What Causes Sexual Addiction
Do the roots of the addiction lie in abuse in genetics? In dysfunctional families? In sexual abuse? Does easy access to porn and illicit sexual encounters via internet result in a greater number of sex addicts?
We ask these questions, and we may never have any answers. For me, the real reason for asking is to try very hard to PREVENT my children from falling prey to this addiction.
I'm reprinting some excerpts from articles looking at this subject. You can click on the titles to read the full articles.
Michael Herkov, PH.D on PsychCentral.com
Genetic or biochemical abnormality?
Why some people, and not others, develop an addiction to sex is poorly understood. Possibly some biochemical abnormality or other brain changes increase risk. The fact that antidepressants and other psychotropic medications have proven effective in treating some people with sex addiction suggests that this might be the case. [WEBMASTER NOTE: I do not believe it is accurate to say that medications have been proven effective. It is being researched; it has not been proven.]
The Biochemical Rewards of Addiction
Studies indicate that food, abused drugs and sexual interests share a common pathway within our brains’ survival and reward systems. This pathway leads into the area of the brain responsible for our higher thinking, rational thought and judgment.
The brain tells the sex addict that having illicit sex is good the same way it tells others that food is good when they are hungry. These brain changes translate into a sex addict’s preoccupation with sex and exclusion of other interests, compulsive sexual behavior despite negative consequences and failed attempts to limit or terminate sexual behavior.
This biochemical model helps explain why competent, intelligent, goal-directed people can be so easily sidetracked by drugs and sex. The idea that, on a daily basis, a successful mother or father, doctor or businessperson can drop everything to think about sex, scheme about sex, identify sexual opportunities and take advantage of them seems unbelievable. How can this be?
The addicted brain fools the body by producing intense biochemical rewards for this self-destructive behavior.
People addicted to sex get a sense of euphoria from it that seems to go beyond that reported by most people. The sexual experience is not about intimacy. Addicts use sexual activity to seek pleasure, avoid unpleasant feelings or respond to outside stressors, such as work difficulties or interpersonal problems. This is not unlike how an alcoholic uses alcohol. In both instances, any reward gained from the experience soon gives way to guilt, remorse and promises to change.
Childhood Sexual Abuse
Research also has found that sex addicts are more likely than non-sex addicts to have been sexually abused. One study found that 82 percent of sex addicts reported being sexually abused as children.
Dysfunctional Families
Research has found that sex addicts often come from dysfunctional families. Sex addicts often describe their parents as rigid, distant and uncaring. These families, including the addicts themselves, are more likely to be substance abusers. One study found that 80 percent of recovering sex addicts report some type of addiction in their families of origin.
Personality Disorders
Not mentioned in Herkov's article is the role of personality disorders in sexual addiction. JoAnn mentions this on MarriedtoaSexAddict.com, stating, "Sex addiction has such complex roots it would take volumes to try to explain all the possibilities. I am dedicating an entire section of my eBook on Personality Disorders [to] the development of personality and Personality Disorders." Click here to go to her eBook page.
The following is excerpts from the report by Timothy W. Fong, MD. It is dated 2006, but is, in all, an interesting presentation. You can read the whole thing by clicking on the title above.
Compulsive sexual behavior, otherwise known as sexual addiction, is an emerging psychiatric disorder that has significant medical and psychiatric consequences. Until recently, very little empirical data existed to explain the biological, psychological, and social risk factors that contribute to this condition. In addition, clinical issues, such as the natural course and best practices on treating sexual addictions, have not been formalized. Despite this absence, the number of patients and communities requesting assistance with this problem remains significant. This article will review the clinical features of compulsive sexual behavior and will summarize the current evidence for psychological and pharmacological treatment.
...cultural changes have increased the acceptability and availability of sexual rewards. For some, though, this increase in availability has uncovered an inability to control sexual impulses resulting in continued engagement in these behaviors despite the creation of negative consequences—otherwise known as sexual addiction. This term has been used synonymously with others, such as compulsive sexual behaviors, hypersexuality, and excessive sexual desire disorder. It can take many forms, and although it may seem obvious to diagnose, standardized criteria have yet to be developed. Furthermore, debate is ongoing about where this behavioral pattern fits into the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV), and how it should be classified and conceptualized. Is it an addictive disorder, an impulse-control disorder, or a variant of obsessive compulsive disorders? Does it merit enough empirical evidence to stand alone as a separate disorder? Finally, what are the boundaries and limits that distinguish disease patterns, at-risk behaviors, and socially appropriate expression?
Compulsive sexual behavior has not yet received extensive attention from researchers and clinicians. To date, there have been very few formalized studies of compulsive sexual behaviors. As an example, a keyword search on PubMed, as of October, 2006, for “sexual addiction” yielded 518 articles, while “compulsive sexual behavior” yielded 264 (in comparison, “substance abuse” yields 164,104). Funding agencies, such as the National Institutes of Health (NIH), and pharmaceutical companies have not supported research into the etiology and mechanisms of compulsive sexual behavior and, as a result, evidenced-based treatments are limited. Despite the paucity of research, a significant number of patients with sexual addictions do present for treatment. This is evidenced by the number of treatment centers dedicated to the treatment of sexual addictions in both residential and intensive outpatient settings. Mental health professionals in any setting are likely to encounter patients with this hidden addiction and require better tools to diagnose and manage them. This article will review the terminology, the epidemiology, and the existing treatments that are currently available for compulsive sexual behaviors.
