Sex and Intimacy Sex, porn addiction and intimacy in relationships in a digital age 2017-06-01T19:25:23Z https://blogs.psychcentral.com/sex/feed/atom/ Robert Weiss LCSW, CSAT-S http://www.robertweissmsw.com/ <![CDATA[Infidelity and “Gaslighting:” When Cheaters Flip the Script]]> https://blogs.psychcentral.com/sex/?p=1831 2017-05-17T19:00:47Z 2017-05-17T18:59:59Z couple holding handsGaslighting is a form of psychological abuse where one partner persistently denies the reality of the other partner (via consistent lying, bullying, and obfuscating the facts), causing that person, over […]]]> couple holding hands

Gaslighting is a form of psychological abuse where one partner persistently denies the reality of the other partner (via consistent lying, bullying, and obfuscating the facts), causing that person, over time, to doubt her (or his) perception of truth, facts, and reality. Some people may be familiar with this term thanks to Gaslight, the 1944 Oscar winning film starring Ingrid Bergman and Charles Boyer. In the story, a husband (Boyer) tries to convince his new wife (Bergman) that she’s imagining things, in particular the occasional dimming of their home’s gas lights. (This is part of his plan to rob her of some very valuable jewelry.) Over time, the wife, who trusts that her husband loves her and would never hurt her, starts to believe his lies and to question her perception of reality.

In the 21st century, the rather antiquated and convoluted plot of Gaslight seems a bit silly. Still, the psychological concept of gaslighting – insisting that another person’s perception of reality is wrong and/or false to the point where that person begins to question that perception – is well accepted, particularly in connection with sexual and romantic infidelity.

Gaslighting is similar in many respects to one of my favorite (if I’m allowed to have one) psychiatric syndromes, folie à deux, which literally translates to “madness in two.” Basically, folie à deux is a delusional disorder in which delusional beliefs and/or hallucinations are transmitted from one individual to another due to their close proximity, emotional connection, and shared reality. In short, crazy for two. If you are in a close relationship with an actively psychotic person – for instance, a person who hears voices and is afraid of being watched – you might also start to hear voices and fear being watched. Such is the power of emotional connections and our desire to hold onto them. We can actually distort our own sense of reality.

The primary difference between folie à deux and gaslighting is that with gaslighting, the person denying reality is perfectly aware of the fact that he or she is lying, usually as a way to manipulate the other person. But the effects are no less profound. Consider the following story, told to me by Alexandra, a female client who came to see me after learning about her long-term boyfriend’s infidelity.

Jack and I met at a party. I was 25, he was 30. We’ve been dating for six years now, living together for five, and he keeps promising me we’ll get married and start a family, but that never quite happens. The last three or four years, even though we’re sharing an apartment, I almost never see him. He works in finance, and I know the hours are long, but sometimes I feel lonely and I try to call him but he doesn’t answer his phone, even when he’s gone all night. He doesn’t even respond to my texts, just to let me know he’s not dead. If I dare to ask him about using cocaine with his friends or sleeping with another woman, he calls me insecure and paranoid and all sorts of other things. Then he reminds me that his job is really demanding and I should cut him some slack. He tells me that if I truly want to get married and have kids with him then I need to stop acting crazy. Well, a couple of days ago I saw him at a café with another woman, kissing her across the table. That night, after he was asleep, I went through his phone and found out he’s been having affairs with at least three other women. In the morning, when I confronted him, he told me that he wasn’t at the café where I saw him, and that I was misinterpreting all the texts I found. And I actually started to believe him! Now, instead of being mad, I feel crazy. I can’t eat, I can’t sleep, I can’t think straight, and I have absolutely no idea what is real and what isn’t.

Sadly, Alexandra’s story is not unusual. In cases of romantic and sexual infidelity, almost every betrayed partner experiences gaslighting to some degree. They sense that something is wrong in the relationship, they confront their significant other, and then the cheater “flips the script,” adamantly denying infidelity and asserting that the betrayed partner’s discomfort is based not in fact, but in paranoia and unfounded fear. Basically, cheaters insist that they’re not keeping any secrets, that the lies they’ve been telling are actually true, and that their partner is either delusional or making things up for some absurd reason.

The (typically unconscious) goal of gaslighting is to get away with bad behavior. Cheaters gaslight because they don’t want their spouse to know what they are doing, or to try and stop it. So they lie and keep secrets, and if/when their partner catches on and confronts them, they deny, make excuses, tell more lies, and do whatever else they can do to convince their partner that she (or he) is the issue, that her (or his) emotional and psychological reactions are the cause of rather than the result of problems in the relationship. Basically, the cheater wants the betrayed partner question her (or his) perception of reality and to accept blame for any problems.

At this point, you might be thinking that you could never be a victim of gaslighting because you’re too smart and too emotionally stable. If so, you need to think again. Alexandra, in the example above, has a PhD in Economics from a world-class university, currently teaches at that same school, has wonderfully supportive parents and friends, and has zero history of emotional and psychological instability (beyond her partner’s cheating). Yet her boyfriend manipulated her perception of reality for the better part of six years, eventually causing her to question both her instincts and her sanity, before she finally caught him red-handed. And then, instead of being angry with him, she was angry with herself and unsure of the truth.

The ability to fall for a cheating partner’s gaslighting is NOT a sign of low self-esteem or a form of weakness. In fact, it is based in a human strength – the perfectly natural tendency of loving people to trust the people that we care about, and upon whom we are healthfully emotionally dependent. In short, we want (and even need) to believe the things that our loved ones tell us.

In large part, betrayed partners’ willingness to believe even the most outrageous lies (and to internalize blame for things that are clearly not their fault) stems from the fact that gaslighting starts slowly and builds gradually over time. It’s like placing a frog in a pot of warm water that is then set to boil. Because the temperature increases only slowly and incrementally, the innocent frog never even realizes it’s being cooked. Put another way, a cheater’s lies are usually plausible in the beginning. “I’m sorry I got home at midnight. I’m working on a very exciting project and I lost track of time.” An excuse like that sounds perfectly reasonable to a woman (or man) who both loves and trusts her (or his) partner, so it’s easily accepted. Then, as the cheating increases, so do the lies. Over time, as betrayed partners become habituated to increasing levels of deceit, even utterly ridiculous fabrications start to seem realistic. So instead of questioning the cheater, a betrayed and psychologically abused partner will simply question herself (or himself).

Sadly, gaslighting can result in what is known as a “stress pileup,” leading to anxiety disorders, depression, shame, toxic self-image, addictive behaviors, and more. As such, gaslighting behaviors are often more distressing over time than whatever it is that the betrayer is attempting to keep under wraps. With Alexandria, for instance, the most painful part of her boyfriend’s behavior wasn’t that he was having sex with other women, it’s that he was never trustworthy and made her feel crazy for doubting his endless excuses.

For more information about gaslighting and its role in infidelity, plus useful advice on how to overcome this deep and horribly painful betrayal of trust, check out my recently published book, Out of the Doghouse: A Step-By-Step Relationship-Saving Guide for Men Caught Cheating.

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Robert Weiss LCSW, CSAT-S http://www.robertweissmsw.com/ <![CDATA[Infidelity: Why Do Men Cheat?]]> https://blogs.psychcentral.com/sex/?p=1823 2017-02-23T20:47:51Z 2017-02-23T20:47:14Z In my recently published book, Out of the Doghouse: A Step-by-Step Relationship-Saving Guide for Men Caught Cheating, I define infidelity as “the breaking of trust that occurs when you keep intimate, meaningful secrets from your primary romantic partner,” noting that this definition encompasses behaviors other than actual sexual intercourse, that purely online behaviors can still be cheating, and that behaviors that might qualify as cheating in one couple might be perfectly OK for another couple, depending on the relationship boundaries that each couple has agreed upon. For instance, one couple might decide that occasionally looking at porn does not violate their relationship fidelity, while another couple could feel differently.

In addition to defining infidelity, Out of the Doghouse presents a roadmap for healing damaged relationships. Essentially, the book was written to help men move beyond their usual feeble efforts to smooth things over by saying “I’m sorry” and trying buy forgiveness with flowers and jewelry—actions that can temporarily calm the stormy seas but do nothing to re-establish relationship trust, which is what a distraught partner needs if the relationship is going to survive and eventually thrive.

