It turns out there is a significant discrepancy between local and national criminal definitions of what constitutes “Forcible Rape” and the FBI crime statistic definition of rape.  Since 1927 (yes that is not a typo) the FBI’s Uniform Crime Report (UCR) Summary Reporting System (SRS) has defined forcible rape as “the carnal knowledge of a female, forcibly and against her will”.  This meant forcing penile/vaginal penetration (yes, that is what “Carnal knowledge of a female” means) against the will of a female partner was the only form of rape tabulated by the FBI yearly crime report. This has resulted in decades of lower national rape statistics. Why?  Because if the rape was any sexual act other than penile/vaginal intercourse, no matter how violent and non-consensual, until now it was not included in FBI rape statistics. Although expanded criminal definitions of rape and definitions for statistical tabulation have been increasingly congruent in other places, the FBI (the foremost source of national crime information on rape and source for determining federal grants and Congressional health care policy initiatives) was for a period of 85 years increasingly inaccurately tabulating the prevalence of rape.  Thus, a person could be imprisoned by the state or Federal courts for non-consensually forcing an object into the anus of a man and the FBI not tabularize this criminal conviction as rape.

The new FBI statistical definition is: “The penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim” (downloaded January 7, 2012 at http://blogs.usdoj.gov/blog/archives/author/trusso/)

My sexual health training with drug and alcohol treatment professionals promotes ”consent” as the most basic sexual health boundary for every person in recovery. The 2012 FBI Uniform Crime Report definition now recognizes rape when a victim is incapacitated and unable to consent to sex because of their ingestion of drugs or alcohol.  It is now even more essential for drug and alcohol treatment professionals to integrate forcible rape linked with substance use as basic elements of a comprehensive drug and alcohol assessment and treatment.  How many male clients (and most likely a smaller number of women) in our nations drug and alcohol treatment programs have forcibly raped an incapacitated man or women after the victim ingested drugs or alcohol?

As I train drug and alcohol treatment professionals around the country, I am told about the low confidence, lack of training, and at times unwillingness of treatment programs to discuss forced non-consensual sex (rape) unless it is the story of the victim.  The perpetrators’ story often remains unseen.

Several years ago a man disclosed to me that he had been to three different treatment programs over seven years and relapsed within a year after each treatment.  Demoralized, he came to my office to be assessed for “sexual addiction”.  Part of my assessment with every new client interview is their history of non-consensual sex.  Addiction treatment alumni are well prepared to have me ask about sexual abuse (survivor of non-consensual sex). What new clients are unprepared for is my interest in their committing non-consensual sex.

This particular client disclosed he and his dealer had raped several women when he was drunk in the years leading up to his first treatment.  In all three well-respected inpatient drug and alcohol treatment programs he had never disclosed this to anyone. When asked why, he said, “no one ever asked”.  He concluded it was not appropriate to discuss and if discovered the program would report his crimes to the police.  His relief upon his disclosure with me was palpable.  He improved his sexual health by bringing a long held sex/drug-linked secret into the open. His recovery now had better sexual health statistics. Eventually his hope for maintaining recovery increased.

Much like the FBI, the frequency and numbers of recovering men and women who have forcibly raped an incapacitated drug and alcohol intoxicated victim must no longer remain as hidden within drug and alcohol treatment programs.  Perhaps a new source of sex/drug-linked research and funding may now become available by collecting data on drug and alcohol linked forcible rape? I hypothesize that bringing this non-consensual sex/drug-linked data into the open will improve treatment outcomes, decrease risk of chronic relapse and improve sexual health of both recovering rape victims and perpetrators.

Have you ever wondered if a client you are working with has raped?  Do you feel unprepared or unwilling to talk about this component of consent in sexual relations as part of counseling sex/drug-linked behavior?

Dennis Grantham, Editor-in-chief of Behavioral Healthcare Magazine spoke with SAMHSA Public Information Officer, Brad Stone about my recent blog describing the surprising censorship of “sex” and “sexual” on their online feedback forum. (See previous blog ( ******health: ***/drug-linked patterns of addiction: SAMSHA Online Stakeholder Forum on Principles of Recovery censors “Sexual Health” )  Mr. Grantham had previously interviewed me to discuss what happened and asked for my perspective on what at first glance looked like sexual health censorship.  As in most matters of censorship surrounding sex, the truth is in the details, not our emotional reactivity.  Yes, I was surprised, but I was not suspicious.  Mr. Stone confirmed that the situation involved a too large of a protective filter to ensure that potentially inappropriate or offensive remarks did not taint open, public debate and commentary.  SAMHSA’s backup process for the imperfect world of software filtering and avoiding the expense of live forum monitoring is to identify words essential to their mission as they are censored (like sex and sexual) and then notify IT department to fix the situation.   Mr. Grantham empathized with SAMHSA’s well intentioned invitation for safe and pertinent public comment.  ”How does a large government agency that impacts important areas of public health have a really open, public comment process, yet somehow assure that the process doesn’t offend, won’t cause embarrassment, or can’t be thrown off the track by an angry or clever verbal saboteur?”

