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Sexually compulsive behavior & “Sex addicion”

    There has been a lot of controversy in the scientific community over the term "sex addiction" over the years because there is an ongoing debate about whether it should be classified as an "addiction," or a "compulsive disorder," or and "impulse control disorder." Each of the categories have very specific criteria that need to be met to fin order to formulate the diagnosis of "sex addiction." Because there was no consensus about which category it should fall under when the last DSM was modified, it is still not listed as a formal diagnosis.


    As mentioned above, there is no formal diagnosis of sex addiction in either the ICD-9 or the DSM-5 Furthermore, the diagnostic criteria is bound to change again when the ICD 10 is introduced (later this year), so this section may become irrelevant once the new version is published.


   There are many resources on the internet that provide information on a myriad of subjects. Rather than reinvent the wheel, I chose a site that offers a fairly good description of the basic facts that are associated with the term "sex addiction." The MedicineNet clearly states that its intention is to provide material that is for informational purposes only. When reviewing this information, be sure you understand that this information is not intended to be a substitute for professional medical advice, or provide diagnostic or treatment recommendations.


    The following provides some basic facts that are associated with the concept of "sex addiction."


Addiction facts (as per MedicineNet)

  • Sexual addiction is a condition that involves the sufferer becoming excessively preoccupied with thoughts or behaviors that give a desired sexual effect.

  • More than 30 million people are thought to suffer from a sexual addiction in the United States alone. [This population includes both men and women].

  • Paraphilias are disorders that involve the sufferer becoming sexually aroused by objects or actions that are considered less conventional and/or less easily accessible to the sex addict.

  • Sexual addictions may be either paraphilic or nonparaphilic. Nonparaphilic addictions are classified by the Diagnostic and Statistical Manual of Mental Disorders (DSM) as sexual disorder, not otherwise specified.

  • No one factor is thought to cause sexual addiction, but there are thought to be biological, psychological, and social factors that contribute to the development of these disorders.

  • Sex addicts have been described as suffering from a negative pattern of sexual behavior that leads to significant problems or distress.

  • As is true with virtually any other mental-health diagnosis, there is no one test that definitively indicates that someone has a sexual addiction. Therefore, health-care practitioners diagnose these disorders by gathering comprehensive medical, family, and mental-health information to distinguish sexual addiction from medical and other mental-health disorders.

  • Many people with a sexual addiction benefit from the support and structure of recovery groups or cognitive behavioral therapy (CBT). When sexual compulsions become severe, the sufferer may require inpatient treatment or participation in an intensive outpatient treatment program.

  • Seroetoninergic (SSRI) antidepressants, anti-seizure medications, naltrexone, and medications that decrease male hormones have been found to decrease the compulsive urges and/or impulses associated with sexual addictions for some sufferers.

  • The prognosis of sexual addictions depends on a number of factors.

  • Prevention of sexual addiction may involve interventions that enhance self-esteem and self-image, addressing emotional problems, educating children about the dangers of excessive internet use, monitoring and limiting computer use, and screening out pornographic sites.

  • Sex addiction is associated with a number of potential medical, occupational, legal, social, and emotional complications.

  • Research on sexual addiction includes exploring potential risk factors and developing accurate screening and assessment tools for these disorders.


   Signs and symptoms that are typically associated with sex addiction include: Compulsive masturbation (self-stimulation); Multiple affairs (extra-marital affairs); Multiple or anonymous sexual partners and/or one-night stands; compulsive use of pornography to achieve sexual satisfaction; Unsafe sex (without condoms); excessive phone or computer sex (cybersex); Prostitution or use of prostitutes; Exhibitionism; Obsessive dating through personal ads; Voyeurism (watching others) and/or stalking; Sexual harassment; and Molestation/rape.


     Symptoms also include a need for more amount or intensity of behavior to achieve the desired effect (tolerance); Physical or psychological feelings of withdrawal when unable to engage in the addictive behavior; The person making plans for, engaging in, or recovering from the behavior more or longer than planned; Desire or unsuccessful attempts to decrease or stop the behavior; Neglecting important social, work, or school activities because of the behavior; Continuing the behavior despite suffering physical or psychological problems because of or worsened by the sexual behavior.