With all of the great information presented in Doghouse, I am perpetually amazed that the information betrayed spouses tend to be most interested in, at least initially, is the section on why their man cheated. When I talk to cheating men, of course, they initial give all kinds of excuses for their behavior, tending to rationalize, minimize, justify, and blame everyone but themselves for the damage done. They tell themselves (and anyone else who questions their actions) things like:

  • This is totally normal. All guys want to cheat, and when the opportunity arises, they act on it.
  • If my wife hadn’t gained so much weight since the kids came, I wouldn’t have even thought about sleeping around.
  • Monogamy means no romantic connections, like no kissing, no cuddling, and no getting attached. Well, a lap dance in a strip club is hardly a romantic connection. It’s just what guys do for fun.
  • If my job wasn’t so stressful, I wouldn’t need the release that porn gives me.
  • I’m only sexting. I don’t meet up with any of these women in person, so it’s not cheating.
  • My dad looked at porn and it wasn’t a big deal. Well, I have webcam chats and interactive sex. What’s the difference?

In addition to the statements listed above (and hundreds of similar rationalizations), cheating men also tell themselves, “What she doesn’t know can’t hurt her.” This is the biggest lie of all, as betrayed spouses invariably say they sensed an emotional and sometimes even a physical distancing before they learned about the cheating. Sadly, betrayed spouses often blame themselves for this distancing, wondering what they’ve done to create it and to provoke their mate’s defensiveness and anger if/when they questioned him about the lack of intimacy they felt.

Given these facts, it’s hardly surprising that cheated on spouses tend are so deeply invested in learning the real reasons their man cheated, as opposed to what they’ve heard with his endless and endlessly lame excuses. Generally, the true impetus for a man engaging in infidelity centers on one or more of the following:

  • Insecurity: He may feel as if he is not handsome enough, rich enough, smart enough, powerful enough, young enough, etc. To alleviate his insecurity, he seeks validation from women other than his mate, using their spark of interest to feel wanted, desired, and worthy. In short, he uses sextracurricular activity to bolster his flagging ego and feel better about himself.
  • Entitlement: He may feel like he deserves something special that is just for him—a sensual massage, a prostitute, a few hours with porn, a sexual affair, etc. He convinces himself that he is put-upon in some way by the people in his life, and he uses this to justify his cheating.
  • Selfishness: His primary consideration may be for himself and himself alone. He can therefore lie and keep secrets without remorse or regret as long as it gets him what he wants. It’s possible that he never intended to be monogamous. Rather than seeing his vow of fidelity as a sacrifice made to and for his relationship, he views it as something to be avoided and worked around.
  • Psychological Trauma: He may be reenacting and/or latently responding to unresolved childhood traumas—neglect, emotional abuse, physical abuse, sexual abuse, etc. Basically, from a psychological standpoint, his childhood wounds have created attachment issues that leave him unable and/or unwilling to fully connect with and commit to one person.
  • Co-Occurring Issues: He may have an ongoing problem with alcohol and/or drugs that affects his decision-making, resulting in regrettable sexual decisions. Or maybe he has a problem with sexual addiction, meaning he compulsively engages in sexual fantasies and behaviors as a way to numb out and avoid life. (This “desire for escape” is also why alcoholics drink, drug addicts get high, compulsive gamblers place bets, etc.)
  • Unrealistic Expectations: He may feel that his partner should fulfill his every whim and desire, sexual and otherwise, 24/7, regardless of how she is feeling at any particular moment. He fails to understand that she has a life of her own, with thoughts and feelings and needs that don’t always involve him. When his expectations are not met, he seeks validation and fulfillment elsewhere.
  • Misunderstanding Limerence: He may not understand the difference between romantic intensity and long-term love. So he mistakes the neurochemical rush of early romance, technically referred to as limerence, for love, and he acts accordingly.
  • Lack of Male Social Support: Over time, he may have undervalued his need for supportive friendships with other men, expecting his social and emotional needs to be met entirely by his significant other. And when she inevitably fails in that duty, he seeks validation and fulfillment elsewhere.
  • Biology: He may think it is a man’s evolutionary right/imperative to spread his seed as widely as possible. So he acts on this belief even though it conflicts with his commitment to monogamy and breaches relationship trust.
  • Unfettered Impulse: He may have not thought much about cheating until Busty Brenda hit on him at the office party, letting him know she was up for it whenever, wherever. But then, without even thinking about what his behavior might do to his relationship, he went for it.
  • It’s Over, Version 1: He may want to end his current relationship, but instead of just telling his significant other that he’s unhappy and wants to break things off, he cheats and forces her to do the dirty work.
  • It’s Over, Version 2: He may want to end his current relationship, but not until he’s lined up a replacement relationship. So he sets the stage for his next relationship while still in the first one, without ever letting his current partner know she is being strung along in this way.

For most men, there is no single factor driving the decision to cheat. And sometimes a man’s reasons for cheating evolve over time as his life circumstances change. Regardless of a man’s reasons for cheating, he needs to understand that he didn’t have to do it. There are always other options—couple’s therapy, taking up golf, being open and honest and working to improve the relationship, even separation and/or divorce. All of these are choices that don’t involve degrading and potentially ruining one’s integrity and sense of self.

Interestingly, betrayed spouses typically realize over time that they don’t actually care why their man cheated, even if that information seemed incredibly important in the immediate aftermath of discovery. Eventually, what they tend to focus on the most is the loss of relationship trust wrought by all of the cheater’s lying and secret keeping. Similarly, men who’ve cheated often realize that the reasons they did it matter far less than what they are going to do in the future—what kind of husband, father, lover, friend, and partner they will be moving forward. Can they be honest and maintain fidelity, or will it be more of the same?

I will discuss the process of healing from infidelity and restoring relationship trust in future postings to this site.

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Robert Weiss LCSW, CSAT-S http://www.robertweissmsw.com/ <![CDATA[Sex and Porn Addictions: Misconceptions and Bias]]> http://blogs.psychcentral.com/sex/?p=1815 2016-12-14T01:58:48Z 2016-12-14T01:58:48Z I’ve spent the past 25 years providing clinical treatment to sex addicts and their families, while also training therapists and documenting the clinical evolution of this increasingly common issue. Throughout […]]]>

I’ve spent the past 25 years providing clinical treatment to sex addicts and their families, while also training therapists and documenting the clinical evolution of this increasingly common issue. Throughout this time I have been constantly surprised by a small but vocal group of misguided and/or under-informed professionals who doggedly insist that sexual addiction is not a real disorder. And this denial continues despite an increasing array of neurobiological and social science research that clearly supports the concept of sexual addiction.

Much of this research is summarized in Harvard professor Martin Kafka’s 2010 position paper arguing in favor of Hypersexual Disorder (as he prefers to label the issue) as an official diagnosis in the American Psychiatric Association’s diagnostic bible, the DSM-5. Numerous other studies supporting sexual addiction—available here, here, here, here, here, here, here, and here, to cite but a few—have been published since Kafka’s summary. Moreover, anyone who’d like an up-close and personal look at sexual addiction can simply go to an open meeting (where everyone is welcome) of any 12 step sexual recovery group (SAA, SCA, SA, SLAA) to hear people talk about their addiction and the problems it has created.

Still, despite the obvious clinical realities and mounting scientific evidence, sex addiction deniers are as vociferous as ever. This small but noisy subset of clinicians fervently clings to their badly outdated 1970s ethos: “Do it because it feels good. And if it feels good, it can’t possibly be a problem. Ever. For anyone.”

Much like those who think that our increasing weather and eco-instability problems are random events unrelated to human activity, these misguided “sexologists” appear to have chosen willful ignorance over facts and reality. For instance, therapists have known for decades that early-life trauma and attachment concerns can and often do lead to adult addictions and adult intimacy disorders, but the sex addiction deniers say, “Not so.” More recently, therapists all over the country (and around the world) have anecdotally reported an evolving clientele of young adults self-identifying with porn-related compulsivity/addiction (related to the unfettered 24/7 availability of digital pornography), but the sex addiction deniers say, “Not so, they’re just kids trying to get comfortable with their sexual desires.” And so it goes.

