This document discusses recovering from addiction and revisiting sex and intimacy. It begins with recapping topics from last week's session such as anatomy, STDs, and pregnancy prevention. It then discusses various sexually transmitted infections including bacterial, viral, and parasitic STIs. The document also covers how mental health issues can impact sexual function and discusses the effects of various substances like alcohol, marijuana, opioids, and stimulants on sexuality. It emphasizes taking a holistic intersystem approach to treatment involving the individual, couple, and intergenerational systems. Mindfulness techniques are presented as a way to focus on intimacy and pleasure rather than performance goals.

1. Recovering from Addiction:
Revisiting Sex and Intimacy

2. Recap from last week
• Intro to sex ed
• Male and female anatomy
• Sexually Transmitted Diseases, prevention, and treatment
• Pregnancy & prevention

3. Sexually Transmitted Infections
Parasitic
• Pubic lice (Crabs)—live in pubic hairs near genitals
• Can be itchy and cause inflammation
• Easily spread
• Scabies (Mites)—dig holes beneath surface of the skin—can cause
itchiness
• Treated with lotions, shampoos, clean bedding etc with hot water
• Trichamoniasis: can affect urethra, bladder, or get under foreskin
• Can be transmitted through sex and sex toys
• Can irritate genitals and cause frothy discharge
• Usually treated with oral antibiotic called metronidazole (Flagyl)

4. Sexually Transmitted Infections
Bacterial
• Chlamydia: most commonly transmitted
• Spread through sex, often no signs/ symptoms
• Symptoms: itchy, inflamed genitals, discharge, painful urination
• Treated with antibiotics—if untreated can cause infertility
• Gonorrhea: often transmitted same time as chlamydia
• Similar symptoms to chlamydia
• Easily treated with antibiotics—if left untreated, it can cause infertility
• Syphilis:
• Great imitator—shows signs that other diseases show
• 3 stages:
• 1st: Small, painless sore where bacteria enters body (Easily treatable with antibiotics)
• 2nd: Feeling unwell, flat smooth warts appear in genital area
• 3rd: Heart problems, mental issues, and even death

5. Sexually Transmitted Diseases
Viral
• Human Papilloma Virus (HPV)
• Most common in Canada
• Transmitted through oral, anal, vaginal sex, and skin to skin contact
• Some types can show warts—others can manifest as cancer if untreated for many years
• No signs or symptoms—difficult to spot
• Vaccines out there to prevent HPV
• Hepatitis B
• Causes problems with the liver
• Easily transmitted through sexual activity, razors, needles, and toothbrushes
• Symptoms: tiredness, yellowing skin, nausea, vomiting, and decreased appetite
• Genital Herpes:
• Caused by herpes simplex virus
• Symptoms: Painful sores on genitals
• Transmitted through sexual activity and skin to skin contact
• There is no cure—effective treatments for recurrent outbreaks exist

6. Sexually Transmitted Diseases
• Human Immunodeficiency Virus (HIV)
• Attacks immune system of the body
• Spread through sex, razors, needles, and toothbrushes
• Flulike symptoms, sore throat, joint and muscle pain, skin rash, rapid weight loss
• Eventually—sickness continues—possibility of death from other infections or cancers
• Taking antiretroviral therapy (ART) reduces the amount of the virus in the blood and body fluids
• Keeps you healthy
• Greatly reduces risk of transmitting HIV to sexual partner
• Using condoms consistently and correctly is a necessary prevention method
• HIV IS NOT SPREAD THROUGH SKIN TO SKIN CONTACT, & IT IS NOT AIRBORNE!!
• If you do not engage in sexual activities or share needles, toothbrushes, or razors with an HIV+ person—you
are not at risk of contracting the STI

8. Mental Health
and Sexual Function

9. What’s on the agenda today?
• Mental health and Sexual Function
• Substance Use/ Abuse and Sexual Function
• Sex/Drug-Linked behaviour and how to change it
• Defense Mechanisms and moving past them

10. Sexual health is not separate from mental
health.

11. When working through mental health issues—
medications offered sometimes cause adverse
sexual health effects
To help work through these issues:
• Proper psychoeducation
• Efficacious treatment modalities
• Comprehensive, biopsychosocial approach

12. Intersystem Approach
• Considers biological vulnerabilities, psychological coping styles, and
interactional/ intergenerational systems
• Co-occurrence is typically the rule rather than exception
• Understanding the interplay helps to develop a holistic solution

