HomeWelcome and Psychotherapy servicesCouples TherapySex TherapyProblematic Sexual BehaviorSupervision & ConsulationSpeaking Engagements

"When a patient reports being a sex addict, we cannot assume that it reveals anything more than a concern about how the person regards normophilic [non-paraphilic] sexual behaviors, whether the problem can be solved with basic sex education, whether guilt and shame are involved, or if deeper psychological factors are involved."

- Paul Joannides PsyD

Problematic Sexual Behavior: Is it really sex addiction? People can, and do, struggle with the choices they make about where, when and with whom to be sexual. Without doubt, making poor choices about ones sexual behavior can damage ones career options, the ability to meet obligations, and interpersonal relationships. However, does this simple ‘cause and effect’ analysis between poor risk assessment skills and negative outcomes really mean that someone is a “sex addict”?

There is on-going debate in the professional and public arena about the diagnostic validity of “sex addiction”. Those who support the sex addiction perspective argue that sexual behavior can become an out of control process that is similar to substance abuse and dependency. The sex addiction camp also argues that problematic sexual behavior is “a brain disease” like any other addiction and that when one “hits bottom” the only way back to “sanity” is through admitting “powerlessness” over ones sexual behavior and joining a twelve-step program similar to AA.

The problem with the sex addiction model is that assumptions used to support this perspective have never been scientifically validated. Sex has never been shown to cause dependency in the way one can become physically dependent on chemical substances. As a clinician who has been treating men and women struggling with problematic sexual behavior for over a decade, I have found that these behaviors have their roots in complex biological, psychological, relational and social issues that are often overlooked and under-appreciated when treated from an addiction framework. An alternative to the sex addiction perspective involves moving beyond formulaic models of intervention and developing an understanding of what drives and sustains the behavior.

Defining Dependency: Prior to outlining what drives problematic sexual behavior and developing treatment interventions that invite change and healing, it’s important to clarify the diagnostic criteria that have to be met in order for someone to be considered physically dependent; the actual term used to describe what is commonly referred to as “addiction”. In order for someone to be accurately diagnosed as “dependent” they must present with two specific symptom profiles a) tolerance and b) physiological withdrawal. 

Tolerance: Tolerance means that one needs an increasing amount of a chemical substance to get the same effect they used to experience with smaller doses of that substance. People do not develop tolerance for sexual behavior. There are no documented studies demonstrating a correlation between consuming larger amounts of sexually explicit material or engaging in greater amounts of sexual behavior to attain the same effects of pleasure once reached by less frequent sexual activity.

Withdrawal: Withdrawal refers to the onset of unpleasant physiological symptoms that begin to appear when a particular chemical substance, that one has developed a physiological tolerance to, is suddenly not available. Physiological withdrawal often includes escalating symptoms such yawning, runny nose, sneezing, heightened sense of anxiety, irritability, rage, depression, changes in mental status and orientation, paranoia, delusional thoughts and transient psychotic symptoms, abdominal pain, vomiting, diarrhea, body, bone and joint pain, seizures and, in the case of certain substances such as alcohol, the risk of death.

In the absence of sexual behavior, no matter how intense and frequent the behavior may have been, people do not manifest withdrawal symptoms and do not require medical attention to mitigate the physiological intensity of their discomfort. True, these individuals may feel complex emotions such as heightened anxiety, shame and suicidal ideation when they reflect on their behavior. These responses only highlight the individuals difficulties tolerating intense emotional experiences and struggles with self-soothing, not the presence of withdrawal from sexual behavior. 

Sex addiction is not a recognized DSM-5 diagnosis: For all of the controversy surrounding The DSM-5, often referred to as the “bible” of psychiatric diagnosis, it clearly states:

 . . . Groups of repetitive behaviors, which some term behavioral addictions, with such subcategories as “sex addiction,” “exercise addiction,” or “shopping addiction,” are not included because at this time there is insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions needed to identify these behaviors as mental disorders. (American Psychiatric Association, 2013, p. 481).

In essence, what the authors of The DSM-5 have said is that there is insufficient evidence that sex is an addictive process.