Sadly, these “sexual health” professionals choose to bolster their misguided arguments with poorly conducted and generally refuted research, coupled with confusing statements conflating the term “sex addiction” with phrases like “sex negative” and “1950s sexual conservatism.” Basically, sex addiction deniers seem to think that sex addiction treatment forces preconceived moral, cultural, and/or religious values onto vulnerable people who are already tortured by sexual shame. However, that’s not the type of care that properly trained sex addiction therapists actually provide. Not at all.

Unfortunately, thanks in large part to these aging ideas and voices, America does not yet have a formal diagnosis for sexual addiction. (Notably, the World Health Organization’s diagnostic manual, the ICD-10, used pretty much everywhere but in the US, will likely include sex addiction with its next set of updates.) So individuals with substance abuse and gambling issues can be “officially” diagnosed and treated. The APA has even recognized internet gaming as a valid problem worthy of official investigation. But people who are compulsive with pornography and other sexual behaviors are inexplicably left in the dark. At times, this causes those who are already hurting and feeling crazy because they just can’t seem to stop masturbating to porn or hooking up via sex apps to feel even worse. And without an official label and directions for treatment, some sex addicts won’t pursue the excellent help that’s actually available. As such, they end up hopeless, discouraged, and depressed because they feel as if there are no answers.

Interestingly, even Psychology Today lags behind when it comes to sexual addiction, as their editors routinely reject, with one recent exception, any article that even mentions the problem as a treatable disorder. This frustrating stance recently pushed approximately a thousand psychotherapists to formally petition the magazine (click here or here to read the petition), asking the editors to reconsider their outdated position, noting that it serves neither the profession nor the individuals dealing with this disorder.

Given the undeniable clinical evidence and the increasing body of research backing it up, one wonders why some people are so intractably resistant to the idea of sexual addiction. Maybe we’re just caught in an argument about nomenclature. After all, for whatever reason the psychiatric community (as represented by the APA) seems to not like the word addiction. To this end, the APA has almost completely eliminated that term from the DSM-5, choosing instead to call alcoholism and drug addiction substance use disorders and gambling addiction gambling disorder. Oddly, the APA has altered the lexicon in this way even though the vast majority of people dealing with these issues are perfectly OK self-identifying as addicted and seeking help based on that label/diagnosis.

So now we are left with a confusing mish-mash of colloquial labels to describe the unfortunate individuals dealing with an ongoing, out-of-control pattern of sexual behaviors—sexual addiction, sexual compulsivity, hypersexuality, and hypersexual behavior, to name but a few. For what it’s worth, after treating this population for decades, I prefer the term sexual addiction. It’s not a pretty term, but it’s accurate. By any commonly used diagnostic criteria we are absolutely dealing with an addiction, so let’s call it an addiction. Moreover, the people who are suffering from this issue tend to identify with this label more than any other.

It is an unfortunate fact of human sexuality treatment that American professionals with differing opinions have chosen to build walls rather than windows. The sexology field and the sexual addiction field have so much they could learn from each other, yet ideological barriers have prevented our working together and developing common ground and a common language inclusive of all of our philosophies, experiences, and research.  Well, I believe the time has come for us to stop throwing intellectual rocks at one another and to start working together. If we don’t do this, then how can we ever put resolution of our clients’ challenges first? It seems to me that only by moving beyond labels and preconceived notions as a field will we be able to steer our fellow humans onto the best healing pathway for their specific needs. That day can’t arrive soon enough for me and many of my clients.

 

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Robert Weiss LCSW, CSAT-S http://www.robertweissmsw.com/ <![CDATA[What is Sex, Porn, and Sexting Rehab All About?]]> http://blogs.psychcentral.com/sex/?p=1809 2016-11-25T21:50:47Z 2016-11-25T21:49:52Z OK, sex addiction and sex addiction treatment are in the news again. This sort of thing typically happens at least a few times a year. The regular news cycle is […]]]>

OK, sex addiction and sex addiction treatment are in the news again. This sort of thing typically happens at least a few times a year. The regular news cycle is burbling along, and then some famous person lands in the middle of a big sex scandal (or several). At that point, everybody seems to want answers to these three very specific questions:

  1. What is sexual addiction?
  2. Is this person really a sex addict, or simply making excuses and/or trying to garner sympathy?
  3. What happens in sex addiction rehab?

The first question is easy to answer: Sex addiction is an out-of-control pattern of compulsive sexual fantasies and behaviors that causes problems in the addict’s life.

Answering the second question is also relatively straightforward. Put simply, sex addiction is diagnosed based on the following criteria:

  1. Preoccupation to the point of obsession with sex.
  2. Loss of control over sexual behaviors, typically evidenced by multiple failed attempts to quit or cut back.
  3. Directly related negative consequences (relationship issues, trouble at work or in school, depression, anxiety, loss of interest in previously enjoyable hobbies and activities, social and emotional isolation, legal trouble, etc.)

If the individual in question meets these three criteria, he or she is sexually addicted. Otherwise, that person is not a sex addict.

The answer to question #3 is a bit more involved, but still relatively straightforward.

Sex addiction rehab mirrors, in many ways, substance abuse treatment—generally implementing the same basic structure and cognitive-behavioral approach. The primary differences are the addictive behavior itself—compulsive sexuality rather than compulsive substance abuse—and the way in which sobriety (and therefore success) is defined.

With substance abuse issues, the ultimate goal is (nearly always) long-term abstinence. With sex addiction, however, sobriety is about learning to be sexual in non-compulsive, non-problematic, life-affirming ways. This is similar to the approach we take with eating disorders, another arena in which long-term abstinence is not feasible.

Nevertheless, sex addicts are typically asked to remain completely abstinent (including abstaining from masturbation) during their stay in rehab, which typically lasts anywhere from 30 to 90 days. This brief time-out from sex is mandated because most sex addicts, by the time they finally seek professional help, have completely lost touch with reality when it comes to their sex lives. They just have no idea which of their behaviors are problematic and which are not. Temporarily stepping away from all sexual activity gives them space in which to clear their heads and gain some clarity.

A common misperception about sex addiction rehab (and rehab for other forms of addiction) is that addicts, after completing an inpatient program, will be cured of their addiction. In reality, there is no cure for addiction (of any type). In this respect addiction is like diabetes—treatable, but not curable. So instead of focusing on curing a person who can’t actually be cured, rehab focuses on understanding the addiction and its consequences, establishing early sexual sobriety, and preparing the addict for the lifelong process of post-rehab recovery.

Psychotherapeutic tasks in sex addiction rehab are geared toward the following:

  1. Addressing the addict’s denial—the minimizations, rationalizations, and outright lies the addict uses to justify his or her addictive behaviors. This means we go through the real facts of the situation to help the addict see the truth and the consequences of his or her addiction.
  2. Identifying and eliciting responses to past trauma, abuse, grief, and other issues that typically drive all forms of intimacy and relationship dysfunction, including sexual addiction.
  3. Identifying the addict’s triggers toward sexual acting out, and developing a healthy set of behaviors that the addict can turn to instead the addiction.
  4. Helping to heal family strife, including the provision of support to betrayed spouses and other affected family members.
  5. Starting the process of lifelong recovery from sexual addiction by creating supportive and responsive therapeutic communities the addict can rely upon not only during but after inpatient treatment.

For the most part, sex addiction rehab focuses on the present—the here and now—utilizing highly directive methodologies like Cognitive Behavior Therapy (CBT). With this approach, sex addicts are asked to look at the people, places, experiences, and feelings that trigger and reinforce their sexually addictive thoughts and behaviors. Then they develop and learn to implement methods of short-circuiting the addictive cycle. Essentially, they learn to recognize that they’ve been triggered, and to act in ways that counteract rather than reinforce their desire to act out sexually. That said, treatment proceeds with the past in mind, taking into account the fact that sex addicts tend to be trauma-driven rather than individuals who simply have no capacity for empathy or remorse. In other words, we understand that sex addicts are not bad people; instead, they are good people who’ve engaged in regrettable behaviors as part of their addiction.

