By: Kurt D. LaRose
2005 and Rev 2018
While the DSM5 footnotes sex addiction, suggesting the next revision will include this as a disorder, alternative possibilities are explained in the following updated text and in the very last slide of the power point (for example, more sex positive/sex affirming options, organizations who focus on sexuality and sexual health along with other considerations alternative disorders where hypersexuality can be a symptom—and not “sex addiction.
The term sexual addiction is not without controversy. Some argue that the label of sexual addiction is nothing more than a way to standardize what is acceptable sexual behavior, by a majority society driven to establish heterosexual monogamy as the norm (Falla, 2001). But more likely, there exists the possibility that because the topic of sexual addiction conjures up perceptions of child molesters and exhibitionists, people would prefer to collude to place these “perverts” into a category that calls for punitive actions for their bizarre sexual behaviors. And maybe it is the idea that the sexually mesmerized person engages in patterns that are simply disgusting and dirty (Carnes, 1991); thus, out of sight, out of mind becomes the protocol. With the advent of the internet sex is readily available, and internet anonymity provides an open door for many to indulge (Gordon & Cooper, 2003). And as if there was not enough of a debate about sex addiction, newer terms to hit the psychological scene are words like internet sexuality (Golden & Cooper, 2003) and internet sex addiction (Griffiths, 2001).
The idea of providing treatment to sex addicts, based upon the addiction model, seems less desirable for a population that is cynically judged as morally inept. Somehow, such a discussion rings familiar back to the early days of Alcoholics Anonymous when the drunk was nothing more than a moral misfit with insufficient will power; the drunk was involved in “moral turpitude” (Levin, 1999, p. 33).
There is also the debate as to whether or not an addiction can emerge from something that is not ingested, because it is when substances are consumed that a physical and psychological dependence emerges; the mood altering effect of chemicals is a basis on which dependence evolves. But behaviors, just like chemicals, can be mood altering (Carnes, 1983; May 1988). The argument is complicated by the idea that people cannot become addicted to something that is a natural human function, such as sex, no matter how bizarre some of the behaviors may seem (Klein, 2003). Others disagree, saying that sex can become an addiction and that addictions can be non-substance based affecting the neurochemistry of the brain in the same way that chemicals do (Carnes, 1991; May, 1988; Milkman & Sunderwirth, 1987).
That the brain is altered, before, during or after sexual activity has been shown in various studies. Endorphins have been shown to increase dramatically after multiple orgasms (Milkman & Sunderwirth, 1987). The brain also has certain molecules that are present in higher amounts, particularly related to sexual activity. For example the peptide phenylthylamine (PEA; a molecule related to cell functioning found in the brain) can be found in the blood in higher amounts anytime surrounding sexual activity (Carnes, 1991; Spink, n.d.). Interestingly, PEA has characteristics very similar to amphetamines, and as such PEA may affect dopamine levels in the brain in a similar manner. If PEA is injected into monkeys they become hypersexual and super erotic (Liebowitz, 1983 as cited in Carnes, 1991).
Holden (2001) brings to the forefront some experts who suggest that neuroadaptation occurs to the degree that the brain is altered by recurrent and persistent behaviors in such a way that behaviors become perpetuated (see also May, 1988). Behaviors, like chemicals, induce neurochemical changes in the brain and the compulsion/addiction becomes one associated with an activity such as sex (Schneider & Irons, 2001). As behaviors continue over time the nerve cells in the brain literally and permanently change – behavior changes how neurotransmitters function, how the neuroreceptors function, and synaptic connections can become permanently severed; the process of change in the brain is called habituation (a temporary brain adjustment) and adaptation (a permanent brain alteration) (May, 1988).
The idea that sexual behavior should be viewed through the lens of addiction and dependence is not new (Orford, 1978 and 1985 as cited by Schneider & Irons, 2001). However, Klein (2003) postulates that lumping sexual behavior into an addiction category enables criminals, and any other “sex addict,” to be removed from responsibility for abhorrent actions. But some research indicates that sex offenders are missing a key characteristic of the addiction mentality: despair about their own sexual acting out behavior (Eisenman, 2001). Additionally, from an addictions perspective, sex offenders do not automatically fall into the category of addicts (Carnes, 1991; Earle & Crow, 1989).
