Understanding sexual addiction.

During the past three decades, professionals have acknowledged that some people use sex to manage their internal distress. These people are similar to compulsive gamblers, compulsive overeaters, or alcoholics in that they are not able to contain their impulses--and with destructive results.

DEFINITION

To facilitate classification and understanding of psychological disorders, mental health professionals rely on the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association and now in its fourth edition.

Each edition of this book represents a consensus at the time of publication about what constitutes mental disorders. Each subsequent edition has reflected changes in understanding. The DSM's system is, therefore, best viewed as a "work in progress" rather than the "bible."

The term sexual addiction does not appear in DSM-IV. In fact, the word addiction itself does not appear. It condenses the criteria for addictive disorders--such as substance abuse and pathologic gambling--into three elements:

* Loss of control (compulsivity). "There is a persistent desire or unsuccessful efforts to cut down or control substance abuse." "Has persistent unsuccessful efforts to control, cut back, or stop gambling."

* Continuation despite adverse consequences. "The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance use." "Has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling."

* Obsession or preoccupation. "A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects." "Is preoccupied with gambling." (1)

COMPLEX PROBLEM

Typically, individuals in trouble for their sexual behavior are not candid about whatever incident has come to light, nor are they likely to reveal that the specific behavior actually is a part of a consistent, self-destructive pattern. The nature of this illness causes patients to hide the severity of the problem from others, to delude themselves about their ability to control their behavior, and to minimize their impact on others.

Often some event will precipitate a visit to the primary care provider. Sexual excess of some type will create a physical problem. Sexually transmitted diseases, damage to genitals, unwanted pregnancies: all are among the reasons for such a visit. Most patients will say that the event is a unique situation.

The primary care provider will often treat the physical problem without probing for more information. If, however, there is sexual addiction, the problem will not disappear. A wide range of behaviors can be problematic, including compulsive masturbation, affairs, use of pornography, voyeurism, exhibitionism, sexual harassment, and sex offending.

Health care providers must understand that underneath what appears to be an isolated event may be a more complex pathologic problem with a host of related factors such as the following:

* A high incidence of depression and suicide

* The presence of high-risk and dangerous behaviors including self-harm designed to escalate sexual experiences

* The high probability of other addictive behaviors including alcoholism, drug abuse, and pathologic gambling

* Extreme disruption of the family, including battering, sexual abuse, and financial distress 

BEHAVIORS

Clinicians should remember that the discovery of something sexual does not make an addictive illness. A long-term affair, for example, would be a problem for a spouse but would not be a compulsive pattern. Likewise, a person with exploitive or violent behavior does not necessarily have an addictive illness.

I have been gathering data on sexual addiction since 1985. In the process, I have found that sexually addictive behavior clusters into 10 distinct types. Patients often will be active in more than one cluster. That is one of the most important lessons of sexual addiction: Patterns exist among behaviors.

The 10 distinctive types of behaviors are:

* Fantasy sex. Arousal depends on sexual possibility. The individual neglects responsibilities to engage in fantasy and/or prepare for the next sexual episode.

* Seductive role sex. Arousal is based on conquest and diminishes rapidly after the initial contact. It can be heightened by increasing risk and/or number of partners.

* Voyeuristic sex. Visual stimulation is used to escape into an obsessive trance. Arousal may be heightened by masturbation or risk (peeping), or violation of boundaries (voyeuristic rape).

* Exhibitionistic sex. The individual attracts attention to the body or its sexual parts. Arousal stems from the shock or the interest of the viewer.

* Paying for sex. Arousal is connected to payment for sex and, with time, it actually becomes connected to money itself. Payment creates an entitlement and a sense of power over meeting needs. The arousal starts with "having money" and the search for someone in "the business."

* Trading sex. Arousal is based on gaining control of others by using sex as leverage.

* Intrusive sex Arousal occurs by violating boundaries with no repercussions.

* Anonymous sex Arousal involves no seduction or cost and is immediate. It has no entanglements or obligations associated with it and often is accelerated by unsafe or high-risk environments such as parks and restrooms.

* Pain-exchange sex. Arousal is built around specific scenarios or narratives of humiliation and shame.

* Exploitive sex. Arousal is based on target "types" of vulnerability. Certain types of vulnerable people (such as clients/patients) become the focus.

In addition, in recent years people have begun to use cybersex in unexpected numbers, and many are finding themselves accessing sex in problematic ways.

Individuals suffering from sexual addiction have found sex on the Internet a natural extension of what they are already doing. They can act out any of the previously mentioned 10 types of sexual behavior on the Internet. They can find sex partners, be voyeuristic, start affairs, and swap partners, among other things.

There are also many individuals who never would have experienced sexual compulsive behavior had it not been for the Internet. Consider this:

* About 200 sex-related Web sites are added each day, and there are more than 100,000 existing sites.

* Sex on the Internet constitutes the third largest economic sector on the Web (software and computers rank first and second), generating one billion dollars annually.

* A total of 65 million unique visitors use free porn sites, and 19 million unique visitors use pay porn sites each month.