It is important to state, once again, that sex addiction rehab does not cure sexual addiction. Instead, it interrupts long-established patterns of sexual acting out, and it provides a safe, structured setting in which sex addicts can build awareness of their addictive problem and coping skills they can turn to instead of their addiction. Usually, with or without the benefit of inpatient sex addiction treatment, addicts must battle their issue on an ongoing basis. Their desire to act out sexually does not ever completely go away. It lessens, certainly, and they learn to respond in non-addictive ways when triggered, but the desire to engage in their addiction does not fully disappear, no matter how good the treatment center or how motivated the addict.

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Robert Weiss LCSW, CSAT-S http://www.robertweissmsw.com/ <![CDATA[Addictions are Learned Behaviors]]> http://blogs.psychcentral.com/sex/?p=1804 2016-11-09T19:32:06Z 2016-11-09T19:31:50Z Anyone who’s ever been to a 12-step meeting has heard at least one or two recovering addicts say something like, “I got high because I had a crappy day at […]]]>

Anyone who’s ever been to a 12-step meeting has heard at least one or two recovering addicts say something like, “I got high because I had a crappy day at work and things got worse when I got home and I just got tired of feeling miserable.” That statement is very much in line with the commonly accepted idea of addictive behaviors as maladaptive coping responses used to deal with unwanted emotional discomfort. Essentially, addicts don’t want to feel stress, anxiety, sadness, and the like, so they “escape” and “numb out” by using a pleasurable and therefore emotionally distracting substance or behavior.

Generally, addicts develop this escapist response pattern early in life thanks to living in a dysfunctional home filled with inconsistent, neglectful, and perhaps even abusive caregivers. Essentially, as children they assume that these problems are their fault rather than the fault of their parents and/or others who should be caring for them. As a result, they develop a shame-based sense of self, where they believe they are defective and just plain not good enough to deserve the love and consistent care that they want/need. Over time, rather than turning to their unreliable and/or abusive caregivers, they learn to self-soothe their unmet emotional needs by ingesting a pleasurable substance or engaging in a pleasurable behavior. Eventually, that pleasurable (and therefore potentially addictive) substance or behavior becomes their go-to coping mechanism.

Later in life, as adults, they continue to use that or a similar coping mechanism. They think, “I could never trust anyone to be there for me when I was little and needed help or affection or someone to just listen to me, and I still can’t. As a kid, my mom was busy eating herself into an early grave, and my dad was busy drinking and cheating on my mom. Every time I reached out to one of them, they just shot me back down and I ended up feeling worse.  So now, as an adult, when I have feelings that others might be able to help me with, I just can’t seem to reach out to them. I can’t bring myself to trust them, even if I intellectually know they’ll be there for me in a healthy way. So I reach out to a substance or a behavior instead, just as I did when I was little. That’s my coping mechanism for when I’m suffering.”

Of course, anyone who’s ever been around an addict for any length of time knows that addicts also use when they’re not suffering emotionally (or in any other way). In fact, addicts can be having a perfectly wonderful time and they’ll still turn to their addiction because that’s what they do no matter what. Yes, addicts use when they have a bad day, but they also use when they have a good day. They use because the sun came up. They use because the weather is nice. They use because election season is finally over. They use because they use. Period.

Of course, this idea puts a bit of a damper on the idea of addictions as maladaptive coping responses to unresolved childhood trauma and in-the-moment emotional discomfort—until one fully understands the ways in which traumatic early-life development and addictive substances and behaviors affect our neurobiological wiring.

Before getting into that, however, I think it might be wise to elucidate a bit on the role of early-life trauma in the formation of addictions. For starters, a considerable amount of research shows a direct link between childhood trauma, especially chronic (repeated and/or ongoing) trauma, and a wide variety of later life issues, including addictions. One significant and relatively well-known study tells us that people with chronic early-life trauma are:

  • 8 times as likely to smoke cigarettes
  • 9 times as likely to become obese
  • 4 times as likely to experience ongoing anxiety
  • 5 times as likely to experience panic reactions
  • 6 times as likely to be depressed
  • 6 times as likely to qualify as promiscuous
  • 6 times as likely to engage in early-life sexual intercourse
  • 2 times as likely to become alcoholic
  • 1 times as likely to become intravenous drug users

Does this point to a strong connection between early-life trauma and addiction? You decide.

From my perspective, those of us who struggle with addiction and similar psychological issues typically learned early and well how to cope with abuse, neglect, and other forms of family dysfunction. We spaced out, we dissociated, and we found stimulation through substances, touching, and/or fantasy. That was our coping mechanism. It’s how we survived.

While other kids were bouncing on dad’s knee, we worried that he might hit us because he was drunk again. And thanks to this and other chronic abuse, neglect, fear, and caregiver unreliability, we came to believe that we were unworthy of proper love and care. That resulted, over time, in a distorted and highly negative sense of self, with every adverse experience simply reinforcing our deleterious self-image—defective, not good enough, unlovable. And with that as the general message bouncing around in our heads, it’s understandable that we might choose to escape through use of an addictive substance or behavior.

But what about the aforementioned addict who uses because the sun came up? Having a need/desire to self-soothe and emotionally self-regulate isn’t always this person’s motivation for picking up. In fact, this addict, like most true addicts, uses no matter what—even when life is just peachy, thank you very much. So what gives?

This is where neurochemistry and associative learning (also referred to as Hebbian Theory) come into play. Neurochemically speaking:

  • Addictive substances and behaviors uniformly evoke an intense pleasure response in the brain. This response is pretty much the same regardless of the substance or behavior that triggers it. (Dopamine, adrenaline, serotonin, and a few other pleasure-related neurochemicals are released into the brain and received by receptor neurons located in the nucleus accumbens—the brain’s rewards center.)
  • Thus activated, we start to feel pretty great, and anything that may have been bothering us a short while ago blissfully (though temporarily) fades away.
  • At the same time, the rewards center transmits information about how good we’re feeling to the memory and decision-making centers of our brain. In this respect, our neurons are a bit like adolescent girls texting information back and forth during an unusually tedious algebra lecture. They’re just downright gossipy.
  • Over time, this neurochemical exchange of information “teaches” our brains that using a particular addictive substance or behavior is a great way to not feel crummy. And this knowledge encourages us to repeat the usage as needed and/or desired.

Thus, it is relatively easy to understand why some people might consciously choose to use alcohol, drugs, or an addictive behavior (eating, gambling, video gaming, being sexual, etc.) as means of generating short-term relief from emotional turmoil, and why they might make this choice over and over. This does not, however, explain why an addict uses even when he or she is feeling fine. You know, “The birds are chirping so I think I’ll get high.” That sort of thing.

This is where associative learning comes into play. If you’re unfamiliar with the concept, watch a toddler who’s learning to walk, and then watch a child or an adult who’s mastered the process. The toddler must simultaneously and very consciously think about all sorts of things while he or she is figuring it out. “If I lift up this foot, I need to move it forward and put it back on the ground or I’ll fall. Whoops, I just fell. Let’s try that again.” But once the process is learned that same toddler can run around the house wreaking havoc with nary a conscious thought. This is associative learning at its best. We do something over and over and eventually we no longer have to think about it, because the methodology for doing it becomes hardwired into our brain.

Stated another way: Neurons that repeatedly fire together will eventually wire together.

This is as true with addiction as any other process. Basically, a traumatized person returns over and over to an addictive substance or behavior whenever he or she feels a twinge of emotional discomfort. Eventually, after this has occurred often enough, that person’s “using” neurons wire together, turning the choice to get high into an ingrained habit that is no easier to forget than learning how to walk. In this way, a conscious though maladaptive response to unresolved early-life trauma and later-life emotional discomfort becomes a habit (an automatic response) that, in certain circumstances, we might also refer to as an addiction.

This is why addicts don’t just use because they’re having a bad day. They use because that’s what the wiring in their brain tells them to do. They use no matter what.