Another variable to be considered in assessing whether or not sexual behavior can lead to sexual addiction is that other disorders may be diagnosable. Hypersexuality can be a symptom of disorders such as Bipolar (Geller, Bolhofner, Craney, Williams, DelBello, & Gundersen, 2000) and hypersexuality can also be a side effect to certain medications, such as Wellbutrin and Prozac (“Bupropion and Hypersexuality,” 2004). Some believe that sex addiction is really an impulse control disorder (Barth & Kinder, 1987). And because sexual behaviors can include compulsivity and obsessions there is a belief that sex addiction is actually a variation of an obsessive compulsive disorder (Jenike, 1989 as cited in Coleman, 2003). But even in this debate a common denominator exists that makes the idea of sexual addiction plausible: “compulsivity is often a precursor to addiction” (Griffiths, 2001, p. 339).
The inter-psychic processes of the sexually compulsive person cannot be ignored either, as it has been an important consideration for addiction recovery since the foundation of recovery was first realized, most notably with the evolution of Alcoholics Anonymous (AA). It is good to consider the AA viewpoint given that it’s model has been adapted to a multitude of other “addictions” with a degree of respectable success; the 12-step process of recovery is widely accepted as an effective treatment modality, even by those who do not fully support the disease model for addiction (Coleman, 2003). Admittedly, AA propagated the physical aspects of addiction and promoted the concept of addiction as a disease, but psycho-social-spiritual factors consume the AA recovery model, making it clear that mental and emotional processes are key components of addiction (Alcoholics Anonymous, 1976). “In the not-too-distant past, psychological factors were seen as the single most important predictors and/or precursors of future alcoholism” (Kinney, 2000, p. 166). The same holds true for sexual addictions; the psychological aspects that either precede or are simultaneous with compulsive sexual behaviors are key ingredients in defining sexual addiction (Carnes, 1991).
Suffice it to say that the debate about the term sexual addiction will not be settled here. The reality is, that no matter what the literature says about sexual behaviors, sexual compulsions, and/or sexual addiction, there is almost universal consensus that there are patterns of sexual behavior that cause people to need treatment. One thing is for certain; sexual behavior can be and is problematic for a multitude of people. Even normal sexual development is not without difficulty.
Sexual addiction has emerged as a disorder that can be diagnosed and treated (Carnes, 1983, 1991; Earle & Crow, 1989; Sex and Love Addicts Anonymous, 1986). It should be noted that in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994), the DSM IV and more recently in the DSM 5, there is not a category to diagnose sexual dependence; nor does the term addiction appear. The DSM identifies paraphilia, unconventional sexual behavior (such as pedophilia, exhibitionism, voyeurism, and sexual masochism to name a few), and it identifies sexual disorders. Whether or not the DSM will someday include a category for sex dependency remains to be seen, however if it does, it will not be the first time the manual changed it’s diagnostic criteria adding and deleting various disorders (Klein, 2003). There is a footnote to the more recent DSM5 suggesting at some point a behavioral disorder of sex addiction may be forth coming.
“Sexual addiction,” if it ever does become a diagnostic term (as of 2018, in the US anyway, it is not), will be an interesting development, as other behavioral addictions are taking shape, such as gaming, internet addiction and gambling. Further as experts in sexual health and in sexuality progress and study the evolving neuro-biological literature, a better understanding of brain processes may explain behavioral patterns in a more biologically rooted framework. The impact of culture, morality, sexual evolution and more sex affirming and sex positive explanations to what was once believed to be “sick” are increasingly being resolved and strengthened through science and evidenced based models, that operate outside of the spiritually based “programs of recovery.” Increasingly, as LGBTQ literature is emerging, the hetero-centric view of sexual behavior could be apart of an implicit bias in what is judged as healthy and unhealthy—and arguably may move clinicians to view sexual behavior more objectively. Straight and LGBTQ couples, in and out of relationships who engage sexually by consent, within the boundaries of what each determines to be positive, loving, affirming, and healthy convolute a universal standardization of addiction. Even the addiction literature and paradigms are shifting, post DSM-IV eras—whereas criminality is no longer a diagnostic indicator removing from ‘addiction’ qualifiers the right/wrong views of behavior, as a way to identify ‘sickness’. The point is, healthy sexual behavior that is outside of ones personal preferences, ldiagnostic historical paradigms, majority cultural likes/dislikes, moral spiritually based codes and even legal codes are not entirely sufficient to consider what other consenting adults do in repetition in their various communities of sexual commonality—as necessarily unhealthy. Safety, of course, is the line in which some standard has to be considered (see batterers for interventions related to violent partners).
