Sexual addiction

Sexual addiction refers to the phenomenon in which individuals report being unable to manage their sexual behavior. It has also been called sexual dependency, and sexual compulsivity. The existence of the condition is not universally accepted by sexologists and its etiology, nature, and validity has been debated.

Proponents of the concept have offered varying descriptions, each according to their favored model of the putative phenomenon. Proponents of an addiction model of the phenomenon refer to it as "sexual addiction" and offer definitions based on substance addictions; proponents of lack-of-control models refer to it as "sexual compulsivity" and offer definitions based on obsessive-compulsive disorder (OCD).

Definition

Sexologists have not reached any consensus regarding whether sexual addiction exists or, if it does, how to describe the phenomenon.^[1][2] Some experts, like Dr. Drew Pinsky, believe that sexual addiction is literally an addiction, directly analogous to alcohol and drug addictions. Other experts believe that sexual addiction is actually a form of obsessive compulsive disorder and refer to it as sexual compulsivity.^[3] Still other experts believe that sex addiction is itself a myth, a by-product of cultural and other influences.^[4][5]

Terminology

"Nymphomania" and "satyriasis" are not listed as disorders in the DSM-IV, though they remain a part of ICD-10, each listed as a subtype of "hypersexuality."^[6]

Official status

The American Psychiatric Association publishes and periodically updates the Diagnostic and Statistical Manual of Mental Disorders (DSM), a widely recognized compendium of acknowledged mental disorders and their diagnostic criteria. The most recent version of that manual, DSM-IV-TR, was published in 2000 and does not recognize sexual addiction as a diagnosis.^[7] Although some authors had expressed that excluding sexual addiction from the DSM represents a problem,^[8] the proposed diagnosis was rejected for consideration for inclusion in the DSM-5.^[9] Darrel Regier, vice-chair of the DSM-5 task force, said that "[A]lthough 'hypersexuality' is a proposed new addition...[the phenomenon] was not at the point where we were ready to call it an addiction."

The DSM-IV-TR does, however, include a miscellaneous diagnosis called Sexual Disorders Not Otherwise Specified, and includes as one of the examples of it: "distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used." Other examples include: compulsive fixation on an unattainable partner, compulsive masturbation, compulsive love relationships, and compulsive sexuality in a relationship.^[7] Hypersexuality, by itself, is a criterion symptom of hypomania and mania in bipolar disorder and mania in schizoaffective disorder as they are currently defined in the DSM.

The World Health Organization produces the International Classification of Diseases (ICD), which is used globally and is not limited to mental disorders. The most recent version of that document, ICD-10, includes "Excessive sexual drive" as a diagnosis (code F52.7), subdividing it into satyriasis (for males) and nymphomania (for females).^[6]

Symptoms and proposed diagnostic criteria

Proposals based on addictions models

Irons and Schneider have noted that "Addictive sexual disorders that do not fit into standard DSM-IV categories can best be diagnosed using an adaptation of the DSM-IV criteria for substance dependence."^[8] Similarly, Lowinson and colleagues use the addiction model and define sexual addiction as a condition in which some form of sexual behaviour is employed in a pattern that is characterized at least by two key features: recurrent failure to control the behaviour and continuation of the behaviour despite harmful consequences.^[10] Patrick Carnes, another proponent of the addiction model of sexual addiction, argued that most professionals in the field agree with the World Health Organization's definition of addiction.^[11]

Carnes

Patrick Carnes, a proponent of the idea of sexual addiction, proposed using:^[12]

1. Recurrent failure (pattern) to resist impulses to engage in extreme acts of lewd sex.
2. Frequently engaging in those behaviors to a greater extent or over a longer period of time than intended.
3. Persistent desire or unsuccessful efforts to stop, reduce, or control those behaviors.
4. Inordinate amount of time spent in obtaining sex, being sexual, or recovering from sexual experience.
5. Preoccupation with the behavior or preparatory activities.
6. Frequently engaging in violent sexual behavior when expected to fulfill occupational, academic, domestic, or social obligations.
7. Continuation of the behavior despite knowledge of having a persistent or recurrent social, academic, financial, psychological, or physical problem that is caused or exacerbated by the behavior.
8. Need to increase the intensity, frequency, number, or risk of behaviors to achieve the desired effect, or diminished effect with continued behaviors at the same level of intensity, frequency, number, or risk.
9. Giving up or limiting social, occupational, or recreational activities because of the behavior.
10. Resorting to distress, anxiety, restlessness, or violence if unable to engage in the behavior at times relating to SRD (Sexual Rage Disorder).