13. Depressive Disorders
• 35-70% of those with a major depressive disorder (MDD) have a sexual
dysfunction
• Low libido
• Erectile dysfunction
• 30-70% of patients taking antidepressants report sexual dysfunction
• Sexual dysfunction is a common side effect of antidepressant treatment
• Antidepressants can be used to treat premature ejaculation
• Neurotransmitters involved in sex (dopamine, serotonin, norepinephrine)
are the same as those in psychiatric illnesses
• Antidepressant treatment inhibits dopamine release in hypothalamus and
mesolimbic pathway by serotonin higher serotonin in CNS means inhibited libido,
ejaculation, and orgasm

14. Bipolar Disorders
• Mania vs. depression
Mania:
• Increased goal directed activities, racing thoughts, distractibility, decreased
need for sleep, grandiosity—hypersexuality, risky behaviours (unfaithful,
pregnancy, STIs)
Depression:
• Significant lack of motivation, fatigue, low desire
• Treatment: Mood stabilizers (ED, impotence, decreased libido)

15. Anxiety & Associations
• Anxiety may be so bad it limits sexual functioning
• Performance-based anxiety
• Trying to be perfect instead of enjoying limits sexual/ psychological pleasure
• Less intimate relations—greater engagement with prostitutes
• Impairments in subjective satisfaction
• Lowered desire and arousal
• Trauma group—
• OCD, PTSD, PD (panic disorder), and BDD (body dysmorphic disorder) associated with sexual difficulties
• OCD may be sexually avoidant and have difficulty achieving orgasm
• Panic attacks impact sexual function
• BDD –preoccupied with how appearance looks during sex--unable to enjoy
• Treatment drugs cause further sexual complications—need to use alternative methods

16. Somatic Disorders
• Sexual issues arise due to excessive time spent focusing on symptom
• Anxious about symptom
• Persistent thoughts about symptom
• Invests time into symptom related matters
• If pain related to sex—person may fear sex itself or be disinterested in
it
• Vaginal discomfort—not wanting to engage in sex

17. Substance Use Disorders

18. What’s the connection?
• Different substances and uses affect how we function sexually
• Aside from performance—we also need to address how we feel
sexually
• There are both short term and long term effects

19. Alcohol
• Women experience less vaginal lubrication
• Men are unable to achieve or sustain an erection
• Men and women unable to achieve orgasm
• May increase women’s desire, but with moderate use overall
decreases desire in both women and men

20. Marijuana
• Short Term: Increased sexual desire, enhanced
orgasm quality, increase sensation of touching/
physical closeness
• Increased sexual pleasure and satisfaction
• With chronic use—sexual performance
dampened, decreased ability to achieve orgasm,
dyspareunia
• Decreases luteinizing hormone and testosterone
• Decreases sperm count and impaired motility

21. Opioids
• Sex can be impossible, not pleasurable if suffering from pain syndrome
• Inhibit hormones in the neuroendocrine system—decreased testosterone
and diminished spermatogenesis
• Decrease libido
• Delayed orgasm/ ejaculation
• Long term use associated with hypogonadism and increased risk of
erection problems

22. Stimulants
• Increased sexual desire and libido—inhibition of orgasm
• Disinterest in intimacy with partner—hostility and aggression
• With continued use—impotence and anorgasmia

23. Cigarettes
• Vasoconstriction of pelvic area vessels
• Atherosclerosis (disease of the arteries—plaques fatty acid on the
walls)
• Effect on hormones (lower luteal-phase progesterone metabolite
levels; can sabotage menstrual cycles—earlier menopause &
infertility)
=LEADS TO IMPOTENCE

24. Exercise:
Reflect on your past sexual experiences.
Have you experienced the mentioned symptoms?
What did your sex life constitute of during active
use? How would you like it to change?

25. How do we deal with these issues and
concerns?

26. The Intersystem Approach as a
Treatment Modality
• Individual system
• CBT—working through unproductive thought processes
• Co-exploring conclusions about self, world, others, & challenging unhealthy
beliefs
• Mindfulness—focusing on the breath and bodily sensations as a means of
being focused—belly breathing prior to anxiety provoked from sex
• Couple system
• Intergenerational system

27. The Intersystem Approach as a
Treatment Modality
• Individual system
• Couple system
• Impact of symptoms on relationship
• Enhanced CBT
• Emotionally Focused Couples Therapy (EFT)
• Depression, trauma
• Identify longings, express past hurts & fears—build stronger attachments
• Intergenerational system

28. The Intersystem Approach as a
Treatment Modality
• Individual system
• Couple system
• Intergenerational system
• Internalized messages from family of origin
• Inner dialogues
• What was the feeling toward sex from family?
• Did family members have substance abuse issues etc?
• Share how you learned about sex? Any stressors?

