Sexual addiction: A diagnosis whose time has come
It’s time to stop viewing compulsive sexual behavior as a moral problem. An addiction model can offer patients new insights, as well as routes to treatment and recovery.
‘In the beginning, we thought this was curable. We didn’t realize that this was a compulsion.’ Cardinal Theodore McCarrick, Archbishop of Washington, DC, in a televised interview April 21, 2002.
Sex is in the news. From pedophilic priests to philandering politicians, people at every level of society get into trouble over their sexual behavior. Among clinical disciplines, psychiatry has a celebrated tradition of addressing sexual problems (Box 1).1-4 We can therefore expect to be asked for help when a person’s inappropriate sexual behavior brings him into conflict, whether with his internal values or with society.
Are we prepared to treat these predatory patients and protect their potential victims? As the U.S. Catholic church has clearly demonstrated, many approaches to prevention and treatment—moral, medical, and traditional—are often ineffective. Rather than viewing compulsive sexual behaviors as moral failures, it may be time to conceptualize and treat them as addictions.
PSYCHIATRY’S VIEWS OF SEXUALITY
Among modern clinical disciplines, psychiatry has one of the more celebrated traditions of addressing sexual problems.
In Three Essays on the Theory of Sexuality,1 Freud identified problem areas as “deviations with respect of the sexual object” and “deviations in respect of the sexual aim.” This early focus on physiologic function as a model of “normal” was succeeded by psychoanalytic attempts to address otherwise normal sexual behavior that was compulsive and, arguably, at odds with societal values.2
Masters and Johnson3 weighed in with Human Sexual Response, physiologically interesting studies of sexual behavior that raised many questions about ethics and underlying psychological processes. Finally, psychiatry’s interest in the subject may have peaked with the publication of Helen Singer Kaplan’s The New Sex Therapy,4 which integrated findings and practices from a number of disciplines.
Sexual addiction as a diagnosis
Patrick Carnes popularized the concept of addictive sexual behavior in the consumer self-help book, Out of the Shadows,5 and in Contrary to Love,6 a volume aimed at clinicians. In characterizing addictive sexual behavior, Carnes cast a large net to include masturbation, heterosexual sex, pornography, prostitution, homosexuality, exhibitionism, voyeurism, and other practices that may be associated with sexual excitement.
The unifying quality was the habitual or compulsive nature of the behavior with the goal of altering mood, regardless of its social, legal, medical, emotional, or other maladaptive consequences (Box 2). As common as these cases are, they tend not to reach the mainstream psychiatry literature until a pharmaceutical treatment is tried.7,8
DSM-IV-TR provides diagnostic criteria for paraphilias such as exhibitionism, fetishism, voyeurism, pedophilia, and sexual masochism or sadism. These are descriptions of behavior, whereas sexual addiction is a cycle of mental and emotional experiences that may have a behavior phase.
CASE STUDY THE WANDERING PASTOR
A middle-aged clergyman presents for counseling due to repeated heterosexual affairs that have been reported to the head of his district and are a potential cause for dismissal. While the affairs have been largely ego-dystonic, he cannot overcome the compulsion to repeatedly seek and become involved in these superficial relationships.
His job offers him much unstructured time, which he frequently fills with fantasies of pursuing sexual experiences. He uses his pulpit, family visits, counseling sessions, and public service activities to make new sexual contacts. He notes that he is more likely to become preoccupied with such relationships when he is distressed or depressed, and he is aware of craving or feeling states that predispose him to looking for such relationships.
The clergyman has tried prayer, counseling, psychoanalytic psychotherapy, brief courses of cognitive-behavioral therapy (weeks to months), and medication trials with various antidepressant and antianxiety agents. These treatments have been unsuccessful.
The addictive behavior may or may not be legal, and it may or may not involve a victim. The common denominator is that the addictive behavior attempts, in a chronically ineffective way, to upregulate mood and sense of self.
DSM-IV may not recognize the term “sexual addiction,” but many patients will recognize the addiction concept, identify with it, and find it useful to understand their compulsive sexual behaviors. An addiction model is already being used by a variety of 12-step and self-help approaches to sexual addiction that have spun off of the success of Alcoholics Anonymous. This model accepts the unlikelihood of cure while offering hope for rehabilitation.
Advantages As a diagnosis, sexual addiction offers patients and psychiatrists two advantages:
- It recognizes a series of temporal mental, emotional, and behavioral events with which sufferers can identify without prohibitive pain and unbearable damage to self-concept.
- It leads to a potential treatment solution that is widely available, relatively inexpensive, and addresses the volition paradox (controlling the uncontrollable) that confounds other approaches.
The cycle of addiction
The validity of a medical diagnosis is based on patterns of family history, prognosis, treatment response, and course of disease. Sexual addiction, with its predictable course and family history, may meet these diagnostic criteria.
Sexual addicts, like mythical vampires, lead secret lives designed to feed the addiction process rather than life itself. The planning, arrangements, cruising, and cover-ups compete for time with family, friends, career, and hobbies. This creates a chronic situation of unmanageability of circumstances. To cope, the addict creates a strange belief system, such as the pedophile priest’s belief that sex between men and boys is natural and that the trauma lies in reporting and investigating it.9 Belief systems such as these are often socially supported by organizations and in publications by like-minded persons.
Self-interested distortions lead the addict to wrongly perceive that victims are cooperating and the self and others are not being harmed. The result is often gross misinterpretations of reality, such as the man who thinks he is flirting at the office but is charged with sexual exploitation by a co-worker. A sequence of mental events (Figure 1) leads to, and helps the addict cope with, the addiction cycle.