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Robert Weiss LCSW, CSAT-S http://www.robertweissmsw.com/ <![CDATA[Men, Pornography, and the Desire to Quit]]> http://blogs.psychcentral.com/sex/?p=1798 2016-10-13T18:13:33Z 2016-10-13T18:09:23Z Men, Pornography, and the Desire to QuitA few months ago I wrote about a recent French study looking at porn use among adult males and its consequences. In that study the research team concluded, among other findings, that men who look at porn to self-soothe and regulate their emotions were significantly more likely to experience porn related consequences and to view their usage as problematic. (Click here to read my earlier article.)

Now we have a relatively similar American study authored by Shane Kraus, Steve Martino, and Marc Potenza (from Bowling Green, Yale, and Yale). This research further examines the clinical characteristics of male porn users, in particular their interest in seeking treatment. The study surveyed 1,298 adult men who’d used porn at least once in the past 6 months. Participants were recruited via three websites—Craigslist.com, Psych-Research.com, and Psych.Hanover.edu. To ensure unbiased results the participants were not paid, though a $2 donation was made to the American Cancer Society for each completed questionnaire. The mean age of the men studied was 34.4, with test subjects hailing from the US (80%), Canada (8%), and various other English speaking countries (11%).

Participants in the study answered questions about:

  • Demographics—age, relationship status, education, etc.
  • Sexual History—number of sexual partners, frequency of masturbation, history of STDs, etc.
  • Porn History—frequency, hours per week, attempts to cut back, attempts to quit, etc.
  • Hypersexual Behavior—unsuccessful attempts at control, impairment in functioning, general consequences, etc.
  • Treatment History—current interest in seeking treatment, past history of treatment, success of past treatments, etc.

One in fifteen (6.4%) of the men studied reported previous treatment related to porn use. One in seven (14.3%) reported a current interest in seeking treatment.

More than one in four (28%) of the survey participants scored at or above the suggested Hypersexual Behavior Inventory cutoff, indicating the possibility of sexual addiction. This number almost exactly matches results in the French study, where 27.6% of the men studied either met or exceeded the HBI cutoff.

Note: The numbers in both studies are probably skewed in relation to the general population, as both survey samples were recruited exclusively online, and participation was limited to men who’d recently used pornography.

Of the individuals currently interested in treatment related to porn use, 71% scored at or above the HBI’s sex addiction cutoff, with 29% not meeting that standard. About this latter group, the authors of the study state:

Specifically, it would be important to understand whether additional factors (e.g., relationship status, level of religiosity, and personal values/beliefs) relate to men’s self-reported interest in seeking treatment for use of pornography.

This strikes me as a reasonable interpretation of the findings, very much in accord with anecdotal evidence provided by certified sex addiction treatment specialists (CSATs) who, in a general way, report that a small percentage of clients seeking assistance related to porn use have based their self-assessment of sex/porn addiction on shame and self-loathing rather than on commonly accepted clinical criteria. Moreover, this seems to occur far more often in clients with conservative religious backgrounds—environments where porn and other forms of non-marital sex are often vilified.

Further analysis shows that when compared with treatment disinterested men, the treatment interested population uses porn more often and for longer periods of time, has many more cut back and quit attempts, and scores significantly higher overall on the Hypersexual Behavior Inventory. These findings are unsurprising, and they line up perfectly with the criteria typically used by CSATs to identify and diagnose sex and porn addiction:

  • Preoccupation to the point of obsession (best evidenced by frequency and duration of use)
  • Loss of control (typically evidenced by multiple failed attempts to quit or cut back)
  • Negative consequences—ruined relationships, depression, social/emotional isolation, anxiety, trouble at work or in school, loss of interest in previously enjoyable hobbies and activities, financial issues, legal problems, etc. (best evidenced using the Hypersexual Behavior Inventory)

Findings regarding failed attempts to cut back or quit altogether are especially enlightening in this study. With treatment disinterested men 34.6% had tried to cut back at least once, and 25.0% had tried to quit at least once. With treatment interested men the numbers were much higher, with 87.1% trying to cut back at least once, and 74.7% trying to quit at least once. Moreover, treatment interested men were 4.1 times as likely to have tried cutting back on four or more occasions, and 6.9 times as likely to have tried quitting on four or more occasions—numbers that indicate the same “loss of control” we see with other types of addiction.

Unfortunately, the new study did not look deeply at motivations for use. If it had, it would likely have confirmed the French study’s finding that attempts to self-soothe and regulate emotions are directly linked to negative consequences—an important result as it provides another significant parallel between sexual addiction and other forms of addiction. (In general, addictions of all types are motivated more by a desire for escape than a desire for pleasure.)

Still, Kraus, Martino, and Potenza have provided yet another link in the chain that will eventually force the hand of the American Psychiatric Association, an organization that has so far chosen to willfully ignore the existence of sexual addiction—this despite an APA commissioned position paper written by Harvard’s Dr. Martin Kafka recommending the inclusion of Hypersexual Disorder, as Kafka prefers to call this issue, in the DSM-5.

For now, CSATs and others who treat sexually addicted clients will continue to diagnose and treat sexually addicted individuals as we have always done, using the generally accepted though unofficial diagnostic criteria outlined above to identify the disorder (erring on the side of caution by under rather than over diagnosing), and then treating the disorder in ways that have proven effective with not only sexual addiction, but other addictions. Most often this involves a combination of inpatient and/or outpatient individual and group therapy that relies heavily on cognitive behavioral and accountability tasks, coupled with social learning and external support (including participation in 12-step groups like SA, SAA, SCA, and SLAA).

For more information about sexual addiction and treatment, you may want to read my recently published book, Sex Addiction 101: A Basic Guide to Healing from Sex, Love, and Porn Addiction, and the accompanying book of exercises, Sex Addiction 101, the Workbook. For treatment referrals, click here or here.

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Robert Weiss LCSW, CSAT-S http://www.robertweissmsw.com/ <![CDATA[What People Really Want to Know About Sex (My Reddit.com “Ask Me Anything” Experience) 
]]> http://blogs.psychcentral.com/sex/?p=1786 2016-08-12T15:02:15Z 2016-08-11T23:49:40Z what people really want to know about sexA few weeks ago I agreed to host a Reddit AMA without actually knowing what I’d agreed to do. So I did a quick bit of research and found out that Reddit is a huge website that hosts “discussion threads” on almost any topic you can imagine. And many of the site’s most popular discussions originate with AMA (Ask Me Anything) sessions, where celebrities or subject matter experts answer any and all questions posed by Reddit’s nearly 12 million subscribers. I also found out that a whole bunch of people who are way more famous than I am have hosted one of these AMA sessions. At that point I thought, “OK, fine, if crusty old Morgan Freeman can do this, so can I.”

So I sent the good folks at Reddit a picture of myself holding a handwritten sign listing my name, my occupation, and the date of my AMA. This is a requirement, apparently. I’m not sure why. And then I waited for the questions to roll in, wondering what, exactly, people with free reign were going to ask me.

Mostly the questions fell into one of two categories: queries about relationships and human sexuality, and queries about sexual addiction and/or porn addiction.

Questions about Relationship Intimacy and Human Sexuality

Quite a few people asked about the quantity and quality of sexual activity within a serious relationship, including the following:

  • What are some helpful tips for people whose sex drives are dwindling due to work related stress and other distractions?
  • What is the most common issue you see with today’s generation when it comes to relationships and sex?
  • After years of marriage it seems quite common for couples to lose the spark, especially when it comes to sex. In your opinion, what are some of the common reasons for this and ways to reignite the passion in a relationship?

I also got plenty of questions about infidelity such as:

  • How do you feel about open relationships? Do they work, or are they always a disaster?
  • As a woman I would feel cheated on if my boyfriend would watch porn. The thought of him being sexual looking at other women would hurt me. Is there a simple explanation as to why men think this behavior is OK but women don’t?
  • With so many millions of people using apps like Ashley Madison, it seems nobody is really faithful anymore. So why should I be monogamous?

I also got a few questions about fetishes and kinks, including:

  • Is pedophilia more common in men than in women?
  • There is a particular rare sexual fetish, colloquially known as “sissy.” Many men who have it consider it a disorder…. It is often greatly intensified by pornography. … Do you have it in your practice? Are you aware of any successful recovery from it?

