When All You Know How to Use Are Hammers, Doesn’t Everything Resemble a Nail?
Over the past several months I have been writing blogs for Psych Central that extensively explain the DSM-5 Hypersexuality Diagnosis and the concept of sexual addiction. I have written about the basics of what it means to be a sex addict, how sex addicts can (like someone with an eating disorder) achieve “sobriety,” and the great effect technology is having on those with impulsive and compulsive sexual problems. These blogs have generated a great deal of discussion among clinicians in the multiple forums and groups where they have been posted around the globe. One of the more emphatic threads of comment I often receive is a judgment of sorts—that those who recognize sexual addiction as a treatable disorder must somehow be “sex negative,” that those who acknowledge and treat sexual addiction somehow believe that anyone who engages in ego-dystonic sexual behavior or enjoys sexual proclivities that do not mirror the larger culture’s values is a sex addict. This is not the case. In fact, nearly all sexual addiction specialists readily acknowledge that most of the vast range of human sexual behavior is neither problematic nor evidence of an addiction.
Sex Addiction: The Colloquial Definition
The simplest way to understand sexual addiction is by comparing it to alcoholism. Though many adults drink alcohol, the fact that they drink, perhaps regularly and occasionally to excess, doesn’t make them alcoholics. In fact, true alcoholics make up a relatively small percentage of the drinking population, and their problem is typically defined by a loss of control and an obsession to drink, along with concrete and consistent negative consequences directly related to drinking. In similar fashion, most healthy adults regularly engage in all types of sexual activity, both with others and with themselves, but that doesn’t make them sex addicts. Some people cheat. Some people engage in periods of self-soothing hypersexuality while going through a specific loss or life change. Some individuals are strongly fetishistic, while others have strongly different values than the larger population around sex, intimacy, monogamy, and relational sexuality. These people are not defined as sex addicts for any of the above reasons. The simple fact is sex addicts are a small percentage of the sexually active adult population, and, similar to alcoholics, their problem is most easily defined by a loss of control and an obsession/preoccupation with sex, along with consistently negative life consequences directly related to their sexual behavior.
Sexual Addiction Is…
Sexual addiction is a dysfunctional preoccupation (meaning this specific preoccupation negatively affects their work, relationship, family, legal, health, and social situations) with sexual fantasy and behavior, often involving the obsessive and repetitive pursuit of non-intimate sexuality, pornography, compulsive masturbation, romantic intensity, and objectified partner sex. It is defined by:
• Loss of control over the pursuit of sex – Sex addicts consistently break promises made to themselves and others to curtail, shift, or eliminate certain sexual behaviors, and often continue to act out those behaviors in secret.
• Ignoring and/or denying the consequences caused by sexual acting out – Sex addicts continue to engage in problematic (for the particular individual) sexual behaviors despite negative consequences, often blaming the consequences on someone or something else. This can cause temporary or permanent harm to intimate relationships and family life, along with employment, school, legal, and physical and emotional health problems.
• Escalating patterns of problematic sexual behavior – Sex addicts, seeking to maintain or escalate the emotional and physical “high” of sexual acting out, will end up engaging in problematic sexual behaviors more frequently and/or for longer periods of time, and many will escalate to more intense sexual behaviors, some of which are illegal.
Unlike those who enjoy sex as personal exploration, recreation, or part of healthy intimacy, the sex addict’s focus is on using the excessive pursuit of sexual images and experiences to bolster an unstable emotional and internal world. Sexual fantasy, urges, and behaviors are used to prop up flagging moments of emotional self-stability, at the same time masking underlying social deficits, extensive histories of trauma, and personality challenges. In this way, sex addicts use sexual fantasy and behaviors to distract and dissociate from life stressors and challenges. Over time, the search for sexual intensity becomes a driving force and sole life focus. In this way, sex addicts lose opportunities to grow emotionally, becoming instead dependent on sexual fantasy, urges, and behaviors to self-regulate.