Goodman

Goodman proposed:^[13]
A maladaptive pattern of behavior, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

1. tolerance, as defined by either of the following:
   1. a need for markedly increased amount or intensity of the behavior to achieve the desired effect
   2. markedly diminished effect with continued involvement in the behavior at the same level or intensity
2. withdrawal, as manifested by either of the following:
   1. characteristic psychophysiological withdrawal syndrome of physiologically described changes and/or psychologically described changes upon discontinuation of the behavior
   2. the same (or a closely related) behavior is engaged in to relieve or avoid withdrawal symptoms
3. the behavior is often engaged in over a longer period, in greater quantity, or at a higher intensity than was intended
4. there is a persistent desire or unsuccessful efforts to cut down or control the behavior
5. a great deal of time spent in activities necessary to prepare for the behavior, to engage in the behavior, or to recover from its effects
6. important social, occupational, or recreational activities are given up or reduced because of the behavior
7. the behavior continues despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the behavior

Proposals based on obsessive/compulsive models

Schneider identified three indicators of sexual addiction: compulsivity, continuation despite consequences, and obsession.^[14]

1. Compulsivity: This is the loss of the ability to choose freely whether to stop or continue a behavior.^[15]
2. Continuation despite consequences: When addicts take their addiction too far, it can cause negative effects in their lives. They may start withdrawing from family life to pursue sexual activity. This withdrawal may cause them to neglect their children or cause their partners to leave them. Addicts risk money, marriage, family and career in order to satisfy their sexual desires.^[16] Despite all of these consequences, they continue indulging in excessive sexual activity.
3. Obsession: This is when people cannot help themselves from thinking a particular thought. Sex addicts spend whole days consumed by sexual thoughts. They develop elaborate fantasies, find new ways of obtaining sex and mentally revisit past experiences. Because their minds are so preoccupied by these thoughts, other areas of their lives that they could be thinking about are neglected.

Eli Coleman proposed:^[17]

1. involves recurrent and intense normophilic (nonparaphilic) sexually arousing fantasies, sexual urges, and behaviors that cause clinically significant distress in social, occupational, or other important areas of functioning; and
2. is not due simply to another medical condition, substance use disorder, or a developmental disorder

Epidemiology

Sexual addiction is hypothesized to be (but is not always) associated with obsessive-compulsive disorder (OCD), narcissistic personality disorder,^[18][19], and manic-depression.^[20] There are those who suffer from more than one condition simultaneously (co-occurring disorder), but traits of addiction are often confused with those of these disorders, often due to most clinicians not being adequately trained in diagnosis and characteristics of addictions, and many clinicians tending to avoid use of the diagnosis at all.^[1][21][22]

Specialists in obsessive-compulsive disorder and addictions use the same terms to refer to different symptoms. In addictions, obsession is progressive and pervasive, and develops along with denial; the person usually does not see themselves as preoccupied, and simultaneously makes excuses, justifies and blames. Compulsion is present only while the addict is physically dependent on the activity for physiological stasis. Constant repetition of the activity creates a chemically dependent state. If the addict acts out when not in this state, it is seen as being spurred by the obsession only. Some addicts do have OCD as well as addiction, and the symptoms will interact.^[21]

Addicts often display narcissistic traits, which often clear as sobriety is achieved. Others do exhibit the full personality disorder even after successful addiction treatment.^[18]

Etiology

Proponents of the concept have described sufferers as repeatedly and compulsively attempting to escape emotional or physical discomfort by using ritualized, sexualized behaviors such as masturbation, pornography, including obsessive thoughts. Some individuals try to connect with others through highly impersonal intimate behaviors: empty affairs, frequent visits to prostitutes, voyeurism, exhibitionism, frotteurism, cybersex, Zoophilia, and the like.

