Introduction to special issue on digihealth and sexual health

In the first editorial of the year, Volume 35, Issue 1, I (MLCT) mentioned that I would be attending the World Association for Sexual (WAS) Health congress as an invited member of the Pink Therapy panel entitled, “Reflections from the Rainbow.” The Pink Therapy panel was composed of some amazing international colleagues, including Dominic Davies, Douglas Braun-Harvey, and Drs. Antonio Prunas, Miguel Rueda Sáenz, and Agata Loewe. This was the most rewarding panel experience in which I have ever participated!

Going into this panel experience, I had been thinking of the work of Doug Braun-Harvey (and his colleague Michael Vigorito) in framing out-of-control sexual behaviors (OCSB) in the context of the World Health Organization’s (WHO, 2006) definition of sexual health¹ and their related six sexual health principles² (Braun-Harvey & Vigorito, 2015). During our time together at WAS, Doug and I talked about how he came to his understanding of OCSB in the context of sexual health–a positionality that was and is divergent from many scholars and clinicians in terms of what they call, ‘sex addiction.’ This was a revolutionary way of conceptualizing these behaviors for people experiencing them and the providers working with them. In addition, this framework provided clarity and consistency for scholars trying to measure the concept of OCSB. Finally, there was a definition of sexual health to contrast with behaviors that are less sexually healthy for people experiencing such issues and people trying to help them. This shift in the field’s thinking was so revolutionary that one of the premier sexuality-related organizations in the United States of America (USA)–the American Association for Sexuality Educators, Counselors, and Therapists (AASECT)–was able to adopt a clearer position on theories and therapies related to ‘sex addiction,’ which was not to embrace them (2016)³.

The reason I had the OCSB framework in mind was because I had recently come from presenting at the annual American Association for Marriage and Family Therapy (AAMFT) on digital attachment (Hertlein & Twist, 2018a, 2018b; Hertlein & Twist, 2019) or what I have shortened to digiattachment (Twist, 2019a; Twist & Hertlein, 2019). In my presentation, I had begun to think about how before the reframing of OCSB occurred, it was framed as ‘sex addiction.’ I began to see parallels between this framing in the context of sex and the framing of technology. It occurred to me that many people seem to be mistaking technology-related anxiety behaviors and technology-related attachment behaviors as ‘technology addiction’ (Hertlein & Twist, 2018a, 2018b; Hertlein & Twist, 2019). And much like the holes in seeing ‘sex addiction’ as an addiction were identified by Braun-Harvey and Vigorito (2015) I began to see the holes in the idea of ‘technology addiction.’

Indeed, both ‘technology’ and ‘sex addiction’ are viewed as process addiction disorders or impulse control disorders by some (Carnes, 2001; Delmonico & Carnes, 1999; Spada, 2014). Yet, there has been no consensus for either of these so-called forms of ‘addiction’ as to what definitionally, symptomatically, criterion-wise, or by languaging/labeling/terminology actually constitutes either as an ‘addiction’ (Hertlein & Twist, 2019; Ley, 2012; Ryding & Kaye, 2018; Starcevic & Billieux, 2017). Furthermore, until the WHO (2006) provided a clear definition of what constitutes sexual health it was difficult to determine what it meant to be sexually less healthy (Braun-Harvey & Vigorito, 2015). It is a parallel process in the area of technology-related behaviors and related definitions. Indeed, with no clear definition of what are healthy technology-related behaviors and usage, it makes it virtually impossible to determine what are out-of-control, pathological, addictive, and/or phobic technology-related behaviors (Hertlein & Twist, 2019). Also like Braun-Harvey and Vigorito (2015) noted about OCSB, one cannot really discern what is considered problematic technology use as to whether it is distinct behavior that is qualitatively different from what is the norm, and if so, in what ways, or if it is a problem on an extreme end of a”normal” range of technology behaviors (Hertlein & Twist, 2019).

Finally, although the WHO recently recognized Gaming Disorder (WHO, 2018) and Compulsive Sexual Behavior Disorder (WHO, 2019), the American Psychiatric Association (APA, 2013) has not defined any technology-related behaviors nor out-of-control sexual behaviors as mental health disorders to date. Moreover, the AASECT (2016) has gone a step further in taking the position that there is no evidence for diagnosis of ‘sex addiction’ nor treatment, and thus recommends its members not engage in practices that condemn or pathologize what appear to be consensual sexual activities and behaviors (e.g., engagement with online and offline pornography, frequent sexual self- or partnered-activity, etc.).

We (MLCT and NM) submit a similar position with regard to technology usage. Indeed, there are many people—the majority—who incorporate technology into their lives in ways that can be both pleasurable and productive. We also submit that the best way to assess people’s technology use is to look at people’s relationships to their technology as a relationship (Blumer & Hertlein, 2015; Hertlein & Blumer, 2013), and to evaluate their relationship using similar tools the we use to evaluate the health of individuals within themselves and within their relationships. Some such tools that can be used for such assessment of the nature of the relationship between people and their technology include: digiattachment theory (see Hertlein & Twist, 2018a, 2018b; Twist, 2019a, 2019b), the couple and family technology framework (see Hertlein, 2012; Hertlein & Blumer, 2013; 2015; Hertlein & Twist, 2019), and through the lens of digisexual identity (McArthur & Twist, 2017, 2019). Yet, it does little good to have assessment tools through which to measure the nature of the relationship between people and technology without a clear definition of what it means to be digitally healthy or to experience out-of-control-digital behaviors (Twist, 2020).

