Jim, 37, married with two young children but currently separated from his wife, recently entered sex addiction treatment with the following concerns:
"I started therapy a few years ago, ostensibly to deal with my anger. But the real reason I sought help, unknown to my wife, was that I literally could not stop myself from seeing prostitutes and sensual massage workers. Over the preceding two years, I’d had hundreds of encounters with sex workers, some of them unsafe, which left me depressed, self-hating, and very angry. I engaged in a lot of this sexual behavior before my marriage, too, but once I met my wife the whole thing seemed to go away. For a while. But then it started up again, and I just couldn’t control it.
"My first therapist (of three years) assured me that I would stop seeing prostitutes once our therapy got to the root of my childhood abandonment and intimacy issues. But that just hasn’t happened. In fact, since I first started therapy my behaviors have gotten worse—I’ve been arrested twice for soliciting prostitutes, and I also got a pretty serious STD. When my wife finally found out about all of this last week she took the kids and left, maybe for good. I really need help stopping this behavior. Sure, I’ve made progress with my other issues, but I continue to see sex workers, even more so in the few days since my wife left. I just feel like I’m getting worse, not better."
Recently, a colleague published an article on this site discussing why he no longer utilizes the addiction model when dealing with patients who come to see him for help with problem sexual behaviors. His concerns centered on his belief that sex addiction treatment doesn’t leave room for nontraditional forms of sexual expression (bisexuality, homosexuality, kinks, fetishes, etc.). He seems to think that sex addiction therapists uniformly impose external cultural and/or religious beliefs as the guiding principles of treatment, rather than accepting clients as they are regardless of their sexual arousal template. In particular, he implied that when a client arrives with an ego-dystonic (unwanted) sexual arousal pattern—for example, an unwanted same-sex attraction—the sex addiction model will be used to shame and potentially harm that client when the therapist should actually be helping the client accept his or her sexual reality.
As a certified and very experienced sex addiction treatment specialist, I can assure you that this is not the case. In actuality, the vast majority of properly trained sex addiction therapists take a very different, much broader approach. We actively recognize that sexual addiction has nothing whatsoever to do with who or what it is that turns a person on. Instead, we define sexual addiction by out-of-control behaviors that are causing negative consequences in the client’s life, much as we define alcoholism and drug addiction by out-of-control substance use that leads to serious life problems.
The simple truth is that sex addiction exists, just like alcoholism, drug addiction, compulsive gambling, compulsive shopping, eating disorders, and other addictive/compulsive issues. Moreover, people suffering from sexual addiction deserve informed, empathetic, and properly directed treatment just like any other person dealing with a destructive addiction or compulsion. Jim, described above, is just one example. People like him, desperate for help with sexually compulsive behaviors that are destroying their lives, are the reason I am a sex addiction therapist.
For the doubters, I present below the latest research-based facts on the etiology, neurobiology, and effective treatment of sexual addiction, along with a brief statement on a few issues I believe the clinical community needs to address and overcome.
The Etiology of Sexual Addiction
Sadly, sex addicts (like addicts of all stripes) are usually survivors of profound and chronic early-life trauma—neglect, emotional abuse, physical abuse, and sexual abuse (both overt and covert). Often, these survivors begin to self-medicate their emotional discomfort relatively early in life, usually during adolescence but sometimes even before. This process of self-soothing typically involves alcohol and/or drugs. However, many people also learn (or are taught) that they can self-soothe with sexual behaviors (including sexual fantasy and masturbation), sometimes by eroticizing and reenacting an aspect of their trauma (particularly if/when part of their abuse was sexual). While distracting in the moment, over time these behaviors tend to exacerbate preexisting feelings of shame and emotional discomfort, thus creating an even greater need for emotional self-soothing, escape, and dissociation.
This survival practice of abusing alcohol, drugs, and/or sexual arousal to self-soothe the pain of early-life trauma often carries forward into adulthood. As adults, these deeply shamed survivors may find themselves mired in an addictive cycle of self-hatred and shame buffered by sexual fantasy and sexual behavior. They may use this to self-soothe and distract from internal emptiness and the fear of becoming emotionally vulnerable. This is the most common etiology of sexual addiction—how and why it manifests. Essentially, when people consistently and impulsively use sex (or alcohol, drugs, gambling, eating, spending, etc.) as a way to avoid uncomfortable emotional states, they are quite likely to qualify as addicts and experience the negative life consequences that typically ensue. Even when deeply committed to another person, sex addicts under emotional stress will time and time again choose the emotional intensity of sexual fantasy, pursuit, and behavior as a way to self-soothe and self-regulate rather than risk the pain that emotional vulnerability and intimacy brought them when they were young.