* Approximately one percent of Internet users have a severe problem that focuses almost exclusively on cybersex, with major neglect of the rest of their life's activities. (2)

SUCCESSFUL TREATMENT

A number of key factors are involved in successful recovery from sexual addition. They include:

* A good addiction-oriented primary therapist. Most successful recoveries involve a relationship with a therapist over a three-to five-year period, the first two years of which are very intense.

* A 12-step sexual addiction group. The probability of relapse is extremely high if the addict does not attend meetings.

* A 12-step program for other addictions. If the addict has other addictions, a 12-step program is necessary for those as well. A suggestion that makes things easier is to find a sponsor or sponsors who attends all of the same meetings your patient does. This way, there is a consolidation of relationships.

* Program work, not just attendance. Completing step work, finding a sponsor, and doing service are all key elements of recovery. Individuals should become actively involved in the program's activities. In a recent outcome study of an inpatient program for sexual addiction, researchers discovered that only 23 percent actually complete the first nine of the 12 steps in 18 months. However, of those who did, recidivism was rare. (3)

* Early family involvement. Family participation in the patient's therapy improves the chance for success.

* Spiritual support. Addicts report that the spiritual work started in their 12-step communities and continued in various spiritual communities was critical to the changes they needed to make.

* Exercise along with good nutrition and a healthy lifestyle. Addicts who reduce their stress, start an exercise program, and eat more healthfully do better in their recovery.

In discussing what had helped them in their recovery, over 190 sex addicts indicated that these treatments were the most helpful (in order from most to least): a higher power (87 percent); couples 12-step group based on sexual addiction (85 percent); a friend's support (69 percent); individual therapy (65 percent); a celibacy period (64 percent); a sponsor (61 percent); exercise/nutrition (58 percent); a 12-step group based on subjects other than sexual addiction (55 percent); partner support (36 percent); inpatient treatment (35 percent); outpatient group (27 percent); therapy (21 percent); family therapy (11 percent); and after care (hospital) (9 percent). (4)

HEALTHY SEXUALITY

The goal of treatment is healthy sexuality. Some therapists insist on a period of celibacy, which does help to reduce chaos and make patients available for therapy. But recovery from sexual addiction does not mean sexual abstinence.

The objective of treatment is to help individuals develop a healthy, strong sexual life. One of the risks is that the patients may slip to a position of sexual aversion, in which they think all sex is bad. Sexual aversion, or "sexual anorexia," is simply another variant of sexual compulsive behavior.

Patients will sometimes bounce from one extreme to the other. True recovery involves a clear understanding about abstaining from certain sexual behaviors combined with an active plan for enhancing sexuality.

Recovery from sexual addiction is likened to recovery from eating disorders. Food is a necessary part of life, and recovery from eating disorders requires defining what is healthy eating and what is not. Similarly, the goal of recovery from sexual addiction is learning what is healthy sexuality for the individual.

Healthy sexuality for most sexually addicted individuals involves not only a change in behavior but also an avoidance of fantasizing about behaviors that are unhealthy. Sexual fantasizing can be healthy, particularly for a reasonably healthy couple that uses their increased excitement to move toward rather than away from the partner. However, sexual imagery that is not respectful of other human beings increases objectification, depersonalization, and destructive bonding based on hostility rather than affection. Asking patients about his or her "sobriety" definition and about the content of fantasies provides clues to help with treatment and recovery.

KEEPING UP

To determine how well the patient is doing in establishing a healthy lifestyle, clinicians can ask some simple questions. Does the patient have tools for avoiding relapse during times of hunger, anger, loneliness, and tiredness? Is the patient attending 12-step self-help meetings? If not, what are the obstacles preventing the patient from doing so? What are the patient's perceptions of what goes on at a meeting? Does he or she have a sponsor (a person longer in recovery who can guide the newer member)?

Is the patient seeking a counselor or therapist who is knowledgeable in addiction recovery? Is there balance between work and recreation? Is the patient exercising or engaging in any sports? Is the patient actively working to improve his or her relationship with a spouse or significant other? Is the spouse also attending a self-help meeting? These are all indicators to determine if the individual is fully engaged in building a healthier lifestyle.

CONCLUSION

The treatment of sexual addiction has taken a long time to gain recognition and respect as an area of medical specialty.

As with other disorders, such as alcoholism or anorexia, clinicians face many challenges in learning about sexual addiction. Most who take time to learn find patients who are profoundly grateful.

In many ways, the field of sexual addiction lags behind both professional and lay awareness of alcoholism or anorexia. Yet, important strides are being made in both understanding and awareness.

Appreciating the issues and challenges of sexual addiction will help clinicians when their patients' behaviors cross the line from problems of judgment to symptoms of a clinical disorder.

References

(1.) Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (Washington, DC: American Psychiatric Association, 1994), pp. 181, 618.

(2.) P. Carnes et al, In the Shadows of the Net (Center City, MN: Hazelden Foundation, 2001), pp. 6-7.

(3.) P. Carnes, "Sexual Addiction and Compulsion: Recognition, Treatment, and Recovery," CNS Spectrums, Vol. 5, No. 10, October 2000, pp. 63-68.

(4.) Ibid.

Patrick Carnes, Ph.D.

Clinical Director for Sexual Disorders Services

The Meadows

Wickenburg, AZ