Problems with research methodology: Developing a good research study is a painstaking process that involves precision in how to ask questions, select people and populations to study, data collection, and data interpretation that, if evaluated by an ethical researcher, either supports or invalidates the original research question. To claim that information obtained from a study is statistically valid and represents the general population, researchers must demonstrate that the information being presented was obtained from a large population based probability-sample. This means that the people chosen for the studies were randomly selected from the general population and matched for issues such as age, race, ethnicity, gender, sexual orientation, socioeconomic status etc., and the information obtained from the study could not be better accounted for by alternate explanations or chance.

Much of the research data obtained to support the sex addiction perspective has been obtained through research methodologies that do not meet the above criteria. The methodologies primarily used in these studies have tended to rely on convenience sampling, participant self-selection and snowball sampling. Convenience sampling means that the people being studied were easily accessible to the researchers such as people in already in treatment who self-identify as 'sex addicts' and, as such, were not randomly selected for the study. 

Convenience sampling is like interviewing people in coffee shop and asking them to share their feelings about coffee and then making a statement that 98% of people surveyed love coffee. What this information is actually reporting is that 98% of the people interviewed at a coffee shop liked coffee. While this may be an expected outcome, it cannot be used to make the claim that 98% of ALL people in the general population like coffee.

Self-selection is a research methodology in which people choose, or self-select, to become participants in a study. People who self-select to enter a research project often do so because they identify with the issue being studied and want to share their stories. Snowball sampling is a sampling process by which a research participant refers a friend, colleague, or acquaintance to take part in the study. It’s important to know that people often associate with those who have had similar experiences and world-views as themselves. As such, convenience sampling, self-selection, and snowball sampling has a tendency to over-represent similar perspectives, ideas, and experiences.

It’s important to recognize that there is nothing wrong with the types of research methodology discussed above. In fact this type of research methodology is commonly used in anthropology and other forms of social research where specific questions about peoples, cultures, and populations are needed. However, the information being reported can only be applied to the people being studied and cannot be applied to the general population.

How studies can misrepresent data and public perception of behavior: The problem with studies utilizing convenience sampling, self-selection, and snowball sampling is that the data is often presented to the general public, which may not be aware of the complexity for research design and methodology, as definitive. In the case of 'sex addiction' when people are emotionally distraught or struggling to understand their own behavior, or the behavior of a loved one, they want simple explanations and a quick path to the problems resolution. The information obtained from studies utilizing convenience sampling, self-selection, and snow-ball sampling meet these requirements by supporting a false belief human experience is a unified and linear experience that lends itself to simple intervention and outcomes.

Neuroscience: Neuro-imaging technology such as Magnetic Resonance Imaging, functional Magnetic Resonance Imaging, Positron Emission Tomography scans have allowed science to peer into the structure, functioning and activity of the human brain in ways that were previously unimaginable. Those that support the sex addiction perspective frequently point to studies that make fantastic claims about the brains of “sex addicts”. These claims often report that the reward centers of the brains of 'sex addicts' become highly activated when exposed to sexually arousing imagery. Supporters of the sex addiction model will then argue that this is proof that sexually explicit materials have altered the brains of those diagnosed as 'sex addicts'.

Again, this is a mis-interpretation of research data. When exposed to sexually arousing imagery the brains’ pleasure centers do, in deed, become activated. If one repeats a behavior long enough the brain learns to anticipate, accommodate and change through the process of repetition. This is how we learn about what is pleasurable, what is not pleasurable, and what behaviors we may want to explore. The same regions of the brain that are activated when exposed to sexually arousing images or behavior are also activated when we see, or meet with, friends and loved ones, eat our favorite foods, and engage in non-sexual pleasurable activities such as exercising, listening to music, or enjoying a favorite memory. We are hard wired to respond to, anticipate, and pursue pleasure and can use this pleasure to self sooth complex emotions, feeling states, and unmet needs.

In addition, the human brain is regularly altered by repetitive behavior. When you hear to the virtuosity of a musician you are experiencing, first hand, how the brain of that individual has been altered by practice and performance to create a more efficient and skilled artist. When a particular behavior is discontinued our brains scramble to make sense of the loss of the routine and comfort that this behavior once offered. Think of friend, or perhaps yourself, who has tried to change how they eat? Have you noticed the initial discomfort and change in mood when experiencing the ups and downs of trying to engage in behavior change? This example highlights how a behavior can become habit and how habit can create discomfort when altered.