This is common question I must address in almost all of my sexual health training, education and psychotherapy.  How do I help men and women have sexual health conversations and navigate their feelings of shame or embarrassment while managing their behavioral defenses provoked by these feelings, behaviors which of course are designed to throw the conversation off track?

I applaud both Mr. Grantham and SAMHSA’s public information response.  The journalist avoided common defenses of looking for a suspicious motivation unwittingly discovered (makes for good press, bad sexual health conversation). The PR person (SAMHSA) handled the sexual health conversation with candid transparency about the fallibility of technology.

Barriers to sexual health conversations prohibit collaborative efforts to integrate sexual health within a wide range of health care services.  This sexual health barrier (****** as censorship of the word sexual) led to constructive sexual health conversation.  Remaining curious and listening led to understanding the origins of a sexual health barrier.  We all must keep our eye on the larger goal of incrementally removing barriers to sexual health conversations among medical and addiction treatment professionals.  If you notice barriers to sexual health discussions among your health care professional colleagues, let me know, I want to listen.

I applaud SAMSHA for piloting online feedback forums, specifically their recent Internet discussion concerning SAMSHA’s 2005 Working Definition of Recovery and 12 Guiding Principles. This August over 350 people contributed their ideas and comments on the definition of recovery. (Complete listing of the 363 responses is online: http://feedback.samhsa.gov/forums/129063-closed-definition-of-recovery)

As a sexual health author, trainer and psychotherapist I am interested in the integration of sexuality within many areas of mental health.  In my 2009 book “Sexual Health in Drug and Alcohol Treatment: Group Facilitator’s Manual I wrote about the significance of SAMSHA’s 12 guiding principles of recovery omitting any reference to human sexuality, sexual health or sexual behavior. I believed then, as I do now, that the absence of “sexual health” in the Working Definition of Recovery and 12 Guiding Principles of Recovery reflects a broader lack of acknowledging or discussing sexuality, sexual health and sex/drug-linked relapse prevention within current treatment and recovery.

So it was pretty typical for me to enter sexual health in the “give us your feedback” search box.  I was curious if other contributors noticed the unfortunate omission of sex/drug-linked patterns of addiction in the Definition of Recovery.

Much like the SAMSHA document, my search found no postings addressing sex, sexuality or sexual health in the then over 300 entries. I again studied the 12 Guiding Principles looking for a good home for two words:  sexual health. The fourth principle “Recovery is holistic” looked like a good recommendation. I typed my feedback with enthusiasm and pressed send.  I was happy to be having a sexual health conversation not only with SAMSHA but also with the hundreds of site participants and readers.  As a sexual health advocate, I felt grateful and inspired.

Seconds later I saw this headline at the top of the Definition of Recovery Forum.

****** health: ***/drug-linked patterns of addiction remain invisible in the 10 principles

The word “sexual” and “sex” was replaced in my headline with censored asterisks. I then opened my complete written text (you can to, just go to: http://feedback.samhsa.gov/forums/129063-closed-definition-of-recovery/suggestions/2208381-health-drug-linked-patterns-of-addict) and found the entire post with the same censorship filter. Now my entries read like a profanity laced live television program.

“This section needs to clearly state “****** health” as an integral component of recovery.”

“It is well known within drug and alcohol treatment professionals as well as women and men in recovery that ****** behavior linked with drug and alcohol use is too often the primary reason for relapse.”

“Recent pilot program outcome studies support the hypothesis that addressing ***/drug-linked patterns of addiction within early recovery improves client retention and decreases ***/drug-linked relapse risk.”

I train addiction treatment providers to proactively introduce sexual health within their treatment programs rather than reacting to client sexual events (like having sex at a treatment program) that force clients and staff to talk about sex. I have listened to hundreds of addiction treatment program staff discuss their daily obstacles for initiating important sexual health conversations. Reading my censored SAMSHA sexual health recommendation was yet another dimension within the already multitudinous barriers to discussing sex/drug-linked relapse prevention.

Well, those software filter asterisks were totally unexpected.  I was stunned.  A major government science and health care information forum was programmed to censor the words “sex” and “sexual” (interestingly though not “sexuality”).  I had to ponder this situation.  I sent some notices out to my sexual health allies in drug and alcohol treatment.  They posted messages in response to my post as well as the censorship.  They voted.  At the close of the discussion forum my post was in the top 20 hot ideas and the top 25 overall votes among the over 360 entries.  Questions still remain about the censorship.

Can it be that drug and alcohol treatment professionals are so accustomed to marginalizing sex within professional discussions of treatment and recovery that no one who put this marvelous SAMSHA Internet resource together understood the practical consideration of how to welcome sex/drug-linked concerns to this forum?  Did no one ask if the existing filter would be too limiting?  What is the impact on moving forward with addressing sexuality in drug and alcohol treatment when the Substance Abuse and Mental Health Administration online discussion forum censors the word sex?

What are your thoughts?  Write a comment. Initiate a sexual health conversation today. Oh, and you won’t get censored for writing the word *******.