Questions about Sex and Porn Addiction

Queries about sex and porn addiction fell into two basic subcategories. First, people wanted to know what sex/porn addiction is and how to know if they’ve got it. They asked:

  • Is there a difference between having a lot of sex and being a sex addict?
  • Is there any research proving that an addiction to porn can cause erectile dysfunction?
  • How do I know if I’m sex addicted?
  • Can women be sex addicts, or is it really only men who have this problem?
  • How much sex is too much sex?

Next, people who felt that they or someone they know might be sexually addicted wanted to know about the process of recovery. Questions included:

  • What is sexual sobriety? Is it total abstinence? If I get sober from sex addiction will I ever be able to have sex again?
  • I have a friend who has a problem with sex addiction. … How can I help support him through this?
  • Is masturbating without porn a good first step towards reversing porn addiction, or is masturbation inherently involved?

General Thoughts

As the AMA lasted only an hour and I had to type out my answers, I wasn’t able to answer every query, but I did get to most of them. If you’re curious, the entire AMA, including my answers, can be found at this link.

As a therapist and commentator, what I found most interesting about the AMA was the nature of the questions, mostly the fact that this completely open and non-therapeutic forum centered on the same concerns that my clients have expressed in therapy for 25+ years. They worry about the amount of sex they’re having, both in and out of committed relationships, and sometimes they worry about the type of sex they’re having (or fantasizing about). They also want to know about relationship commitments and infidelity, in particular whether it’s OK to cheat, what constitutes cheating, and how their relationships can heal from a significant betrayal.

I’m not sure there are any major conclusions that I can draw from the above, except to say that in my years as a therapist specializing in sex and intimacy issues people’s concerns have not changed much. Sure, with digital technologies the “venue” of their worries sometimes looks a bit different, but their basic apprehensions and fears are amazingly constant.

Maxxasatori/Bigstock

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Robert Weiss LCSW, CSAT-S http://www.robertweissmsw.com/ <![CDATA[Pornography: Shame-Based Clients vs. Addicted Clients]]> http://blogs.psychcentral.com/sex/?p=1781 2016-08-02T00:24:41Z 2016-08-02T00:24:27Z laptop

Just Because a Client Says He’s Porn Addicted…

As digital technologies become more ubiquitous and porn usage becomes more prevalent and socially acceptable, clinicians, especially certified sex addiction therapists (CSATs), have seen a corresponding increase in the number (and variety) of people seeking help with shameful and/or compulsive porn use and related life problems. Importantly, there are multiple and often very different populations seeking such assistance. For instance, some clients seek treatment because they are addicted, while others seek treatment because they feel shame about their porn use. Unfortunately, this second population will sometimes self-diagnose as being addicted, even when they’re not.

Needless to say, these two porn-using populations have different motivations for treatment, different underlying issues, and very different treatment needs. An approach that works with one group might be harmful with the other, and vice versa. As such, it is vital that clinicians accurately differentiate between true sex/porn addicts and the people who label themselves as such based more on shame than actual addiction benchmarks.

Admittedly, both groups come to treatment unhappy about their use of pornography, often to the point where they experience significant depression and/or anxiety. And both groups are generally displeased with their sexual fantasy lives and the way they’re living them out. Moreover, both groups are usually keeping secrets and/or lying about their sexual desires, their porn use, and, sometimes, their real world sexual activity. However, shame-based clients might be utilizing a self-diagnosis of sex/porn addiction as a way of justifying sexual fantasies and behaviors about which they feel deep emotional discomfort. Recognizing this, therapists should never automatically accept any porn using client’s sex/porn addiction self-assessment. To do so would be a disservice to both the client and the psychotherapeutic community. Proper clinical assessment is always required.

Shame-Based Porn Users vs. Addicted Porn Users

There are two primary categories of shame-based porn users. First up is the person whose religious and/or moralistic belief system vilifies pornography (and, perhaps, sexuality in general). A typical client of this type is a young man with a strict religious background who looks at porn occasionally, maybe a few times per week for 20 or 30 minutes. Though porn use does not directly affect this client’s day-to-day functioning, he feels horrible about the behavior because his church, his family, and pretty much every other important person in his life has labeled this activity as sinful. Sometimes this client (or those around him) will insist that he is addicted to porn. Otherwise, why would he use it when he knows it might get him thrown out of his church and damned to an eternity of hellfire and brimstone?

The second type of shame-based porn using client is the individual with ego-dystonic sexual attractions. A typical client of this sort is a married, supposedly heterosexual man who feels great shame about his use of gay porn, which he looks at occasionally for short periods of time with no direct effects on his day-to-day functioning. However, his self-esteem is nonexistent and he’s deeply depressed. In therapy, he may blame his same-sex fantasies and behaviors on sex/porn addiction, viewing that as the lesser of two evils. This client seems to think (or wants to believe), “I only want to have sex with men because I’m an addict. If I wasn’t addicted, I wouldn’t have these desires.”

Is it possible for a shame-based porn user to also be addicted? Absolutely. But only if that person’s behaviors meet the criteria used to properly assess for sex/porn addiction. These benchmarks are:

  • Preoccupation to the point of obsession with porn and/or real world sexual activity (lasting six months or longer)
  • Loss of control over the use of porn and/or real world sexual activity, generally evidenced by multiple failed attempts to quit or cut back
  • Real world consequences directly related to out of control porn use and/or sexual activity. These consequences may include ruined relationships, trouble at work or in school, loss of interest in previously enjoyable hobbies and activities, social isolation, lack of self-care, declining physical and emotional health, financial struggles, legal issues, etc.

The Need for Proper Diagnosis

Neither of the shame-based clients described above meets the criteria for sex/porn addiction, and no properly trained clinician would treat them as such. Instead, we would try to help them normalize, accept, and integrate their sexual desires and behaviors so they don’t feel so much shame, and to reconcile their desires and behaviors with their religious and cultural/social ideals. In other words, we would try to help these men find a sexual comfort zone, which might or might not include future porn use. Moreover, if these clients attempted to self-label as a sex/porn addict, we would educate them as to the nature of that disorder, helping them understand that addiction is not their issue.

In truth, treating either of these non-addicted individuals for sex/porn addiction, using the techniques that have proven effective in that regard, would be counterproductive, as this work would reinforce their mistaken belief that their attractions and behaviors are abnormal and wrong. In other words, to tell them that yes, their sexual desires and activities are problematic would just bolster their shame. And that in turn would deepen their presenting symptoms (depression, anxiety, lowered self-esteem, and the like).

Meanwhile, trying to treat a person who really is sex or porn addicted by “helping him feel better about his desires and behaviors” can be equally damaging, as this approach seemingly encourages more of the obsessive, out-of-control activity that’s creating the addict’s problems. It’s a bit like telling an alcoholic, “Oh, don’t worry about it. Everybody has a cocktail once in a while.” Such an approach willfully ignores the addict’s loss of control and the resultant negative consequences. So, once again, when dealing with clients seeking treatment related to porn use, proper assessment and diagnosis is a must. Without it, clinicians can do more harm than good.

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Robert Weiss LCSW, CSAT-S http://www.robertweissmsw.com/ <![CDATA[


Can Therapists “Officially” Diagnose Sexual Addiction?]]> http://blogs.psychcentral.com/sex/?p=1777 2016-07-15T22:34:53Z 2016-07-15T22:28:29Z therapy sessionA Hopeful Outlook

In the April 2016 edition of Addiction, Dr. Richard B. Krueger of Columbia University and the New York State Psychiatric Institute provided a short commentary on the ways in which psychotherapeutic clinicians, if and when it’s appropriate, can make a DSM-5 and/or an ICD-10-CM diagnosis of sexual addiction. This is important primarily as it relates to insurance companies, who don’t especially like to pay for the treatment of any issue that can’t be identified with a numeric or an alphanumeric code.

In addition to his other impressive academic and professional credentials, Dr. Krueger served as a member of the American Psychiatric Association’s Sexual and Gender Identity Disorders Workgroup, tasked with making recommendations to the APA regarding the latest version of its diagnostic manual, the DSM-5, published in 2013. Furthermore, Dr. Krueger is a member of the World Health Organization’s Sexual Health and Disorders Committee, charged with making recommendations for changes to the next version of that group’s diagnostic manual, the ICD-11, scheduled for publication in 2018.

