerged among those interviewed as to why they chose to engage in sex work, primarily: disability accommodation, interest, and ability.

Sex Work and Autism: A Disability Justice Issue

Difficulties with ‘Civ’ Jobs. Half of the participants mentioned that a large part of the reason they chose to engage in sex work was because they struggled with working a civilian job.

“When I started they gave me a bunch of accommodations without me even really stating that I was disabled. I just kind of said you know, I want to come into work at 10, because its hard for me to come in at 9, and so for, like a couple of years they let me have accomodations, and then they just took them, you know, pulled the rug out from under me, and then I had… I struggled from that point forward to be able to do the job. So eventually I quit and did sex work.” (JJ)

“I could never live a 9 to 5 life. I couldn’t do it. Like I said, I did it for a couple of years. It literally drained me, I think by the end of it… You lose every sense of yourself, and you stop feeling like a human. Just like a drone, yeah, like you are not human. You are just like a little worker bee. And you come home and just collapse like you like your bones… just like, you’re just dead.” (VD)

Jobs that require long periods of masking for autistic people without accommodation can eventually cause burnout, as participants noted above. Unlike working in an office or for a company, most sex workers are independent contractors or fully self-employed, and so are able to design their work lives around the accommodations they need. Participants stated that the primary benefit of being a sex worker was creating a schedule that allowed them downtime between periods of masking.

“I really put effort into making my schedule something that I can actually sustain. This is the only work I found that I could do that with, you know. One huge difference is the amount of hours, you know, like… I’ve done multi days with clients, but you know, I take time away from them and try to structure it as best as I can to get my unmasking time. But yeah, like when you’re at work for 8 hours, you have to mask for 8 hours, but if you’re with a client for one hour, that’s only one hour of masking.” (JJ)

“You know you’re with somebody for 2 hours, and then I can do nothing for 2 hours or 2 days, and then I can work again. So it’s a lot more compartmentalized and easier to manage your energy. (I get to) be my own boss and have my own schedule, because right? No way am I waking up at 7 you know, all these things, same with my husband, to where we’ve just made this cozy little life for ourselves, where we just have our own schedule. We do what we want. We’ve just made it work, I guess, out of necessity, cause you don’t live in the real world. The normal world.” (VD)

Other benefits participants cited were being able to engage in preferred routines, work during non-traditional hours, and spend more time at home.

The Need for Clarity. The majority of participants shared that they value the transactional nature of their profession, which allows them to have direct communication and avoid ambiguity.

“The rules are really clear, and things are straightforward, and I think, having something be so directly transactional, its like a comforting level of straightforwardness. Theres not so much like reading between the lines. ” (N S)

“Having this really clear cut guideline to be like, okay this is like within the session, this is the expectations. And like the negotiation of like okay, what am I comfortable offering and what do they want? And that really appealed to me that kind if laying that out. I found ambiguity really off putting.” (WF)

A common complaint of autistic people made by neurotypicals is that we take things literally, or have difficulty reading between the lines. In my experience with neurotypicals, I often have to ask for direct communication, because they can be quite evasive for fear of conflict or confrontation. They will often end the relationship rather than engage in direct communication because it is so uncomfortable for them. When working in a strip club, prices and what is included are usually set by a club and stated for a dancer. When working independently, providers and Dommes set their own rates and offerings. It is considered poor manners on the part of a client to ask for off-menu items or to attempt to haggle over pricing, and often results in the client being blocked from communicating with that provider, and/or added to a black list, especially if the client has no previous relationship with the provider. Clear communication and explicit boundaries were a commonly stated benefit of sex work for those interviewed.

Sex Work as a Special Interest or Overlapping with a Special Interest

The majority of the autistic sex workers I interviewed mentioned that they had been interested in sex work from a young age.

“My first interest was always sex work, like I think I found out about the concept of sex work when I was 12. I saw a woman, Brooke Hogan, she had that show Brooke Knows Best… So I was 9… and she took a pole dancing class. That’s when I was just like really, really fascinated by pole dancing. And then I found out about the concept of sugaring when I was 12, and from there it was just kind of like, that was a like the deep fascination.” (NS)

“My very French primary school was actually next to a strip club. One day my name was on the sign—[redacted] mistress of leather and lace or something, and I was like,’ that’s me! That’s my name! I’m gonna be stripper’, like in my head, at seven years old.” (VD)

There is a common adage that ‘no little girl dreams of growing up to be a stripper’, but my research would suggest otherwise. Additionally, many respondents shared that their sex work job overlapped with one or more of their special interests, including specific kinks, the medical field, and fitness. Sex work is often framed as a choice made out of desperation, but for many of my participants, it was a choice made out of an early interest and curiosity.

