Rethink

Photo: Idea go

This topic seems to be timely. Every now and again some politician, celebrity or sportsman comes ‘clean’ and admits to have a ‘problem’. They say they cannot ‘control themselves’, are ‘addicted’, etc. Today’s article is going to consider the status of out-of-control sexual behaviour as sexual addiction.

Let’s start with a bit of introduction.

Sexual addiction refers to phenomenon in which individuals report being unable to manage their sexual behaviour and it is defined as any sexually-related, compulsive behaviour which interferes with normal living and social functioning. Sexual addiction has been called sexual dependency, sexual compulsivity and hypersexuality.

Regardless of the name, it is a compulsive behaviour that dominates the addict’s life. Sexual addicts make their behaviour a priority more important than family, friends, and work. Sex becomes the organizing principle of addict’s lives (Carnes, 1991).

Carnes (1983; 1991) as one of the pioneers in the area of sex addiction uses topology of Core Beliefs, as well as the four step cycle of addiction: preoccupation, ritualisation, compulsive sexual behaviour and despair, in order to describe sexual addiction. Whereas Goodman (2001) describes sexual addiction as sexual behaviour that produces pleasure but also great discomfort and it is characterised by reoccurring failure to control the behaviour, and inability to stop the behaviour despite serious consequences.

A vast amount of research and reviews has been conducted in the area, in order to officially identify the behaviour, as well as to investigate the behaviour itself. However, some argue that the sexual behavioural excess cannot be classed as addiction without external substance as a goal. Consequently, sex as addiction was removed from the DSM manual in the fourth edition.

Therefore due to the lack of clear criteria and diagnosis in the DSM-IV many researchers employed the criteria for substance abuse. Unfortunately, the confusion associated with defining the constructs associated with the disorder has greatly influenced the absence of effective scales in measuring the out-of-control behaviour (Giugliano, 2008). Other than employing Carnes’ (1983,1991) and Goodman’s (2001) ideas, much of the previous literature employed the 12-step disease model approach to addictive behaviour, best known through the Alcoholics Anonymous (Plant & Plant, 2003).

However, this view has received much criticism despite its powerfulness. Mainly due to the abstinence promise (imagine that!), as well as recognising own powerlessness and the religious implications (Greater Power/God).

Perhaps it is an impulse-control disorder that develops into an addiction?

Quite recently, Giulgilaino (2008) conducted a series of in-depth interviews with adult men who self-identified themselves as having out-of-control sexual behaviour problem. Qualitative research provided rich data that indicated that out-of-control behaviour could be most reasonably viewed as compulsive, impulsive or addictive/dependence (including tolerance and withdrawal symptoms). The participants have reported their behaviours to be to some degree spontaneous or impulsive earlier in their disorder. Even though the compulsivity of the behaviour did not fully fit into the DSM-IV description of compulsivity due to the reported feelings of pleasure, this still has been presumed a valid notion as the pleasure decreases with time and like impulsivity, is more characteristic earlier in the disorder. The tested men reported increase of intensity, frequency and levels of risk (tolerance symptoms), as well as withdrawal symptoms (anxiety and depression) due to cessation. The findings indicated that the out-of-control behaviour starts as an impulse-control disorder but later the behaviour develops into addictive disorder. The study provided support for Carnes’ (1991) and Wines’ (1997) research identifying problematic sexual behaviour as a disorder of sexual addiction/dependence.

However, the study had limitations such as small sample size and only interviewing males which prevented broad generalisations, however, the study gains it strength from extensive narrative data in the sufferers’ own words.

Perhaps it is an impulse-control disorder but not an addiction?

In support of the concept of out-of-control sexual behaviour as impulsive, Barth and Kinder (1987) disputed the notion of sexual addiction and compulsion, and argued that many labels assigned to the disorder were inaccurate in their description. Their support came from the fact that sexual impulsivity did not involve use of chemical substances and did not cause withdrawal symptoms to be pronounced an addiction. Barth and Kinder (1987) also rejected the notion of compulsion, as it was not consistent with the DSM-IV definition of compulsion as a ‘behaviour that does not provide pleasure or gratification’. It was assumed that the sexual behaviour was pleasurable (even if the feeling decreases over time) and therefore could not be classed as a compulsion (Barth & Kinder, 1987). In their review paper Barth and Kinder (1987) propose a notion that out-of-control sexual behaviour should be seen as atypical impulse control disorder rather than addiction.

Then again perhaps it is an addiction?

In favour of defining problematic sexual behaviour as addiction Plant and Plant (2003) argued that sex activates the same areas of the brain as those activated by psychoactive drugs. In their comparison review Plant and Plant (2003) stated that both sexual behaviour and drug use produce pleasure and also serve social, cultural and emotional purposes, and both can become problematic and involve some degree of compulsivity. Sex addiction is often associated with other problematic behaviours (Plant and Plant, 2003), Carnes (1983) reported his sex patients to also have other serious problems. Therefore, the types of activities in which people engage reflect not only their personal wellbeing or lack of it, in addition to social mores (Plant and Plant, 2003). This notion emphasises how important it is to understand aetiology of the sexual maladaptive behaviour, as well as underlying processes.

Are attachment issues at to core of the problem?

Study by Zapf et al. (2008) treats out-of-control sexual behaviour as addiction, and positively correlated the sexual addiction with insecure attachment style. The participants were tested on the Sexual Addiction Screening Test and the test of Experiences in Close Relationships Revised. The sexually addicted males were found to have high anxiety responses in their romantic relationships as well as high avoidance behaviours; these individuals may fear intimacy, be extremely needy of emotional intimacy, experience jealousy and even be unable to rely on their partners. This notion is of great importance in terms of treatment, as therapy should address not only the problematic sexual behaviour but also relationship problems.

