Assessment and Treatment of Addictive Sexual Disorders:
Relevance for Chemical Dependency Relapse
by Jennifer P. Schneider, M.D. and Richard R. Irons, M.D.
Substance Use & Misuse 36(13), 1795-1820, 2001.
Despite some skepticism about the existence of sexual addiction, the addiction model has proven very useful for treating compulsive sexual behaviors. Addictive sexual disorders often coexist with chemical dependency and are a frequently unrecognized cause of chemical dependency relapse. Sex addiction also contributes significantly to the spread of HIV disease. This paper reviews the differential diagnosis of addictive sexual disorders, their assessment, their treatment, and their interaction with chemical dependency, and provides information about 12-step (mutual-help) resources.
Jennifer P. Schneider M.D. practices internal medicine and addiction medicine in Tucson, Arizona, U.S.A. and is the author of two books on sex addiction: Back From Betrayal and Sex, Lies, and Forgiveness: Couples Speak on Healing from Sex Addiction., and co-author of The Wounded Healer: Addiction-sensitive Approach to the Sexually Exploitative Professional. She can be reached at: Arizona Community Physicians, 1500 N. Wilmot, Suite B-250, Tucson, AZ 85712., U.S.A. E-mail: email@example.com; Website: www.jenniferschneider.com
Richard Irons, M.D. is Director of the Professional Resource Center, 7114 S.W. Cannock Chase Road, Topeka, KS 66614-1527, co-author of The Wounded Healer. His e-mail address is: firstname.lastname@example.org.
Despite some skepticism about the existence of sexual addiction, the addiction model has proven very useful for understanding and treating compulsive sexual behaviors. Estimated to affect 3-6% of the U.S. population (Carnes, 1991), addictive sexual disorders often coexist with chemical dependency and are a frequently unrecognized cause of chemical dependency relapse. Sex addiction also contributes significantly to the spread of HIV disease: Some persons whose behavior is compulsive may have multiple sex partners without attending to safe sex; others may be involved in an exchange of sex for drugs.
In this paper we review the various psychological explanations which have been put forth for compulsive sexual behaviors; present a general definition of addiction and how behaviors can fall within the framework of an addiction; describe the range of addictive sexual behaviors and how they relate to traditional psychiatric diagnoses of sexual disorders; explain how multiple addictions can interact and affect each other; review the natural history of untreated sexual addiction; describe how sex addiction is assessed, and present a differential diagnosis of excessive sexual behaviors; summarize a treatment approach based on the addiction paradigm; mention the role of particular medications in treating addictive sexual disorders; and supply contact information for the 12-step mutual-help programs for sex addicts and their partners.
Out-of-control behaviors: Addiction, Compulsion, or Impulse control disorder?
You have heard the story before. A person in sustained remission from
substance dependence suddenly and unexpectedly engages in some romantic and/or sexual behavior that is self destructive and self defeating. This particular type of behavior, [often viewed as either seduction, romance, or
victimization] had occurred previously while the person had been using his or her substance of choice. Now the sexual behavior continues in the absence of the drug. The person comes to a counselor, sponsor or to an Alcoholics Anonymous (AA) meeting, and discloses the activity. The shame feels unbearable. The recovering person doubts the advice and counsel given during recovery, AA, and from therapists or other supportive friends. At this "turning point" the person must decide if the sexual behavior is part of the addictive disorder. And if it is, he or she must supplement the recovery program with principles and safeguards to prevent behavioral as well as chemical relapse.
In many such cases, identification and treatment of a previously undiagnosed mood disorder or personality disorder may improve the patient's quality of recovery. In other cases, however, a second, unrecognized addictive disorder may be present. Until this behavioral addiction is conceptualized, understood, and addressed, sustained sobriety from drug use is unlikely. The addict must now admit that he or she is powerless over a mood-altering behavior or fantasy.
Many addiction treatment professionals limit the concept of addictive disorders to substance-induced disorders (formerly referred to as chemical dependency). According to this view, an addictive disorder is one that is caused directly by the effect on the brain of an ingested, injected, or inhaled mood-altering chemical. A corollary of this paradigm is that an excessive, out-of-control behavior such as compulsive gambling, compulsive overeating, or compulsive sexual behavior cannot be an addiction because an exogenous chemical has not been consumed.
This view has been challenged recently by several authors. Orford (1978) reviewed some examples of excessive sexual behavior and concluded that "a theory of dependence must take into account forms of excessive appetitive behavior [i.e., referring to the appetites] which do not have psychoactive drugs as their object." He made the following analogy:
Debate over definitions in this area is intriguingly reminiscent of debates on the same subject when drug-taking, drinking, or gambling are under discussion. In none of these areas is there agreement about the precise points on the continuum at which normal behavior, heavy use, problem behavior, excessive behavior, "mania," or "ism" are to be distinguished from one another. When reading of the supposed characteristics of the "real nymphomaniac," one is haunted by memories of attempts to define the "real alcoholic" or the "real compulsive gambler." (Orford, 1985. P. 106 ).
Writing about out-of-control sexual behaviors, Carnes (1983, p. 4) posited that they represent an addiction and defined sexual addiction as a "pathological relationship with a mood-altering behavior." The emphasis on the behavior or the experience as causation rather than on a particular chemical was earlier supported by Peele (1981), who wrote, "Drug addiction is based on the experience a drug gives a person and the place this experience has in the person's life. Anything that produces a comparable experience can likewise be addictive."