Satel and Lilenfeld neuro-scientists and co-authors of Brainwashed: The Seductive Appeal of Mindless Neuroscience, suggest caution when discussing the brain and addiction;

“ For all its benign aspirations, there are numerous problems with the brain disease model. On its face, it implies that the brain is the most important and useful level of analysis for understanding and treating addiction. Sometimes the model even equates addiction with a neurological illness, plain and simple. Such neurocentrism has clinical consequences, downplaying the underlying psychological and social reasons that drive drug use” (Satel & Lilenfeld, 2013, p. 58.).

As stated earlier in this article, behaviors have complex factors supporting their continuation. Reducing any behavior to a single causal factor only invites a dumbing down of the complexity of human experience and behavior. 

Different explanations for problematic sexual behavior: Paul Joannides, a clinical psychologist, sex researcher, sex therapist, and practicing psychoanalyst, has reported that . . .

"Patients and their therapists face many challenges trying to conceptualize problematic sexual behaviors. It would be a very unusual patient who arrives in a clinicians office and says, “I think I have dysregulated sexuality.” Instead the word “sex addiction” is often used. When a patient reports being a sex addict, we cannot assume that it reveals anything more than a concern about how the person regards normophilic [non-paraphilic] sexual behaviors, whether the problem can be solved with basic sex education, whether guilt and shame are involved, or if deeper psychological factors are involved. (Joannides, 2012, p. 80.)."

Joannides offers sound advice when he advocates for considering alternate explanations for the presence of problematic sexual behavior. There is substantial data that suggests that people who struggle with problematic sexual behavior often have other issues that are better account for their actions such as obsessive compulsive disorder, anxiety, major depressive disorder, bipolar disorder and PTSD. In addition, many of the diagnostic criteria pertaining to personality disorders, described as fixed and repetitive self-defeating strategies to regulate painful emotional states that impact multiple interpersonal relationship, include high-risk behaviors that threaten the well being of self and others. Below are some of the most common issues I’ve observed in treating men and women who have reported problematic sexual behavior.

Lack of sex education: A comprehensive sex education, and this should be considered an evolving list, would foster skills in discussing and understanding, without shame or judgment, the importance of appreciation of our bodies and the bodies of others, sexual and gender diversity, contraception, STI prevention, family planning, masturbation and self pleasuring as tools of self exploration and discovery, communication of diverse and varied sexual needs and desire with partners, the role of emotional, relational and interpersonal communication strategies, a recognition that sexual desires, needs, and practices evolve over time, erotic, sexual and relational styles, skill development, monogamy and consensual non-monogamy, pleasure focused vs. goal focused sexuality, and the role of consent in sexual and erotic relationships. Unfortunately, with few exceptions, our culture has turned to its back on realistic and comprehensive sexuality education and allowed, through its fear and discomfort with the topic of sexuality, religion, morality and, paradoxically, commercially created pornography has become a source of information for people curious about sex and sexuality.

It's been argued that pornography reinforces harmful messages about body image, gender roles, consent and how people "should be" sexual. These claims have been researched, argued, and debated for centuries and for every study showing the lack of support for these positions, another study argues that there is data supporting these arguments. The beat goes on. If one seeks sexuality information through pornography, which again has become the de facto portal for sexual information in our culture, they run the risk of being judged and labeled a sex addict. An interesting take on the absence of sexuality education, and its impact on men, women, and sexuality, is discussed by Cindy Gallop, in a short TED TALK. In this discussion, which can be viewed at this web address http://www.youtube.com/watch?v=FV8n_E_6Tpc., Gallop argues not against pornography, as she herself reports enjoying this media, but against the belief that pornography represents a model of how every man and woman should be having sex. In combating this misinformation, Gallop has created the website Make Love Not Porn, which can be found at http:makelovenotporn.com . A particularly helpful area of this website is "Know It: Porn World vs. Real World", in which the mythology of pornography is compared to the realities of complex sexual behavior between consenting adults. This resource is well worth the read!

Adjustment Disorders and psychosocial stresses: Adjustment disorders account for alterations in mood, behavior and conduct following a major change in ones life. Adjustment disorders can range from the birth of a new child, the death of a family member, a change in employment status and various other anticipated and unanticipated life transitions. When faced with life transitions, people may seek new ways, or resort to old behaviors, to reduce the anxiety and difficult emotions that accompany change. Some individuals may increase or decrease the amount of sexual behavior they have in order to deal with these life transitions. This shift in sexual activity is normative as sex and masturbation are common stress relievers. However, if an individual, spouse or family member notices these changes in sexual activity they may become anxious and label the behavior “sex addiction”. This new label may then become the focus of attention rather than how the individual, couple or family cope with the changes and stresses confronting them.