Although the APA ultimately rejected, with little explanation, its own Workgroup’s rather strong recommendation—eloquently presented in a position paper by Harvard’s Martin Kafka—to include Hypersexual Disorder (aka, sexual addiction) in the DSM-5, Dr. Krueger believes there are ways to work around this rejection. I will discuss his suggestions momentarily, after a brief look at the history of sexual compulsivity as defined in these dueling diagnostic manuals.

A Short History of Sexual Addiction Diagnoses

In the United States it has been possible to diagnose sexual addiction, albeit indirectly, since the DSM-III was published in 1980 with a brief mention of hypersexual behaviors. In the next versions, the DSM-IV and the DSM-IV-TR, the APA backtracked but still included a diagnosis of Sexual Disorders Not Otherwise Specified, which specifically allowed for diagnoses with hypersexual behavior as an element. The DSM-5 is another story entirely, but I’ll address that issue momentarily.

In Europe and most of the rest of the world, where the ICD is generally utilized when making diagnoses, Pathological Sexuality appeared in the ICD-6 and ICD-7. In the ICD-8, the diagnosis Unspecified Sexual Deviation appeared, with pathological sexuality not otherwise specified as a possible manifestation. In the ICD-9, published in 1975, the diagnosis became Sexual Deviation and Disorders, Unspecified. In 1989, in the ICD-9-CM (a version of the ICD created specifically for use in the United States), the diagnosis of Unspecified Psychosexual Disorder was listed. In the ICD-10, released in 1992, the diagnosis of Excessive Sexual Drive appeared.

About this diagnosis, the ICD-10 stated:

Both men and women may occasionally complain of excessive sexual drive as a problem in its own right, usually during late teenage or early adulthood. When the excessive sexual drive is secondary to an affective disorder (F30-F39), or when it occurs during the early stages of dementia (F00-F03), the underlying disorder should be coded. Includes: nymphomania, satyriasis.

Needless to say, this statement used dated, shaming, and inaccurate language that has little to do with sexual addiction as we now understand it.

The Current Approach to a Sex Addiction Diagnosis

Earlier this year, the ICD-10-CM was published, and Excessive Sexual Drive was decommissioned as a diagnosis. The new recommendation, using the diagnostic code F52.8, is Other Sexual Dysfunction Not Due to Substance or Known Physiological Condition. Unfortunately, this diagnosis still includes the dated terminology of its predecessor, listing excessive sexual drive, nymphomania, and satyriasis as possible manifestations.

Meanwhile, the DSM-5 lists a pair of equally unwieldy options: Other Specified Sexual Dysfunction and Unspecified Sexual Dysfunction.

Other Specified Sexual Dysfunction, diagnostic code 302.79, is defined as follows:

This category applies to presentations in which symptoms characteristic of a sexual dysfunction that cause clinically significant distress in the individual predominate but do not meet the full criteria for any of the disorders in the sexual dysfunctions diagnostic class. The other specified sexual dysfunction category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific sexual dysfunction. This is done by recording “other specified sexual dysfunction” followed by the specific reason (e.g. “sexual aversion”).

Unspecified Sexual Dysfunction, diagnostic code 302.70, is defined as follows:

This category applies to presentations in which symptoms characteristic of a sexual dysfunction that cause clinically significant distress in the individual predominate but do not meet the full criteria for any of the disorders in the sexual dysfunctions diagnostic class. The unspecified sexual dysfunction category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific sexual dysfunction, and include presentations for which there is insufficient information to make a more specific diagnosis.

Dr. Krueger suggests these as viable options when clinicians must officially diagnose sex addicts. And for insurance purposes these alternatives may work. However, the criteria are largely unrelated to the benchmarks used by certified sex addiction treatment specialists (CSATs) when identifying sexual addiction.

Typically, CSATs identify sexual addiction based on three measures:

  • Sexual preoccupation to the point of obsession
  • Loss of control over sexual urges, fantasies, and behaviors (typically evidenced by failed attempts to quit or cut back)
  • Negative life consequences related to compulsive sexual behaviors, such as ruined relationships, trouble at work or school, loss of interest in nonsexual activities, financial problems, loss of community standing, shame, depression, anxiety, legal issues, and more

It would be nice to work with an official diagnosis that reflects the reality of sexual addiction as described above. For the time being, however, 302.79 and 302.70 in the DSM-5 and F52.8 in the ICD-10-CM provide the language we must work with if and when we need an official diagnosis (for whatever reason).

What Does the Future Hold?

As of now, Compulsive Sexual Behavior Disorder is being considered as a possible diagnosis in the ICD-11, scheduled for publication in 2018. The suggested definition of this disorder is posted on the ICD-11 beta draft website. It reads, in part:

Compulsive sexual behavior disorder is characterized by persistent and repetitive sexual impulses or urges that are experienced as irresistible or uncontrollable, leading to repetitive sexual behaviors, along with additional indicators such as sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other activities, unsuccessful efforts to control or reduce sexual behaviors, or continuing to engage in repetitive sexual behaviors despite adverse consequences (e.g., relationship disruption, occupational consequences, negative impact on health). … The pattern of sexual impulses and behavior causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning.

If you compare this to the diagnostic criteria currently used (unofficially, of course) by certified sex addiction treatment specialists, you’ll find that the ICD-11’s suggested language is an almost exact match. Furthermore, the dated, potentially shaming, and not exactly accurate language of the past has been eliminated.

Importantly, in my opinion, this suggested language is very much in line with wording suggested in Kafka’s APA commissioned position paper, proposing the following diagnostic criteria for Hypersexual Disorder:

A. Over a period of at least 6 months, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors in association with 3 or more of the following 5 criteria:

  • Time consumed by sexual fantasies, urges or behaviors repetitively interferes with other important (non-sexual) goals, activities and obligations.
  • Repetitively engaging in sexual fantasies, urges or behaviors in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability).
  • Repetitively engaging in sexual fantasies, urges or behaviors in response to stressful life events.
  • Repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges or behaviors.
  • Repetitively engaging in sexual behaviors while disregarding the risk for physical or emotional harm to self or others.

B. There is clinically significant personal distress or impairment in social, occupational or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges or behaviors.

C. These sexual fantasies, urges or behaviors are not due to the direct physiological effect of an exogenous substance (e.g., a drug of abuse or a medication).

Specify if:

  • Masturbation
  • Pornography
  • Sexual Behavior with Consenting Adults
  • Cybersex
  • Telephone Sex
  • Strip Clubs
  • Other:

So it appears that scholars and clinicians in the both the United States and the remainder of the world agree on the basics of what sexual addiction is and how it should be diagnosed. The only remaining question is whether the World Health Organization (and eventually the APA) will finally hop on board the reality train, officially and accurately recognizing sexual addiction, whatever we choose to call it, as the debilitating yet treatable disorder that it is.

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Robert Weiss LCSW, CSAT-S http://www.robertweissmsw.com/ <![CDATA[New Study Links Compulsive Porn Abuse and Sexual Dysfunction]]> http://blogs.psychcentral.com/sex/?p=1773 2016-07-01T22:43:34Z 2016-07-01T22:43:34Z laptop

A recent study by Aline Wéry and Joel Billieux, both from the Université Catholique de Louvain, published in the journal, Computers in Human Behavior, sheds light on the characteristics, usage patterns, motives, and consequences of addictive online sexual activity.

Wéry and Billieux conducted a large-scale online study of French speaking men recruited on a university messaging service, social networks, research networks, and sexuality related forums. Anonymity of participants was guaranteed in an effort to achieve more honest answers. In the end, there were 434 qualified participants—men aged 18 or older (mean age 29.5) who’d engaged in online sexual activities during the previous three months.

Each participant completed a 91 item survey subdivided into six sections.