Neurochemical theories

Earle has argued that neurochemical changes, similar to an adrenaline rush in the brain, temporarily reduce the discomfort an individual experiences with urges and cravings for sexualized behaviors that can be achieved through obsessive, highly ritualized patterns of sexual behavior.^[23]

Psychological distress theories

Patrick Carnes (2001, p. 40) argues that when children are growing up, they develop “core beliefs” through the way that their family functions and treats them. A child brought up in a family that takes proper care of them has good chances of growing up well, having faith in other people, and having self worth. On the other hand, a child who grows up in a family that neglects them will develop unhealthy and negative core beliefs. They grow up to believe that people in the world do not care about them. Later in life, the person has trouble keeping stable relationships and feels isolated. Generally, addicts do not perceive themselves as worthwhile human beings (Carnes, Delmonico and Griffin, 2001, p. 40). They cope with these feelings of isolation and weakness by engaging in excessive sex (Poudat, 2005, p. 121).

Addiction theories

According to Patrick Carnes the cycle begins with the "Core Beliefs" that sex addicts hold:^[24]

1. "I am basically a bad, unworthy person."
2. "No one would love me as I am."
3. "My needs are never going to be met if I have to depend on others."
4. "Sex is my most important need."

These beliefs drive the addiction on its progressive and destructive course:^[24]

• Pain agent — First a pain agent is triggered / emotional discomfort (e.g. shame, anger, unresolved conflict). A sex addict is not able to take care of the pain agent in a healthy way.

• Dissociation — Prior to acting out sexually, the sex addict goes through a period of mental preoccupation or obsession. Sex addict begins to dissociate (moves away from his or her feelings). A separation begins to take place between his or her mind and his or her emotional self.

• Altered state of consciousness / a trance state / bubble of euphoric fantasized experience — Sex addict is emotionally disconnected and is pre-occupied with acting out behaviours. The reality becomes blocked out/distorted.

• Preoccupation or "sexual pressure" — This involves obsessing about being sexual or romantic. Fantasy is an obsession that serves in some way to avoid life. The addict's thoughts focus on reaching a mood-altering high without actually acting-out sexually. They think about sex to produce a trance-like state of arousal to eliminate the pain of reality. Thinking about sex and planning out how to reach orgasm can continue for minutes or hours before they move to the next stage of the cycle.

• Ritualization or "acting out." — These obsessions are intensified by ritualization or acting out. A sex addict first cruises, then goes to a strip show to heighten arousal until they are beyond the point of saying no. Ritualization helps distance reality from sexual obsession. Rituals induce trance and further separate the addict from reality. Once the addict begins the ritual, the chances of stopping that cycle diminish greatly. They give into the pull of the compelling sex act.

• Sexual compulsivity — The next phase of the cycle is sexual compulsivity or "sex act". The tensions the addict feels are reduced by acting on their sexual feelings. They feel better for the moment, thanks to the release that occurs. Compulsivity simply means that addicts regularly get to the point where sex becomes inevitable, no matter what the circumstances or the consequences. The compulsive act, which normally ends in orgasm, is perhaps the starkest reminder of the degradation involved in the addiction as the person realizes they are a slave to the addiction.

• Despair — Almost immediately reality sets in, and the addict begins to feel ashamed. This point of the cycle is a painful place where the Addict has been many, many times. The last time the Addict was at this low point, they probably promised to never do it again. Yet once again, they act out and that leads to despair. They may feel they have betrayed spiritual beliefs, possibly a partner, and his or her own sense of integrity. At a superficial level, the addict hopes that this is the last battle.

According to Mr.Carnes, for many addicts, this dark emotion brings on depression and feelings of hopelessness. One easy way to cure feelings of despair is to start obsessing all over again. The cycle then perpetuates itself.^[25]

Treatment

Numerous professional therapists and counsellors offer treatment for sexual addiction.

In addition, self-help groups such as Sex Addicts Anonymous, Sexaholics Anonymous, Sexual Compulsives Anonymous and Sex and Love Addicts Anonymous are popular with proponents of the sexual addiction concept. These are large groups based on the 12-step system of Alcoholics Anonymous. There are various online support forums for these groups as well as meetings in metropolitan areas.

Help may also be available through an out-patient or in-patient program or private counselor.