Defining Compulsive Sexual Behaviors
The DSM-IV currently does not list compulsive sexual behavior as a separate disorder with formal criteria. There are 12 listed sexual disorders and they are divided into disorders of sexual dysfunction, paraphilias, and gender identity disorder. Among these disorders, there is no mention of repetitive, continued sexual behaviors that cause clinical distress and impairment. In fact, the only place where compulsive sexual behaviors might be included is within the context of sexual disorder, not otherwise specified (NOS) or as part of a manic episode. In other words, hypersexuality, sexual addiction, or compulsive sexual behaviorsare terms that are not found within the DSM-IV.
Some of the reasons for why there is a lack of formalized criteria include the lack of research as well as an agreed-upon terminology. This is due, in part, to the heterogeneous presentation of compulsive sexual behaviors.4 For instance, some patients present with clinical features that resemble an addictive disorder—i.e., continued engagement in the behavior despite physical or psychological consequences, a loss of control, and a preoccupation with the behavior. Others will demonstrate elements of an impulse control disorder, namely reporting irresistible urges and impulses, both physically and mentally, to act out sexually without regard to the consequences. Finally, there are patients who demonstrate sexual obsessions and compulsions to act out sexually in a way that resembles obsessive compulsive disorders. They do so to quell anxiety and to minimize fears of harm. For these patients, the thoughts and urges to act out sexually are ego-dystonic, whereas other types of patients describe ego-syntonic feelings about their sexual behaviors.
One important feature to note is that hypersexuality is not necessarily symbolic or diagnostic of compulsive sexual behaviors. Libido and sexual drive can be seen as similar to other biological drives, such as sleep and appetite. States of hypersexuality induced by substances of abuse, mania, medications (e.g., dopamine agonists), or even other medical conditions (e.g., frontal-lobe tumors) can induce episodes of impulsive and excessive sexual behaviors. However, once those primary conditions are treated, the sexual behaviors return to normalcy in terms of frequency and intensity.
Clinical Features
Compulsive sexual behaviors can present in a variety of forms and degrees of severity, much like that of substance use disorders, mood disorders, or impulse-control disorders. Often, it may not be the primary reason for seeking treatment and the symptoms are not revealed unless inquired about. Despite the lack of formalized criteria, there are common clinical features that are typically seen in compulsive sexual behaviors.
One of the fundamental hallmarks of compulsive sexual behavior is continued engagement in sexual activities despite the negative consequences created by these activities. This is the same phenomenon seen in substance use and impulse control disorders. Psychologically, sexual behaviors serve to escape emotional or physical pain or are a way of dealing with life stressors.6 The irony is that the sexual behaviors becomes the primary way of coping and handling problems that, in turn, creates a cycle of more problems and increasing desperation, shame, and preoccupation.
Identifying a compulsive sexual disorder is a challenge because of its sensitive and personal nature. Unless patients present specifically for treatment of this disorder, they are not likely to discuss it.10 Much like other impulse control disorders, the physical and psychological signs of compulsive sexual behaviors are often subtle or hidden. Even signs of excessive sexual behaviors (such as physical injury to the genital area) or the presence of sexually transmitted diseases does not necessarily indicate compulsive sexual activity. Their presence does signal the need to screen for those behaviors but one cannot assume a compulsive sexual disorder exists based on physical examination alone.
Consequences of compulsive sexual behaviors can vary with some being similar to that seen in other addictive disorders while others are unique. Medically, patients are at a higher risk for sexually transmitted diseases (STDs) and for physical injuries due to repetitive sexual practices. Human immunodeficiency virus (HIV), Hepatitis B and C, syphilis, and gonorrhea are particularly concerning consequences.13,14Virtually unknown is the percentage of those individuals with STDs who meet criteria for compulsive sexual disorders.
Another significant consequence is the loss of time and productivity. It is not uncommon for patients to spend large amounts of time viewing pornography or cruising (also called mongering) for sexual gratification. Financial losses can mount quickly, and patients can accumulate several thousands of dollars of debt in a short amount of time. In addition, there is a long list of legal consequences, including arrest for solicitation and engaging in paraphilic acts that are illegal. One look at recent news headlines will likely reveal several stories focusing on illegal sexual activities or behaviors that jeopardize someone's livelihood or wellbeing.
The psychological consequences are numerous. Effects on the family and interpersonal relationships can be profound. Compulsive sexual behaviors can establish unhealthy and unrealistic expectations of what a satisfying sexual relationship should be. At the same time, the deception, secrecy, and violations of trust that occur with compulsive sexual behaviors may shatter intimacy and personal connections. The result is a warped view of intimacy that often leads to separation and divorce and, in turn, puts any future healthy relationship in doubt.