  1. Socio-demographic variables (14 items), including age, education/occupation, relationship status, sexual orientation, number of sexual partners in the last year, and type of sexual partners (ongoing romance, sex buddy, sex worker, etc.)
  2. Online sexual activities and related behaviors (25 items), including weekly time devoted to online sexual activities, types of online sexual activities, money spent, frequency of masturbation during online sexual activities, viewing sexual content previously considered uninteresting or disgusting, and feelings of shame related to online sexual activities.
  3. Problematic use of online sexual activities, assessed using a 12 item Internet Addiction Test adapted for online sexual activities, primarily looking at addictive patterns of use, loss of control, and negative impact on daily life.
  4. Motives to engage in online sexual activities (23 items), including sexual satisfaction, curiosity/information, mood regulation, anonymous fantasizing, socializing, improving offline sexuality, etc.
  5. Sexual dysfunctions, assessed using the 15 item International Index of Erectile Function (IIEF), which assesses for erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall sexual satisfaction.
  6. Self-perceived problematic involvement with online sexual activities, including whether the study participants subjectively considered their online sexual activities to be problematic, and, if so, whether they had thought about seeking professional help.

To me, a certified sexual addiction treatment specialist with more than 20 years of experience in the field, the findings of this study are pretty much as expected. In short, the research team found that test subjects spent an average of three hours per week engaged in online sexual activities, with answers ranging from 5 minutes per week to 33 hours per week. The most ubiquitous online sexual activity was viewing pornography, engaged in by 99% of participants, with subject matter ranging from “vanilla” to hardcore, including kinks and fetishes.

The findings listed above are not exactly earth shattering, as numerous studies have produced similar results. Where this particular research gets interesting is when it looks at men’s motivations to engage in online sexual activities and the specifics of problematic usage.

As for impetus to use, sexual satisfaction (94.4%), feeling arousal (87.2%), and achieving orgasm (86.5%) topped the list. That is unsurprising. However, attempts to regulate mood and emotions were also strong motivators, with test subjects listing relax/decrease stress (73.8%), alleviate boredom (70.8%), forget daily problems (53%), alleviate loneliness (44.9%), and combat depression/sadness (38.1%) as common reasons for their online sexual behaviors, clearly showing that a desire to escape and dissociate from stress and other forms of emotional discomfort can and very often does drive online sexual activity. Furthermore, regression analysis showed that the strongest link between reasons for going online and problematic usage was mood regulation. In other words, men who engaged in online sexual activities to self-soothe and regulate their emotions were significantly more likely to experience problems related to their online sex life than men who went online for sexual satisfaction, arousal, and orgasm.

These findings are very much in line with what we know about other addictions, where addicts are less interested in the experience of pleasure and more interested in escape and dissociation. In other words, addictions aren’t about feeling good, they’re about feeling less.

Recognizing that a high percentage of test subjects were using online sexual activities for escape, and knowing that a desire for escape is present as a driver in all forms of addiction, we would expect a corresponding percentage of test subjects to report significant consequences and to self-assess their online sexual activities as problematic. And that is exactly what occurred.

  • 61.7% stated they occasionally felt shame or similar negative feelings regarding their online sexual activities.
  • 49% reported that they sometimes searched for sexual content and/or activities that were not previously interesting to them, or that they considering disgusting.
  • 27.6% self-assessed their online sexual activities as problematic.
  • Of the men who assessed their use of online sexual activities as problematic, 33.9% had at least considered asking for professional help.

Importantly, the men who assessed their use of online sexual activities as problematic reported lower erectile function and lower overall sexual satisfaction as a common consequence. In response to this finding, the authors of the study hypothesized that men with sexual dysfunction issues may be less confident in their sexual capacities and therefore less able to perform and less sexually satisfied with real world partners.

I, however, believe a more accurate hypothesis, developed after working with countless men (porn addicted and sometimes merely porn conditioned), is that men who spend the vast majority of their sexual lives looking at and masturbating to an endless, constantly changing supply of intensely arousing sexual imagery, getting jolt after jolt of adrenaline from this experience, are likely to find a lone real world partner considerably less stimulating than porn, perhaps to the point of sexual dysfunction. In other words, a porn user’s brain can be conditioned over time to expect hyper-stimulation as part of sexual arousal to the point where a single in-the-flesh partner simply cannot provide the needed neurochemical rush. Hence, with real world partners the user may experience erectile dysfunction (ED), delayed orgasm (DE), and anorgasmia (inability to reach orgasm).

And this is not the first study linking variations of sexual addiction to erectile dysfunction. A 2012 survey of 350 self-identified sex addicts found that 26.7% reported issues with sexual dysfunction. A smaller study looking at 23 male sex addicts found that 16.7% reported erectile dysfunction. Another small study, this one looking at 19 male sex addicts, found that 58% reported issues with sexual dysfunction. So regardless of the study, we are clearly and consistently seeing a link between addictive online sexual activities, in particular compulsive porn use, and sexual dysfunction.

Typical signs of porn-induced male sexual dysfunction include:

  • A man is able to achieve erections and orgasms with pornography, but he struggles with one or both when he’s with a real world partner.
  • A man is able to have sex and achieve orgasm with real world partners, but reaching orgasm takes a long time and his partners complain that he seems disengaged.
  • A man is able to maintain an erection with real world partners, but he can only achieve orgasm by replaying porn clips in his mind.
  • A man increasingly prefers pornography to real world sex, finding it more intense and more engaging.

Without doubt, linking erectile dysfunction to compulsive porn use is the most important (and the sexiest) conclusion of this particular study. However, the finding that men engage in online sexual activities because they are seeking mood regulation almost as often as they seek sexual pleasure is also significant, as is the link between attempts at mood regulation and problematic use. After all, we know from other research that the desire for self-soothing is present in addictions of all types, so much so that the most efficacious forms of treatment focus not on stopping addictive use with willpower, but on developing healthier coping mechanisms that addicts can turn to when feeling depressed, anxious, lonely, bored, fearful, abandoned, etc. In fact, learning to cope with emotional distress in healthy ways (usually by connecting with supportive and empathetic others) is generally regarded as a key element of lasting sobriety and a better life.

Addiction to online sexual activities, especially porn, is no exception to this general rule. And today it is more important than ever that clinicians recognize this fact. After all, porn grows more ubiquitous and easily accessible by the day, with people of all ages, all over the world, finding anonymous, unfettered, mostly free access to pretty much anything they can imagine. And people are definitely taking advantage. For instance, one excellent study analyzing Internet searches found that 13% of the study’s 400 million analyzed searches (coming from approximately 2 million people) sought some form of erotic content. The authors of this study, Ogi Ogas and Sai Gaddam, discuss the Internet’s impact on porn use in detail in their book, A Billion Wicked Thoughts, at one point writing:

In 1991, the year the World Wide Web went online, there were fewer than 90 different adult magazines published in America, and you’d have been hard-pressed to find a newsstand that carried more than a dozen. Just six years later, in 1997, there were about 900 pornography sites on the Web. Today, the filtering software CYBERsitter blocks 2.5 million adult Web sites.

Even more astounding is the fact that Ogas and Gaddam conducted their research in 2009 and 2010, long before “user-generated pornography” became a thing. Today, sexy selfies are almost as prolific as professionally generated porn. And these images and videos are available on social media, dating sites, and all sorts of other sites that don’t officially qualify as “adult.” So the amount of online porn that is currently available 24/7/365 is pretty much unmeasurable. Porn is being generated so quickly and posted in so many places that there is no possible way for researchers to accurately track it.

Sadly, those who have become emotionally dependent on porn are often reluctant to seek help because they don’t view their solo sexual behaviors as an underlying source of their unhappiness and/or they are simply too ashamed. And when they do seek assistance, they often seek help for related symptoms—depression, loneliness, relationship troubles, sexual dysfunction, and the like—rather than the porn problem itself. Many take medications and/or attend psychotherapy for extended periods without ever discussing (or even being asked about) pornography and masturbation. As such, their core problem remains underground and untreated, and their symptoms do not abate.

For more information about porn addiction (and sexual addiction in general), check out my recently published books, Always Turned On and Sex Addiction 101. If you think you, a client, or someone you know may need clinical assistance with sex, porn, or love addiction, therapist and treatment referrals can be found here and here.

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