See also

• Antisexualism
• Bipolar Disorder
• Cybersex
• Disease model of addiction
• Involuntary celibacy
• Society for the Advancement of Sexual Health
• Obsessive-compulsive disorder
• Pornography addiction
• Self-help groups / programs: twelve-step programs:
  • Sexaholics Anonymous
  • Sex and Love Addicts Anonymous
  • Sexual Compulsives Anonymous
  • Sex Addicts Anonymous
• Sex and Love Addiction
• Sex Rehab with Dr. Drew
• Sexual obsessions
• Sexual Addiction and Compulsivity: The Journal of Treatment and Prevention

References

Further reading

Sexual Addiction and Compulsivity: The Journal of Treatment and Prevention, a journal in which proponents explore the topic, has devoted an entire issue to AIDS and sex addiction as a worldwide problem.

• Carnes, P. (2005) "Facing the Shadow: Second Edition." Carefree, AZ: Gentle Path Press ISBN 9780977440009
• Carnes, S. (2008) "Mending a Shattered Heart." Carefree, AZ: Gentle Path Press ISBN 9780977440061
• McDaniel, K. (2008) "Ready to Heal: Women Facing Love, Sex, and Relationship Addiction. Second Edition" Carefree, AZ: Gentle Path Press ISBN 9780977440030
• Carnes, P. (2007) "Recovery Start Kit." Carefree, AZ: Gentle Path Press ISBN 9780977440023
• Feeney, Judith and Patricia Noller. Adult Attachment. Thousand Oaks, CA: Sage Publications, 1996.
• Kasl, Charlotte Davis. Women, Sex, and Power: A Search for Love and Power. New York, NY: Harper and Row, 1990.
• Schaumburg, Harry W. False Intimacy: Understanding the Struggle of Sexual Addiction. Colorado Springs, CO: NavPress 1997.
• Kort, Joe 10 Smart Things Gay Men Can Do To Improve Their Lives (chapter on sexual addiction relating to gay men) ISBN 1555837824

Alyson, 2003

• Earle, Ralph and Crow, Gregory Lonely All The Time: Recognizing, Understanding and Overcoming Sex Addiction, for Addicts and Co-Dependents New York, New York: Pocket Books 1989
• Sterry, David Henry I Was a Poster Boy for Sex Addicts. nthWORD Magazine Spring/Summer 2009

Science based (research based) books on sexual addiction:

• Carnes, S. (2008) "Mending a Shattered Heart." Carefree, AZ: Gentle Path Press ISBN 9780977440061
• McDaniel, K. (2008) "Ready to Heal: Women Facing Love, Sex, and Relationship Addiction. Second Edition" Carefree, AZ: Gentle Path Press ISBN 9780977440030
• Carnes, P. (2007) "Recovery Start Kit." Carefree, AZ: Gentle Path Press ISBN 9780977440023
• Carnes, P. (2005) "Facing the Shadow: Second Edition." Carefree, AZ: Gentle Path Press ISBN 9780977440009
• Sexual Addiction: an integrated approach, AVIEL GOODMAN, Madison, CT, International *Universities Press, Inc. 1998,ISBN 0 8236 6063
• Carnes, P. (1983). Out of the shadows: Understanding sexual addiction. Minneapolis, MN: CompCare.
• Carnes, P. ( 1991). Don't call it love: Recovery from sexual addiction. New York: Bantam Books.
• Carnes P., Kenneth M. Adams (2002). Clinical Management of Sex Addiction.
• Cooper, PhD, Al Cybersex: The Dark Side of The Force A Special Issue of Sexual Addiction & Compulsivity.
• Cooper, PhD, Al Sex and the Internet: A Guidebook for Clinicians
• Earle, Ralph, and Marcus Earle Sex Addiction: Case Studies and Management New York: Brunner Mazel, 1995.
• Jennifer Schneider, M.D., Ph.D. and Robert Weiss, M.S.W., C.A.S. Cybersex Exposed.
• Milkman. H., & Sunderwirth, S. (1987). Craving for ecstasy: The consciousness and chemistry of escape. New York: Lexington Books.
• Schaeffer, Brenda Is It Love or is it Addiction? Second Edition Center City, MN: Hazelden, 1997.

