#66274: Sexual Addiction

The terms compulsivity and impulsivity are often used interchangeably in clinical settings. However, this is incorrect. The American Psychological Association defines these concepts as [3]:

Compulsive behaviors are generally more patterned and have a clear purpose: to alleviate anxiety. The classic obsessive-compulsive behavior of excessive handwashing, for example, is engaged in to relieve disturbing mental obsessions about germs, dirtiness, or other sources of anxiety. On the other hand, impulsive behavior is usually not planned, consciously or unconsciously. When it comes to sex, many individuals participate in sexually impulsive acts. Engaging in such acts does not necessarily make one a sexual compulsive or a sex addict, just like getting drunk one time does not make a person an alcoholic. However, if the impulsivity develops into a pattern, an individual may be experiencing a form of sexual addiction.

According to some sexual addiction experts, compulsivity, as it applies to any addiction, refers to the behavior (e.g., sexual activity, drinking, gambling) being out of control [4]. Not all instances of sexual compulsivity are necessarily part of a broader sexual addiction condition; some instances of sexual compulsivity or impulsivity are tied to a more clinically significant Axis I or Axis II disorder [1]. For example, sexual compulsivity could be a feature of manic episodes, a facet of a borderline personality disorder, or better explained by a paraphilia diagnosis as delineated by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) [5]. This is not to say that a person with bipolar disorder, for instance, cannot be a sex addict, but careful assessment is necessary.

Interestingly, many clinicians and professionals prefer the term sexual compulsivity to sexual addiction, typically because they are not comfortable with the concept of addiction [6]. However, as with compulsivity and impulsivity, there is a difference, and this difference should be clearly understood.

While the DSM-5-TR does include a category of Substance-Related Disorders, it generally does not use the term addiction in its descriptions of individual disorders. The DSM-5-TR uses the label substance use disorder to identify chemical addiction [5]. Gambling addiction is referred to simply as gambling disorder, and other conditions that are often referred to as addiction could be labeled as impulse control disorders. However, addiction is used widely as an all-inclusive clinical term, and the term appears in the names of many professional associations, such as the American Society of Addiction Medicine, the National Association for Addiction Professionals, and the National Institute on Drug Addiction. For the purposes of this course, the term "addiction" will be used to describe continuing a behavior (e.g., drinking alcohol, smoking cigarettes, gambling, engaging in sexual activity) even when the activity causes repeated pain and consequences [7]. Addiction usually implies a holistic impact on an individual as a result of continuing to engage in the harmful behavior. Carnes defines sexual addiction as an entire pattern of maladaptive behaviors, cognitions, belief systems, and consequences; the behavior alone can be identified as sexual compulsivity [1]. A simple way to identify addiction compared to compulsivity is to recognize that addiction involves how compulsive behaviors impact (or are impacted by) the rest of a person's functioning.

In the treatment field at large, use of the term addiction is becoming increasingly unpopular and, in some sectors, discouraged [90,91]. While this course makes an argument for continued use of the concept of addiction, whatever descriptors that work best for clients should be considered, in the spirit of client-focused care.

Various experts in sexual addiction have attempted to define the disorder. Laaser views sexual addiction as a situation in which a behavior that is generally healthy (i.e., sex) becomes unhealthy [26]. Carnes, on the other hand, identifies sexual addiction as "a pathological relationship with a mood-altering experience" [83]. Weiss identifies a sex addict as someone who, like an alcoholic or overeater, uses sexual compulsions "to avoid past or present pain and escape the realities of life" [8]. Nelson characterizes sexual addiction as usage of sex as a mood-altering substance that continues to be used in greater dosages, eventually permeating every aspect of an individual's life [6]. Crowe and Earle identify sex addicts as people who are afraid of intimacy and repeatedly and compulsively try to connect with others in highly impersonal ways (e.g., prostitution, masturbation, cybersex, emotionless affairs) [6]. This point about the fear of intimacy and lack of genuine connection is a key aspect of sexual addiction and will be explored in more detail later in this course.