The Overlap between Talents Grounded in Autistic Modes of Cognition and Sex Work Skills

Beyond preference, my interviewees shared with me that they felt that being autistic also uniquely informed their ability to do sex work, as well as gave them unique strengths that allowed them to excel in their profession.

Navigating Stigma. One aspect that came up quite often was that participants felt they were better suited to navigate the stigma of sex work than allistics.

“(SWs) are usually the people that are kind of already used to being outcast a little bit. Like if you’ve never had social approval, you’re not really losing anything when you get into stripping. But if you’re used to kind of like standing in the sun there, I could see how this job would be like repelling a little bit, because its like you’re used to having their cheers, their support. There’s a quote, its like, ‘I don’t care about your boos cause I’ve seen what makes you cheer.’ Like we can’t really dance for their applause, because it’s like, we’ve never gotten it.” (NS)

“I’d already like been through this like day job that didn’t work out, you know, quitting every other job, hating normal life, that by that point I’d adapted my life around my way, to where I was like, I’ve reached ‘the fuck it’ stage of life where I do what I want. I don’t have to answer to anybody…Like obviously this job, people have a problem with, you know, this kind of work. Like neurotypicals, they can’t. The stigma is too much for them. For us, we’re like, who cares? We’ve already reached that ‘I don’t give a fuck’ point.” (VD)

“But I never was like, oh, I’m gonna actually do this professionally, ’cause it was when I was also at this point in the United States, about like legality, and like also just having these things being released and just stigma and slut shaming. So, whilst I was like interested in it, I also was like, this has to be secret and private, and also I won’t be able to like actually, you know, explore it more because I had a lot of negative internalized associations. But when I came to the UK was when I was really more like, the ‘fuck it’ button, that was brought forward, but also because I felt a bit like, because sex work is legal.” (WF)

Whether as a result of getting to a point where they no longer cared about others’ perceptions, or because they were already used to a level of ostracization from growing up neurodivergent, autistic sex workers may be less impacted or influenced by the stigma associated with their professions than would allistics (non-autistic people). This may be a reason why we see more of them in the field.

‘Spidey Sense’. Historically a conception of autistics is that they are less empathetic than non-autistics. Surprisingly, many of my participants cited being able to ‘read’ their clients beyond what they were simply saying as a unique skill that they felt was in part due to their autistic neurotype.

“I think it (being autistic) makes me better. I think it makes me a lot more in tune… and to kind of be able to see deeper, so we can see beyond just what people say… and that helps you make more money, ‘cause you know, they feel like you’re almost psychic in a way like… I think it just makes us more empathetic.” (ND)

“There’s this thing that I think is associated a lot with like people with autism and animals, it’s like a kind of non-verbal communication… tuning into sort of things that aren’t in those social contracts of polite society. But even sensing that someone is overstimulated like in a restaurant or something… it’s kind of like being able to pick up on those cues I think are really important.” (WF)

While respondents shared a preference for direct verbal communication, and often felt they had a hard time deciphering tone in a text message, it was fascinating to hear that they self-reported as perhaps being more skilled at picking up on subtle body language or being adept at reading people in person beyond what was communicated at a verbal level.

Masking as Transferrable Skill to Persona.

It was my personal theory that there might be a relationship between masking and persona; that perhaps we find so many AFAB autistic people in sex work in part because of their skilled masking abilities. Perhaps these masking skills are in some way transferrable to the sex work skill of curating and/or embodying a persona.

Persona. [New Latin, from Latin]:

a. An individual’s social façade or front that especially in the analytical psychology of Carl Gustave Jung reflects the role in life the individual is playing.

b. The personality that a person (such as an actor or politician) projects in public.

Masking.

a. Strategies used to hide Autistic characteristics or portray a non-autistic persona.

The concept of persona is an important aspect of being a Sex Worker. Much like a musician or a politician, sex workers cultivate a public-facing image for the purpose of appealing to a specific client or creating a specific sort of dynamic with their audience. For safety and legality, the vast majority of sex workers (inclusive of strippers, online performers, and in-person service providers) use a pseudonym in their professional lives to maintain a level of anonymity and avoid doxxing. Professional Dominatrixes will also generally use an honorific in their names to indicate their status in a D/s dynamic, such a ‘Mistress’, followed by a pseudonym. Specific names connote certain images and ideas, and thus name choice in certain industries of sex work is a large component of the curation of one’s persona. One wouldn’t expect a Mistress Evil to be the girl next door, any more than they would expect a Susie Cupcake to provide topping heavy medical torture scenes. While a pseudonym is not a persona, it is an important aspect of it.