Excessive sexual behaviors have been given different labels by different authors. Quadland (1985) termed the disorder sexual compulsivity, Barth and Kinder (1987) called it sexual impulsivity, Schwartz (1992) -- noting the high frequency of sexual victimization of children who later become sexually compulsive -- considered it an aspect of posttraumatic stress disorder (PTSD), whereas Coleman (1990) believed it to represent a variant of obsessive-compulsive disorder (OCD). OCD is an anxiety disorder (as distinguished from a personality disorder) consisting of recurrent obsessions or compulsions which are severe enough to be time-consuming or cause marked distress or significant impairment and are disturbing to the person. The most common obsessions are repeated thoughts about contamination, repeated doubts, a need to have things in a particular order, aggressive impulses, and sexual imagery. The individual attempts to suppress the obsessive thoughts and reduce anxiety with some repetitive behavior (i.e. a compulsion), which typically consist of washing and cleaning, counting, checking, requesting reassurances, various repeated actions, and ordering.
Shaffer (1994) identified psychodynamic distinctions between addiction and OCD to explain his disagreement with the OCD hypothesis:
The loss of insight among addicts and the maintenance of discrimination among OCD sufferers distinguishes these populations. While the excessive behavior patterns of OCD are disconnected from the dysphoric affect that energizes their activity, addictive behavior remains attached to these noxious emotions. Consequently addicts escape their discomfort by acting out through excess behavior patterns, while OCD patients avoid the conscious experience of psychic pain through repetitive intemperate activity. (Shaffer, 1994, p. 16; italics in original).
The relevance of the differential labeling of excessive sexual behaviors is that the different labels lead to different primary treatment modalities. In particular, labels of compulsivity, "impulsivity", and OCD suggest the use of pharmaceuticals as primary treatment modalities, a PTSD label warrants trauma treatment, whereas the addiction paradigm implies the effectiveness of addiction treatment, which includes group therapy, mutual-help groups based on the Alcoholics Anonymous (AA) model, and an emphasis on relapse prevention. In the experience of the authors and others (Carnes, 1989; Carnes, 1991a; Schneider, 1996a; Schneider, 1996b; Schneider, 1994; Schneider, 1990; Irons, 1994; Irons, 1997a; Earle, 1989), addiction treatment can halt compulsive sexual behaviors in patients who could not stop when treatment consisted of traditional psychotherapy and/or medications.
In clinical practice, the label matters less than the treatment approach. Whether clinicians refer to their patients as having an “addictive” or a “compulsive” disorder, most have found that these patients benefit from a treatment program which incorporates elements of addiction treatment. In this paper, we will use the terms “addictive” and “compulsive” interchangeably.
A general definition of addiction
A general definition of addiction can be deduced from the diagnostic criteria for substance dependence found in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (1994). These criteria are reproduced in Table 1; each criterion is followed by a statement of its essential feature:
Table 1: DSM-IV Diagnostic Criteria for Substance Dependence
(1) Tolerance, as defined by either of the following:
(2) Withdrawal, as manifested by either of the following:
(3) The substance is often taken in larger amounts or over a longer period than was intended (loss of control).
(4) There is a persistent desire or unsuccessful efforts to cut down or control substance use (loss of control).
(5) A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects (preoccupation).
(6) Important social, occupational, or recreational activities are given up or reduced because of substance use (continuation despite adverse consequences).
(7) The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. (adverse consequences).
The criteria of tolerance and withdrawal reflect the physiological effects of certain chemicals, such as alcohol and opioids. Neither criterion is necessary for a diagnosis of addiction, and, in fact, many drugs (e.g. cocaine, amphetamines, marijuana, inhalants) do not have well-defined withdrawal symptoms. Conversely, some self-identified sex addicts relate experiencing a withdrawal syndrome (dysphoria, anxiety, difficulty concentrating) when they cease their compulsive sexual behaviors. Many sex addicts also describe tolerance; for sex addicts addicted to computer internet sexual activities, this has meant progressively more hours on the internet, a larger number of online sexual partners, more bizarre or riskier activities, or going from virtual (online) to actual sexual encounters (Schneider, 2001, in press; Schneider, 2000).
The remaining five criteria are all behavioral , and can be summarized as shown in Table 2 (Schneider, 1994):
Table 2: Definition of Addiction
1. Compulsivity: Loss of the ability to choose freely whether to stop orcontinue a behavior.
2. Continuation of the behavior despite adverse consequences, such as loss of health, job, significant relationships, or freedom.
3. Obsession or preoccupation with the activity.
The presence of all three of these elements can be used as an operational definition of any addiction, whether to a substance or a behavior. They suggest that what constitutes an addiction is not the quantity of drug consumed or behavior engaged in, but rather the consequences to the person. In many people, large quantities of highly addictive drugs consumed over a long time do not create psychological addiction, although they may result in withdrawal symptoms if the drug is stopped suddenly (i.e. they have produced a physical dependence). A prime example of this is the use of long-term high-dose opioid therapy for treatment of chronic non-cancer pain. This treatment modality is gradually gaining acceptance among chronic pain specialists. In 1996 the American Pain Society and American Academy for Pain Management issued a joint consensus statement which supports the use of opioids to treat intractable pain. The statement said, in part, "Addiction is a compulsive disorder in which an individual becomes preoccupied with obtaining and using a substance, the continued use of which results in a decreased quality of life. Studies indicate that the de novo development of addiction when opioids are used for the relief of pain is low. . .Tolerance, or decreasing pain relief with the same dosage over time, has not proven to be a prevalent limitation to long-term opioid use."
In contrast to the constriction which addiction brings to an addict's life, the chronic pain patient being treated effectively with opioids experiences an expansion of his lifestyle because he is able to increase his functioning as a result of greater comfort. In the experience of one of the authors (Schneider) as well as other chronic pain specialists (Portenoy, 1994), if such patients experience resolution of their pain (for example, a patient with a long-term severe knee pain due to osteoarthritis undergoes total knee arthroplasty), they can be tapered off the opioid without difficulty. In other words, these patients did not develop an addiction to morphine despite months or years of exposure of their brains to this drug. This supports the view that the underlying cause of chemical addiction is not a direct effect of the drug on the brain, but rather a pathological relationship which the person has with the drug, and the role that the drug serves in their life.