Biological considerations: There are various biological issues that can be mistaken for problematic sexual behavior; the most common include reactions to medications such as those used to treat Parkinson’s Disease, stimulants used to treat attention and hyperactivity as well as neurological pathologies. In addition people who have suffered traumatic brain injuries may also manifest symptoms of problematic sexual behavior. Rather then label the behavior, and the person, as a sex addict a comprehensive evaluation of the presenting behavior, physical health and changes in medication regimen should be considered.

Changes in sexual styles, desires and practices: Sometimes people discover aspects of their sexuality and eroticism they may not have previously recognized, or were reluctant to share, with their partner. These feelings of discomfort may be related to fear of rejection, not knowing how or make sense of their feelings and desires, or a wish to engage in sexual behaviors with themselves as an expression of a sexuality that is uniquely their own. Some people report a desire to open their relationship to other sexual possibilities but do not know how to broach the topic of consensual non-monogamy with their partner. Rather than risk loosing the relationship they choose instead to engage in sexual behavior without their partners knowledge, or consent, only to be discovered at a later date. When discovered the individual may be confronted with an unappealing choice; admit that they are a sex addict or loose the relationship. Often times, individuals will opt to take on the label of being “sick” rather than discuss the evolving nature of their sexual needs and desires. This is not to condone or approve infidelity. Infidelity is a powerful source of emotional pain and injury in any relationship. Further complicating this scenario is the reality that research has shown that people who engage in extra-relational affairs  do, in fact, love their partners and do not wish to leave the marriage, but feel un-prepared to discuss their feelings and needs with their partner. In these cases, being able to understand what drove a particular choice and behavior can set the foundation for change, healing, and more open and honest style of communication in the relationship.

Relational conflict: Sometimes people engage in destructive behaviors to avoid dealing with conflict and resentment within their relationship. These behaviors may include repeated affairs, withholding sex, or any number of activities and behaviors that communicate anger, grief and disappointment. This type of relationship creates a useful application for the term “sex addict” as one member of the relationship can avoid engaging by claiming they, or their partner, is “sick”. Another growth blocking application of the term “sex addict” within this relational dynamic is when the partner who has discovered the behavior labels their partner’s behavior as “addiction”, and uses shame to force their partner into compliance, engaging in tracking their partners whereabouts, avoid their own hurt, anger, and broken trust, opting instead for  ongoing punishment of their partner while limiting options for growth and healing.

Attempts to “master” psychological trauma or a return to the familiar?: Sometimes people who have experienced traumatic situations and may engage in risky behavior or abstain from sex altogether, sometimes moving between these two poles in an attempt to deal with and resolve the original injury. These patterns of sexual behavior had previously been described as 'repetition compulsions' and were thought to be attempts to master the original injury by re-creating situations where one can feel powerful over a traumatic event that left them feeling powerless. However, as the field of psychology and traumatic studies has advanced there is now a great deal of research that shows those who have suffered traumatic events in their lives tend to return to emotionally arousing and intense situations not because they want to suffer but because, for them, chaos and pain are akin to 'home', and they know how to deal with intensity through hypervigilance, planning, and anticipation of negative outcomes. In short their neurology and psyche have become adept at processing potential dangers that create a sense of being centered. Paradoxically, people who have experienced traumatic events often become anxious in the absence of intensity reporting that they fear being injured again if they let their guard down.

Unfortunately, these behaviors and activities further prevent the individual from dealing with the emotional and psychological wounds of their trauma and ultimately undermine their attempts to heal. While not an excuse for the behavior this process does help to shed a compassionate light on the complexity of problematic sexual behavior as an attempt to mitigate the pain of un-attended wounds.

Other considerations: Sometimes people make bad choices and, rather than keep a secret from their spouse, choose to disclose this information to their partner; this does not make them a sex addict. This makes them a human being looking to make amends for a choice and behavior they regret. Sometimes people repeatedly break promises and cannot be trusted to remain faithful to their partner as they lack the capacity, or inclination, to reflect on how the consequences of their behavior impacts others. 