However, again, there are limitations to this study, as Zapf et al. (2008) did not include any female participants in the research. It is of interest to study possible differences in out-of-control sexual behaviour between males and females. Yet, males seem to dominate the participant pool in sex addiction studies.

Are sex offenders addicted to sex?

Not likely. A case study by Eisenman (2001) of sex offenders has shown that sex offenders fulfil three out of four steps of sex addiction as identified by Carnes (1983), with despair not playing a role as no remorse was shown. Sex played disproportionate part in their life through thoughts and behaviour (preoccupation) providing support for Carnes (1983). Moreover the sex offenders have involved in ritualised behaviours; reported to feel powerless and could not control their compulsive behaviours, even when they knew it would be in their best interest,  therefore providing support for Goodman (2001). However, main criticism for the study stems from the fact that the sexual offenders used sex as tool to establish power and was anger driven. Therefore it cannot be established whether being a sex offender is equivalent to being a sex addict. Almost all of the studied sex offenders experienced sexual abuse during childhood, therefore once victims themselves, they were using sex to victimise others.

The notion of the four stages by Carnes (1983) had some usefulness in identifying the disorder but is not fully employable in case of sex offenders; the study also provided support for the compulsive nature of the addiction.

Bancroft and Vukadinovic (2004) suggested that there was no single aetiology that provided explanation for out-of-control sexual behaviours, therefore it was argued against the use of either addiction explanation or compulsion/obsession explanation as descriptors of the behaviour. Bancroft and Vukadinovic (2004) found various causations to the problematic or out-of-control sexual behaviour: affect (depression/anxiety), reduction, inhibition responses, neurobiological factors, self regulation, and motivational reward system. Even though Bancroft and Vukadinovic (2004) oppose against calling problematic sexual behaviour an addiction, it still was admitted that the use of addiction terminology and philosophy can prove greatly helpful in terms of treatment for struggling individuals.

Summary.

There are a few main views of out-of-control sexual behaviour: However, there is much of disagreement concerning the behaviour. The verdict whether problematic or out-of-control sexual behaviour is an addiction is influenced by the ideology, views on the nature of addiction and official identification in the DSM-IV rather than evidence. Perhaps it should be decided once and for all if it is an addiction or not and if not can it be classed as a disorder? If so what type etc. Clear and official guidelines would help clinicians and practitioners to correctly identify problematic behaviour and differentiate between patient’s promiscuity and out-of-control sexual behaviour. More in depth research may provide the much needed evidence to legitimise the disorder and include it in the future revision of the DSM.

Additionally, treatment needs to include its own assessment tools. As much as treatment models for substance abuse may prove helpful, it is essential to develop strategies and treatment plans specifically for individuals experiencing difficulty controlling sexual behaviour. Because of the complexity of human sexuality (Giugliano, 2008), sex if not abused is healthy and innate, and treatments designed for substance abuse may prove ineffective (especially the abstinence part).

In different individuals the behaviours have different meanings (Eisenman, 2001) and serve different purposes. The problematic behaviour has different, unique motivation and aetiologies. It is of great importance to study the history of each patient as well as consider subtypes of sexual addiction and other co-occurring issues.  Zapf et al. (2008) proposed to include the addict’s partner to study the addict’s behaviour. Finally, the study of out-of-control sexual behaviour would greatly benefit from investigating sexually addicted women, members of different ethnic groups as well as of various sexual orientations.

References:

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4^th ed). Washington, DC

Bancroft, J., & Vukadinovic, Z. (2004). Sexual addiction, sexual compulsivity, sexual impulsivity, or what? Toward a theoretical model. Journal of Sex Research, 41, 225-234.

Barth, R. J., & Kinder, B.N., (1987). The mislabelling of sexual impulsivity. Journal of Sex and Marital Therapy, 13, 15-23 .

Carnes, P. (1983). Out of the shadows: understanding sex addiction. Hazeldon, Center city: Minessota.

Carnes, P. (1991). Don’t call it love: Recovery from sexual addiction. New York: Bantom Books.

Eisenman, R., (2001). Sex Addicts: Do they really exist? Journal of Evolutionary Psychology, 2001.

Giugliano, J. R. (2008). Sexual Impulsivity, Compulsivity or Dependence: An Investigative Inquiry. Journal of Sexual Addiction & Compulsivity, 15, 139-157

Goodman, A. (2001). What’s in the name? Terminology foe designating syndrome of driven sexual behaviour. Journal of Sexual Addiction and Compulsivity , 8, 191-213.

Kinsey, A.C., Pomeroy, W.B., Martin, C.E. (1948). Sexual Behaviour in the Human Male, WB Saunders: Philadelphia

Kinsey, A.C., Pomeroy, W.B., Martin, C.E., Gebhart, P. H. (1953). Sexual Behaviour in the Human Female, WB Saunders: Philadelphia

Plant, M. & Plant, M. (2003). Sex addiction: a comparison with dependence on psychoactive drugs. Journal of Substance Use, 8, 260-266.

Wines, D. (1997). Exploring the applicability of criteria for substance dependence to sexual addiction. Sexual Addiction and Compulsivity, 4, 195-220.

Zapf, J. L., Greiner, J., Carroll, J., (2008). Attachment Styles and Male Sex Addiction. Sexual Addiction & Compulsivity, 15, 158-175.