President Obama writes: “To accomplish these goals, we must undertake a more coordinated national response to the epidemic.  The Federal government can’t do this alone, nor should it. Success will require the commitment of governments at all levels, businesses, faith communities, philanthropy, the scientific and medical communities, educational institutions, people living with HIV, and others.” (White House Office of National AIDS Policy, 2010)

Kip Castner of Maryland’s Infectious Disease and Environmental Health Administration (IDEHA) embodies the White House Strategy. Mr. Castner concluded that Maryland [with one of the highest per-capita rates of HIV transmission in the country] could only do better in the third decade of this epidemic by collaborating with drug and alcohol treatment professionals to talk about the sexual lives of men and women in treatment.  He asked me to help him.  Since 2006 Mr. Castner has been co-hosting sexual health education workshops with Maryland’s Alcohol and Drug Abuse Administration (ADAA), to bring Sexual Health in Drug and Alcohol Treatment relapse prevention curriculum (Braun-Harvey, 2009) to Maryland.  Mr. Castner is the first state government HIV health agency leader to actively integrate sex/drug-linked relapse prevention approaches to accomplish the complimentary goals of reducing HIV transmission and reduce sex/drug-linked relapse risk among recovering women and men.

This five year mission has resulted in the State of Maryland creating a team of nine trainers from the fields of drug and alcohol treatment, HIV prevention and/or sex education who will begin teaching Maryland Drug and Alcohol Treatment Programs to provide sexual health relapse prevention groups within existing addiction treatment programs.

The beauty of this intervention is that it is congruent with a central mission of the White House Policy on AIDS/HIV. “The Strategy should be used to refocus our existing efforts and deliver better results to the American people within current funding levels” (White House Office of National AIDS Policy, 2010) Mr. Caster has witnessed the dwindling dollars in state budgets.  He is convinced that the collaborative sexual health in recovery relapse prevention intervention delivers better HIV prevention results by integrating the dual purpose of providing clients with evidence based sex/drug-linked relapse prevention skills that will also contribute to reducing HIV transmission.  Give an addict in recovery sexual health tools to prevent sex/drug-linked relapse and it will likely decrease HIV transmission.  It is a win-win-win.  Do not increase costs with a new separate HIV program.  Effectively utilize existing resources [drug and alcohol treatment programs already run many groups] through cross discipline collaboration.  Decrease risk of HIV infection by improving drug and alcohol treatment outcomes among women and men with high sex/drug-linked patterns of addiction.

After five years of collaboration with Mr. Castner and his every growing team of converts, Maryland in now the first in the country to establish a team of nine outstanding professionals to guide drug and alcohol treatment services to provide sex/drug-linked relapse prevention groups for their clients.

The National HIV/AIDS Strategy for The United States recommends that drugs associated with sexual transmission of HIV infection [What I have termed sex/drug-linked patterns of addiction] should be targeted with prevention efforts. The White House Office of AIDS collaborative strategy to decrease the ravages of HIV/AIDS in America is embodied in Maryland’s pioneering work in implementing the sexual health in recovery curriculum.  Who are the visionaries from HIV or drug and alcohol services in the remaining 49 states currently contemplating collaboration to address client sex/drug-linked patterns of addiction within their high risk HIV transmission and substance abusing populations?  Write and let us all know what you are doing.

I am an integrationist at heart.  I find my most inspired ideas by listening to the dilemmas of an impassioned professional and considering with whom they may want to talk or what information they may want to learn to better understand their situation.  I usually suggest a person, book or research from a field not often investigated within the help-seekers sphere. With clients I often have to interrupt their wish for “one stop-shopping.” The client (often to avoid the discomfort of going outside their familiar cocoon) wants me, their therapist, to be the Walmart of mental health.  They want me to have the answer for almost anything they need.

The last nine years of my work integrating sexual health with drug and alcohol treatment evolved from a brief conversation with Cheryl Houk, the executive director of Stepping Stone, a San Diego drug and alcohol treatment center.  Cheryl described her staff being overwhelmed by the sexual behavioral problems among the rapidly expanding number of crystal-methamphetamine-addicted residents. Cheryl was “sick of people dying” after being administratively discharged from the Stepping Stone residential program (which for some meant instant homelessness) not from drinking or using but because the client had broken a sexual behavior program rule.  My expertise in treating former Stepping Stone residents with out of control sexual behavior led to the cross disciplinary moment of inquiry, connection and collaborative problem solving.  She said, “I need your help.”

Conceptualizing, developing, and implementing sexual health groups for drug and alcohol treatment has strengthened by belief that we are not so often stuck with intractable problems in treating the myriad complexities of addiction, but rather limited by our tendency to stay within our own community to answer even the most vexing situations.  Risking professional discomfort and exposing a clinical failing is central to both our resistance and resolution for creating treatment improvements not just in drug and alcohol treatment, but also in many of our most perplexing health care issues.

I hope to have not only sexual health conversations but many more not yet imagined integrative discussions about the world of behavioral health.   So, I’m reaching out to you, and I want to know:  Who are you?  What is your voice?  What bridge is still under construction in your life?  Where will the simple act of reaching out lead us?

This post originated in Behavioral HealthCare magazine.