Milkman (1987) provided a theoretical neurochemical framework for understanding how drugs and behaviors can have a similar addictive effect on the brain. According to him, when humans pursue any given desire to gratification, they experience three basic types of neurochemical responses: arousal, satiation, or an increase in fantasy or preoccupation with the object. Arousal is accompanied by increase in the neurotransmitters dopamine and norepinephrine, satiation with gamma-aminobutyric acid (GABA), and fantasy with serotonin. Mood-altering behaviors can create the same central nervous system (CNS) responses as mood-altering substances, and often the behaviors and substances are used in combination. For example, arousal can be achieved with stimulants (e.g. cocaine, amphetamines), gambling, or participating in high-risk behaviors -- all would result in an increase in brain norepinephrine and/or dopamine. Sedation can be achieved with alcohol or benzodiazepines, with excessive food consumption, or with television viewing. In other words, when a person is addicted, the addiction is in fact to a set of behaviors involving a drug or activity, and the behaviors themselves can induce neurochemical changes similar to those induced by exogenous drugs.
Addictive sexual behaviors.
The range of fantasies, urges, and behaviors which can be considered addictive sexual disorders may be appreciated by reviewing the ten categories developed by Carnes (1991a), which are listed in Table 3:
Table 3: Patterns and Themes of Addictive Sexual Disorders
1. Fantasy sex: Items focused on sexual fantasy life and consequences due to obsession. Themes include denial, delusion, and problems due to preoccupation.
2. Seductive role sex: Items focused on seductive behavior for conquest Multiple relationships, affairs, and unsuccessful serial relationships.
3. Anonymous sex: engaging in sex with anonymous partners, having one < night stands.
4. Paying for sex: paying prostitutes for sex, paying for sexually explicit phone calls.
5. Trading sex: receiving money or drugs for sex or using sex as a business. Highly correlated were swapping partners and using nudist clubs to find sex partners.
6. Voyeuristic sex: Items focused on forms of visual sex, including pornography, window peeping, and secret observation. Highly correlated with excessive masturbation, even to the point of injury.
7. Exhibitionist sex: exposing oneself in public places or from the home or car; wearing clothes designed to expose.
8. Intrusive sex: touching others without permission.
9. Pain exchange: causing or receiving pain to enhance sexual pleasure. Use of dramatic roles, sexual aids, and animals were common themes.
10. Exploitative Sex: Use of force or partner vulnerability to gain sexual access. Using position or power (e.g. professional, religious) to sexually exploit another person; rape.
It should be understood that the examples in the above list are not necessarily representative of an addictive disorder; just as alcohol can be used socially as well as compulsively, items such as sexual fantasies, multiple relationships, masturbation, and viewing pornography can be normative and/or life-enhancing for most people. A diagnosis of an addictive disorder should be entertained only when the elements of Table 2 are present. It should also be noted that many of the examples in Table 3 are viewed differently in different cultures. For example, paying for sex is normative in many cultures, especially among unmarried males. Exploitative sex with social inferiors (e.g. household servants) is also not uncommon in a number of cultures. Whereas sex addiction is as universal as any other addiction, its expression is likely to differ in different cultures.
Sexual improprieties and excesses that are considered addictive in nature can usually be classified into one of three major DSM-IV categories:
*Paraphilia (either one or more specifically identified in the DSM-IV or Paraphilia Not Otherwise Specified [NOS] ),
*Impulse Control Disorder NOS, or
*Sexual disorder NOS.
Five of Carnes' categories can be readily identified in the DSM-IV as specific paraphilias. These include voyeuristic sex, exhibitionistic sex, pain exchange (sexual sadism, sexual masochism), as well as some intrusive sex (frotteurism), and exploitative sex (pedophilia). Four of the remaining categories may be correlated with paraphilias: fantasy sex may be associated with paraphilic urges not acted upon, anonymous sex may be used to permit expression of paraphilic behavior with decreased risk of consequences, and paying for sex or trading sex are means by which a partner who may permit paraphilic activity may be purchased.
Sex addicts typically engage in an average of three compulsive behaviors, which may consist of more than one of the above categories. Carnes (1991b) observed significant gender differences in the prevalence of these behavior types. Men tended to engage in sexual excesses that objectify their partner and require little emotional involvement (voyeurism, paying for sex, anonymous sex, and exploitative sex). Women, who constitute about one-third of sex addicts, were significantly more likely to engage in sexual excesses that distort power, either in gaining control over others or being a victim (fantasy sex, seductive role sex, trading sex, and pain exchange). Women sex addicts use sex for power, control, and attention (Carnes, 1991b, Kasl, 1989). In the rapidly expanding area of cybersex addiction (addiction to online sexual activities), men, who are more visually oriented than women, are more likely than women to access pornographic sites, whereas women, who generally prefer interactions and relationships, tend to access Internet chat rooms Cooper, 2000).
The following three actual cases (Schneider, 1991) exemplify some patterns of sex addiction:
Case 1: A 52-year old married minister had a 10-year history of sexual involvement with female parishioners who came to him for counseling. He experienced marital stress because he was often away from home in the evenings "counseling" rather than spending time with his family. Overcome by remorse and guilt, he promised himself to break off with the women. however, he was unable to avoid new involvements. After several women came forward with their stories, the minister was fired, evicted from his church-owned house, and publicly exposed.
