Sexual addiction, also known as sex addiction, is a state characterized by compulsive participation or engagement in sexual activity, particularly sexual intercourse, despite negative consequences. Proponents of a diagnostic model for sexual addiction, as defined here, consider it one of several sex-related disorders within an umbrella concept known as hypersexual disorder. The term "sexual dependence" is also used to refer to people who report being unable to control their sexual urges, behaviors, or thoughts. Related models of pathological sexual behavior include hypersexuality (nymphomania and satyriasis), erotomania, Don Juanism (or Don Juanitaism), and paraphilia-related disorders.
The concept of sexual addiction is contentious. There is considerable debate amongst psychiatrists, psychologists, sexologists, and other specialists whether compulsive sexual behavior constitutes an addiction, and therefore its classification and possible diagnosis. As of 2017, sexual addiction is not a clinical diagnosis in either the DSM or ICD medical classifications of diseases and medical disorders. Some argue that applying such concepts to normal behaviors such as sex, can be problematic, and suggest that applying medical models such as addiction to human sexuality can serve to pathologise normal behavior and cause harm
Neuroscientists, pharmacologists, molecular biologists, and other researchers in related fields have identified the transcriptional and epigenetic mechanisms of addiction pathophysiology. Diagnostic models, which use the pharmacological model of addiction (this model associates addiction with drug-related concepts, particularly physical dependence, drug withdrawal, and drug tolerance), do not currently include diagnostic criteria to identify sexual addictions in a clinical setting. In the brain disease model of addiction, which uses neuropsychological concepts to characterize addictions, sexual addictions are identifiable and well-characterized. In this model, addictive drugs are those that both reinforce and reward. Addictive behaviors (those that can induce a compulsive state) are similarly identified and characterized by their rewarding and reinforcing properties.
Video Sexual addiction
Mechanisms
Current neuroscience research on compulsive sexual behavior indicates that it is well-characterized as an addiction and that it develops through the same biomolecular mechanisms that induce drug addictions. Sexual activity is an intrinsic reward that has been shown to act as a positive reinforcer, strongly activate the reward system, and induce the accumulation of ?FosB in part of the striatum (specifically, the nucleus accumbens). Chronic and excessive activation of certain pathways within the reward system and the accumulation of ?FosB in a specific group of neurons within the nucleus accumbens has been directly implicated in the development of the compulsive behavior that characterizes addiction.
In humans, a dopamine dysregulation syndrome, characterized by drug-induced compulsive engagement in sexual activity or gambling, has also been observed in some individuals taking dopaminergic medications. Current experimental models of addiction to natural rewards and drug reward demonstrate common alterations in gene expression in the mesocorticolimbic projection. ?FosB is the most significant gene transcription factor involved in addiction, since its viral or genetic overexpression in the nucleus accumbens is necessary and sufficient for most of the neural adaptations and plasticity that occur; it has been implicated in addictions to alcohol, cannabinoids, cocaine, nicotine, opioids, phenylcyclidine, and substituted amphetamines. ?JunD is the transcription factor that directly opposes ?FosB. Increases in nucleus accumbens ?JunD expression can reduce or, with a large increase, even block most of the neural alterations seen in chronic drug abuse (i.e., the alterations mediated by ?FosB).
?FosB also plays an important role in regulating behavioral responses to natural rewards, such as palatable food, sex, and exercise. Natural rewards, like drugs of abuse, induce ?FosB in the nucleus accumbens, and chronic acquisition of these rewards can result in a similar pathological addictive state. Thus, ?FosB is also the key transcription factor involved in addictions to natural rewards as well, and sex addictions in particular, since ?FosB in the nucleus accumbens is critical for the reinforcing effects of sexual reward. Research on the interaction between natural and drug rewards suggests that psychostimulants and sexual reward possess cross-sensitization effects and act on common biomolecular mechanisms of addiction-related neuroplasticity, which are mediated through ?FosB.
Maps Sexual addiction
Diagnosis
None of the official diagnostic classification frameworks list "sexual addiction" as a distinct disorder.
DSM
The American Psychiatric Association (APA) publishes and periodically updates the Diagnostic and Statistical Manual of Mental Disorders (DSM), a widely recognized compendium of mental health diagnostics.
The version published in 1987 (DSM-III-R), referred to "distress about a pattern of repeated sexual conquests or other forms of nonparaphilic sexual addiction, involving a succession of people who exist only as things to be used." The reference to sexual addiction was subsequently removed. The DSM-IV-TR, published in 2000 (DSM-IV-TR), did not include sexual addiction as a mental disorder.
