The day after I listened to the New Yorker audio clip of Harvey Weinstein sexually harassing a woman, Steve walked into my office for an initial therapy session.

Steve was in his 50s, married, and a partner at a successful firm. Two female subordinates claimed Steve had come on to them, and his CEO said he’d get fired if he didn’t “get help.”

“I made a few comments about cleavage, I think, and once a woman and I kissed in an elevator — but she was into it,” he said. “I don’t think I did anything wrong.”

I had to stop myself from rolling my eyes.

I’m a clinical social worker who specializes in interpersonal relationships. Among my clients are men who struggle with various sexual dysfunctions. I’m fine with hearing them talk vividly about their sex lives and fantasies (well, I can handle it), but what Steve had to say made me increasingly triggered.

As the 50 minutes ticked by, it became clear Steve had no desire to own his mistreatment of women. All braggadocio and defensiveness, he told me his charisma has proven so potent he habitually had to fend off women. He added that his mom always said women would have catfights over him because he was so irresistible.

Then things took a darker turn. “Pardon my French, but those cunts at work are just pissed I didn’t seriously pursue them.”

I attempted to get underneath the bravado. “It must be scary to feel your livelihood, your essence, be threatened,” I prodded.

His response: “What would you know about that? You’re a woman.”

Enough was enough. At the end of our session, I told Steve it felt like he wanted an enabler, not a therapist. We weren’t a good fit. I ushered him out the door.

Steve’s story is classic — powerful man gets caught harassing or assaulting women and says he’ll seek therapy or that he’s struggling with “sex addiction.” Weinstein, who claims he’s a sex addict and checked himself into rehab, is the latest example. Anthony Weiner cited sex addiction as the reason for his habit of sexting underage girls. Weiner is headed to prison next month, but he’s a rarity — when the rich and powerful are caught committing sex crimes, they often go to rehab instead of jail.

But the outcry about Weinstein’s alleged blatant, multiple offenses toward prominent accusers has renewed a conversation in the mental health community about how we should regard a host of sexual issues — problems that often get lumped together under the one-size-fits-all label of “sex addiction.” Part of the debate is over whether sexual addiction even exists. Whatever various sexual dysfunctions signify, some argue these behaviors don’t fit well under the “addiction” umbrella.

However, few dispute there are people who struggle with mental health issues surrounding sex. But these people are not the same as harassers and people who assault women — and sex criminals who use therapy as a PR or legal dodge make it harder for those who are genuinely struggling to get help.

True, some harassers recognize they are acting in ways that they suspect skirt a line and feel some guilt and shame — issues that might be productively dealt with in therapy. Given all these complex considerations, what do therapists like me do when a Harvey Weinstein type lands in our office?

Is sex addiction a real thing?

First off, many experts do not believe that sex addiction qualifies as a mental disorder. It’s not listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the handbook of the American Psychiatric Association that’s considered the authoritative guide on diagnosing psychiatric illnesses in this country. A major reason is that these dysfunctional behaviors don’t elicit serious physical symptoms of withdrawal, such as anxiety or illness.

David Ley, a clinical psychologist and the author of The Myth of Sex Addiction, goes further. “Nearly 95 percent of alleged sex addicts are male,” he told me. “It’s an excuse and distraction used by powerful men when they get caught engaging in impulsive promiscuous behavior.”

Piper Grant, a sex addiction therapist, is among the minority of clinicians who dispute the DSM’s exclusion of sex addiction. “Regardless, there are people dealing with severe issues around sex — it’s the uncontrollable behavior and the secretiveness that severely impede functionality,” she says. Indeed, “hypersexual disorder” will be listed in next year’s edition of the World Health Organization’s diagnostic guide (which is less respected in the US compared with the DSM).

For now, sex addiction is widely dismissed in our country, and reimbursement for treatment is rare.

The patients I’ll treat versus the patients I won’t

Consider someone who has sex phone lines on speed dial, chronically masturbates, or visits prostitutes compulsively. Some people cross a line from manageable indulgence to a ceaseless activity that damages finances, relationships, and careers. Even if there isn’t empirical evidence to label you an addict, you are ill. I’ve seen this in my own clients — Ted was jolted into seeking treatment after his girlfriend broke up with him because he watched PornHub seven hours a day.

The predominant thinking remains that sexual acting out is not an addiction but a symptom of a personality disorder. Ted and I worked on his excessive porn-viewing habit using cognitive behavioral therapy techniques such as role playing, journal keeping, and homework exercises like identifying and challenging negative thoughts. We also used psychodynamic therapy to help him realize that he first turned to porn as a teenager to escape the discomfort of listening to his mother and father fight.

Male patients with sex-related issues vary greatly. If I see the troubled human at the core capable of insight and inwardly wanting to make a change, I’m much more likely to work with someone even if his behavior reeks of misogyny. My patient Dafir’s depression lifted once he enrolled in a class called “How to Be a Pickup Artist.” The instructor’s motto was that if students didn’t “bag a perfect 10, it wouldn’t count.” But Dafir became aware his insecurities came from a deep-seated fear that women didn’t find him attractive. I disliked some of Dafir’s views and that he felt so positive about the class. But my job wasn’t to make him over to what I felt appropriate — it was to help him see himself and, hopefully, women in a somewhat clearer way.

My boundary is not to treat patients who sexually step over the line and touch someone against her will. I end up leaving the session feeling in need of therapy myself. Before Steve, there’s only been one man I’ve had to turn away for this reason. Jose admitted, eyes averted, voice quavering, that at age 14 he’d knocked a girl off her bicycle and touched her breast. Jose served time in juvenile detention and decades later expresses deep remorse. He still occasionally has urges, but he fights them successfully. He deserves help. But I’m not the one for that job. I referred him to a male colleague.

I’ve never had an abuser like Harvey Weinstein come into my office — my would-be patient Steve did not reach that level. It’s not that I don’t believe that Weinstein has pathological issues as well as distorted views of women. But people who repeatedly harass and assault women are often unable or unwilling to admit fault. I also believe that if someone commits a crime, as Weinstein allegedly has, he should be punished. Any therapy sessions should happen in his jail cell.

Regardless of the validity of sex addiction or how badly a patient wants to get better, mental health is not an excuse to sexually assault and shame and coerce victims into silence. Settlements bound by nondisclosure agreements muzzle the victim. Our criminal justice system is intimidating at best and often further victimizes people who have already endured so much. This all contributes to a culture of complicity.

We must stop mythologizing the wealthy and powerful — giving those with grievous pathology a “wink wink” free pass. Until then, they will continue to buy and bully their way into taking what and whom they feel is their due for having achieved such a lofty position. Weinstein fell off Mount Olympus not because his alleged sexual crimes were heinous but because he committed the only immorality that matters: losing influence.

In retrospect, I might have been able to help Steve. I could have tried to peck away at his twin shells of denial and entitlement. But I have too many patients who are survivors of rape and harassment. I have witnessed their unbearable pain and intense difficulty forging healthy relationships. When faced with the victims, it’s challenging for me to feel empathy for Steve.

Without that ability, I fear I would have eventually given in to the overwhelming desire to kick him in the balls.

Names and identifying details of patients are changed.

Sherry Amatenstein is a LCSW is a therapist based in New York City. Her latest book is the anthology “HOW DOES THAT MAKE YOU FEEL? True Confessions From Both Sides of the Therapy Couch.” You can read her last piece for Vox here.

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