Case 2: A 32-year old woman from a rigidly religious family married an alcoholic. After 2 years of marriage, she became involved in the first of many extramarital affairs. To prevent detection by her husband, she withdrew from him emotionally and neglected the marital relationship. She recognized that she was not spending enough time with her children. Despite feelings of guilt, she did not seek help until she cheated on her new lover.
Case 3: A 28-year old homosexual man spent evenings "cruising" local parks, public restrooms, and pornographic bookstores for sexual contacts. This activity consumed several hours a day. His primary outlet was sex with multiple anonymous male partners. When he learned that the majority of gay men in his city had tested positive for the human immunodeficiency virus (HIV), he began to worry constantly about his risk of contracting HIV. Still, he was unable to change his unsafe sexual practices despite repeated promises to himself to do so.
All three persons described above eventually experienced sufficient adverse consequences that they recognized their behavior was out of control, sought help, and received addiction counseling supplemented by attendance at self-help, 12-step programs for sex addiction. All three were able to stop their problematic sexual behavior and to sustain monogamous relationships. The minister changed professions; he and his wife now counsel other couples. The husband in Case 2 joined AA shortly before his wife joined a self-help program for sex addicts, and both remained active in their respective 12-step programs for many years. The gay man in Case 3 formed a stable relationship with another HIV-negative man.
Sexual addiction often coexists with chemical dependency and is frequently an unrecognized cause of relapse. This is particularly true with cocaine addiction. Washton (1989) reported that 70% of cocaine addicts entering his outpatient treatment program were found to be addicted to sex as well. Many patients had become trapped in a "reciprocal relapse" pattern, in which compulsive sexual behavior precipitated relapse to cocaine or vice versa. In a more recent survey of the sexual behaviors of cocaine and methamphetamine addicts in treatment (Rawson, 1998), 76% of male methamphetamine and 51% of male cocaine addicts reported being obsessed with sex, and 64% of male methamphetamine addicts and 42% of male cocaine addicts reported that their sexual activity while under the influence of their drug of choice felt "perverted" or "abnormal." The tendency of sexual activity to promote relapse to drug use was confirmed by the finding that 40% of male methamphetamine addicts and 47% of male cocaine addicts stated that sexual fantasies triggered drug use. Although chronic cocaine use eventually impairs sexual function, Washton (Rawson, 1998) reported that no tolerance develops to the intensified libido and sexual fantasies stimulated by cocaine. The long-term cocaine addict whose sexual dysfunction leaves him no way to satisfy his sexual fantasies, may intensify his sexual obsessions even more.
Epidemiological studies have confirmed the connection between cocaine, sex, and sexually transmitted diseases (STDs). In a review of 16 epidemiological studies relating crack cocaine use, sexual behavior and STDs, Marx (1991) found that 15 of the studies reported a connection, often related to an exchange of drugs for money and lack of self-care while high on the drug. The possibility of a concurrent addictive sexual disorder was not recognized in Marx et al's discussion.
Sexual fantasy or behavior and substance use often are combined through the repetition of ritualized behavior. Irons (1997) listed the ways in which mood-altering substances can be used ritualistically by a person while engaging in sexual activity:
*to re-enact scenarios from movies, books, fantasy, or past experience;
*to create mood and intensify sexual pleasure;
*to decrease inhibitions and fears;
*to treat sexual dysfunction or performance anxiety;
*to permit the expression of sexual aggression or paraphilia;
*to provide a later rationalization or excuse for shameful or objectionable behavior.
Mood-altering substances can also be used to influence a sexual partner in the following ways:
*to increase the partner's vulnerability;
*to attempt to overcome a partner's resistance, objections, or sexual dysfunction;
*to promote emotional numbness;
*to distort the partner's reality and memory;
*to compensate the partner for sexual services.
Addictive sexual and chemical disorders tend to coexist. Table 4 summarizes the findings from three anonymous surveys done several years apart, all involving recovering sex addicts: 75 ascertained through 12-step sex-addiction programs (Schneider, 1996b), 289 addicts similarly found (Carnes, 1991a) , and 82 ascertained through therapists (Schneider, 1998). The numbers reflect self-reporting by the addicts; they sum to over 100% because some addicts reported more than one concurrent addiction:
Table 4: Concurrent Addictions Among Recovering Sex Addicts
|Carnes (1991a)||Schneider, (1996b)||Schneider, (1998)|
|Substance Use Disorder||42%||39%||
|No other addictions||17%||17%||
All three surveys yielded similar findings: A large majority of sex addicts reported at least one other coexisting addiction.
In group of 155 health professionals who had allegations of sexual impropriety, 55% were diagnosed with an addictive sexual disorder (Irons, 1994); interestingly, the prevalence of a concurrent substance use disorder in the group of sex addicts (38%) was almost twice as high as the prevalence in the group of non-sex addicts (21%). Thus, the presence of sexual compulsivity was a comorbid marker for chemical dependency.
When assessment for addictive sexual disorders is carried out on patients admitted for chemical dependency treatment, sex addiction is frequently found. For example, among 1,407 male patients admitted during a 4-year period in one treatment facility which specializes in treating physicians but admits non-physicians as well , concurrent sex addiction was found in approximately 33% of the chemically dependent physicians and 25% of the chemically dependent non-physicians (Gordon, 1995). Many patients at this facility had been previously treated for drug dependency, but the dually addicted patients had more relapses before the present admission In the presence of concurrent drug and sexual dependence, relapse to one of the addictions -- or failure to treat it initially -- is likely to lead to relapse in the other.
