Sex Addiction: Diagnosis and Treatment

After the plethora of recent sex scandals, a growing number of celebrities have sought treatment in sex addiction clinics. While many people assume sex addiction is a recognized psychiatric disorder, mental health professionals continue to debate the validity of the diagnosis. It has not (yet) been included in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the diagnostic manual widely used by researchers and clinicians in the United States. Nevertheless, it is estimated that sex addiction affects 3–6 percent of the population.

Since it is not an officially recognized disorder, therapists are few and far between. Two of them are Michael Bohan, M.D. and St. George Lee, M.D.. Dr. Bohan is a practicing sex addiction and trauma therapist in Virginia Beach. Dr. Lee is a sex addiction therapist based in Newport News, VA and the author of Light in the Darkness: A Guide to Recovery from Addiction, in which he recounts his own struggle with sex addiction and subsequent recovery, and shares the insights he gained from his disease.

In their presentation as part of the Williamsburg Place Lecture Series, they defined sex addiction as “a persistent and escalating pattern or patterns of sexual behaviors acted out despite increasingly negative consequences to self and others.” This is similar to the National Institute on Drug Abuse using the term addiction to describe “compulsive drug seeking despite negative consequences.” Addiction to sex features strong similarities to other addictive behaviors, and sex addiction—like many other addictions—is frequently accompanied by co-occurring mental health issues such as depression, unprocessed trauma, or substance use disorder (SUD).

Although it can affect all genders, “we mainly deal with men,” said Bohan. Sex addiction often—but not always—involves the victimization of partners and others. This may include coercive control, stalking, affairs, pornography, intimate partner violence, murder suicide, and lust murders. At this point, Bohan and Lee presented an important legal obligation for therapists. “All assessments need to be prefaced with the comment that if anything the patient tells the counselor sounds like illegal behavior, the counselor will need to inform social services and the police.”

Bohan and Lee found that at the core of most sex addictions is childhood trauma: “We see it all the time,” Bohan said. The consequences of sex addiction are typically progressive and predictable. Similar to SUDs, the addict minimizes the consequences and largely blames others. Family and friends also rationalize the behavior because they want to believe the repeated promises of change offered by the addict.

Dr. Bohan provided a list of typical consequences:

SOCIAL: lost in sexual preoccupation, distanced from loved ones, friends

EMOTIONAL: anxiety from constant fear of discovery

PHYSICAL: STD and HIV/AIDS risk

LEGAL: divorce, restraining order, prison (child porn)

FINANCIAL: cost of affairs, prostitutes

SPIRITUAL: self-loathing, loneliness, resentment

As with SUDs, the addicts gets caught in a vicious cycle. Fantasy, ritual, and obsession (anticipation phase) are briefly relieved by the sex act (comparable to substance use). The “high” is then quickly followed by despair (withdrawal), triggering the next anticipation phase called “sensitization” by sex addiction expert Patrick Carnes. In both substance abuse and sex addiction the pleasure center of the brain is hijacked.

“Sex addiction is the parallel to cocaine addiction,” explained Bohan. “It’s an upper. And what happens when you stop using cocaine? Where are you? Down!” That’s why the chance of depression and the risk of suicide are elevated for people suffering from sex addiction.

Increasing tolerance, dependency, and sensitization to triggers are common denominators of all addictions, explained Lee and Bohan. A triggering device for sex addicts that is hard to avoid nowdays is the computer. “The creation of the internet has increased sex addiction about eightfold,” says Lee. The sad result of ubiquitous sexual stimuli: most sex addicts are unable to have normal sex with their partners.

The reason for that is something called “vandalization.” Sex addicts tend to have a vandalized “lovemap”—a term used by sex addiction expert John Money. Vandalization typically occurs in childhood—in other words, the child molester was himself molested as a child. Money’s book Lovemaps describes how adults normally experience a sexual orgasm and how with sex addicts the lovemap—Carnes uses “arousal template” to refer to the same thing—has been severely compromised, frequently as a result of shaming for normal sex play, early exposure to pornography, or sexual assault in childhood. According to Money, individual lovemaps develop between ages 5–8.

Vandalization may then lead to distorted sexual expressions like hypersexuality (compulsive sexual activity), hyposexuality (avoidance of any sexual activity), or paraphilia. Bohan and Lee provided an extensive list of paraphilias including predation, fetishes, mercantile/venal, strangulation, sado-masochistic repertory, urophilia, and many more.

Most of these distorted sexual expressions lead to what Bohan and Lee described as “intimacy block.” Sex addicts are largely incapable of being present, nurturing, honest, and accountable—most of them have never been truly intimate with anybody.

Consequently, one of the main goals of recovery from sex addiction is to achieve growth in the intimacy dimension. That typically requires individual and couples counseling. The “elements of courtship” (Carnes) have to be (re)acquired. They include noticing, flirtation, romance, individuation, and intimacy before engaging in foreplay and intercourse, ultimately resulting in commitment.

In recovery, sex addicts need to culivate empathy for the people they have hurt and acknowledge their damaging behavior. But they also need to process their own trauma. “Most addicts were victimized in childhood and need to express empathy towards their wounded self which led them to this state,” said Bohan.

Anger, blame—which is projected self-hatred, shame, and resentment have to be overcome, said Lee. “Recovery then puts you in a loving position, you develop serenity, and acceptance of others and yourself.”  

 


 

RECOMMENDED BOOKS:

St. George Lee. Light in the Darkness: A Guide to Recovery from Addiction. (2000)

Patrick Carnes. Out of the Shadows: Understanding Sexual Addiction. (2009)

John Money. Lovemaps: Clinical Concepts of Sexual/erotic Health and Pathology.  (2011)