Some authors suggested that sexual addiction should be re-introduced into the DSM system; however, sexual addiction was rejected for inclusion in the DSM-5, which was published in 2013. Darrel Regier, vice-chair of the DSM-5 task force, said that "[A]lthough 'hypersexuality' is a proposed new addition...[the phenomenon] was not at the point where we were ready to call it an addiction." The proposed diagnosis does not make the cut as an official diagnosis due to a lack of research into diagnostic criteria for compulsive sexual behavior, according to the APA.
ICD
The World Health Organization produces the International Classification of Diseases (ICD), which is not limited to mental disorders. The most recent version of that document, ICD-10, includes "excessive sexual drive" as a diagnosis (code F52.8), subdividing it into satyriasis (for males) and nymphomania (for females). However, the ICD categorises these diagnoses as compulsive behaviors or impulse control disorders and not addiction.
CCMD
The Chinese Society of Psychiatry produces the Chinese Classification of Mental Disorders (CCMD), which is currently in its third edition - the CCMD-3 does not include sexual addiction as a diagnosis.
Other diagnostic criteria
Some mental health providers have proposed various, but similar, criteria for diagnosing sexual addiction, including Patrick Carnes, and Aviel Goodman. Carnes authored the first clinical book about sex addiction in 1983, based on his own empirical research. His diagnostic model is still largely utilized by the thousands of certified sex addiction therapists (CSATs) trained by the organization he founded. No diagnostic proposal for sex addiction has been adopted into any official government diagnostic manual, however.
During the update of the Diagnostic and Statistical Manual to version 5 (DSM-5), the APA rejected two independent proposals for inclusion.
In 2011, the American Society of Addiction Medicine (ASAM), the largest medical consensus of physicians dedicated to treating and preventing addiction, redefined addiction as a chronic brain disorder, which for the first time broadened the definition of addiction from substances to include addictive behaviors and reward-seeking, such as gambling and sex.
Borderline personality disorder
The ICD, DSM and CCMD list promiscuity as a prevalent and problematic symptom for Borderline Personality Disorder. Individuals with this diagnosis sometimes engage in sexual behaviors that can appear out of control, distressing the individual or attracting negative reactions from others. There is therefore a risk that a person presenting with sex addiction, may in fact be suffering from Borderline Personality Disorder. This may lead to inappropriate or incomplete treatment.
Medical reviews and position statements
In November 2016, the American Association of Sexuality Educators, Counselors and Therapists (AASECT), the official body for sex and relationship therapy in the United States, issued a position statement on Sex Addiction that states that AASECT, "...does not find sufficient empirical evidence to support the classification of sex addiction or porn addiction as a mental health disorder, and does not find the sexual addiction training and treatment methods and educational pedagogies to be adequately informed by accurate human sexuality knowledge. Therefore, it is the position of AASECT that linking problems related to sexual urges, thoughts or behaviors to a porn/sexual addiction process cannot be advanced by AASECT as a standard of practice for sexuality education delivery, counseling or therapy."
In 2017, three new USA sexual health organizations found no support for the idea that sex or adult films were addictive in their position statement.
In November 16, 2017 the Association for the Treatment of Sexual Abusers (ATSA) published a position against sending sex offenders to sex addiction treatment facilities. Those centers argued that "illegal" behaviors were symptoms of sex addiction, which ATSA challenged they had no scientific evidence to support.
Treatment
Counselling
As of 2017, none of the official regulatory bodies for Psychosexual Counselling or Sex and Relationship therapy, have accepted sex addiction as a distinct entity with associated treatment protocols. Indeed, some practitioners regard sex addiction as a potentially harmful diagnosis and draw parallels with gay conversion therapy. As a result, treatment for sex addiction is more often provided by addiction professionals than psychosexual specialists.
Cognitive behavioral therapy is a common form of behavioral treatment for addictions and maladaptive behaviors in general. Dialectical behavior therapy has been shown to improve treatment outcomes as well. Certified Sex Addiction Therapists (CSAT) - a group of sexual addiction therapists certified by the International Institute for Trauma and Addiction Professionals - offer specialized behavioral therapy designed specifically for sexual addiction.
Support groups
Online support groups
NoFap is an online community founded in 2011. It serves as a support group for those who wish to avoid the use of pornography, masturbation, and/or sexual intercourse.
In-person support groups
In-person support groups are available in most of the developed world. None yet have any scientific evidence to support that they are helpful, so attend at your own risk. These groups include:
- Sex Addicts Anonymous: For those who want to reduce or eliminate their use of pornography, masturbation, and/or unwanted sexual activity.
- Sex and Love Addicts Anonymous: Similar to the above.