The interaction of sexual and chemical dependency in the relapse process is illustrated by the following actual cases (Schneider, 1991):
Case 4: A 30-year old salesman who was addicted to cocaine and sex left work early many days to go to his dealer's house, where he would inhale cocaine and drink beer. He then spent hours in a cycle of visiting pornographic bookstores where he would masturbate and snort cocaine, and then driving around while drinking beer and inhaling cocaine until he had recovered enough to visit the next pornographic bookstore. When he finally sought help for his cocaine addiction, he found himself relapsing repeatedly until he finally addressed his sex addiction. He related, "The sex addiction came first, but cocaine was like pouring gasoline on a fire. My relapses began with sexual behaviors, but because the sex and drugs were so interrelated and were part of the ritual, the sex served as a potent trigger for the cocaine, so I would end up doing that too." To stay clean and sober, he had to avoid both drugs and compulsive sex.
Case 5: A 40-year old physician was actively involved in Alcoholics Anonymous and appeared to be doing well until one day when he failed to appear at work and was found at home, intoxicated. Remorseful and depressed, he explained to his therapist that drinking was not his primary problem: He had been engaging in sex with anonymous partners in public restrooms and felt such anguish about his sexual behavior that he thought his only choices were suicide or drinking; he chose alcohol. Sexual issues had not been addressed during his prior treatment for alcoholism.
When concurrent addictions are present and one addiction is being treated, there is a tendency for the addict in early recovery to intensify the untreated addiction. A well-known example is the increased use of cigarettes, caffeine, and sugar by new AA members. An increasing number of chemical dependency treatment centers have recognized this tendency with regard to smoking and are now insisting that clients cease all chemical use, including cigarettes.
A phenomenon related to multiple concurrent addictions is the tendency, in early recovery, to switch addictions. The well-known "thirteenth stepping," the seeking of sexual partners at 12-step meetings, may in some cases represent a flight into addictive sexual activity. Substituting one addiction for another may temporarily help an addict refrain from drinking, but is unlikely to lead to sustained sobriety.
Natural History of Untreated Sexual Addiction
The progression of untreated sexual addiction was described by Carnes (1989). The initiation phase is characterized by an exceptionally intense impact of observed or experienced sexual activities on the adolescent and young adult. At some point, sex becomes the "drug of choice," used to cope or escape. Catalytic environments and catalytic experiences lead to the establishment phase, in which there is repetition of an addictive cycle. The four phases of this cycle consist of preoccupation, ritualization, and sexual acting out, followed by despair, shame and guilt -- which in turn are alleviated by renewed preoccupation. With time, the addiction may escalate, with greater intensity, more frequency, more risk, and greater loss of control. Intermittently the behavior may de-escalate, at times by means of substituting another addictive behavior (such as a period of heavy drug use or workaholism), or it may progress to the acute phase in which the individual becomes alienated from significant others and is constantly preoccupied with the addiction cycle. In some, the addiction becomes immutable, and acting out is limited only by opportunity, physical consequences, or incarceration.
Assessment for Addictive Sexual Disorders
As addiction specialists increasingly recognize the high prevalence of multiple addictions and their role in relapse, more and more of them screen their chemically dependent clients for the presence of concurrent addictions. Many CD treatment centers in the United States provide clients at entry with checklists designed to uncover co-existing eating disorders, compulsive sexual behaviors, compulsive gambling and spending problems, and other addictive and compulsive disorders.
The 25–question self-administered test shown in Table 5 is a useful diagnostic tool for screening adult men for sex addiction (Carnes, 1989). If 13 of the 25 questions are answered in the affirmative, in about 96% of cases the respondent is sexually addicted. This screening tool must be used with caution in homosexuals, whose behavior can involve secrecy and shame even though most are not addicts. The Sexual Addiction Screening Test has been adapted for women and for gay males, although (unlike the original SAST) the new versions have not been validated; these versions can be obtained from the Sexual Dependency Unit at DelAmo Hospital in Torrance, California, U.S.A. To request these tools, visit the DelAmo Hospital web site at www.delamohospital.com and click on e-mail.
Table 5 Carnes' Sexual Addiction Screening Test
1. Were you sexually abused as a child or adolescent?
2. Have you subscribed to or regularly purchased sexually explicit magazines?
3. Did your parents have trouble with sexual behavior?
4. Do you often find yourself preoccupied with sexual thoughts?
5. Do you feel that your sexual behavior is not normal?
6. Does your spouse (or significant other) ever worry or complain about your sexual behavior?
7. Do you have trouble stopping your sexual behavior when you know it is inappropriate?
8. Do you ever feel bad about your sexual behavior?
9. Has your sexual behavior ever created problems for you or your family?
10. Have you ever sought help for sexual behavior that you did not like?
11. Have you ever worried about people finding out about your sexual activities?
12. Has anyone been hurt emotionally because of your sexual behavior?
13. Are any of your sexual activities against the law?
14. Have you made promises to yourself to quit some aspect of your sexualbehavior?
15. Have you made efforts to quit a type of sexual behavior and failed?
16. Do you have to hide some aspects of your sexual behavior from others?
17. Have you attempted to stop some parts of your sexual activities?
18. Have you ever felt degraded by your sexual behavior?
19. Has sex been a way for you to escape your problems?
20. When you have sex, do you feel depressed afterward?
21. Have you felt the need to discontinue a certain form of sexual activity?
22. Has your sexual activity interfered with your family life?
23. Have you been sexual with minors?
24. Do you feel controlled by your sexual desire?
25. Do you ever think that your sexual desire is stronger than you are?
Reprinted, with permission, from Carnes (1989)
In cases when the Sexual Addiction Screening Test suggests the presence of an addictive sexual disorder, more detailed interviews and evaluations must follow. A diagnostic work-up includes the following elements (Schneider, 1997):
A medical history and physical examination; biopsychosocial history; relationship history and marital status; family, growth, and developmental history; a comprehensive sexual history; and screening tests for other addictions (such as the Michigan Alcohol Screening Test [MAST]). Formal psychological testing is particularly helpful with patients who present with strong defenses or denial. When legal problems or professional sexual misconduct is involved, multidisciplinary assessment is strongly encouraged; in such cases, it is crucial to obtain information from collateral sources, such as police records and victims' reports. In selected cases involving male sex offenders, penile plethysmography is of value; this test is rarely used outside of forensic examinations.