Articles in scientific journals:

• Treating the Sexually Addicted Client: Establishing a Need for Increased Counselor Awareness
• W Bryce Hagedorn, Gerald A Juhnke. Journal of Addictions & Offender Counseling. Alexandria: Apr 2005.Vol.25, Iss. 2; pg. 66.
• Boredom Proneness, Social Connectedness, and Sexual Addiction Among Men Who Have Sex With Male Internet Users
• Michael P Chaney, Andrew C Blalock. Journal of Addictions & Offender Counseling. Alexandria: Apr 2006.Vol.26, Iss. 2; pg. 111, 12 pgs
• SEXUAL ADDICTION AND MARRIAGE AND FAMILY THERAPY: FACILITATING INDIVIDUAL AND RELATIONSHIP HEALING THROUGH COUPLE THERAPY, Mark H Bird. Journal of Marital and Family Therapy. Upland: Jul 2006.Vol.32, Iss. 3; pg. 297, 13 pgs
• 'The snake and the seraph'--Sexual addiction and religious behaviour. Thaddeus Birchard. Counselling Psychology Quarterly. Abingdon: Mar 2004. Vol. 17, Iss. 1; p. 81
• Sexual Addiction, Sexual Compulsivity, Sexual Impulsivity, or What? Toward a Theoretical Model John Bancroft, Zoran Vukadinovic. The Journal of Sex Research. New York: Aug 2004.Vol.41, Iss. 3; pg. 225, 10 pgs
• Addictions without substance series part II: Sexual addiction, Thaddeus Birchard. Drugs and Alcohol Today. Brighton: Jul 2006.Vol.6, Iss. 2; pg. 32, 3 pgs
• Understanding sexual addiction, Patrick Carnes. SIECUS (Sex Information and Education Council of the U.S.) Report. New York: Jun/Jul 2003.Vol.31, Iss. 5; pg. 5
• Carnes, P., Nonemaker, D., & Skilling, N. (1991). Gender differences in normal and sexually addicted populations. American Journal of Preventive Psychiatry and Neurology, 3, 16-23.
• Cooper, A. (1998). Sexuality and the Internet: Surfing into the new millennium. CyberPsychology and Behavior, I, 187194.
• Cooper, A, Delmonico, D., & Burg, R. (2000). Cybersex users, abusers, and compulsives: New findings and implications. Sexual Addiction and Compulsivity, 7(1-2), 5-29.
• Cooper, A., Scherer, C., Boies, S., & Gordon, B. (1999). Sexuality on the Internet: From sexual exploration to pathological expression. Professional Psychology: Research and Practice, 30, 154-164.
• Corley, M., & Schneider, J. (2002). Disclosing secrets: Guidelines for therapists working with sex addicts and co-addicts. Sexual Addiction and Compulsivity, 9, 43-67.
• Delmonico, D., & Carnes, P. (1999). Virtual sex addiction: When cybersex becomes the drug of choice. CyberPsychology and Behavior, 2, 457-463.
• Dodge, B., Reece, M., Cole, S., & Sandfort, T. (2004). Sexual compulsivity among heterosexual college students. Journal of Sex Research, 41, 343-350.
• Eisenman, R., Dantzker, M., & Ellis, L. (2004). Self-ratings of dependency/addiction regarding drugs, sex, love, and food: Male and college female students. Sexual Addiction and Compulsivity, 11, 115-127.
• Griffiths, M. (2001). Sex on the Internet: Observations and implications for Internet sex addiction. Journal of Sex Research, 38, 333-342.
• Kafka, M., & Hennen, J. (1999). The paraphilia-related disorders: An empirical investigation of nonparaphilic hypersexuality disorders in outpatient males. Journal of Sex and Marital Therapy, 25, 305-319.
• Kafka M., & Prentky R. (1992). A comparative study of nonparaphilic sexual addictions and paraphilias in men. Journal of Clinical Psychiatry, 53, 345-350.
• Kalichman, S., & Cain, D. (2004). The relationship between indicators of sexual compulsivity and high risk sexual practices among men and women receiving services from a sexually transmitted infection clinic. Journal of Sex Research, 41, 235-241.
