Reflections on Compulsive Sexual Behavior
Lately it is not uncommon for me to get an emotional phone call, where the breathless voice on the line says “I’m a sex addict! My partner threw me out! Can you help me?” The anguish is palpable and my heart goes out to both the caller and the partner. Of course I want to help. This article is an attempt to elucidate my thoughts on the subject of “sex addiction."
What is “Sex Addiction?" That is the $64,000.00 question. No one knows. Is it looking at pornography on the internet? How much looking constitutes addiction? How do we define “pornography?" Is it compulsive pursuit of prostitutes? Serial affairs? Is it about quantity of sex? Is it about specific sexual activities? Risk taking? Or simply about not being able to stop? What do we mean by this term? As of yet, science has not given us an answer.
The “sex addiction” treatment industry has an answer. (And quite an industry it is, that has mushroomed around this “diagnosis” in recent years.) Programs offer both inpatient and outpatient treatment, largely in the image of chemical dependency treatment. They charge a lot of money for their programs so they stand to gain significantly by having the public buy their definition.
What is Addiction?
Chemical dependency or substance addiction has over the last 50 or 60 years, been studied and precisely defined. Prior to this time, alcoholism was viewed as a terrible moral flaw and character defect. In the 1950’s a pair of brilliant and desperate alcoholics discovered that although they seemed to be unable to stop drinking on their own, together they managed to do it. They then found that if they went on to help still other alcoholics to stop drinking too, it helped them to stay sober. They developed a program that evolved into what we now know as the 12 Steps of Alcoholics Anonymous (AA.) This was truly the best and most effective method ever to come along, for people addicted to alcohol to become sober. It quickly spread around the world. Before long it became apparent that the 12 Steps as they were utilized by alcoholics, were equally effective for those addicted to other drugs. So Narcotics Anonymous followed in the footsteps of AA, and similar miracles and transformed lives followed.
On the heels of AA and NA came true scientific research about addiction and what it actually is. Science began to uncover a whole physiology that went along with the much observed psychology and behaviors of addiction. We got a precise definition, and a precise “phenomenology.” Phenomenology means a picture that is objective, based on observable characteristics from many angles. It specifically leaves out the subjective, or perceptual biases based on morality, religion, philosophy, culture or personal taste or point of view.
We also got a precise nosology, (nosology is the branch of medicine that deals with the classification of diseases.) making alcohol and drug addiction diagnosable by known specific criteria. This did not happen overnight of course. But by the middle 1980’s there was a sophisticated and growing field of study in both medicine and psychology about addiction.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the official text for diagnosis, utilized by health care providers and insurance companies. Being at least allegedly research based, it evolves with history as culture and the general knowledge base grows and changes. For example barely thirty years ago, homosexuality was listed in the DSM as a diagnostic category, and practitioners were working hard to “cure” those “afflicted.” Young people born after these changes might find it absurd or hard to believe that being gay was considered a “mental disorder” not that long ago. Those of us who have been around for a while, lived through the changes and perhaps even witnessed the effort required to remove homosexuality from the DSM. This is a clear example of how science blurs with politics and morality in the murky world of diagnosis. Bessel van der Kolk, veteran researcher, clinician, academician and author says it plainly “Diagnosis is a political instrument.”1
In the DSM, there is a precise list of criteria for the diagnosis of Substance Dependence, the clinical jargon for addiction. The list includes: tolerance, which means progressively increased amounts of the substance are required to achieve the desired effect; withdrawal, which is a characteristic syndrome of physiological and psychological symptoms that appear when the substance is removed; persistent desire (ie craving) and unsuccessful efforts to cut down substance use; much time and preoccupation spent on obtaining and using the substance, even to the neglect of important social, occupational or recreational activities; and continued use in spite of consequences.2 Although there is a lengthy chapter detailing variations on these themes, there is a uniform, agreed upon diagnostic tree that clinician or client can consult to ascertain whether the diagnosis fits.
Alcohol and drug treatment programs assess and diagnose with precise criteria, and generally treat the addiction with a combination of detoxification, which means safely withdrawing the person from the substance with medical support if needed; drug and alcohol education so clients have a clear understanding of the nature of addiction and recovery; individual and group counseling or therapy; general healthcare including good food, exercise, sleep perhaps supplements, and attention to whatever health deficits may have resulted from the addiction. A major component of most programs is 12 Step which is still considered to be the most effective path to recovery and certainly a centerpiece of the “aftercare” plan.