A variety of psychiatric disorders are associated with excessive sexual behaviors. These are listed in Table 6 (Irons, 1997), which presents common DSM-IV, Axis I diagnoses. In addition, Axis II personality disorders and traits (such as antisocial personality disorder or narcissistic personality disorder) are often contributory, and in some cases may be the primary etiology of an excessive sexual disorder, especially of paraphilic sexual behavior. As discussed above, several diagnoses listed in Table 5 can be manifested as an addictive sexual disorder and are therefore amenable to addiction treatment; others, however, require a different treatment approach. For example, bipolar affective disorder is treated primarily with medications such as lithium or sodium divalproate; obsessive-compulsive disorder requires a combination of medications (e.g. fluvoxamine) plus cognitive-behavioral therapy; and delirium, dementia, or other cognitive disorder call for a neurologic workup to rule out a physical, metabolic or degenerative causation.
Table 6: Differential Diagnosis of Excessive Sexual Behaviors
Sexual disorder Not Otherwise Specified (NOS)
Impulse control disorder NOS
Bipolar affective disorder (type I or II)
Post-traumatic stress disorder
Adjustment disorder (disturbance of conduct)
Substance-induced anxiety disorder (obsessive-compulsive symptoms)
Substance-induced mood disorder (manic features)
Delusional disorder (erotomania)
Gender identify disorder
Delirium, dementia, or other cognitive disorder Treatment of addictive sexual disorders
Recovery from sexual addiction is in some ways more analogous to recovery from eating disorders than to recovery from substance use disorders (chemical dependency, CD). Unlike CD treatment, whose goal is abstinence from use of all psychoactive substances, the therapeutic goal in addictive sexual disorders is abstinence only from compulsive, self-destructive , and self-defeating sexual behaviors. Development of healthy sexuality is a primary goal that is usually achieved only through commitment to a program of continued recovery and therapy. As with other addictions, which are considered to be chronic, relapsing diseases, there is always the theoretical possibility of a relapse. For this reason, the patient learns to call himself a “recovering” rather than a “recovered” addict.
Addictive sexual disorders frequently coexist with substance-use disorders. David E. Smith, former president of the American Society of Addiction Medicine, wrote (Smith, 1994), "For many individuals, their sexual compulsivity stops when they enter recovery [from chemical dependency]. For others it persists and takes on the characteristics of a primary disease." It is generally agreed that no matter what the primary addiction, if a substance-use disorder is present, it must be treated first. However, once the patient is stabilized off the chemicals and can think clearly, knowledge that a concurrent addiction is present can orient the treatment team toward the patient's needs. For sexually addicted patients (and dually addicted patients who have received primary treatment for chemical dependency), inpatient treatment is appropriate for those who are unlikely to be able to engage in treatment as outpatients, are a danger to themselves or others, or have significant concurrent medical or psychiatric conditions requiring close observation and intensive treatment.
Early treatment, both inpatient and outpatient, is similar to that of chemical dependency, comprising education about addiction in general and about sex addiction in particular, a combination of group and individual therapy, and , if possible, involvement of family members in a family program of education and confrontation. Shame, a major issue for sex addicts, is best addressed in a group, where other recovering persons can provide support confrontation, and shame reduction.
Attendance at twelve-step program meetings based on the Alcoholics Anonymous model is highly recommended. So-called "S" meetings are available in many countries in addition to the United States: In 2000, meetings of Sexaholics Anonymous (SA) were known to be taking place in Argentina, Austria, Australia, Brazil, Canada, Columbia, Germany, India, Ireland, Israel, Italy, Japan, Luxembourg, Netherlands, Philippines, Puerto Rico, El Salvador, Singapore, Spain, Switzerland, Trinidad Tobago, and the United Kingdom. There were SLAA meetings in Argentina, Australia, South Australia, West Australia, Brazil, Canada, Great Britain, France, Germany, Ireland, Israel, Italy, Mexico, Netherlands, New Zealand, Poland, Scotland, Spain, Sweden, Switzerland. In 2000, registered meetings of Sex Addicts Anonymous (SAA) were in existence in Buenos Aires (Argentina), Mexico City, Canada, London, Stuttgart (Germany), and Uruguay. S-Anon, a program for families of sex addicts, has meetings in Canada and Germany.
Educational materials and information about meeting locations of 12-step self-help programs -- whether in the U.S. or other countries -- for addicts, partners of addicts, and couples, can be obtained by contacting the addresses listed in Appendix 1. Salmon (1995) described the histories, detailed definitions of "sexual sobriety," and beliefs of each of the groups listed in the Appendix. Although there are some differences among the various programs for the addict, the similarities are much greater and recovery can be obtained through any of them. The two programs for family members have no significant differences.
Early in the treatment it is suggested that patients abstain from all sexual activities, including masturbation, for 30-90 days. (Because masturbation is so often a part of the compulsive behavior of the sex addict, it is important to refrain from this activity as well). An abstinence period enables them to learn that they can indeed survive without sex, and allows them to get in touch with feelings that have been avoided and covered up with sexual activity. When they stop all sexual activity, some addicts report psychological withdrawal symptoms.