The addiction cycle Carnes describes a four-stage addiction cycle: preoccupation, ritualization, sexual acting out, and despair (Figure 2). Stressful or painful experiences—a narcissistic injury, a disappointment, stress-related anxiety—or the boredom and emptiness of unstructured time may initiate the sequence. The sufferer learns, through repetitive trials and reinforcement mechanisms, to take the maladaptive path into the addiction cycle rather than making a healthy emotional adaptation.
Reasons why one person takes the path to addiction when others do not may include genetics (emotional temperament), developmental and familial circumstances, and state-dependent learning. However the cycle is entered, the preoccupation stage begins the action that characterizes all addictions—diversion of attention from the painful state and anticipation of relief or pleasure.
With all addictive substances, the preoccupation phase exhibits tolerance. Longer time frames require higher doses, and increased stimulation of ritualization is required to produce the same mood-altering effect. The addict begins to devote increasing time and energy to the addiction, consuming resources that persons around him or her realize would be better invested in friends, family, career, or recreation (real life).
It is overstatement to characterize the patient’s denial and distortions as thought disorder. Nevertheless, many patients report waking as if from a dream to realize how their perceptions, rationalizations, and behavior have become inconsistent with their own long-held values and sense of reality.
The acting-out phase is often followed by a brief sense of relief and return to normal thinking which—paradoxically—obscure the emergence of despair and rekindling of the addictive cycle. The psychological phase of despair has several important clinical implications. In alcohol addiction, for example, pseudodepression in a freshly detoxified alcoholic often resolves with abstinence. When superimposed on clinical depression, the phase may take on vegetative signs and symptoms, with dangerously increased suicide potential.
Multiple addictions Another fascinating possibility is the generic nature of the despair phase as opposed to the preoccupation phase. It opens the door to mixed or multiple addictions, in which several addiction cycles are linked and serve to defend and obscure each other (Figure 3).
An example is the alcoholic sex addict who is promiscuous after an alcohol binge. He may explain his drinking at a party as a reaction to the presence of several previous sex partners and attribute his promiscuity to intoxication. Thus, the addiction process underlying both behaviors is concealed, as is the functional relationship between the two. Often there is partial awareness (e.g., the alcohol/sex addict has noticed that his promiscuous acting out frequently occurs after, but only rarely during, an intoxication episode).
Figure 1 BELIEF AND THINKING CYCLE OF SEXUAL ADDICTION
Figure 2 FOUR-STAGE SEXUAL ADDICTION CYCLE
Figure 3 MULTIPLE-ADDICTION CYCLE
The diagnosis of sexual addiction is often made by the patient who recognizes himself in a description of the cycle of addictive thoughts and behavior. Many patients report being aware that their thinking is distorted or their behavior is out of control. They often can admit that their behavior is inconsistent with their values.
Screening For clinicians, what are the diagnostic signs of sexual addiction? Numbers of sex partners or frequency of sex may not provide adequate information or reliable criteria. The 25 items on Carnes’ Sexual Addiction Screening Test (SAST)6 bring previously off-the-radar subjects into consideration. For example, questions on the survey include:
- Have you subscribed to or regularly purchased sexually explicit magazines like Playboy or Penthouse?
- Do you ever feel bad about your sexual behavior?
- Have you made promises to yourself to quit some aspect of your sexual behavior? 6
The SAST questionnaire offers a self-report symptom checklist that can be correlated with normative data on sexual addiction. It yields a likelihood that the disorder—rather than the guilt mobilized by the behaviors—should be considered as a focus of treatment.
Although treatment of sexual addiction is beyond the scope of this article, the psychiatrist plays an important role:
- Pharmacologic interventions can be appropriate and helpful for symptoms of anxiety and depression that many addicts develop, particularly in withdrawal states.
- Cognitive-behavioral psychotherapeutic approaches can help restructure distorted thinking and alter behavioral patterns.
- Transference-oriented psychodynamic therapies can help modify the basic faulted sense of self and impaired relationships that foster addiction.10
Treatment is also available through 12-step programs such as Sex Addicts Anonymous, Sex and Love Addicts Anonymous, and Sexaholics Anonymous (“Related resources”).
- Dodes L. The heart of addiction. New York: Harper Collins, 2002.
- Sex Addicts Anonymous. www.sexaa.org
- Sexaholics Anonymous. www.sa.org
- Sex and Love Addicts Anonymous. www.slaafws.org
1. Freud S. Three essays on the theory of sexuality (1905). Complete psychological works (standard ed., vol. 7). London: Hogarth Press, 1953.
2. Hershey D. On a type of heterosexuality, and the fluidity of object relations. J Amer Psychoanal Assn 1989;37(1):147-71.
3. Masters WH, Johnson VE. Human sexual response. Boston: Little, Brown & Co, 1966.
4. Kaplan HS. The new sex therapy. New York: Times Books, 1974.
5. Carnes P. Out of the shadows. Understanding sexual addiction. 2nd ed. Center City, MN: Hazelden Foundation, 1992.
6. Carnes P. Contrary to love. Helping the sexual addict. Center City, MN: Hazelden Foundation, 1989.
7. Kafka MP, Hennen J. Psychostimulant augmentation during treatment with selective serotonin reuptake inhibiters in men with paraphilias and paraphilia-related disorders: A case series. J Clin Psychiatry 2000;61(9):664-70.
8. Coleman E, Gratzer T, Nesvacil L, Raymond NC. Nefazodone and the treatment of nonparaphilic compulsive sexual behavior: a retrospective study. J Clin Psychiatry 2000;61(4):282-4.
9. Cannon A, Kelly K, Bentrup N. Is there any end in sight? U.S. News & World Report, April 22, 2002.
10. Dodes L. The heart of addiction. New York: Harper Collins, 2002.