Sexual anorexia, also referred to as hyposexual desire disorder, is not a widely known or appreciated concept. In work with any sexual addict, deprivation of sexual expression should not necessarily be the treatment goal [64]. Yet, sexual deprivation is how many sexual addicts choose to deal with their addiction. It may be equated to the "cold turkey" approach of drinking or smoking cessation.

In the DSM-5-TR, there are two sexual desire disorders: female sexual interest/arousal disorder and male hypoactive sexual desire disorder [5,84]. Both disorders may be marked by absent/reduced interest in sexual activity, sexual/erotic thoughts or fantasies, and/or initiation of sexual activity, though the female condition may also include physiologic non-response to sexual cues. The term sexual anorexia encompasses both of these disorders.

The word anorexia is generally defined as being without appetite. Nelson has described sexual anorexia as an obsessive state in which the physical, mental, and emotional task of avoiding sex dominates one's life [6]. Sexual addiction and sexual anorexia can exist in the same person or same family at one time; extremes are the common theme. Often, a cycle of binging on sexual compulsions then abstaining entirely becomes apparent. Both conditions (addiction and anorexia) consist of an obsession with sex, but the object or manifestation of the obsession is different. In many cases, this anorexic behavior is a response to recognized addictive behavior or trauma [11].

The idea of sexual anorexia and the addiction/anorexia cycle may be difficult to understand. However, clients who present for clinical attention are often plagued by all-or-nothing thinking—in this case, engaging in as much sexual activity as possible or none at all. Sexual anorexia is quite parallel to "dry drunk syndrome" seen in some chemical addicts [65]. Simply put, these individuals are abstinent but have not addressed any of the emotional issues that motivate their problem drinking or drug use (e.g., no recovery). "Dry drunks" are often impatient, depressed, irritable, impulsive, and difficult to be around as a result of the removal of their coping mechanism (e.g., drinking) without replacement with healthier coping strategies. Sexual anorexia is similar. If the core motivating issues are not addressed, a sex addict may evolve into a sexual anorectic who is depressed and difficult to be around. As such, sexual anorexia can lead to its own level of interpersonal problems. Furthermore, those who stop any addictive behavior but do not address the underlying issue(s) are at greater risk of relapse.

Sexual anorexia has also been linked to rigid (to the point of compulsive) religiousness [11]. Sexual anorexia can result when individuals use religiosity to address their sexual addiction; this is often prefaced by a period of religious compulsivity [12]. Unfortunately, sexual anorexic behaviors may be encouraged as a "cure" for sexual addiction by some therapists or counselors, particularly if a client is seeking help from within their faith community.

Prior to the advent of Alcoholics Anonymous in 1935 and the American Medical Association's recognition of alcoholism as a disease in 1952, alcoholism and addiction were largely viewed as sin problems [14]. This perspective is referred to as the moral model. According to this view, alcoholics and addicts are morally flawed, and repentance, conversion, or total commitment to a religious program will address the sin and solve the problem. Interestingly, this moral model view still abounds in many circles today.

In addiction treatment, the moral model views addicts as weak-willed and essentially faulty. Many religious groups, specifically those with more fundamentalist or conservative beliefs, approach addiction as a sin problem, not a treatable disease. Compulsive behaviors are best addressed through dedication to the spiritual pursuits as defined by the tenets of that religion. Examples of such cure-through-religion courses or counseling include Blazing Grace and Reformers Unanimous International Ministries, which address addiction problems primarily through the use of biblical passages, and Comunità Cenacolo, a conservative Catholic movement that rejects the idea of therapeutic intervention and advocates addicts living together as a religious community to overcome addiction problems [15,16,17]. These three programs are a few of the many faith-based programs that still operate from the moral model. In most cases, these extreme faith-based programs reject, and often condemn, the necessity of therapeutic intervention. However, it is important to note that not all faith-based recovery programs are as extreme in their moral model stance as the programs listed here.