An abstinence period can also be helpful to the sex addict's partner, who is often experiencing a great deal of stress at this particular time. The partner may have recently learned of the addict's sexual acting out. If other people were involved, fears of contracting a sexually transmitted disease may be present. An abstinence period takes the pressure off the partner or spouse, or may have found it difficult in the past to decline sexual overtures from the addict (Schneider, 1990). Partners of sex addicts typically report a history of having been repeatedly lied to and of having been excluded from important decisions affecting them (Schneider, 1998). Accordingly, when a decision is made as part of treatment to initiate an abstinence period, it is highly desirable to include the partner in the decision, or at least to provide the partner with a full explanation of the reasons behind the decision and request her (his) cooperation.
Psychotherapy is often of significant value following primary treatment, especially ongoing therapy for shame, childhood trauma, false beliefs, and the consequences of past actions. In the early recovery period, sex addicts and their partners frequently have sexual and interpersonal difficulties, often to a greater degree than they had during the active addiction phase (Schneider, 1990). Therapists can provide support and reassurance during this phase. If the compulsive sexual behavior was same-sex, as is quite common even among men who identify themselves as heterosexual, therapists can help patients work through conflicts regarding sexual orientation.
Sex therapy is generally most effective at a later stage of treatment, in the second year and beyond. When treating patients with addictive sexual disorders, sex therapists may need to set aside some of their beliefs (for example, views on the desirability of masturbation). It is important to carefully define and rigorously monitor the recovery boundaries of clients and of the professional-client relationship.
By the time sex addicts seek help, their marriage or relationship is often in great turmoil. Communication is lacking, and distrust, anger, and resentment are pervasive. Couples counseling by a therapist supportive of the sex-addiction treatment model can facilitate forgiveness and rebuilding of trust. Such counseling is unlikely to be effective, however, as long as the significant other persists in viewing himself/herself solely as the victim. Significant others should be encouraged to obtain individual therapy to deal with their own dependence issues, fear of abandonment, external locus of control, and low self-esteem, as revealed through therapy and supplemented by participation in their own mutual-help recovery program (See Appendix for addresses).
Drug therapy has a definite place in the treatment of addictive sexual disorders. The tendency of selective serotonin reuptake inhibitors (SSRIs) such fluoxetine, sertraline, paroxetine, and fluvoxamine to inhibit orgasm is a benefit for some sex addicts. Others report that SSRIs modulate the intensity of their sexual preoccupation and suppress compulsive fantasies, allowing them to become more fully engaged in treatment and self-help groups (Sealy, 1995; Stein, 1992). Other clinicians report relief of sexual obsessions with imipramine or lithium (Kafka, 1991). Anti-androgenic progestational agents such as medroxyprogesterone acetate (MPA) or cyproterone acetate (CPA) lower serum testosterone levels and diminish deviant sexual arousal (Gottesman, 1993); these drugs have been used primarily in sex offenders. Triptorelin, a long-acting agonist analogue of gonadotropin-releasing hormone, selectively inhibits pituitary-gonadal function, and also decreases serum testosterone levels. Monthly injections of this drug , in combination with supportive psychotherapy, decreased deviant sexual fantasies and desires in a group of men with pedophilia or other paraphilia (Rosler, 1998). Shuah-Haim (1997) reported on a patient in whom monthly injections of leuprolide diminished serum testosterone levels and decreased inappropriate sexual behavior.
Compared with recovery from substance-use disorders, improvement in the quality of life in recovery from sex addiction generally takes longer. The first year is often characterized by great turmoil (Carnes, 1991). The second six months of recovery is the period of highest risk for relapse. Health, legal, occupational, and relationship consequences of the addiction take their greatest toll during the first year. Because sex addicts were often sexually abused as children (87% according to Carnes, 1991) and because they have distorted ideas about sex, they generally lack experience that facilitates development of healthy sexuality. In the second and third years of recovery, there is improvement in career status, finances, friendships, and self-esteem. In the fourth and fifth years, relationships with the significant other, with parents, and with children mature.
As with chemical dependency, sex addiction is a chronic progressive disorder whose treatment goal is more to "manage" than to "cure." Considering oneself as "recovering" rather than "recovered" helps the addict remain aware of the possibility of relapse. Lapses and relapses in sex addiction often have more severe consequences than in substance dependency: Another sexual encounter by a married sex addict may result in divorce; a single occurrence of exhibitionism may lead to arrest or imprisonment; one more episode of unsafe sex may be the one that transmits HIV infection; a single inappropriate sexual touch of a patient may result in loss of one's medical license. Accordingly, relapse prevention is a key component of treatment of sex addiction. Some addicts benefit by a continuing care contract with their therapist. The contract defines certain sexual behaviors they are willing to avoid, and describes the consequences should the behavior occur. Delineating healthy and necessary boundaries in a written contract is usually therapeutic.
Readers interested in additional information or responses to specific questions can write or e-mail:
The National Council on Sexual Addiction and Compulsivity (NCSAC)
1090 S. Northchase Parkway
Suite 200 South
Atlanta, GA 30067
Tel. (770) 968-5002
e mail: email@example.com
Problematic excessive sexual behaviors often coexist with substance use disorders and are often an unrecognized source of relapse to drug use. They are also associated with inattention to safe sexual practices and therefore have contributed to the HIV epidemic. The first suggestions that compulsive use of sex can be considered an addictive disorder came only 15-20 years ago, and this concept is still not accepted in many professional circles. For this reason, in the year 2000, data on prevalence, treatment outcome data, and hard research results are still scarce.