Relapse prevention is of course an important aspect of the education component in addiction recovery, as relapse is one of the most insidious aspects of chemical dependency. Shorter lived returns to substance use are referred to as “slips” and relapse is the full blast return to active use. It is essential to learn how to guard against either.
About “Sex Addiction?”
The last 20 years brought the internet, and with it the proliferation of widely available erotic and sexually explicit materials of every imaginable and unimaginable stripe. No longer did anyone have to skulk naughtily or shamefully into an “adult” bookstore or video store to find “girly” magazines or movies. In the comfort and privacy of one’s own home, virtually everything could be had. Al Cooper coined the term “the Triple A Engine”: Anonymous, Affordable, and Available, to explain what appeared to be a new order of magnitude of its use.3 As technology advanced so did the complexity and variety of available services and visual opportunities. We all began to hear stories of individuals spending numerous hours of day and night (often while on the clock at their places of employment,) engaged with these materials. Money was spent, relationships jeopardized. Therapists began to get the desperate calls.
In the psychology and the sex therapy field there is much debate about whether in fact there is such a thing as “sex addiction.” One key expert in the sex therapy field, Eli Coleman in his brilliant, brief article “Compulsive Sexual Behavior: What to Call It, How to Treat It?” makes a strong case against the language of addiction. Says Coleman “Although the term ‘addiction’ may be an interesting metaphor, it obviates the essential understanding of the etiology of compulsive sexual behavior.”4 He views sexual compulsivity as a “disorder of regulation,” physiologically very similar to OCD (obsessive compulsive disorder).
By disorder of regulation, he means the nervous system is in effect “wired” too high or too low, with anxiety and/or depression. Self regulation is the attempt to manage emotion and arousal such as to get comfortable in one’s skin. Disorders of regulation can be caused by physiological irregularities, life experiences, or both. This means trauma, neglect, genetics, medical factors, or some combination of them all, may add up to the irregularities. The impact is a greater or lesser urgency of the need to calm down or breathe life into the nervous system. Some people use alcohol or drugs to this end, some use food or work, exercise, gambling, shopping, thrill seeking, sleep, etc. Some like the OCD sufferer use rigidly ritualized, uncontrollable behaviors. The possibilities are limitless. Coleman sees what he calls “compulsive sexual behavior (CSB) as being within this spectrum.
To Coleman Using the rubric of addiction suggests “once an addict, always an addict,” which as of yet is an unanswered research question about CSB. It also implies that the only solution is a rigorous spiritual program like AA. Perhaps most significantly, however, the world of addiction treatment and recovery has traditionally been strongly biased against medications. Coleman’s research shows that sufferers from CSB often respond quite favorably to pharmaceutical treatments, often those used for OCD, ADD or depression. In many cases medications can be decisive in who does and who does not succeed at putting the unwanted behaviors to rest.4 I have indeed observed pivotal impact and success with medications in many of my clients as well.
Sex therapist, physician and author Charles Moser’s main complaint about the “sex addiction” designation is twofold. First he believes it is that it is a catch-all term for all sorts of behaviors, completely lacking in diagnostic precision. For some it may be an expression of OCD, a set of ritualized behaviors to manage anxiety and inner chaos, and in effect self soothe. For others it may be an expression of ADD (attention deficit disorder,) or a way to stimulate, focus or wake up the brain. It may reflect an anxiety disorder or depression. Or some other possibility. Moser’s complaint is that all these diverse diagnostic categories that call for different approaches to treatment, are lumped together under one unflattering umbrella label. Precision in treatment of the actual problem is lost. It’s lousy medicine.
Secondly, in order to understand, diagnose and treat safely and effectively we need to consider not only the behavior itself, but its context and meaning. From there we can determine a diagnosis and treat that. Behavior alone, taken out of context does not yield a diagnosis. Himself a busy physician, Moser says he might easily wash his hands fifty times a day, between patients and between procedures. In some cases washing one’s hands 50 times a day might be the symptom of an irrational fear of germs or a ritualized OCD behavior. In that case the problem is not really the handwashing behavior itself, (although to be sure the behavior may be distressing). The real problem to be treated is the irrational fear and the anxiety. For the busy physician with a seemingly identical behavior, there may be no problem to be treated at all. Moser views the sexual addiction recovery model as falling short in this way. It lacks an understanding of context, meaning and therefore a treatment approach that addresses the real issues.5
I agree with both Coleman and Moser. I think I would add that the designation of “sex addiction” has a tone of shame that other obsessive and compulsive afflictions don’t, or at least not as much. Perhaps it is my own association. Perhaps not. I believe the archaic prejudices about weakness of character, or sordidness associated with the word “addict,” linger.