- Sexaholics Anonymous: For those who want to eliminate their use of pornography, masturbation, unwanted sexual activity, and/or sex outside of marriage. Has a stricter definition of sexual sobriety than its competitors.
- SMART Recovery.
In places where none of the above are available, open meetings of Alcoholics Anonymous or Narcotics Anonymous may be a second-best option.
Support groups may be useful for uninsured or under-insured individuals. (See also: Alcoholics Anonymous § Health-care costs.) They may also be useful as an adjunct to professional treatment. In addition, they may be useful in places where professional practices are full (i.e. not accepting new patients), scarce, or nonexistent, or where these practices have waiting lists. Finally, they may be useful for patients who are reluctant to spend money on professional treatment.
Medications
The term "pre-exposure prophylaxis" (PrEP) generally refers to the use of antiviral drugs to help prevent AIDS. PrEP is an optional treatment for people who are HIV-negative, but have a substantial risk of getting an HIV infection.
In the US, most insurance plans cover these drugs.
Sexual-addiction medications
Some medications can be useful specifically for sexual addiction. Alternatively, doctors can prescribe general-purpose medications that are useful for a variety of behavioral addictions.
General-purpose behavioral-addiction medications
Behavioral addiction is a treatable condition. Treatment options include psychotherapy and psychopharmacotherapy (i.e., medications) or a combination of both. Cognitive behavioral therapy (CBT) is the most common form of psychotherapy used in treating behavioral addictions; it focuses on identifying patterns that trigger compulsive behavior and making lifestyle changes to promote healthier behaviors. Currently, there are no medications approved for treatment of behavioral addictions in general, but some medications used for treatment of drug addiction may also be beneficial with specific behavioral addictions. Any unrelated psychiatric disorders should be kept under control, and differentiated from the contributing factors that cause the addiction.
Epidemiology
According to a systematic review from 2014, prevalence rates of sexual addiction and related sexual disorders ranges from 3% to 6%. Some studies suggest that sex addicts are disproportionately male, at 80%.
History
Sex addiction as a term first emerged in the mid-1970s when various members of Alcoholics Anonymous sought to apply the principles of 12-steps toward sexual recovery from serial infidelity and other unmanageable compulsive sex behaviors that were similar to the powerlessness and un-manageability they experienced with alcoholism. Multiple 12-step style self-help groups now exist for people who identify as sex addicts, including Sex Addicts Anonymous, Sexaholics Anonymous, Sex and Love Addicts Anonymous, and Sexual Compulsives Anonymous.
Society and culture
Controversy
The controversy surrounding sexual addiction is centered around its identification, through a diagnostic model, in a clinical setting. As noted in current medical literature reviews, compulsive sexual behavior has been observed in humans; drug-induced compulsive sexual behavior has also been noted clinically in some individuals taking dopaminergic drugs. Moreover, current medical research involving neuropsychological models has identified sexual addictions (i.e., the compulsive engagement in sexual behavior despite negative consequences) as a true form of addiction (i.e., it possesses all the necessary characteristics to classify it as one) in animal models. Since current diagnostic models use drug-related concepts as diagnostic criteria for addictions, these are ill-suited for modelling compulsive behaviors in a clinical setting. Consequently, diagnostic classification systems, such as the DSM, do not include sexual addiction as a diagnosis because there is currently "insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions needed to identify these behaviors as mental disorders". A 2014 systematic review on sexual addiction indicated that the "lack of empirical evidence on sexual addiction is the result of the disease's complete absence from versions of the Diagnostic and Statistical Manual of Mental Disorders."
There have been debates regarding the definition and existence of sexual addictions for decades, as the issue was covered in a 1994 journal article. According to a 2014 systematic review, sexual addiction (including excessive masturbation and pornography addiction) is a diagnosable behavioral addiction with estimable prevalence rates. The Mayo Clinic considers sexual addiction a form of obsessive compulsive disorder and refer to it as sexual compulsivity (note that by definition, an addiction is a compulsion toward rewarding stimuli). A paper dating back to 1988 and a journal comment letter published in 2006 asserted that sex addiction is itself a myth, a by-product of cultural and other influences. The 1988 paper argued that the condition is instead a way of projecting social stigma onto patients.
In a non-academic opinion report from 2003, Marty Klein, stated that "the concept of sex addiction provides an excellent example of a model that is both sex-negative and politically disastrous." Klein singled out a number of features that he considered crucial limitations of the sex addiction model and stated that the diagnostic criteria for sexual addiction are easy to find on the internet. Drawing on the Sexual Addiction Screening Test, he stated that "the sexual addiction diagnostic criteria make problems of nonproblematic experiences, and as a result pathologize a majority of people."