On the other end of the spectrum from the moral model is the notion that sexual addiction does not exist at all. Some professionals argue that sex addiction is a pseudoscientific cover-up to promote puritanical moral values by the mainstream establishment. One such critic contends that "sex addiction has also been used as a political justification for censorship, eliminating sex education and birth control clinics, and opposing equal rights for gays and lesbians" [18]. Others in the general public believe sex addicts just enjoy sex; the addiction label is only used when they face consequences of their sexual behaviors. Indeed, using addiction as an excuse for poor behavior is not a new concept.

Several theorists suggest that ingestion or reliance on a physical substance is needed to truly justify addiction or dependence. These theorists argue that forms of sexual activities are interactions, not substances [1]. In response, Weiss notes that "acting out sexually becomes the primary way to meet the chemical needs of the brain" [9]. Indeed, anyone who takes an introductory course in addiction learns that it is the dopaminergic response in the brain that makes an experience addicting. Sexual arousal can trigger the release of dopamine and other hormones, including endorphins, which are neurotransmitters in the brain with properties similar to morphine. Some studies have indicated that viewing sexually explicit images can induce the same dopamine response as heroin in addicts [19]. However, a study published in 2013 found that neural responsivity to visual sexual stimuli did not significantly differ in persons with hypersexuality issues compared to healthy controls [85]. Some argue that this lack of verifiable biologic response (as seen in persons with substance dependence) is evidence that sexual addiction is not a real clinical entity.

From a psychosocial perspective, sexual addiction, according to Nelson, qualifies as an addiction based on a client's overwhelming preoccupation with sex, disregard for consequences, and inability to stop on his/her own; these qualifications are similar to the DSM-5-TR criteria for substance use disorder [5,6]. In the DSM-5-TR description of substance use disorder, physical dependence and withdrawal (two obvious physical criteria) are not required. A diagnosis may be assigned based solely on the psychosocial aspects (e.g., persistent but unsuccessful efforts to quit, time spent in pursuit of the substance, important activities given up, etc.) if the consequences experienced by the client are pervasive enough to impact total life functioning. Lemon has suggested that three characteristics of substance use or behaviors may lead to addiction: "relatively rapid and substantial improvement in hedonic state, user unable to find alternative ways of obtaining this improvement, and performance of the behavior leads to maladaptive functioning and chronic dysphoria" [20]. Using these criteria as a guide, any behavior or substance may qualify as an addiction.

Second, there is controversy about sex addiction because there is a great amount of disagreement in the literature regarding what constitutes addiction, relapse, or recovery. Once again, disagreement among professionals and those who write about addictive disorders can often lead to a lack of standardization in how treatment is conceptualized and delivered [66].

The increased incidence of sexual addiction may be linked to the accessibility and affordability of online materials [1]. As discussed, this is a controversial subject. Some professionals see a clear connection between accessibility and development of addiction, whereas others feel that addicts will find the materials regardless of whether they are easily accessible or not. The increase in accessibility to sexual material in recent decades cannot be denied, and it is not just limited to pornography. Advertising has become increasingly sexual, as have popular music, movies, and television. The sexual imagery in popular culture today would have been unthinkable years ago. Exposure to these images via the media can activate the pleasure centers of the brain; if the synapsal firing in the pleasure centers is excessive, particularly in youth, a faulty wiring system can set in. However, research in this area remains scarce.

Exposure to pornography (including unwanted exposure) among children and adolescents in the United States has increased with the widespread use of the Internet [67,68,69]. Additionally, a 2010 survey found that 9% of Internet users 10 to 17 years of age had been victims of unwanted sexual solicitations (e.g., being asked to talk about sex or for personal sexual information), but this represented a 30% decrease from the rate reported in 2005 [30]. This decline in unwanted sexual advances was mainly among pre-teens (10 to 12 years of age) [31]. However, the researchers noted that more solicitations were made by friends and acquaintances, and less by strangers, and most solicitations occurred over social media [31]. The most significant numbers of unwanted sexual solicitations were to male gay-identified and female adolescents [81].