Intervention strategies: If someone tells you that they have THE answer for this problem, no matter how sincere or well meaning they may be, they are not presenting you with accurate information. There is no one size fits all in psychotherapy and there are multiple avenues to treating problematic sexual behavior.

12-Step Groups: This may sound counterintuitive to what I’ve written, but some people do very well in 12-step programs as an initial step towards changing their behavior. The pros of this type of intervention include the fact that it’s free, it offers an opportunity to break social isolation and an environment in which to discuss strategies to change problematic sexual behaviors. One of the most supportive groups in the New England area is Sex and Love Addicts Anonymous or SLAA. SLAA offers it’s members the opportunity to explore and define problematic sexual behavior as they personally define the issue, allowing more room to differentiate between those sexual behaviors that the individual does not want to challenge and those behaviors that the individual finds problematic.

SLAA also offers a supportive space for LGBTQ people who may also be struggling with problematic behavior. As time goes on some people may discover that they need more support, discussion, and exploration of the their sexuality and eroticism than they can feel they get from their 12-step program.

Individual and Couples Psychotherapy: Individual and couples therapy with an experienced and skill clinician who is knowledgeable about human sexuality and has skills in addressing issues of problematic sexual behavior and relational discord can be very helpful resolve these issues. Asking a therapist about their training in human sexuality, experience with treating problematic sexual behavior and skill in addressing and attending to relationship discord is key to locating a clinician that best meets your specific needs.

Group Psychotherapy: Group psychotherapy is a specific type of treatment that focuses on learning to interact with and support others confronting similar issues. Group therapy also provides an opportunity for people to learn how to work through interpersonal conflict in a safe and supportive environment. There are many different types of groups available including short term psycho-educational groups, open ended “drop in” groups, and formal long term psychotherapy groups that offer an opportunity for changing perceptions of self and others.

Medication Consultation: Some people find a combination approach to resolving problematic sexual behavior works best for them and the addition of medication can assist in the process of change. When considering meeting with a psychiatrist or Clinical Nurse Specialist for medication, it is important to ask them about their experience treating people with problematic sexual behavior, their understanding of the issue and how they believe medication may assist in the process of change. 

Conclusion: This article is intended to invite people to make informed decisions about the type of treatment they wish to engage in while removing the stigma and shame that accompanies struggles with human sexual behavior. A comprehensive treatment for problematic sexual behavior begins with a clinician hearing your concerns, learning about the impact the behavior has had on your life, relationships and sense of self, and developing a treatment plan that is tailored to the changes that you wish to make in your life.

Suggested readings:

Coleman, E. (1995). Treatment of compulsive sexual behavior. In Rosen, R. C., &  Leiblum, S. R. (Eds.), Case Studies in Sex Therapy (pp. 333-349). New York, NY: Guilford Press.

Francis, A. (2013). Saving Normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. New York, NY: William Morrow.

Morin, J. (1995). The Erotic Mind: Unlocking the Inner Sources of Sexual Passion and Fulfillment. New York, NY: Harper Collins.

Moser, C. (1999). Health Care Without Shame: A Handbook for the Sexually Diverse and their Caregivers. San Francisco, CA: Greenery Press. 

Hall, K. (2007). Chapter 12: Sexual Dysfunction and Childhood Sexual Abuse. In  Leiblum, S., R. (Ed.). Principles and Practice of Sex Therapy (4th ed.). New York, NY: Guilford Press.

Joannides, P. (2012).  The challenging landscape of problematic sexual behaviors. In, Kleinplatz, P. (Ed.). New Directions in Sex Therapy: Innovations and Alternatives. (2nd Edition) (pp. 69-83). New York, NY: Routledge.

Ley, D., S. (2012). The Myth of Sex Addiction. Lanham, MD: Littlefield Publishing Group, Inc. 

Satel, S. & Lilienfield, S., O. (2013). Brainwashed: The seductive appeal of mindless neuroscience. New York, NY: Basic Books.

Online Educational Resources: 

Sexuality and Educational Council of The United States. http://www.siecus.org/

Planned Parenthood League of Massachusetts. http://www.plannedparenthood.org/ma/ 

Scarleteen: http://www.scarleteen.com/ 

Seniorsite: For the young at heart: http://www.seniorsite.com/sex/#.Uq3XeyiAd8s