    There are a plethora of sex addiction screening quizzes/questionnaires available on the internet today. The few listed here are the ones that show up on the initial 10 listings in a Google search. They include:


    The above references are all variations of the original Sexual Addiction Screening Test (SAST, circa 1989) that was created by Patrick Carnes, who is considered to be "godfather" of the Sexual Addiction movement. He wrote several books about the subject and described, in detail, his basic notion that sexual behavior, outside of the heterosexual monogamous "vanilla" norm was equal to pathology – "addiction."


      Carnes original version of SAST "diagnostic test," was intended to demonstrate and elucidate the factors he believed would identity sexual pathology - "sex addiction." The test was very general in scope, and limited in application because it only sampled a small fraction of the population (as referenced in Wikipedia)


    Carnes later revised the original SAST gender category to include Transgender gender identity, and expanded the sexual orientation subcategories to include heterosexual, bisexual and gay which were predicted to assess "aberrant sexual behavior" in a broader cross section of the population. Despite Carnes’s (and others in the addiction field) attempt to give sex addiction notoriety, the concept of sexually compulsive behavior as an "addiction" still remains controversial today, as evidenced by the fact that it has yet to be included in DSM-5 or ICD-9 as an official "diagnosis."


   When I decided to "specialize" in "sex addiction" as a clinical niche in the late 1990's, (that seemed like a good idea at the time), there was only one person who had popularized the term, as mentioned above, Patrick Carnes. However, when I read his books and pitted his ideas and theories about "sex addiction" against what I learned about the complexities and of the matrix of the mind, psychoanalytic principles, and human sexuality, there was a clear disconnect between what he was assuming and what I understood to be valid and ethical conceptualization of a "clinical" problem. "Clinical" is put in quotes because much of Carnes early work was value-laden with judgment about sexual activity and choices, rather than scrutinized by the rigors of scientific research.


    Furthermore, when I started listening closely to patients stories, I was hard-pressed to "diagnose" these individuals as "addicts." I received many calls from patients who were clearly in distress, sometimes in tears, asking for a therapy appointment to explore treatment for "sexual addiction." Most of them had taken an online sex addiction quiz and were astounded to learn that they may be a "sex addict."


    Patients were instructed to bring in these surveys in for the first scheduled Individual Therapy appointment. In evaluating their responses to these questionnaires, what was curious to me was the harsh value judgments that patients has placed on themselves and the intense shame they felt by deviating from a heterosexual monogamous "vanilla" sex life.  After each question, I asked, "Who taught you that was wrong?" The puzzled look on their faces indicated that the question never occurred to them. It was upon this premise that the Men's Group was born (see reference in the MEN'S ISSUES & MENTAL HEALTH section of dropdown menu of this website).


    Most of the sex addiction questionnaires have a narrow range of questions that do not appreciate the continuum of sexuality and sexual activity. As sex therapists (see SEX THERAPY section in the SERVICES PROVIDED section of this website), we evaluate one's sexual activity and pair-bonding in a much broader context.  As long as the sexual practices are SAFE, SANE (as described by all participants) and CONSENSUAL, the sexual conduct is NOT considered pathological. Of course, whenever those boundaries are crossed and/or there is either harm to self or others, that constitutes a problem that is to be addressed in a therapy framework.


     While the goal of most "sex addiction" group therapy settings focus on confronting the excuses, rationalizations, and denial that are usually synonymous with ego-dystonic hypersexual behavior, there is only one rule for MEN'S GROUP (as described below) – no judgment. Rather, Group members were encouraged to offer support and encouragement (to work through the painful issues that brought them to group therapy) and to learn from each other’s experiences. You might think this "rule" to be curious given that "sex addicts" are perceived to be "bad" or "sick" individuals by the general public. However, there was one underlying theme: ALL group members suffered from some history of trauma (mainly sexual).

     The group consisted of victims of abuse AND identified sex offenders. The criteria for participating in the group was that All had to be actively participating in individual therapy with me (for a minimum of 6 months). As they entered group, they did not know who was who (victim or offender). They all commenced therapy with a clean slate. The "no judgment" policy provided a SAFE place for the guys to open up, perhaps for the first time. What was amazing was that the victims often said, "Man, I thought about doing the same thing [as the offenders], I just didn't go there" and, the offenders lamented, "I WISH I would have had this group before and known that there was an alternative [to acting out]." Some expressed deep regret for "acting out" while others sobbed in despair as they re-told the stories of their own victimization.