A meta-analysis including 40 studies from 1990 to 2016 reported that the rate of unwanted online sexual exposure for youth between 12 and 16.5 years of age was 20.3% [88]. The prevalence for unwanted sexual solicitation was 11.5% [88]. Another study found that psychiatric disorders were significantly higher in adolescents who were exposed to sexual solicitation online. For example, the prevalence of post-traumatic stress disorder after exposure to unwanted sexual solicitation was 57.8% [89].

While research does seem to indicate a correlation between excessive or problematic Internet use for sexual purposes and negative effects, causation has not been clearly determined [79,80]. Some have proposed that a different type of sexual addiction, stemming more from early exposure to graphic sexual material via the Internet than previous trauma, could be developing, with a more rapid onset and differences in chronicity and content [87]. Maltz advises a prevention model, especially in the wake of the problems of Internet pornography and the realities of modern commerce [32]. She urges that cases of pornography-related problems should be addressed on a case-by-case basis to determine the best treatment approach. This requires a comprehensive and extensive evaluative process.

High comorbidity exists between substance use disorders and sexual addiction. Hagedorn and Juhnke contend that those trained to treat chemical dependency should also be trained to treat the commonly comorbid sexual addiction [1]. Part of meeting this challenge is recognizing the reality of process addictions. Process addictions are often referred to as behavioral addictions and include such addictions as sex, gambling, shopping, Internet use, sports, and eating. The term suggests that the behavioral act, or process, is the most addictive aspect, not necessarily the result of engaging in that activity. O'Brien has suggested that a good starting point for conducting assessments is the exploration of out-of-control behaviors and their consequences, even more so than physical tolerance and withdrawal [1]. O'Brien's contention stems from the idea that any substance and any behavior can become addictive as long as it has the potential to create debilitating behavioral consequences.

Underlying sexual addiction issues may be a driving force behind the more readily identifiable chemical dependency issues [1]. According to Seegers, among those who have experienced co-addictions, most have identified sexual addiction as the most difficult recovery [9]. A comprehensive sexual history should be gathered in order to distinguish between sexual addiction, the compulsion aspect of obsessive-compulsive disorder, an impulse control disorder, or a paraphilia [1]. According to the DSM-5-TR, paraphilia is an umbrella term for mental illness characterized by "intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners" (e.g., exhibitionism, frotteurism, voyeurism, pedophilia, sadism, masochism) [5].

According to the British Association for Sexual Health and HIV, sexual history taking should take place in a confidential, private environment.

(https://www.bashhguidelines.org/media/1241/sh-guidelines-2019-ijsa.pdf Last Accessed: March 29, 2023)

Strength of Recommendation/Level of Evidence: ID (Strong recommendation based on non-analytic evidence)

Clinicians experienced in conducting thorough biopsychosocial-spiritual assessments should not find assessing for sexual addiction difficult provided they are willing to talk to clients about sexual development and activity. The impact of a client's sexual behavior should be examined in the scope of the entire biopsychosocial presentation in order to intelligently assess if the behavior is part of an addictive spectrum or if it can better be explained by another mental health issue. In some cases, there will be no pathologic behavior. Both Maltz and Kort, who have divergent views of pornography use, caution that not all instances of pornography use or sexually acting out are necessarily sexual addiction [34,35]. Context is key—the effect of sex (or lack of sex) on the individual's life is important. This will ultimately guide the creation of a treatment plan.

Cultural sensitivity and respecting a client's individuality are critical in conducting the sexual history. Certain cultural or societal pressures or special issues may be inherent to the development of his or her addiction. For example, shame can play a significant role in the developmental histories of gay and lesbian youth or in individuals raised in rigidly religious homes. With such individuals, it may be impossible to gain all of the necessary information in a first assessment session, or until the client feels safe. Assessment should be considered an ongoing process.