I was surprised to learn that for my participants, none really felt that they were playing a “character” when in their persona, as much as they were projecting a version of themselves. The idea of fully creating or embodying a character was deemed too challenging a task for most of my participants.

“She’s really me, you know, it’s not like some sort of crazy, fictionalized character. It’s like, ‘shiny’ me, basically. So that’s what I consider my persona to be, because it would be too much for me to keep up with a ton of lies. I just keep up with the easy ones. I can’t even untangle it, you know. I don’t know if I’m masking or doing a persona, or what I’m doing.” (JJ)

“I definitely play more of a spicy, dominant role at work. And not necessarily a spicy, dominant person outside of work. But like my persona, like my back story, none of that changes. I realized that, like lying being a part of my hustle, was giving me a lot of stress.” (NS)

“Its funny I don’t think I have a character, but my husband knows immediately when I turn it on. I think it would be exhausting to be a mean bitch all the time. Its like a different side of me. It’s not putting on a character. It’s not putting on. Its just tapping into another side of you, cause I’ve always been very dominant. I’ve been very feisty and very interested in everything I do with my job.” (VD)

Persona, like masking, is an attempt by sex workers to obscure certain parts of themselves while highlighting others. In this way, persona is similar to masking in other jobs or in social situations. In sex work specifically, participants noted that they focused on sharing the more likable aspects of themselves in order to get the outcome they desired: generally, positive customer regard and retention.

“(Masking) is like specific to the experience you want to have with them.” (NS)

“It’s very similar to what you’re doing when you’re in a customer service position. But you know, like, when you’re doing customer service, you’re smiling. You’re saying things you would never normally say, kissing ass in ways you find degrading, and all that kind of stuff, so. Yeah, you pretend. Calling it customer service is very much how I would sum it up. It’s like, it’s me. But it’s my customer service version of me.” (JJ FS)

“We have our ‘phone voice’… it’s kind of like putting on your phone voice.” (VD)

One participant who is transmasculine brought up that masking and persona for them was also about performing gender specifically.

“The expectations that I am a woman, and they’re having sex with a woman, the performance you put on to play that, and me, recognizing it is a performance, makes me think more and more about gender, you know.” (JJ)

Participants noted that masking and persona were very similar, even almost interchangeable terms for them. Persona often was used when describing a curated identity for a larger audience, either through online branding and marketing, or a stage set in a strip club; while masking was used to describe one-on-one interactions. Persona may be more about fantasy curation for potential clients, while masking is the behavior sex workers use when with clients to maintain the client’s persona-based fantasy: that he is liked, that she enjoys his company, that she finds him and his behavior eroticizing, that he is safe, or that she is interested in him.

“Masking comes so naturally to me that I can really convince a client very quickly that I like him and make him feel comfortable, and you know all that kind of stuff. I think masking helps with making them feel comfortable.” (JJ)

“I think it’s (persona) not as much masking as I did like in a 9 to 5 or when I was in school, but I think it’s more about hiding parts of yourself. You know, it’s about hiding ourselves. It’s about protecting ourselves. You have to kind of put your strong armor on.” (VD)

“The aspects that I think show up are a lot of the imaginative and performative… the masking, like being able to flip in and out of different roles, and that’s sort of camouflaging to different people, being that kind of adaptable, as it were, like the skills I think are homogenous… It feels quite tiring at times. Persona fatigue, that is absolutely what happens.” (WF)

Conclusion

In conclusion, I believe my findings are in alignment with, and further substantiate, the Female Autism Phenotype theory. My participants were all assigned female at birth, raised as girls, and shared similar experiences regarding barriers to diagnosis, including gender and family-based biases, multiple other diagnosis that focused on their symptoms, and ultimately coming to suspect or discover they were autistic in adulthood. Subjects also shared about their internalizing autistic symptomology and many expressed difficulties maintaining traditional, or so-called ‘civilian’ jobs. Barriers to accommodation in these jobs also framed the decision to do sex work as a disability-justice issue for the majority of my participants.

“There’s so many people who just like to argue against sex work and the idea that it is degrading, and you shouldn’t—no self loving person would ever turn to that, blah blah blah. And my main thing is just that like, we need better disability justice and we need better workplace conditions. We need to live in a non-ableist society before we can solve the problems of sex work… I don’t think sex work is necessarily empowering, or any of the bullshit, I just want to be able to do it, because it’s the only thing that I can do to make money, and I’m not the kind of disabled that they give you benefits for. So I would just encourage people who think that they’re against sex work to think about the reasons that people might chose to do it..” (JJ)

The stigma against sex work as a vocation is often framed in the idea that it is a deviant choice, or one that a person would only make under coercion or in a state of extreme desperation. This was not the experience elucidated by my participants. Reasons given for engaging in the field of erotic labor beyond accommodation needs include a direct interest in sex work, an overlapping special interest, or discovering that they were particular skilled, and therefore successful, at it.