Researchers and authors have taken the liberty of developing diagnostic criteria for sexual addiction that mirror the kinds of criteria used in the DSM for chemical dependency (Carnes, 1991; Levin, 1999). The ideas they postulate make sense. Patrick Carnes (2003) summarizes the various diagnostic criteria that exist for sexual addiction into three simple areas: 1) loss of control, 2) continuation despite consequences, and 3) preoccupation. Carnes has long advocated the idea that sexual behavior can become addictive, while managing to avoid the politically charged debates surrounding sex and sexuality. In one of his books, Don’t Call It Love, Carnes (1991) dissects the process of addiction by interviewing and gathering data on nearly 1,000 identified sex addicts; the story of one addict articulates the prerequisites of loss of control, negative consequences and preoccupation:
“I picked up somebody on the street in another city…I said, “that’ll never happen again.” A year later I picked up a young man in the town where I was a public person…a year or so after that, I went into a porno shop for the first time in another city. I said I’d never do that and vowed I’d never do it in my own town. Soon I was frequenting porno shops at home….I arranged to take about three days off, to travel…I no sooner got on the highways than I was in a cruising state, checking every public rest room. When I got to the city, I cruised the shopping centers and the parks and everything else for two or three days. I was like a sleepwalker. Finally, I parked for a longer period than I ever had in a porno shop and had a sexual encounter with another man….There was a force in me that was moving towards complete destruction…I used money that had been given to me for religious purposes for pornography and prostitution” (pp. 49-52).
Is this addiction? Addiction is often characterized by three symptoms: craving, tolerance and withdrawal (Holden, 2001). Certainly the story depicts the build up of tolerance in the need for more intense and longer times involved in sex related escapades and craving would seem apparent in the three days of constant “cruising.” And while the issue of withdrawal is not addressed here, withdrawal is not necessarily a given in all additions; Holden (2001) points out that even in chemicals that are highly addictive, such as cocaine, withdrawal can be minimal – for some people who have used substances for years, there can be no withdrawal symptoms, but they are nevertheless considered addicts. But withdrawal is documented in the realm of sex addiction, albeit largely a mental and emotional process, particularly when the compulsive behaviors stop or when there is a period of total abstinence from problematic sexual behavior (Sex and Love Addicts Anonymous, 1986).
Identifying behaviors that are signs of sexual addiction is not a clear and precise process. There is the pejorative notion that certain types of sexual behavior would automatically classify a person as a sex addict. And while it may be hard to withhold a degree of prejudice, virtually any sexual behavior that a person engages in is not sufficient, in and of itself, to constitute that person as a sex addict (Carnes, 1991; Earle & Crow, 1989). Behaviors such as exhibitionism, voyeurism, and fetishism are not singly signs of sexual addiction. Cases of rape, incest, and child molestation, are not sufficient to label the person a sex addict. Comparatively, and to a lesser critical degree there is prostitution, affairs (extramarital or one night stands), pornography, phone sex, internet sex, masturbation and frotteurism (“accidentally” rubbing up against someone, or touching them without their permission); and again, these behaviors are not indicative of addiction. Even, according to Earle & Crow (1989), bestiality (sex with animals) and sadomasochism do not place the person who engages in them, into a sexual addiction category. “What differentiates sex addicts from others is their repeated, persistent, uncontrollable thoughts about the sexual activity; their repeated, persistent, uncontrollable behavior; and their in ability to stop” (Earle & Crow, 1989, p. 43).