Thus, to introduce this special issue, we (MLCT and NM) are proposing a definition of digital health (digihealth) and relatedly out-of-control-digital (digi) behaviors (OCDB). But, where does one start with operationally defining such terms? I (MLCT) talked this idea over with Doug Braun-Harvey at the WAS congress and he was encouraging and supportive. He suggested talking with my colleague/s who are experts in their area and then building from there—talking with more people and then forming a workgroup. He said this was similar to how he co-developed his framework on OCSB and relatedly co-developed the AASECT (2016) “Position Statement on Sex Addiction.” So, this is what we (MLCT and NM) are in the process of doing.

I (MLCT) went to Neil McArthur with the idea of developing such definitions and he agreed to collaborate. Then, I discussed the idea of digihealth with about ten graduate students in the fields of public health and family therapy (both doctoral and masters level) in one of my graduate-level sexual and gender diversity courses. Then, I started to draft definitions. Next, I presented a draft of the definitions to a group of about 50 licensed mental and relational health care providers (e.g., family therapists, social workers, counselor, medical providers, etc.) at a training on how to work with technology-related concerns as practitioners and got feedback on the definitions. Finally, I provided the definitions to Neil and then we refined them from there. What follows is the outcome of this process.

Our (MLCT and NM) definition of digihealth is the following:

Digital health is the result of engagement with digital technology in ways that promote physical, psychological, and social well-being. It requires a respectful and positive approach to technology and to online relationships. It results in the possibility of having pleasurable and safe technology-based experiences, free of coercion, discrimination, and violence. For digihealth to be attained and maintained, the rights of persons online and offline must be respected.

Furthermore, this definition of digihealth can be broken down into five core principles, which are as follows: 1) consent—all parties must be freely agreeing and enthusiastic participants in all digital experiences, 2) protection from exploitation and harm—digital-based experiences must occur in ways in which the physical and psychological integrity of participants are protected, 3) honesty—digital experiences must be based on open and true information about the participants to the extent that such information is relevant to the shared experience, and on a shared understanding about the nature of the experience, 4) privacy—participants in digital experiences must retain the right to protect personal information for their own protection and safety, and 5) pleasure—participants must be free to pursue pleasurable digital experiences without shame. Relatedly, OCDB is defined as a digihealth problem in which a person’s consensual digi-related thoughts, urges, and behaviors feel out of control to them (Hertlein & Twist, 2019; Twist, 2020; Twist & Hertlein, 2019). Through this lens then, OCDB can be addressed not through abstinence from technology (as people coming from an ‘addiction’ lens often prescribe), but rather through resolving concerns related to the principles of digihealth, as well as through attention to digattachment, digisexuality, and various components noted in the couple and family technology framework.

We invite you to review the articles in this special issue on digihealth and sexual health through the lens of these definitions. In this special issue there are articles focused on: online pornography use, the influence of online sexual activity on individuals and relationships, usage of sexually explicit materials by sexologists, an interactive website for therapists, adult attachment and online dating, motivations of people sexting in relationships, and the social and ethical implications of robot sex. In addition, we invite you to reach out to us with your thoughts about our definitions of digihealth, digihealth principles, and OCSD, as we are seeking feedback and collaborators.

Disclosure statement

The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Additional information

Notes on contributors

Markie L. C. Twist

Markie L. C. Twist, Ph.D., Program Coordinator, Graduate Certificate in Sex Therapy Program, Full Professor, Department of Human Development and Family Studies, University of Wisconsin-Stout, Menomonie, Wisconsin; and Adjunct Faculty, Department of Environmental and Occupational Health, University of Nevada, Las Vegas School of Public Health, Las Vegas, Nevada.

Neil McArthur

Neil McArthur, Ph.D., Director, Centre for Professional and Applied Ethics, Associate Professor, Department of Philosophy, University of Manitoba, Winnipeg, MB, Canada; Advisory Board Affiliate, Graduate Certificate in Sex Therapy Program, University of Wisconsin-Stout, Menomonie, WI.

Notes

1 A state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.

2 Consent, non-exploitation, protection against sexually transmitted infections and unplanned pregnancy, honesty, mutually pleasurable, and shared values.

3 Founded in 1967, the American Association of Sexuality Educators, Counselors and Therapists (AASECT) is devoted to the promotion of sexual health by the development and advancement of the fields of sexuality education, counseling and therapy. With this mission, AASECT accepts the responsibility of training, certifying and advancing high standards in the practice of sexuality education services, counseling and therapy. When contentious topics and cultural conflicts impede sexuality education and health care, AASECT may publish position statements to clarify standards to protect consumer sexual health and sexual rights. AASECT recognizes that people may experience significant physical, psychological, spiritual and sexual health consequences related to their sexual urges, thoughts or behaviors. AASECT recommends that its members utilize models that do not unduly pathologize consensual sexual behaviors. AASECT 1) 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. Therefore, it is the position of AASECT that linking problems related to sexual urges, thoughts or behaviors to a porn/sexual addiction process cannot be advanced by AASECT as a standard of practice for sexuality education delivery, counseling or therapy. AASECT advocates for a collaborative movement to establish standards of care supported by science, public health consensus and the rigorous protection of sexual rights for consumers seeking treatment for problems related to consensual sexual urges, thoughts or behaviors.