Many of these sex work-specific skills, including reading people, navigating stigma, and the overlap between persona and masking, were suggested by participants as being potentially related to their autistic neurotype. As was articulated by one participant, perhaps sex work is a job that autistic people seek out because of these intersections:

“This job definitely seems to appeal to autistics for sure, because it’s like, people who are already kind of comfortable tailoring certain parts of themselves to the audience and having like, the clear outside boundaries, and the people who are like comfortable being judged on this level” (NS)

In this way, one could argue that perhaps sex work is a valid or even essential labor option for autistic AFAB people. My experience in discovering that many of my stripper coworkers were autistic, and that this trend permeated many arenas of the sex industry, was validated by my participants:

“Obviously I know some neurotypical workers, but I know very few, I would say. Most of the workers I know seem to be on the spectrum to me. Many of us are queer, many of us are trans, many of us are not monogamous. I’ve wondered what these similarities mean.” (JJ)

Further research is needed in general in the field by sex workers on the experiences of sex workers to fight false rhetoric that endanger us by exposing us to more stigma and policing. As more scholarship comes forward that frames the choice to engage in sex work as a disability justice issue, rather than a criminal one, my hope is that decriminalization will be inevitable. Additionally, more research is needed around AFAB presentations of autism, so that girls needn’t wait until adulthood to secure diagnosis. Perhaps as autism is further destigmatized among women, diagnostic barriers will decrease, and allow for more accommodations made for girls at the school and professional level. Although I feel strongly that sex work is a valid vocational choice, it is not appropriate for everyone, and autistic people who do not wish to do sex work, either for religious reasons, trauma, or personal preference also have a right to right livelihood. In a reality where survival for most is tied to wage labor, de-stigmatization of both sex work and accommodation needs for autistic people in essential for our collective survival under capitalism.

References

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Birckhill, R., Atherton, G., Piovesan, A., Cross, L. (2023). Autism, thy name is man: Exploring implicit and explicit gender bias in autism perceptions. PLoS ONE, 18(8). https://doi.org/10.1371/journal.pone.0284013

Butler, Judith. (2006). Gender trouble: Feminism and the subversion of identity. Routledge.

Centers for Disease Control and Prevention. (2017). CDC key findings: CDC releases first estimates of the number of adults living with autism spectrum disorder in the United States. US Center for Disease Control. https://www.cdc.gov/ncbddd/autism/features/adults-living-with-autism-spectrum-disorder.html.

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Hamdani, Y., Kassee, C., Walker, M., Lunksy, Y., Gladstone, B., Sawyer, A., Ameis, S. H., Desarkar, P., Szatmari, P., & Meng-Chuan, L. 2023. Roadblocks and detours on pathways to a clinical diagnosis of autism for girls and women: A qualitative secondary analysis. Women’s Health. 19. https://doi.org/10.1177/17455057231163761

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Glossary of Terms

Civilian job: A non-sex work job.

Doxxing: Deliberately outing a sex worker’s identity or other information with the intention of causing them violence or harm.

Full-service: A sex worker whose services include intercourse.

Independent worker: A sex worker who does not work for an agency or under a pimp/management.

Outing: To reveal one’s own or another person’s status as a sex worker.

Stripper: A sex worker who performs stage dances and/or lap dances in a stripclub or so-called ‘gentleman’s club’, inclusive of ‘strip tease’ or ‘pole dance’, for tips and income. Also called an ‘exotic dancer’, many strippers prefer to be called ‘strippers’ to differentiate them from non-sex work or non-tipped dancers.

Domestic terrorism in the form of mass public shootings has become endemic to contemporary American society. According to the Rockefeller Institute, incidents of mass shootings have steadily increased over the last 50 years (Rockefeller Institute of Government, 2022). While the public struggles to understand the reason for this, citing mental illness, gun control issues, or violence in the media; those tasked professionally with the honor of protecting the American people from such threats have identified a major theme among these terrorists: Misogynistic Extremism.