• Kort, Joe (2004). Covert Cultural Sexual Abuse of Gay Male Teenagers Contributing to Etiology of Sexual Addiction, Sexual Addiction and Compulsivity, Vol 11, 287-300.
• Quadland, M. ( 1985). Compulsive sexual behavior: Definition of a problem and an approach to treatment. Journal of Sex and Marital Therapy, II, 121-132.
• Raviv, M. (1993). Personality characteristics of sexual addicts and pathological gamblers. Journal of Gambling Studies, 9, 17-31.
• Reece, M., & Dodge, B. (2004). Exploring indicators of sexual Compulsivity among men who cruise for sex on campus. Sexual Addiction and Compulsivity, II, 87-113.
• Ross, C. (1996). A qualitative study of sexually addicted women. Sexual Addiction and Compulsivity, 3, 43-53.
• Schneider, J. (2000a). A qualitative study of cybersex participants: Gender differences, recovery issues, and implications for therapists. Sexual Addiction and Compulsivity, 7, 249-278.
• Schneider, J. (2000b). Effects of cybersex addiction on the family: Results of a survey. Sexual Addiction and Compulsivity, 7, 31-58.
• Schneider, J., & Schneider, B. (1990b). Marital satisfaction during recovery from self-identified sexual addiction among bisexual men and their wives. Journal of Sex and Marital Therapy, 16, 230-250.
• Schneider, J., & Schneider, B. (1996). Couple recovery from sexual addiction/co-addiction: Results of a survey of 88 marriages. Sexual Addiction and Compulsivity, 3, 111-126.
• Schwartz, S., & Abramowitz, J. (2003). Are nonparaphilic sexual addictions a variant of obsessive-compulsive disorder? A pilot study. Cognitive and Behavioral Practice, 10, 372-377.
• Sprenkle, D. (1987). Treating a sex addict through marital sex therapy. Family Relations: Journal of Applied Family and Child Studies, 36, 11-14.
• Swisher. S (1995). Therapeutic interventions recommended for treatment of sexual addiction/compulsivity. Sexual Addiction and Compulsivity, 2, 31-39.
• Wan, M., Finlayson, R., & Rowles, A. (2000). Sexual dependency treatment outcome study. Sexual Addiction and Compulsivity, 7, 177-196.
• Weiss, D. (2004). The prevalence of depression in male sex addicts residing in the United States. Sexual Addiction and Compulsivity, II, 57-69.
• Young, K., Griffin-Shelley, E., Cooper, A., O'Mara, J., & Buchanan, J. (2000). Online infidelity: A new dimension in couple relationships with implications for evaluation and treatment. Sexual Addiction and Compulsivity, 7, 59-74.
• Yoder, V., Virden, T, & Amin, K. (2005). Internet pornography and loneliness: An association? Sexual Addiction and Compulsivity, 12, 19-44.
• Kreuger, R. B., & Kaplan, M. S. (January 2002). "Treatment resources for the paraphilic and hypersexual disorders". Journal of Psychiatric Practice 8 (1): 59. doi:10.1097/00131746-200201000-00010. PMID 15985857. 
• Krueger, R. B., & Kaplan, M. S. (Oct-December 2005). "Book Review: Clinical Management of Sex Addiction". Journal of Sex & Marital Therapy 31 (5): 448–450. doi:10.1080/00926230500189307. 
• Laaser, M. R. (1996). "Recovery for couples". Sexual Addiction & Compulsivity 3 (2): 97–109. doi:10.1080/10720169608400105. 
• Nunez, J. (January 2003). "Outpatient treatment of the sexually compulsive ephebophile". Sexual Addiction & Compulsivity 10 (1): 23–51. doi:10.1080/10720160309047. 
• Parker, J., & Guest, D. (January 2003). "Individualized sexual addiction treatment: A developmental perspective". Sexual Addiction & Compulsivity 10 (1): 13–22. doi:10.1080/10720160309044. 
• Schneider, J. P., & Schneider, B. H. (1996). "Couple recovery from sexual addiction/coaddiction: Results of a survey of 88 marriages". Sexual Addiction & Compulsivity 3 (2): 111–126. doi:10.1080/10720169608400106.