Sexual addiction is a disorder that is characterized by repetitive and compulsive thoughts about sex and sexual acts. Like other types of addictions the behavior must have a negative impact on the person so that it leads to issues with the person's social, occupational or legal functioning. The current paper describes sexual addictions, the controversy surrounding their diagnosis, and some proposed diagnostic criteria. The second half of the paper discusses a treatment plan combining cognitive behavioral therapy and a 12-step program in the treatment of internet pornography addiction. Issues surrounding treatment are also discussed.
Sexual addiction is a disorder of intimacy that is characterized by repetitive and compulsive thoughts about sex and sexual acts. Like other types of addictions the behavior must have a negative impact on the person such that it leads to issues with the person's social, occupational or legal functioning (Garcia & Thibaut, 2010). As the disorder progresses the person has to increase the intensity of the behavior in order to get the same results. The behavior can range from excessive masturbation, to the excessive use of pornography or other sexual devices, to illegal activities such as exhibitionism and child molestation. Sex addiction also involves compulsive searching for multiple sexual partners, compulsive sexuality in a relationship, or compulsive fixation on an unattainable partner (American Psychiatric Association [APA], 2000; Garcia & Thibaut, 2010). It is important to note that sex addicts do not necessarily become sex offenders (a little over half of convicted sex offenders are considered sex addicts, but over 70% of child molesters are sex addicts; Kaplan & Krueger, 2010).
The etiology of sexual addiction is not well understood. Like other addictions, there is a purposed biochemical abnormality or other brain-based changes that are believed to increase the risk for developing this disorder (Levine, 2010). Research has indicated that indicate that food, drugs of abuse, sexual interests, and other activities of addiction share a common brain pathway within the survival and reward systems of the brain. These pathways are connected to the anterior areas of the brain that are responsible for judgment and rational thought. It appears that the brains of sex addicts are stimulated in a similar way that a starving or hungry person is informed that food is good. Certain antidepressants and dopamine antagonists have been used with some success in several cases of sexual addiction adding further support to this idea (Levine, 2010). There is also some research that indicates that sexual addicts have a higher prevalence of dysfunctional families or histories of abuse as children than normal controls (Levine, 2010). Sexual addicts and family members of sexual addicts are more likely to have a history of drug and/or alcohol abuse than normal controls also suggesting a possible genetic component (Levine, 2010).
Despite all of this the diagnosis of sexual addiction has been somewhat controversial. The Diagnostic and Statistical Manual of Psychiatric Disorders, Volume Four (DSM-IV-TR) listed sex addictions under the "Sexual Disorders Not Otherwise Specified" category and not under substance abuse and addictive behaviors categories (APA, 2000); however, when the changes for the DSM-5 were proposed some researchers opted to change the name to hypersexual disorder (Kafka, 2010). In the latest edition of the DSM, the DSM-5 does not list sexual addictions as a diagnostic category (APA, 2013). Indeed there has been some controversy regarding sexual addiction as an actual diagnostic entity prior to conceptualizing the DSM-5 diagnostic categories (Mosher, 2011; Winters, 2010). According to the APA there was not enough evidence to include sexual addiction in any form in the DSM-5 diagnostic categories or even in the Index for Further Study section (Reid, Carpenter, Hook, et al., 2012), thus the validity of the diagnostic entity is questionable (at least according to the APA). Moreover, a recent EEG study suggested that high sexual desire and not a disorder of hypersexuality explained the behavior of so-called sexual addicts (Steele, Staley, Fong, & Prause, 2013). Nonetheless, disordered or not, when an individual's behavior becomes problematic for them a counselor should be prepared to help them adjust their actions to a more functional and comfortable level.
Since there are no clinical diagnostic criteria for sexual addiction trying to ascertain normal form disordered sexual practices is not always easy. McConaghy (2003) and Kaplan and Krueger (2010) suggested several possible diagnostic indictors of a problem with hypersexuality based on the criteria for drug or alcohol abuse:
1. Being preoccupied with sex or craving sex and wanting to cut down on this but unsuccessfully limiting these activities/cravings.
2. Thinking of sex so often that it deters one form performing other obligations or continually engaging in sexual practices despite a desire to stop.
3. Spending considerable time doing sex-related activities such as looking for partners or spending hours visiting pornographic sites online.
4. Neglecting one's obligations such as occupational, school, or family obligations due to one's pursuit of sexual activities.
5. Engaging in more sex and with more partners than intended.
6. Continuing to engage in the sexual behaviors despite negative consequences, such as broken relationships, legal problems, or possible health risks.
7. Needing to increase the frequency or scope of sexual activity to achieve the desired effect (e.g., more frequent visits to prostitutes, more sex partners, more porn sites, etc.).
8. Feeling irritable when one is not able to engage in the desired sexual behavior.
If a person meets or more of the above criteria a sexual disorder is suspected. As there is no formal physically-based tolerance or withdrawal in non-substance based addictions the individual with a sexual disorder will feel psychological and not physical manifestations of these issues (criteria seven and eight above).
Due to the variety of types of sexual addictions a specific plan for each type of addiction will need to be developed (although there generalities that can apply to all of them as well). This recovery plan will be aimed at males addicted to internet pornography. In order to determine if there is an abuse or addiction issue the intake will include a structured interview to screen for psychological problems including covering aforementioned diagnostic indicators for sexual disorders (applied to the use of porn). Most of the psychotherapy programs approach sex addiction with the same types of strategies that have empirical evidence for treating chemical dependency (Kaplan & Krueger, 2010). This program often consists of individual cognitive behavioral therapy (CBT) and if possible enrollment in a 12-step program that is aimed at sexual addictions such as Sex Addicts Anonymous (SAA). In addition, having clients followed by their primary care physicians or a psychiatrist can also be a part of the program as sex addiction is more common among substance abusers and treatment of substance abuse/dependence may also be needed (Kaplan & Krueger, 2010). The model would best be a Christian model that incorporates CBT so as to comply with the 12-step program.
The CBT treatment program will consist of 20 weekly sessions; 12-srep participation will be ongoing for as long as the clients feel that they need it, but a minimum of 20 weeks. There are two main components in the CBT program (Young, 2007):
1. Functional analysis component where the client and therapist work together to identify the thoughts, feelings, and circumstances regarding the client's use of internet porn. This assists the client to determine the risks and factors that are likely to promote this behavior and also later to lead to a relapse. The functional analysis also helps the person to understand what needs the use of porn serves for him specifically and to develop insight and identify situations where the person has difficulties coping.
2. Skills training compliments the functional analysis. A person needing assistance to decrease their viewing of pornography is also using this activity as a means of coping with their life problems. The goal of CBT is to help the person develop positive coping skills.
The therapy helps the person unlearn old habits and learn to develop more positive habits and skills. This is accomplished by educating the client to alter the way they view their addiction and learn new ways to cope with the situations and circumstances that fuel it. The 12-step program compliments the CBT program and helps the individual develop life-style changes to work hand in hand with the skills learned in CBT.
Issues in Treatment
One of the biggest issues in treatment of any addiction is relapse ((Kaplan & Krueger, 2010). This issue is so prevalent that entire books have been devoted to it and addictions counselors treat relapse as part of the recovery process (Young, 2007). This is where education regarding relapse as not being a failure, but instead a learning experience can help as well as a plan to avoid relapse. Another issue of course related to relapse is the high attrition rate in addiction treatment. The 12-step program is geared at developing an ongoing support network for addicts and this can help. Finally, comorbidity of other substance abuse issues or other psychiatric disorders is a problem…