   In addition to the mention of group therapy above (Therapeutic Process Group), some people with a sexually compulsive behaviors benefit from the structure of peer-led support groups like Sex Addicts Anonymous (SAA) and Sexaholics Anonymous (SA). In my experience however, ALL of the guys who had previously participated in these two groups complained that once they started working on the background trauma issues that contributed to the onset of their sexually compulsive behavior, they found these groups to be counterproductive rather than helpful.

   Individual Psychotherapy provides a forum for individuals to: explore historical factors that led to unhealthy sexual behaviors; identifying and changing negative thought patterns and limiting beliefs about self and sex; discover internal value-driven conflicts about sex and sexuality; gaining insight and self-awareness; bring unconscious issues into conscious awareness; and discussing the connection between interpersonal issues and unhealthy sexual behavior that is damaging to self and others.

   Family and couples therapy is essential because addictive/compulsive behavior always impacts the family and spouse/significant other. These therapy sessions provide an opportunity to address pent-up emotions, unresolved conflicts, "enabling," and intimacy issues that may be contributing to the unhealthy breakdown of the relationship.

   Cognitive behavioral therapy (CBT) can help to identify triggers that may lead to sexually destructive (acting out) behaviors, reevaluate distortions that contribute to acting out behaviors, and ultimately control those behaviors. When sexual compulsions become severe, the sufferer may require inpatient treatment centers or intensive outpatient programs.

    Medication often plays a key role in sexually compulsive/hypersexual disorder treatment. Some medications may help reduce compulsive behaviors and obsessive thoughts. Other medications may target specific hormones associated with sexually compulsive behavior or reduce accompanying symptoms such as depression or anxiety. 

   Selective serotonin reuptake inhibitors (SSRI) medications that are often used to treat depression, anxiety, and bipolar disorders, have been found to decrease the compulsive urges associated with sexual addictions for some sufferers. Examples of SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), fluvoxamine (Luvox), and escitalopram (Lexapro). SSRIs are generally well tolerated, and side effects are usually mild. The most common side effects are nausea, diarrhea, agitation, insomnia, and headaches. However, these side effects generally lessen within the first month of SSRI use. Other side effects may include, decreased sexual desire (decreased libido), delayed orgasm, or an inability to have an orgasm. In rare cases, patients may experience tremors, but they have only been reported only in very ill psychiatric patients taking multiple psychiatric medications.

    Mood stabilizers like carbamazepine (Tegretol), divalproex sodium (Depakote), and lamotrigine (Lamictal) that are sometimes used to treat OCD, may also be helpful in decreasing the impulsive behaviors suffered by some sexually compulsive individuals. The side effects may include sleepiness when using Depakote or Tegretol or stomach upset when using Lamictal. Routine blood tests are necessary to monitor patients for serious side effects like severely low white blood cell count (for Tegretol) or severe autoimmune symptoms like Steven Johnson's syndrome (for Depakote and Lamictal prescriptions).

    Naltrexone, a medication that is often used to decrease the effects of narcotic medications, may be useful for decreasing the sexual compulsions, sex drive, or arousal of some sex offenders. That may be particularly helpful for those who pursue celibacy as a means of abstaining from sexual compulsions.

     Finally, there is a class of medications that have been found to decrease male hormones, called anti-androgens. One example of an anti-androgenic medication is medroxyprogesterone acetate (MPA), also known by its trade name of Depo-Provera. These drugs target the effects of androgens (a sex hormone) in males and help decrease sexual urges. They are often used to treat male pedophiles. Also, Luteinizing hormone-releasing hormone (LHRH) decreases testosterone production and helps control the obsessive thoughts associated with sexually compulsive behavior.

   In summary, grappling with recurrent and intense sexual fantasies, sexual urges, and sexual behavior (in excess), can feel overwhelming and lead to dysphoric mood states (e.g., anxiety, depression, boredom, irritability) that tend to perpetuate themselves in response to stressful life events. Furthermore, repetitive but unsuccessful efforts to control or significantly reduce these sexual urges and behaviors can lead to intense feelings of guilt and shame. Although there is no official diagnosis of "sex addiction" you are reading this section for a reason. If you believe that your sexual behavior is out of control or have been told it is and would like to discuss this matter, feel free to schedule an at appointment at 954-779-2855.

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