Sex addiction commonly coexists with other dependency and mental health issues (Carnes, 2003; Kafka & Prentky, 1994; Peck, 1993; Raymond, 2003). Comorbidity is common in cases of sex addiction and chemical dependency, ranging from over 50% (Raymond, 2003) to 57% (Griffiths, 2001). Interestingly, chemical dependency relapse has been linked to a failure, on the part of clinicians, to address coexisting conditions, including sex addiction (Carnes, 2003; Schneider & Irons, 2001). When the prevalence of eating disorders is added into the equation (47.5% comorbidity with sex addiction) the percentage of sex addicts who have at least one other disorder is extremely high. In the Carnes (1991) study sex addiction coexisted with multiple other problems: chemical dependency (42%), eating disorders (38%), compulsive working (28%), compulsive spending (26%) and gambling (5%). Depression prevalence among male sex addicts is more than double (28%) of that in the general population (12%) (Weiss, 2004). “Studies indicate that approximately 70 percent of these [sexually compulsive] patients are diagnosed with mood disorders at some point in their lives. Estimates of anxiety disorders range from about 50 to 90 percent” (Raymond, 2003, p. 17). The impact that stress has on sexual behavior is no doubt a factor to consider as well (this may or may not have anything to do with an illness particularly one that is not yet identified as such in the DSM5).
It is not uncommon for the sex addict to come from highly dysfunctional family of origins. It has been frequently suggested that at the root of the sex addict’s problem is often past childhood abuse (Carnes, 1983, 1991, 2003; Earle & Crow, 1989; Falla, 2003; Golden & Cooper, 2003; Griffiths, 2001; Hunter, 1990; Lew, 1990; Peck, 1993). The number of sex addicts with a history of emotional, physical, and/or sexual abuse varies from study to study. Some researchers agree that sexual addiction often stems from abusive pasts (Coleman, 2003; Earle & Crow, 1989). Sexual abuse history is prevalent in 68% (Griffiths, 2001) to 81% (Carnes, 1991) of sex addicts. Carnes also found that 72% of his sample had been physically abused and 97% were emotionally abused – across both genders. Demographically, sexual addiction appears to be dominated by men. In one study of the sex addiction population 79% of the sample were males (these numbers have been similarly duplicated in other studies); 53% were married or in committed relationships and 63% were heterosexual (Cooper, Delmonico & Burg, 2000 as cited by Griffiths, 2001).
In the treatment of sexual addiction and/or sexual compulsion there are many different modalities: individual counseling, group counseling, 12-step groups and even pharmacological interventions. In sex addiction abstinence is not necessarily a prerequisite to beginning recovery, as is the case with chemical dependency (Carnes, 2003; Coleman, 2003). One goal is to move the sex addict away from what Coleman calls an “intimacy dysfunction” into healthy sexuality, which invariably includes continued sexual behaviors (p. 12). Twelve step groups have, for years, shown a great deal of promise in treating sex addiction (Carnes, 2003; Golden & Cooper, 2003; Peck, 1993) and individual treatment and group therapy are also used to facilitate recovery for sex addicts (Carnes, 2003, 1991).
And just as research on neurochemistry continues to evolve and brings about new awareness of how behavior impacts chemical and cellular adaptation in the human body, medications are being studied and used to treat hypersexuality. With the understanding of PEA and it’s relationship to sexual orgasm, for example, there is also now a discussion underway to develop medications that can increase or decrease such molecules in humans (Spink, n.d.). Anti-depressant medications that target and increase serotonin levels in the brain, particularly SSRI’s, are also effective in treating sexual compulsive behavior (Levitsky & Owens, 1999; Raymond, 2003). Others are suggesting the use of naltrexone to reduce sexual compulsive behaviors, a drug more commonly used with alcohol dependency cases, because it interferes with the reward pathways of the brain (Raymond, 2003).
In summary, it is interesting to view sex from the perspective of addiction. Comparing sexual addiction to alcoholism and chemical dependency is helpful in developing an understanding of what constitutes an addictive process. Even the use of the DSM-IV is helpful in realizing that the course of addiction and its various stages and components are easily mirrored in the behaviors that comprise sexual addiction. Physiological changes in a person cannot only be chemically induced, but it can be behaviorally exogenous. Behaviors can alter the mind’s pathways, change the shapes of cells, alter the production of neurotransmitters, and thus neuroadaptation is becoming more and more a factor in the behavioral addictions. Compulsive disorders are potential explanations for excessive sexual behavior, however dependency includes compulsivity. A highly regarded model for addiction recovery is the 12-step model pioneered by AA; the irony is that one of it’s co-founders, Bill Wilson, was possibly a sex addict, struggling with adulterous affairs even up until his death (Robertson, 1988). And no matter what you call the problematic sexual behaviors of clients, many times their behaviors are rooted in the pain of an abusive childhood. The fact is that sexual behavioral problems, called addictions or compulsions, coexist with a multitude of other diagnosable disorders.