This sense of prejudice extends into some of the other language used in the “sex addiction” world. Bulimia is another compulsive disorder. When a bulimic has a recurrence of the problematic behavior it is viewed as a relapse. When a “sex addict” practices the unwanted behavior it is referred to as “acting out.” In my childhood, “acting out” was a term used with unruly children being told they, or their behavior are “bad.” In the mental health world, disturbed people displaying their feelings in dramatic misbehavior rather than words are described as “acting out.” Again, the language is pejorative, unsympathetic and smacking more of a moral defect than a painful difficulty. For me these add up to prejudices that do not help the person struggling with sexual compulsivity, and definitely contribute to partners believing “My partner is a pervert. What is wrong with me?”
Dopamine is one of the predominant neurotransmitters or brain chemicals. Where many people are familiar with serotonin, they might be less so with dopamine. Seratonin is the chemical more associated with a sense of well-being. Dopamine is associated with excitement, pleasure, reward, and also seeking behaviors. Dopamine is stimulated by some of life’s pleasures like eating and of course sex. Some thrilling or risk taking activities activate dopamine.
Irregularities of the dopamine system may impel behaviors that will stimulate or increase it. For some people gambling, shopping, sky diving or activities involving uncertainty or excitement are used to attempt to self regulate this system. And the dopamine rush may be self re-enforcing. That is to say the linkage between a behavior and the pleasure of the dopamine reward, may inspire the impulse to continue the behavior.
Individuals who spend time looking at erotically stimulating materials and masturbating may get a dopamine surge at orgasm. The practice of looking and the pleasure of the dopamine high may get wired together in their brains or psyches. The dopamine reward may impel the urge to do it again, and even again and again and again. Does this constitute addiction?
As an endurance athlete I get very high from intense exercise. I love to ride my bicycle and I usually know exactly when the dopamine kick will hit. I go back again and again for that joy. It is not the only thing I like about riding my bike, but it is a definite perk. When I go on a long ride, I get as high as a kite, and I know I can count on riding to change my mood. So I repeat these activities as often as I can. Although I have had a couple of serious accidents, I have always returned to riding, more careful perhaps, but undeterred. And admittedly sometimes I take unintelligent risks. For example, the first time I rode 200 miles in one day, the temperature was 105 degrees. I was not willing to give it up. Am I an addict? Some might say a resounding yes. Some say they admire my “discipline!” I know it is certainly not that. Others just think I’m a nut. And what am I addicted to? Dopamine? Bicycling? Is it even compulsive?
All these questions come to my mind as I contemplate the loose and incomplete logic and definitions around the question of sex addiction. Clearly dopamine is involved and often a pivotal factor in compulsive behaviors. Compulsive sexual behavior is no exception. Does it add up to meeting the criteria for addiction as defined in the DSM?
None of this is to minimize the pain and suffering of compulsive sexual behavior. Obsession is an agony as is behavior that one cannot control. Sexual problems create a very particular kind of relationship hell. It is easy for partners to take it personally when pictures on a screen, prostitutes or other people compel the sexual interest, attention and time of their mates. As with most compulsive activities, the world of the compulsion is compartmentalized and hidden from the rest of life. Often in these relationships there is a snowballing deceit so there is a terrible dynamic of betrayal and guilt that spans many levels. Because compulsions may be relentless and difficult to disarm, often a couple goes through more than one go-around of confrontation or “coming clean,” attempting to stop, and the patterns silently and insidiously creeping back.
My belief is that disorders of compulsivity are painful and destructive, and definitely hard to beat. In our culture anything related to sex is likely to carry an additional weight of shame, guilt and disgust. I prefer to use language that is precise and unstigmatizing. I work hard to understand specifically what is the context and meaning of the behavior, and of course to help clients clearly connect the behavior with its impact on their own lives and the lives of significant others. And we attempt to tailor treatments very specifically to the real problem.