29. To truly understand and move forward, we need to
know ALL the details—even the uncomfortable
ones.

30. Asking about sexual concerns and complaints
can only help you discover the help you need.

31. Factors that Complicate Sexual Disorders
• Sex can often be performance based and goal-oriented
• This can damage sexual intimacy—especially when a dysfunction exists (erectile
dysfunction, vaginismus etc)
• Culture, family, religion, contextual sources, and porn often create unrealistic standards
and expectations for what sex should look like
• This “should” causes sexual fear, shame, embarrassment and dysfunction (Adams,
Dubbert, Chupurdia, & Jones, 1996).
• Common sexual myths target penis size, erectile capacity, orgasmic synchronicity and the
decline in sexual enjoyment with aging

32. Using Mindfulness
Mindfulness: open or receptive attention to and awareness of what is
occurring both internally and externally during the present time (Brown
& Ryan, 2008)
• We can use this practice to attend to the feelings we are experiencing
as we experience them
• Focusing on sensations in the moment instead of worrying about
performance can relieve tensions and stresses and therefore increase
pleasure
• For example—ED focusing on caressing and intimacy with partner instead
of obtaining an erection etc.

34. “Sexual recovery is not a calm ocean that you sail over like a stately
ocean liner—you will have your ups and downs—but in your
recovery—here, you have hope—you know you can change
because you already have—the hopelessness of addiction is no
longer your constant state of being—and as you gain hope—you
gain personal power too.”
-Stephan Covington

35. Sex/Drug-Linked Relapse Risk
• When we complete a recovery program—we are less at risk for
relapse
• Sexual health in recovery believes that sex and drug/alcohol use can
be a central reason for failing to complete treatment or relapsing
• Learning about the link between sex and drug/ alcohol use allows
treatment outcomes to improve
• We need to address which sexual situations are risky for relapse for
you

36. Objectives
• Learn common sex/drug-linked situations connected with increasing
risk for relapse
• Practice rating levels of relapse risk with others
• Learn the stop and think recovery skill for responding to sexual
situations during and following treatment
• Practice essential self-reflection skills before entering sexual
situations

37. Point?
• By connecting with sexual situations with level of risk for relapse—we
increase our likelihood of staying sober
• Recovery will increase if sexual situations linked with getting high are
anticipated and thought through
• We need to stop and think before entering sober sex

38. Sex/Drug-Linked Behaviours
• Many of us have linked our sexual behaviour, thoughts, and decisions
with alcohol or drug use
• Many of you have probably been in situations where you were using
as part of sexual behaviors
• Sometimes it may have been about trying to do something new
• Other times it may have been about doing something you found
embarrassing
• Other times it may have been to feel more in love or connected with your
partner
• Perhaps you use it to block out or tolerate a terrible sexual experience— we
all have our reasons and circumstances for being high before, during, or after
sex.

39. Evidence of Sex/Drug-Linked Behaviour
• New evidence suggests that sobriety cannot be maintained if a high
level of sex/ drug linked behaviour is present without skills to prevent
relapse prevention.
• Too often—we’re putting sex on the back burner but today—we are
going to put it on the table.
• Let’s look at past sexual situations and how often sex/ drugs were
linked and then we will predict likelihood of risk of using in future
sexual situations.

40. 5 general motivations for sex/ drug linked
behaviour:
1. To increase ability to sexually function (erection, control of orgasm, agility for
intercourse, orgasm intensity, delay orgasm, or to bring partner to orgasm)
2. To change level of sexual interest, desire, or arousal
3. To experience a specific sexual turn-on
4. To escape from negative or overwhelming feelings and to experience sexual
pleasure or excitement instead (insecurity, trauma, avoiding coming down, fearing
sober sex, fear of partner leaving or you wanting to end relationship)
5. To express feelings of love, affection, and commitment

41. Exercise
Please describe a sex/drug linked situation from our list and rate the
frequency from 0 to 10 of how often this particular situation was a
motivator for you to combine sex and drugs before entering treatment.