Knowledge about human development can assist with the assessment process. Often, adult clients will conduct themselves sexually as adolescents. This conduct should be explored to determine its meaning in terms assessment and/or treatment. Keeping development in mind is also important in evaluating context. Adolescent hormonal changes (often seen as a standard developmental marker) can explain normal increases in sexual interest and activity, though clients may feel their interest is "excessive."

Be aware of the hidden nature of sexual addiction. Intense stigma often leads to significant minimization and rationalization by both the client and their families. This trend really can apply to any addiction, but it seems to be most pervasive with sexual addiction and sexual co-addiction. Hagedorn and Juhnke recommend involving the family in the screening and assessment process to obtain collateral data when appropriate [1].

Some clinicians rely on screening instruments and diagnostic tools during assessments or may be required to use these tools by an employer. There is a variety of psychometrics available to screen and to measure sexual addiction [1,10,36,37,38,39]:

Many of these scales can be accessed online; others must be accessed through academic databases. As an example, the WASTE-Time screening tool consists of items organized into six areas: withdrawal, adverse consequences, inability to stop, tolerance, use of sex as an escape, and time spent on sexual activity (Table 1). The tool also allows for follow-up questions.

One of the critical components of conducting a thorough assessment is to ask relevant questions that are designed to elicit a significant amount of usable data. For many, practice is needed in asking the right questions and finding the set of questions that work best to elicit that data.

The Internet can be a useful resource for helping professionals seeking good questions to include in the assessment of sexual addictions. There are numerous 12-step fellowships that address issues of sexual addiction and compulsivity, which will be discussed in greater detail later in this course. Some of these 12-step programs have online self-screening tools to evaluate for problem sexual behaviors. Although such tools are not clinically validated, they can point toward questions that will elicit the information to make a clinically informed diagnosis. Again, the tools found on these sites are not meant to be clinical.

One tool that may be helpful is The Fourteen Characteristics, published by the 12-step group Sexual Compulsives Anonymous [40]. The Fourteen Characteristics are a set of statements that describe sexually compulsive behavior. Examples include:

A client can be given a copy of The Fourteen Characteristics and asked if he or she relates to any of the statements on the list or if any of the characteristics apply. This then leads to a discussion of the compulsive behaviors and how they are affecting the client's life.

One misconception about screening tools is that they are only effective if, after clients check off the relevant items, the score is perfectly diagnostic and provides all of the answers. Although many screening tools and diagnostic tests may be designed this way, other formats can be useful. For instance, checklists can be an excellent portal to obtaining information from the client.

The clinician should always bring up process addictions, including sex addiction, when conducting the addiction assessment on a clinical interview. At the very least, it can be an educational opportunity, as many individuals may be unaware of or have misconceptions regarding these types of addictions. Even if the education is not of direct relevance to the client, it may provide some awareness about other people. Often, this education process, when done in a respectful manner that meets a client where he or she is at during the assessment, can help show a client that has issues about sexuality may be discussed appropriately and comfortably. Even if the client is not willing to open up about his or her sexual behavior in the first session, the educational work can plant some valuable seeds to feel comfortable about opening up later in the treatment process. It is important not to influence or persuade susceptible individuals to a certain conclusion, and of course, maintenance of professional behavior is paramount.

As noted, many who are addicted to both drugs/alcohol and sex have identified sexual addiction as the most difficult recovery [9]. When sex addicts attempt to control their disease by "white knuckling," they can be successful for various lengths of time, but this is in essence acting in rather than acting out [26]. Therefore, the basis of sex addiction treatment is similar to the traditional basis for treatment of chemical addictions; quitting "cold turkey," and without help, is never recommended. The Carnes model of sex addiction treatment is eclectic, incorporating educational, behavioral, and psychodynamic components. This will be the model discussed in this course.