Misogynistic Extremism is a set of beliefs that includes entitlement to, and simultaneous hatred of, women in general and women’s sexual or romantic attention specifically. Misogynistic extremism is inclusive of the term incels, which is an abbreviation of the term ‘involuntary celibate’, originally coined as ‘invcel’ by a queer Canadian woman to mean a person who would like to be having sex but struggled to find sexual partners (Love Not Anger, 2019). The term was later co-opted by male supremacists and has come to mean men who are unable to sexually access women, they believe, due to their genetically pre-determined unattractiveness (Bates, 2021).

Misogynistic Extremism is also inclusive of red-pill and black-pill theory, the former being the foray of contemporary male supremacist leaders such as Jordan Peterson, Andrew Tate, and the pick-up artists featured in Neil Strauss’s The Game (2005); who attempt to manipulate and control women in order to get romantic and sexual access to them. Black pill theory is when one accepts the futility of navigating the ‘rigged game’ in which women will reject them for sexual or romantic partnership and instead chose to partner with men who are more attractive (Kersley, A. 2021). The most lauded recourse in these groups, in which depression is quite common, is to opt to commit suicide, but to ‘not go out alone’, and instead take down as many people (specifically women and successful heterosexual couples) as possible in an act of mass violence. This is an homage to the incel patron saint, Elliott Rodger, who wrote a 137-page manifesto that attempted to justify his desire to kill all women and the men they partner with, before going on a murder spree in Isla Vista where he stabbed and shot six people to death. It is important to note that this ideology is often intersectional, with strong overlaps in other far right extremist beliefs, inclusive of the great replacement theory—that belief that white people, though superior, are being bred out by minorities (Faehrmann & Zech 2023).

The Overlap Between Misogynist Extremism and Domestic Terrorism

Terrorist violence is unique when compared to other acts of violence, in that it intends to “primarily attack noncombatant populations and exploit the psychological impact of these attacks in their efforts to bring about change to the current political system” or to accomplish a desired societal order (Kupper, 2022). In addition to the unique intentionality of their acts of violence, terrorists are unique in that there acts of violence are usually preceded by a period of indoctrination and radicalization. For Misogynist extremists, this usually occurs over the internet in incel chatrooms. “Almost 1,000 references to dehumanizing misogyny or violent action are recorded each day in the incelosphere as the toxicity of male supremacist content continues to intensify (Townsend, 2022). Obviously, having fringe beliefs, inclusive of the idea that “sex is their inherent birthright as men, and that rape and murder are appropriate punishments for a society they perceive as withholding sex from them (Bates, 2021)”, is not evidence enough to arrest someone for terrorism. However, calls for acts of violence, inclusive of rape and mass civilian slaughter, are common on the forums.

As a result, many government groups charged with protecting the American public have come forward to identify that male supremacist ideologies may be a key indicator in profiling domestic terrorists. According to the Domestic Terrorism Strategic Report of 2022, co-published by the Federal Bureau of Investigation and the Department of Homeland Security, “We assess that involuntary celibate violent extremists (IVEs) pose a persistent threat of violence against women, heterosexual couples, and others perceived as successful in sexual or romantic pursuits” (p. 44). Since the Isla Vista killings, as many as 52 people have been killed by self-identified incels in domestic shooting sprees. According to John Horgan, a deradicalization expert at Georgia State University, there is evidence to suggest the misogynistic extremism trend toward terrorist violence is growing. “Incel-inspired violence is a threat to public safety. So we have no choice but to take it seriously.” (Kersley, 2021).

Interventions and Preventions

Male extremist violent terrorists tend to leave a significant trail, often years or months long, usually deliberately stating their intentions both verbally and in public online forums. Additionally, their behavior is not isolated to their online communities, and tends to predictably raise concern in those who encounter them well before they enact large-scale violence. An example of this is the first incel who was arrested for a hate crime before he was able to enact his terrorism plan, Tres Genco of Ohio. Genco was found out before he could enact his plan because his mother called the police after he had threatened her, and they took her seriously when she said that he had become increasingly aggressive. Because they headed her warnings, the police searched his home and car, finding his manifesto and the armory he had collected to enact his plan to murder women on a college campus.

According to the US Secret Service National Threat Assessment Center, “attackers tend to demonstrate observable concerning behavior across a variety of community systems, which often elicits concern in bystanders before violence occurs. This case study (the 2018 Tallahassee Hot Yoga Studio Massacre) describes how the attacker’s misogynistic views and associated behaviors resulted in him being fired from multiple jobs, banned from public locations, and being arrested” (United States Secret Service, 2022). In both instances, it becomes clear that those who witness such casus belli would be smart to report it, and that authorities have an obligation to take these warning signs seriously.