Most sex addicts describe a numbing rush of intensity when engaged in their obsessive pursuit of sex. This trance-like “bubble” is actually a neurobiological state induced by the intense fantasies and actions that lead toward actual sex. In essence, sex addicts are hooked on the dissociative neurochemical high produced by their intense sexual fantasy life and that fantasy life’s related ritualistic behaviors. Ultimately, sex addicts find as much excitement in fantasizing about and searching for their next sexual encounter as in the sex act itself. As such, they can spend hours, sometimes even days, in this elevated state—high on the goal/idea of having sex—often without any physical contact. Minutes turn into hours and hours turn into days as the sexual addict secretly obsesses, plots, and carries out plans related to porn, strip clubs, massage parlors, sex-finder apps, prostitutes, affairs, and other potentially addictive sexual behaviors.
Sexual Addiction Is NOT…
The diagnosis of sexual addiction is not made simply because an individual engages in fetishistic or paraphilic sexual arousal/behavior, such as cross-dressing or BDSM. Such behaviors may lead the individual to keep sexual secrets, to feel shame or distress, and even to feel out of control, but they are not considered sexual addiction, per se. Nor are unwanted homosexual or bisexual arousal patterns and behaviors. Sexual addiction is not defined by what or whom an individual finds arousing—even if that arousal pattern is unwanted or ego-dystonic. Sexual addiction is instead defined by self- and other-objectified repetitive patterns of sexual urges, fantasy, and behavior utilized to self-medicate, dissociate, and/or stabilize emotional distress and other psychological triggers and conditions. Simply put, healthy people don’t consistently utilize sexual arousal as a means of feeling better when having a bad day. Sex addicts do, as sexual arousal is for them a primary emotional coping mechanism.
Do We Have to Call it an “Addiction”?
Many of the clinicians resistant to the sexual addiction label appear to be more bothered by the name than by the concept. Some feel more comfortable with the designation of Sexual Compulsion, established by Dr. Eli Coleman at the University of Minnesota, or the Out of Control Sexual Behavior model coming out of the Kinsey Institute. Many now know that the APA is considering a potential diagnosis of Hypersexual Disorder (evolved by Dr. Marty Kafka at Harvard) for the upcoming DSM-5, as opposed to the more commonly used Sexual Addiction label. Those of us who treat the disorder don’t particularly care what it’s called—hypersexuality, compulsive sexual behavior, out of control sexual behavior, sexual addiction, etc.—as long as the people in need of assistance are able to get it.
Hypersexual Disorder now appears likely to end up in the appendix of the DSM-5 under “Potential Diagnoses for Further Research.” Though I believe strongly that hypersexuality is a very real disorder that—thanks to the Internet and social media—is becoming more common by the day, I don’t have a particular issue with the DSM’s likely placement, as we need more research on the disorder (whatever we decide to call it), especially in regard to women and adolescents, before it becomes an official diagnosis. Placement in the DSM-5 appendix will encourage needed research dollars and focus on this escalating issue.
So… Is It a Nail?
Issues with labeling and the DSM aside, clinicians treating sexual addiction typically keep the following guidelines in mind: In order for the diagnosis of sexual addiction to be made, professionals must first rule out concurrent drug abuse, as well as those major mental health disorders that sometimes include hypersexuality as a symptom, such as bipolar disorder, obsessive compulsive disorder, and adult attention deficit disorder. Some individuals may have a major mental disorder and sexual addiction, both of which need to be addressed, much as an individual might be alcoholic as well as bipolar and need treatment for both conditions.
With No Diagnosis Comes Misdiagnosis and Morally Based Assessment
Unfortunately, our current lack of a clear, clinical, criteria-based diagnosis for hypersexual behavior has left the door open for some mental health and addiction professionals to incorporate the label of “sex addict” into treatment agendas that are more focused on moral, cultural, or religious values than secular and purely clinical values. As such, these clinicians do harm to the field by abusing the term “sex addict,” labeling individuals seeking insight or help with non-pathological fetishistic or same-sex arousal templates as sexually addicted. This has also lead to clinicians that understand and treat sexual addiction from a non-moralistic perspective being wrongly labeled as “sexual moralists” or “sex negative.” Sadly, the propensity of certain moralistic clinicians to engage in agenda-based treatment both gives the field a bad name and makes an already confusing issue that much harder to understand and treat. This blog is, in part, written as an ongoing attempt to correct these misconceptions along with other commonly misperceived issues related to human sexuality.