This paper has attempted to summarize the available information on addictive sexual disorders. Beginning with a review of the various psychological explanations which have been put forth for compulsive sexual behaviors, we presented a general definition of addiction and how behaviors can fall within the framework of an addiction. While recognizing that the acceptability of some sexual activities is culturally determined, we described the range of addictive sexual behaviors and how they relate to traditional psychiatric diagnoses of sexual disorders as outlined in the DSM-IV. With the aid of individual case histories, we demonstrated how multiple addictions can interact and affect each other. We reviewed the natural history of untreated sexual addiction, described how sex addiction is assessed, and presented a differential diagnosis of excessive sexual behaviors.
Certain types of sexual behavior often become either part of a drug and or alcohol dependency pattern. Through ritualization and reinforcement, they become part of the characteristic pattern by which a given individual expresses his or her addiction in fantasy as well as behavior. Alternatively, a mood altering compulsive sexual behavior may be used a substitute for drug use to feel different, to escape from the pain and consequences they are currently experiencing.
The sex addiction field is currently at the same place historically as alcoholism treatment was around 1950, about a dozen years after the founding of Alcoholics Anonymous. It took many years for alcoholism to be considered a disease and for the medical and psychotherapeutic community to acknowledge the validity of the AA approach to recovery. When the first edition of the book Alcoholics Anonymous was published in 1939, a review of the book in the Journal of the American Medical Association described it as “a curious combination of organizing propaganda and religious exhortation” and concluded that the book “has no scientific merit.” (J.A.M.A., 1939, p.1513) Today this book is still the basic text of alcoholism recovery, available in many languages all over the world.
There is no question but that thousands of persons, both male and female, who had experienced significant consequences from their sexual behaviors but were unable to stop, have been helped by means of addiction-model treatment. Although rigorous outcome data on addiction treatment for this disorder are lacking at this early stage, retrospective data are available and were presented in this article. Based on this information, we summarized a treatment approach that consists of a combination of addiction counseling, group therapy, self-help groups, psychotherapy, and learning relapse-prevention techniques. Until more rigorous studies are available, we recommend that clinicians consider this approach for patients whose self-destructive sexual behaviors have not responded to traditional psychotherapy and for patients with substance-use disorders who are having difficulty maintaining sobriety or achieving a comfortable drug-free lifestyle.
For the addict:
Sexaholics Anonymous (SA)
P. O. Box 111910
Nashville, TN 37222-6901, U.S.
Telephone: (615) 331-6230
Sex Addicts Anonymous (SAA)
P. O. Box 70949
Houston, TX 77270, U.S.
Telephone: (713) 869-4902
Sex and Love Addicts Anonymous (SLAA)
P. O. Box 119, New Town Branch
Boston, MA 02258, U.S.
For the Partner, former partner, or family member
P. O. Box 111242
Nashville, TN 37222-1242, U.S.
Codependents of Sex Addicts (COSA)
P. O. Box 14537
Minneapolis, MN 55414
Phone: (612) 537-6904
web site: www.shore.net/~cosa/
Recovering Couples Anonymous
P. O. Box 11872
St. Louis, MO 63105, U.S.
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Glossary of terms:
Addictive disorder: A disorder characterized by loss of control over the behavior (compulsive use), continuation despite significant negative consequences, and obsession or preoccupation with the activity.
Behavioral addictive disorder: An addictive disorder (see above) in which the addiction is to a behavior (e.g. sex, gambling, risk-taking) rather than to a chemical substance.
Chemical dependency: Addiction to a chemical substance. Also termed “substance dependence.”
Erotomania: A delusional disorder in which a person imagines he or she has a mutual romantic relationship with someone else (often a well-known person), when no such relationship in fact exists.
Excessive appetitive disorder: A disorder in which some appetite (for drugs, food, sex, gambling, etc.) is present to excess.
Frotteurism: A paraphilic sexual disorder involving touching and rubbing against a non-consenting person, usually in crowded places.
Obsessive-compulsive disorder: An anxiety disorder (as distinguished from obsessive-compulsive personality disorder) consisting of recurrent obsessions or compulsions which are severe enough to be time-consuming or cause marked distress or significant impairment and are disturbing to the person. The most common obsessions are repeated thoughts about contamination, repeated doubts, a need to have things in a particular order, aggressive impulses, and sexual imagery. The individual attempts to suppress the obsessive thoughts and reduce anxiety with some repetitive behavior (i.e. a compulsion), which typically consist of washing and cleaning, counting, checking, requesting reassurances, various repeated actions, and ordering.
Paraphilia: A sexual disorder in which there are recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving 1) non-human objects (or parts of the human body), 2) the suffering or humiliation of oneself or one' s partner, or 3) children or other non-consenting persons.
Personality disorder: An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the person' s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. Some examples are: antisocial, narcissistic, avoidant, dependent, and obsessive-compulsive personality disorder.
Post-traumatic stress disorder: A set of characteristic symptoms following exposure to an extreme traumatic stress involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one' s body, or witnessing an event that involves death, injury, or a threat to another person, or learning about unexpected or violent death, serious harm, or threat or death or injury experienced by a family member or other close associate.
Sexual addiction, sexual compulsivity, and sexual impulsivity: These are various terms which try to explain a sexual disorder in which a person manifests apparent loss of control over some sexual behavior or combination of behaviors, which are continued despite significant adverse consequences to the person.
Assessment and Treatment of Addictive Sexual Disorders:
Relevance for Chemical Dependency Relapse
by Jennifer P. Schneider, M.D. and Richard R. Irons, M.D.
Jennifer P. Schneider
Arizona Community Physicians
1500 N. Wilmot, B-250
Tucson, AZ 85712
Tel: (520) 721-7886
Fax: (520) 290-0596
Richard Irons, M.D.
Professional Resource Center
7114 SW Cannock Chase
Topeka, KS 66614
Tel: 785 478 3932
Fax: 785 478 9195