The Role of the Community and the Bystander Effect

In our text The Social Animal (Aronson & Aronson, 2018), the authors addressed a theory of the diffusion of responsibility (p. 134), in which if multiple witnesses are present to an emergency, individuals may feel less obligation to intervene than had they witnessed the situation alone. This is in part due to the social psychological phenomenon of conformity, in which due to the bystander effect (p. 134), “the mere presence of another bystander tends to inhibit action”. This may account for why Greco’s mother was willing to alert the police to her son’s dangerous behavior, but those who worked with the Tallahassee shooter did not.

Increasing and appealing to the idea of personal responsibility to report misogynistic extremist threats of violence may be beneficial in arresting potential terrorists before they are able to enact their hate crimes. In America, where hyper-individuality is a prized social conceit, I propose that a public campaign encouraging people to report misogynistic extremists’ violent rhetoric under the umbrella of “see something, say something” would be beneficial. Appealing to the individual ideal of heroism, or ‘being a hero’, by framing reporting as pro-social, altruistic, and heroic could be most effective in helping create social awareness and a feeling of public responsibility in stopping terrorism before it occurs.

The Role of the Police

Additionally, local police will need to be educated about the relationship between specific forms of criminality and misogynistic extremist terrorism. Currently, police are likely to investigate only one in five cases of domestic violence, and only three of five investigated will result in arrest. Unfortunately, “in more than two-thirds (68.2%) of mass shootings analyzed, the perpetrator either killed family or intimate partners or the shooter had a history of domestic violence” (Geller et al., 2021). Perhaps if local police departments were educated by federal law enforcement on this correlation, they would take accusations of domestic violence more seriously.

There are deradicalization interventions that exist with some level of success that may be effective in helping misogynistic extremists move away from their fringe beliefs before enacting violence. For most incel dropouts, this involves a level of engaging with the pluralistic world: entering the workforce or school, and forming relationships with people who share different worldviews (Kersley, 2021). There is also an argument to be made for educational programming that humanizes women in the eyes of the public to combat the idea that they are sexual service providers and objects.

Frankly, I am less interested in using limited government resources to reform inherently anti-social ideological extremists than in preventing their hate-fueled acts from occurring. Fringe beliefs will always arise in historically privileged groups who suddenly find themselves less favored as they attempt to ‘right’ ever-shifting cultural power dynamics in their favor. For this reason, I favor a dual prong approach to fighting misogynistic extremist violence: targeting the diffusion of responsibility effect of conformity as outlined in our social psychology course this summer (namely through appealing to cultural fantasies around individual heroism); and educating local law enforcement on what federal law enforcement already knows: that violent criminality (specifically domestic violence) and incel beliefs are often correlated with future acts of terrorism.

References

Bates, L. (2021. August 11). The Incel Movement is a form of extremism and it cannot be ignored any longer. The Guardian. https://www.theguardian.com/commentisfree/2021/aug/17/incel-movement-extremism-internet-community-misogyny

Federal Beaureau of Investigation & Department of Homeland Security. (May 2021). Strategic intelligence sssessment and data on domestic terrorism.

https://www.fbi.gov/file-repository/fbi-dhs-domestic-terrorism-strategic-report.pdf/view

Faehrmann, A. & Zech, S. (2023). The great replacement in the Manosphere: Implications for terrorism. https://gnet-research.org/2023/11/30/the-great-replacement-in-the-manosphere-implications-for-terrorism/

Fugardi, R. (2024, March 1). First misogynist incel sentenced on federal hate crime charges. The Southern Poverty Law Center. https://www.splcenter.org/hatewatch/2024/03/01/first-misogynist-incel-sentenced-federal-hate-crime-charges

Geller, L. B., Booty, M., Crifasi, C. K. (2021). The role of domestic violence in fatal mass shootings in the United States, 2014–2019. Injury Epidemiology. 8(28). https://doi.org/10.1186/s40621-021-00330-0

Kersley, A. (2021, October 23). How do you deradicalize an incel? Wired. https://www.wired.com/story/how-do-you-deradicalise-an-incel/

Kupper, Julia. (2022, May 5). Preventing attacks using targeted violence manifestos. FBI Law Enforcement Bulletin. https://leb.fbi.gov/articles/featured-articles/preventing-attacks-using-targeted-violence-manifestos

Lankford, A. & Silva, J. R. Sexually frustrated mass shooters: A study of perpetrators, profiles, behaviors, and victims. Sage Journals. 28(2).
https://doi.org/10.1177/1088767922110697

Love, Not Anger: Beyond Involuntary Celibacy (2019). About. https://www.lovenotanger.org/about/

McCain Institute. (n.d.). The threat landscape: Incel and misogynist violent extremism. https://www.mccaininstitute.org/wp-content/uploads/2021/10/incel-and-misogynist-violent-extremism-read-ahead-materials-august-2.pdf