Elements of a Solid Treatment Approach
We begin with a careful assessment, taking into account the whole person and the person’s whole life. What is the unwanted behavior? What are the patterns? When did it start? Is it related to trauma? Anxiety? Depression? Or something else? We seek to piece together the context and meaning. Is the behavior an attempt to calm down, to escape, to feel alive, to relate to others? Is there a sexual problem that it is an attempt to bypass or compensate for? A relationship problem? An attachment disorder? There are so many possible diagnoses that may lead in different treatment directions.
Of course we seek to link the behavior to its to consequences. One of the hallmark agonies of compulsivity is how behaviors persist in spite of the havoc they wreak. Somehow the person or the brain fails to learn from experience. It is essential to face up to the damage, and in most cases stop the behavior.
In general a solid treatment net includes individual therapy for deep self exploration. Whatever the specific diagnosis, the deeper layers need to be uncovered and processed. Often medications are a tremendous help. Again a precise diagnosis is required. For some people, antidepressants are the medication of choice, and often the SSRI’s (the Prozac family of drugs) which also have libido suppressing properties, are a welcome relief. For others who are more in the anxiety/OCD spectrum, it is anti-anxiety medication that helps manage the compulsion to self-soothe with the unwanted behaviors. For still others, the behaviors may be a symptom of Attention Deficit Disorder, and an attempt to enliven the nervous system. In these cases the ADD medications may be a godsend. As I’ve said, sometimes the right medication makes all the difference.
Couple’s therapy is essential for those who have partners. Often relationship is an area of great difficulty for the CSB sufferer anyway. And as the compulsive sexual behaviors persist and “progress,” relationship and family takes a strong hit, with dishonesty, distance, often sexual problems or impasses in the partnership, etc. However, I have never yet seen a couple who did not have other problems besides the problem of sexual compulsivity between them. Perhaps both believe that all their conflict is a result of that but I have never seen this to be true. It is however a very hard sell, as generally the CSB sufferer feels so much guilt, shame, remorse and fear; and the partner feels so much betrayal, rage, hurt and righteous indignation, that both are entrenched in that belief. There are many couple’s dynamics to sort, process and renegotiate, in the course of repairing the broken trust. This is no small feat. And as I said, it is imperative.
Group support is also tremendously helpful. The benefit of 12 Step recovery is that it is imminently available and free. It is excellent for breaking the isolation which is endemic; coming out of “hiding” among others who may have similar stories and feelings; and facilitating the process of self examination and self reflection. The 12 Steps are compassionate while also directly confronting the damage to self and others that the compulsive behaviors wreak. My complaint about the 12 Step application to sexual compulsivity is its rather moralistic stance, and its adherence to the language of addiction. Yet for many it is the core of a successful recovery package. If not 12 Step groups, some other supportive therapy group around the issues of sexual compulsivity are a necessary treatment element.
Of course general self care around health is important: good nutrition sleep and exercise. Sexuality like perhaps nothing else is at the interface of body mind and relationships. We must carefully attend to all of them!
The rest is an unrelenting commitment to honesty and growth; a willingness to make recovery the centerpiece and top priority of one’s life for a good while; and time. It may be the hardest thing one ever undertakes, and unquestionably the most valuable.
Currently the DSM is up for revision, as it is every few years. There is wide disagreement and debate about whether to create a new diagnostic category of “sex addiction” in the new tome, expected to appear in 2012. Experts are working hard, attempting to come to agreement and also answer these tough questions. As van der Kolk says, we want the DSM to reflect the best and the most current science.6 What do you think?
- Keynote Boston Trauma Conference. June, 2009.
- DSM IV, Critereria for Substance Dependence. P.181. APA, Washington DC. 1994.
- Cooper, A. (ed.) (2000). Cybersex: The dark side of the force. Philadelphia: Taylor and Francis.
- Coleman, E. (2003) Compulsive sexual behavior: what to call it, how to treat it? Siecus Report 31, 12-15;
- Moser, Charles. Personal communication.
- Keynote Boston Trauma Conference. June, 2009.
Ruth Cohn, MFT and Certified Sex Therapist is in private practice in Oakland, CA. Also certified in EMDR and Sensorimotor Psychotherapy, she specializes in work wih adults with histories of childhood trauma and neglect and their intimate partners and families. She can be reached at firstname.lastname@example.org or www.cominghometopassion.com.