Whereas total abstinence from the chemical is recommended in traditional chemical addiction treatment and certain behavioral addiction treatments (e.g., gambling), total abstinence from sex is not necessarily a part of the treatment of sexual addiction. The first part of a successful treatment program for sexual addiction is to cease the acting-out behaviors that are causing the most pervasive problems (e.g., compulsive masturbation, contact with prostitutes, voyeurism, affairs with people other than the spouse). These problems should, of course, be identified in the initial assessment or shortly thereafter. Contracts are often used as part of the treatment process [6]. This is a close parallel to chemical addiction treatment, in which the client is asked to abstain from mood/mind-altering drugs to optimize the effectiveness of the treatment.

Whether sexual addiction is being addressed in an individual counseling office or in a large-scale treatment center, one of the most complicated parts of creating a treatment plan is determining what constitutes a workable treatment goal regarding sexual contact. Some common questions include: Should a sex addict be asked to give up sexual contact with his or her spouse while being treated for the sexual addiction? Is all masturbation off limits? These are difficult questions that must be addressed on a case-by-case basis. A common criticism of addiction treatment in general is that it is too universal in its approach, meaning that the same treatment is often used regardless of substance, compulsion, or manifestation. However, there is no room for this attitude at all in sexual addiction treatment, as the manifestations of the addiction can be so multifarious. Decisions regarding level of sexual contact must also take the treatment setting into account. For instance, a person being treated for sexual addiction in an inpatient setting would be expected to be abstinent from sex with his/her partner because the partner is not there. However, if the person has transitioned to the outpatient level or is being treated exclusively in an outpatient setting, exploring some sexual connection with the partner may be appropriate. The partner's openness to sexuality is another issue altogether.

The masturbation issue is also a delicate one. Of course, there are some religious groups and spiritual approaches that regard masturbation as sinful or ill-advised, so this must be considered when treatment planning with a client. If a client is presenting as a compulsive masturbator, abstaining from the behavior is typically advised, at least until the client can explore other facets of their sexuality and sexual expression. However, in some sexual addiction presentations, masturbation is actually recommended. For instance, if a person, especially a woman, is learning to love herself or view sexual expression in a new way, exploring other avenues of sexual contact may be useful. Some treatment approaches actually encourage clients to re-learn masturbation after they have corrected their core negative beliefs about sex and sexuality. Once again, there is no universal or "best practice" approach here.

Four basic components should be addressed in a treatment plan for sexual addiction. As long as these four components are included, the individualized aims for abstinence of problematic behaviors and resumption (or attainment) of healthy sexuality can be worked in. Clinical discretion regarding how these behaviors are addressed is a must. The four major goals of sex addiction treatment are [1,6]:

These goals are not a step-by-step model, and no one component is more important than another. Rather, they must all work in synchrony to ensure an optimal treatment experience.

According to Earle and Earle, issues of childhood sexual abuse and shame must be dealt with in the treatment process [25]. This is often an important facet of evaluating the core beliefs about the self. Those professionals who feel that dealing with issues of childhood abuse, especially sexual abuse, are outside of their expertise should refer clients to a clinician who is equipped to deal with these issues. Personality disorders and identity issues should also be addressed as part of treatment, as many sexual addiction clients will have signs of entitlement, dependency, and narcissism [26]. When treating impaired professionals for sexual addiction, it is wise to incorporate a third-party evaluator before the individual returns to work [26].

The literature advocates both cognitive-behavioral therapy and psychodynamic techniques as highly effective in treating sexual addiction [1]. Thus, clinicians trained in basic cognitive-behavioral strategies already have many of the tools necessary to treat sexual addiction. The missing piece may be addressing one's own apprehensions about working with issues of sexuality and sexual addiction. All clinicians should engage in self-reflection to evaluate where they stand with issues of sexuality.