O’Toole, M. E. (2000). The school shooter: A threat assessment perspective. US Department of Justice & Federal Bureau of Investigation. file:///Users/admin/Downloads/school_shooter.pdf

Rockefeller Institute of Government. Mass shooting factsheet. https://rockinst.org/gun-violence/mass-shooting-factsheet/

Schildkraut, J., Formica, M. K., Malatras, J. (2018, May 22). Can mass shootings be stopped? The Rockefeller Institute of Government. https://rockinst.org/issue-area/can-mass-shootings-be-stopped/

Strauss, N. (2005). The game: Penetrating the secret society of pickup artists. ReganBooks.

Townsend, M. (2022, October 30). Experts fear rising global ‘incel’ culture could provoke terrorism. The Guardian. https://www.theguardian.com/society/2022/oct/30/global-incel-culture-terrorism-misogyny-violent-action-forums

United States Attorney’s Office, State Department of New York. (2021, December 15). Peekskill man who identifies as an “incel” or “involuntary celibate” pleaded guilty to stalking multiple victims [Press release]. https://www.justice.gov/usao-sdny/pr/peekskill-man-who-identifies-incel-or-involuntary-celibate-pleads-guilty-stalking

United States Secret Service. (2022, March 15). Hot Yoga Tallahassee: A Case Study of Misogynistic Extremism. https://www.secretservice.gov/newsroom/releases/2022/03/secret-services-latest-research-highlights-mass-violence-motived-misogyny

I use specific protocols to help address these issues wherein I basically rewire their entire sexual system. We switch their arousal matrix to a different part of their nervous system, re-map the body for more nuanced pleasure, and follow a specific (but bespoke) retraining of their erogenous tissue to replicate the kinds of sex they want to be having. I use a lot of metaphors (sports! the Karate Kid!) when talking with clients because the work is heavy science nerd shit, but at times feels really woo-woo (especially in the beginning). Most of my clients are very normal guys: IT specialists, bus boys, project managers, teachers, retirees. They’ve usually gone to a few doctors and a few sex workers before they see me. Most of them are in therapy. By the time they get to me, they’re pretty worn down and willing to do the annoying, frustrating, and somewhat bizarre stuff I ask of them (breathing exercises, anyone?).

A large part of my work is myth busting. A lot of men don’t know that much about sex, and the ones who do have a lot of incorrect information. Even if they got sex ed in school (and most didn’t), it wasn’t comprehensive, and they have had to get most of their learning in the field (if they’re lucky) or from pornography (which is like learning to drive by watching formula one, as Emily Nagoski says). I find a lot of my job is normalizing imperfect, non-porn star sex for my clients. Normalizing, for example, that some level of losing an erection is normal for everyone! It happens to 25 year olds, it happens to millionaires, it happens to rock stars. Even professional male escorts keep viagra in their dopp bags because the truth is: the penis is emotional.

(above image from one of my all time favorite movies, Forgetting Sarah Marshall)

A lot of our language around the penis hides its true nature. Its gets “hard”. It penetrates, it fucks, it slams. It’s a sword, a cock, a tool, a prick, a dong, a knob. But I like to think of the penis more as a divining rod. Often, the penis reveals the penis-haver’s true feelings. Sure, sometimes it’s about their partner, but also their day, their stress levels in general, previous trauma, their masturbation habits, or their health. That’s why when working with clients I always make sure they get a comprehensive physical, prefer that they are in therapy, and ask a lot of questions about not just their sex lives, but their life in general.

I’ve been known to say that a lot of sex problems are actually gender problems. We have expectations around the penis that are similar to our cultural expectations of men: unswayed by emotion, perpetually reliable, hard-working, put-your-head-down-and-get-the-job-done-no-matter-what, NO FEELINGS ALLOWED (except being horny or angry, but only when appropriate). I tell clients they want their penis to work the way I want my car to work: push to start. But the penis is emotional, sensitive, truth-telling. Erectile dysfunction specifically is often a symptom of a larger problem, not the problem itself: diabetes, blood pressure issues, underlying negative core beliefs, a lack of safety, fight or flight. Yes I work with clients to help them have a more reliable erection, but we also work on building compassion, understanding, and a better relationship with their genitals; all while divesting from outdated and harmful ideas about sex and masculinity. Having a penis is sort of like having a really great companion dog who alerts you when something is amiss: build a trusting relationship and you’ll have a best friend for life.