The Neurobiology of Sexual Addiction
With current brain imaging technology, we can look at the brains of self-reported sex addicts to see if they react differently than the brains of non-addicts to arousing sexual stimuli. Moreover, we can compare the brain responses of sex addicts to the brain responses of other addicts (in particular, substance abusers). Numerous studies of this nature have emerged in the last two years. The best of this research has been done by Valerie Voon at Cambridge University (UK). Unsurprisingly, Voon has found that the brains of self-reported sex addicts respond in very different ways to sexual stimuli such as porn than the brains of non-addicted people. Moreover, the brain response of sex addicts exposed to sexual stimuli mirrors the brain response of drug addicts when exposed to drug-related stimuli. (See Voon speak about her work in this short video.) These recent findings, together with earlier research (more details in this article), strongly suggest that sexual addiction manifests in the human brain in profoundly similar ways to more commonly accepted forms of addiction, most notably substance abuse.
Sexual Addiction Treatment: Myth vs. Reality
Sexual addiction treatment involves the use of motivational interviewing, cognitive/behavioral, task-oriented, and psychodynamic methodologies to help clients alleviate patterns of problematic sexual behavior that have led to their lives becoming dysfunctional. Prior to any clinical intervention, clients receive extensive assessment, typically using sophisticated, normed, psychometrically validated instruments. Thus, clients do not receive addiction treatment simply because they say they are a sex addict or because their sexual behavior does not meet some arbitrary cultural or religious norm.
Initial treatment goals (beyond assessment) are most often focused on short-term and long-term behavioral change in order to prevent further harm and consequences. Frankly, by the time most sex addicts reach out for help, they’ve experienced multiple and profound negative life consequences directly related to their sexual behavior—relationship losses, trouble at work or school, STDs (given or received), arrest, financial loss, public humiliation, and more. So, clearly, behavior change is an early priority. Down the road for clients who remain in our care, treatment specialists move into more dynamic and trauma-informed methods of treatment. But this is only after a client has developed the ego strength and social support they need to halt destructive patterns of compulsive sexual behavior.
Properly trained sex addiction treatment specialists do not diagnose sex addiction based on how often or in what ways a client is sexual, just as a substance abuse treatment specialist would not try to diagnose alcoholism based on how often or what brand of booze a client drinks. We also do not diagnose sex addiction based on collateral information from understandably hurt and angry spouses. Further, and most important, we do not diagnose a person as sexually addicted based on ego-dystonic (unwanted) sexual orientation, gender identity, and/or fetish arousal patterns. Again, sexual addiction is not based on who or what it is that turns a person on. Instead, we define sexual addiction by out-of-control behaviors that cause negative consequences in a client’s life.
The State of the Field
I have long believed the endless heated clinical debates over whether this debilitating addictive/compulsive disorder exists and, if so, whether we should call it sexual addiction (Patrick Carnes, PhD), hypersexual disorder (Martin Kafka, MD), out-of-control sexual behavior (Kinsey and the APA), or sexual compulsivity (Eli Coleman, PhD) to be unnecessary and unproductive distractions. If I have learned nothing else in my 30 years of treating adults with sexual disorders, it's this: All of us who research and provide clinical care in the various fields of human sexuality have more to gain by learning from each other than by throwing rocks at each other via petty and ultimately meaningless squabbles. If we could just move our egos and fears aside and listen to one another respectfully, we could make some progress and help many more people in need.
Sadly, in my experience, many of the leaders in the fields of sexual health, sexual addiction, and sexual offending treatment would rather duke it out than consider a joint effort. This is troubling, as together we have a chance to gain shared insight into the diagnostic and treatment needs of the various and diverse client populations that we serve—which, by the way, often overlap.
In a perfect world—one in which this post is unnecessary—sex therapists (sexologists), sex addiction treatment specialists, and sexual offender clinicians would all work together, recognizing that we have far more in common than our current public debates reveal. Instead of arguing, we would accept that we have much to learn from one another. With a willingness to walk in each other’s shoes with empathy and curiosity, we could more effectively and completely de-pathologize that which is normative. We could more quickly identify that which is truly harmful to self and/or others. And we could simultaneously evolve more effective and comprehensive forms of treatment.
For more information on sex addiction training and education contact Dr. Patrick Carnes’ International Institute for Trauma and Addiction Professionals (IITAP), the non-profit Society for the Advancement of Sexual Health (SASH), and/or my website.
Robert Weiss LCSW, CSAT-S is senior vice president of clinical development with Elements Behavioral Health. He is the author of numerous books, including Sex Addiction 101: A Basic Guide to Healing from Sex, Love, and Porn Addiction. For more information please visit his website, robertweissmsw.com.