42. Exercise
Please describe a sexual situation from situation from our list. Then
evaluate how likely you will remain sober in this situation after
treatment.

43. Why might these areas address a low or high
likelihood of remaining sober?

44. Moving Toward Sober Sex
• We are practicing pausing and thinking about a sexual situation in
regard to staying sober
• By thinking of the relapse risk in sexual situations prior to being in
them allows us to think before doing.
• Recovery takes reflection and action—thinking about our sexual
desires and pausing to reflect on our motives is an important relapse
prevention tool for sexual health in recovery.

45. Worksheet:
Stopping and Thinking about Sex/Drug Linked
Situations in Recovery

46. Defense Mechanisms

47. Defense Mechanisms
• Next step is to discuss common defence mechanisms that interfere
with sexual decisions.
• Men and women in recovery will increase their likelihood of staying
sober when their sexual decisions include honest self-reflection
regarding the risk of relapse.
• Every recovering addict has a responsibility to develop effective
sexual defences distracting from the difficult and uncomfortable task
of self-analysis in sexuality.

48. Reflection Questions
How often do you honestly discuss your sexual behaviour?
How often do you avoid being truthful about your sex life in recovery?
Are you interested in learning about how your sex life will affect your
recovery?

49. Reflection Questions
Do you avoid situations or opportunities to learn more about sexual
behaviour and recovery?
Are you interested in really seeing the consequences—both short term
and long term of your sexual behaviour?

50. Normalizing Sex-Talk
• The reason we are here today is to normalize the resistance to change
and work on some suggestions for moving beyond defences to look
more truthfully at our sex lives.
• It is not easy and just because we have chosen to be in recovery from
alcohol and drugs—it does not mean we are equally ready or
motivated to look at our sexual selves.

51. Normalizing Sex-Talk
• People who are not really ready to discuss sexual behaviour usually
react defensively when the subject comes up—this is either conscious
or unconscious and is reflected through behaviours, thoughts,
feelings, perceptions, or attitudes that prevent us from knowing
something about ourselves.
• However—these defences interfere with our ability to change—
therefore keeping us unaware of our defences and risking relapse.

52. What are some defences we have observed in
ourselves or those around us when the subject of
sex comes up?

53. Common Defense Mechansims
• Minimizing: Acknowledging some level of concern about sexual life but
discounting this concern as not very significant or serious.
• Rationalizing: Present plausible explanations to justify, excuse, or explain sexual
behaviour.
• Intellectualizing: Avoid painful feelings and emotional reactions, and make the
sexual situation less personal by using unemotional intellectual analysis.
• Blaming: Focus on events outside of one’s self and focus on other people, events,
or circumstances as a cause or responsibility for sexual behaviour or decisions.
Personal responsibility for sexual actions and choices is rejected.

54. Common Defense Mechanisms
• Your Basic Everyday Run-of-the-Mill Denial: Insist that one’s sexual decision
making is not a significant concern for everyday recovery despite a significant
amount of evidence that disputes this conclusion. An ongoing effort to filter out
information that might make a person consider changing his or her sexual
behaviour.
• Hostility: Becoming irritated, mean, critical, angry, sullen, temperamental, or
shaming toward anyone who invites you to look at your sexual behaviour. The
purpose for these reactions is to discourage the person from every bringing up
the subject again.
• Diversion: Create a flurry of concern about other issues (like whether or not
someone loves you or is attracted to you) to make sure there isn’t time or ability
to focus on one’s sexual behaviour and the effect it has on recovery.

55. The Change Process
• Experts who study change find that curiosity and interest in
information and other people’s stories from those who have made
the change help us begin.
• Seeing and understanding our defences helps us avoid the pitfalls of
our defensive responses.

56. Worksheet: Homework
• Measures the frequency you consciously address sex and recovery
and it serves as a checkpoint for yourself and others.
• For those who score less than 13—consider a defence that keeps you
from scoring higher.
• For those who score over 13, consider a defence you think you could
use less often to get a higher score.
• Remember that the more aware you are about your defences and the
more interested you are in your recovery and avoiding relapse due to
sexual behaviour or relationships—the more ready you will be to
address your own relapse prevention behaviour.

57. Let me remind you that practice makes
perfect—there is no defined time frame—the
progress you make will be at your own pace.

58. Ambivalence is good—it is part of the change—
which is necessary, important and demands
respect.

59. As you leave the group today—remind yourself
that a satisfying sexual life is a vital and important
part of recovery.