Its been two weeks since the fires. I’m in a state of overwhelm and freeze after returning to the city where the evacuation line was blocks from my door and several of my friends have lost their homes. My friend Evelyn has come over to help me clear the yard. We’re sweeping and hosing the ash off my patio in makeshift hazmat suits of trash bags, pink latex BDSM gloves and Home Depot particle masks.

Evelyn is one of those people with an encyclopedic knowledge of plants. You can point to any plant: in a shop, the neighborhood, or a book and she’ll know the latin name for it and what species it belongs to, its sun and soil preferences. I can’t even keep a Pothos alive. I once even killed a snake plant.

My neighbors have built a 2-story ADU in their backyard, which unfortunately has ruined my view of the Verdugo mountains, but I’ve resolved to not be a NIMBY about it. LA is in a housing crisis, after all, and the solution is more housing. Instead, while I have her here, I’ve enlisted Evelyn to help me design a barrier between the new build’s second story window and my kitchen so the new tenants won’t see me making coffee in the nude. We have decided on a lattice, white and wood (an homage to the house's white picket fence) at the base of which we will plant climbing plants. I want to plant Lilac at first, nostalgic for early summers in New England. Evelyn talks me out of it, but knowing I love stinky flowers and want to encourage more hummingbirds and butterflies in the yard, she suggests a few different kinds of jasmine.

I ask about Bougainvillea, the Cookie Monster Pajama Pants girl of Southern California backyards. Ubiquitous, dramatic and aggressive, taking over yards at a rapid rate; but loved for their hot pink paper-like flowers. The one in my neighbor's yard gets hacked back twice a year like a poodle with a bad hair cut, only to be blocking their parking spot again a few months later. I assume, as a plant nerd, Evelyn will react as if I have asked someone who works in music how they feel about Coldplay. She does, her side eye barely restrained under her mask, if only out of love for me. She explains like she is telling a 4 year old where babies come from, that, as someone who can barely be trusted to water a cactus, let alone prune something before it comes through the kitchen window, Bougainvillea are not for me. She also tells me that they only explode in their pink flowers when stressed, a sort of ‘violins on the Titanic’ attempt at propagation before they perish. A laugh gets stuck in my throat as the sexologist in me reaches for the horticulturalist at my side: “Oh my god! We’re just like plants!”

As someone who recently turned 40, I pay distinct attention to my menstrual cycle, awaiting the coming irregularities of perimenopause. Because of this I know I am not yet in my ovulation window, which has me wondering why I find myself sighing heavily in my office, or making totally unnecessary small talk with the soft butch behind me at the library. Why I put on the button up shirt with a button missing over the apex of my breasts and decided to wear it anyway. But Evelyn’s insight has me thinking: perhaps I’m sprouting my own flowers.

My friends have expressed the same– a quiet desperation toward sexual connection simmering under the surface. I fantasize about sneaking a kiss with a friend who has a girlfriend, smelling my colleague’s hair who has just lost their home as they cry in my arms. Is it a desire for connection, reproduction, aliveness? I think some combination of the three. I have noticed for myself there are different forms of, ahem, amorousness: periods where I want to be taken roughly, periods where I want to feel skin on skin with someone I cherish. Usually the former happens right before my period, my ‘monthly day of heterosexuality’ as I have taken to calling it. The latter is more likely to coincide with ovulation and its peak in estrogen, my desires leaning toward high intimacy and high emotional rapport. Work remains work, and in the same way I would be able to foam milk and punch a clock despite my desires, I find I am able to show up for my clients though it never satiates my own needs because it is work, performance, labor, service– not authentic intimacy or reciprocation.

It was this way in early covid too: skin hunger, and frankly, horniness, had us climbing the walls as we faced another day of pacing our studio apartments. In the same way the bougainvillea explodes in flowers, parted and arching for any bee in the vicinity; I put on my shortest skirt and offer longer-than-usual hugs to my friends. We’re all creatures of survival, blooming desperately in the worst of times– over-eager shrub and human woman alike.

You can find me on set as an intimacy coordinator, on the radio or in print talking about media portrayals of sex work, in my office working with clients to overcome sexual dysfunction, or facilitating a restorative circle after relational harm.

I am a retired stripper and surrogate partner, as well as a graduate student in psychology, where I am working to be licensed as a couples, sex, and sex addiction specialist.

For my writing, expect a combination of essays about sex and gender from a structuralist and psycho-educational lens, as well as less academic rants about SW and sexual economics.

I’m going to start by publishing some of my academic work and previous journalistic contributions.

I encourage your feedback and thoughts and think this will be more fun if we interact together. So be sure to tell me what you like and want to see more of. I’m stoked to chat with you. LETS GET WEIRD.

xxRisdon