Popular culture
Sexual addiction has been the main theme in a variety of films including Diary of a Sex Addict, I Am a Sex Addict, Black Snake Moan, Confessions of a Porn Addict, Shame, Thanks for Sharing, Choke.
See also
- Compulsive masturbation
- Hypersexuality
- Internet sex addiction
- Pornography addiction
- Sexual obsessions
References
Further reading
Books that provide overview history and treatment techniques for sexual addiction include:
- Out of the Shadows: Understanding Sex Addiction by Patrick Carnes. (Hazelden, 1983) ISBN 978-1-56838-621-8
- Sex and Love Addicts Anonymous: The Basic Text for the Augustine Fellowship (Augustine Fellowship, 1986) ISBN 978-0-9615-7011-8
- Sex Lies and Forgiveness: Couples Speaking Out on Healing from Sex Addiction by Jennifer P. Schneider and Burt Schneider. (Recovery Resources Press, 1991) ISBN 978-0-06-255343-0
- Don't Call It Love: Recovery From Sexual Addiction by Bantam, Patrick Carnes. (1992) ISBN 978-0-553-35138-5
- Sex Addiction: Case Studies And Management by Ralph H. Earle and Marcus R. Earle. (Brunner/Mazel, 1995) ISBN 978-0-87630-785-4
- Sexual Addiction: An Integrated Approach by Aviel Goodman. (International Universities Press, 1998) ISBN 978-0-8236-6063-6
- The Drug of the New Millennium: The Science of how Internet Pornography Radically Alters the Human Brain and Body by Mark B. Kastleman. (Granite Publishing and Distribution, 2001) ISBN 1930980639
- Healing the Wounds of Sexual Addiction by Mark Laaser (Zondervan, 2004) ISBN 978-0-310-25657-1
- Lust, Anger, Love: Understanding Sexual Addiction and the Road to Healthy Intimacy by Maureen Canning. (Sourcebooks, 2008) ISBN 978-1-4022-0868-3
- Erotic Intelligence: Igniting Hot, Healthy Sex While in Recovery from Sex Addiction by Alexandra Katehakis. (Health Communications, 2010) ISBN 978-0-7573-1437-7
- Cruise Control: Understanding Sex Addiction in Gay Men by Robert Weiss. (Gentle Path Press, 2011) ISBN 978-1-4596-0844-3
- Breaking the Cycle: Free Yourself from Sex Addiction, Porn Obsession, and Shame by George N. Collins, Andrew Adleman. (New Harbinger Publications, 2011) ISBN 978-1-60882-083-2
- Making Advances: A Comprehensive Guide for Treating Female Sex and Love Addictions (SASH, 2012) ISBN 978-0-9857-4720-6
- Naked in Public: A Memoir of Recovery From Sex Addiction and Other Temporary Insanities] by Staci Sprout (Recontext Media, 2015) ISBN 978-0-9962-6681-9
Books focusing on partners of sex addicts:
- My Secret Life with a Sex Addict - from discovery to recovery by Emma Dawson. (Thornton Publishing, 2004) ISBN 978-1-932344-70-7
- Hope After Betrayal: Healing When Sexual Addiction Invades Your Marriage by Meg Wilson. (Kregel Publications, 2007) ISBN 978-0-8254-3935-3
- Deceived: Facing Sexual Betrayal Lies and Secrets by Claudia Black. (Hazelden, 2009) ISBN 978-1-59285-698-5
- Your Sexually Addicted Spouse: How Partners Can Cope and Heal by Barbara Steffens and Marsha Means. (New Horizon Press, 2009) ISBN 978-0-88282-309-6
- Mending a Shattered Heart: A Guide for Partners of Sex Addicts by Stefanie Carnes. (Gentle Path Press, 2011) ISBN 978-0-9774400-6-1
- Love You, Hate the Porn: Healing a Relationship Damaged by Virtual Infidelity by Mark Chamberlain. (Shadow Mountain; 2.7.2011 edition, 2011. ISBN 1606419366
- A Couple's Guide to Sexual Addiction: A Step-by-Step Plan to Rebuild Trust and Restore Intimacy by Paldrom Collins and George Collins. (Adams Media, 2011) ISBN 978-1-4405-1221-6
- Facing Heartbreak: Steps to Recovery for Partners of Sex Addicts by Stefanie Carnes. (Gentle Path Press, 2012) ISBN 978-0-98327-133-8
Discussions of the concept of sexual addiction:
- Masters, William H.; Johnson, Virginia E.; Kolodny, Robert C. (1995). "Chapter 17, the section "Sexual Addictions: Fact or Fad?"". Human Sexuality (5 ed.). Harper Collins Publishers. ISBN 9780673467850.
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