Finally, the shame and guilt that those with compulsive sexual behaviors experience is different from those with other addictive disorders. There are no substances of abuse to explain seemingly irrational behaviors. The stigma of not being able to control sexual impulses carries with it a connotation of depravity and moral selfishness. Stigmatization in the media and criminalization of “sexual offenders” creates an atmosphere that does not promote treatment and prevention. As a result, access to care and seeking care, even when one recognizes that sexual behaviors are out of control, is a decision faced with barriers and limitations.
Epidemiology
There have been no national studies documenting the past-year or lifetime prevalence of compulsive sexual behaviors in the general population. Regional and local surveys suggest that approximately five percent of the general population may meet criteria for a compulsive sexual disorder (using criteria that are similar to substance use disorders).7 Further replication of these data is needed but if true, these rates represent a significant percentage of the general population and would be higher than the rates for schizophrenia, bipolar disorder, and pathological gambling. One of the reasons why reliable epidemiological data are lacking is the inconsistency in defining criteria for compulsive sexual behaviors, lack of funding, and the lack of researchers committed to documenting the extent of this problem. Most of what is known about the epidemiological nature of this disorder comes from clinical treatment programs that focus on sexual addictions. Men appear to outnumber women with compulsive sexual behaviors. Comorbidities include substance use disorders and co-occurring impulse control disorders, and there is an association with histories of sexual abuse. Other significant epidemiological data is simply not known, such as the rate of compulsive sexual behaviors among prosecuted sex offenders or the rate among those who work within the adult entertainment industry.
Etiology
As with impulse control and substance use disorders, no single biological cause has yet been identified to explain the origins and maintenance of compulsive sexual behaviors. Neuroscience research, which would be an excellent approach to understand basic brain differences between those with and without compulsive sexual behaviors, has rarely been applied to this population. In particular, neuroimaging studies in patients with compulsive sexual behaviors would be interesting to compare with those involved in substance abuse and other behavioral addictions. To date though, most of the neuroimaging work has been done with nonclinical populations and has examined the biology of sexual arousal in healthy subjects.
Hypersexual behaviors have been reported in patients with frontal lobe lesion, tumors, and in those with neurological conditions that involve temporal lobes and midbrain areas such as seizure disorders, Huntington's disease, and dementia. Frontal lobe damage may trigger the expression of disinhibited behaviors, which could partially explain the increased sexual activity along with decreased control. Still, more investigation is needed to understand the specifics aberrances because there are certainly those individuals with frontal lobe injuries that do not experience the emergence of compulsive sexual behaviors.
Neurotransmitter studies in compulsive sexual behaviors have focused on the monoamines, namely serotonin, dopamine, and norepinephrine.21 Again, research in clinical populations is scant. Normal sexual functioning involves all of these monoamines as evidenced by selective serotonin reuptake inhibitor (SSRI)-induced sexual dysfunction and the increased sexuality observed among those on stimulants. Cases of hypersexual behavior have also been shown to be induced by medications for Parkinson's disease, implicating dopamine systems in compulsive sexual behaviors.22,23 What remains unclear is understanding how these perturbations in neurochemical functions differentiate compulsive sexual behaviors from those with hypersexuality alone without a negative life impact.
In addition to neurotransmitters, the sex hormones are obviously a critical component to sexual functioning. Testosterone levels have been correlated to sexual functioning but curiously, levels do not necessarily correlate to libido and sexual desires.24 The implication of these hormones in compulsive sexual behaviors is critical to understand. It may be that regions of reward and pleasure are modulated by these hormones through facilitating or enhancing the response to sex and the desire for sex.
Clinical Assessment Measures
There are existing screening instruments, which are only as valid as the responder's honesty and integrity. Although this is true of all psychiatric screening instruments, revealing sexual practices is probably the most humbling because of its private nature. Questions about time spent on sexual activities and impact of functioning are important clinically, but also rely on self-report. Patrick Carnes, one of the pioneers in the field of compulsive sexual behavior research, developed the Sexual Addiction Screening Test, which is a 25-item, self-report symptom checklist that can be used to identify those at risk to develop compulsive sexual behaviors. The Sexual Addiction Screening Test has also been modified for women and for internet sexual behaviors. Kafka has suggested a behavioral screening test (i.e., Total Sexual Outlet) in which a total of seven sexual orgasms per week, regardless of how they are achieved, could represent at-risk behavior and requires further clinical exploration.
Treatment: Psychosocial
Various types of psychosocial treatments are available for individuals suffering from compulsive sexual behaviors. The most widely available and accessible are Sexual Addicts Anonymous, Sex and Love Addicts Anonymous, and Sexaholics Anonymous. All three are modeled after 12-step theory and practice, and are available throughout the US. There is almost no data evaluating their efficacy or effectiveness. Nevertheless, participation in these groups is usually recommended because they provide a place for fellowship, support, structure, and accountability, and they are free of charge.
Inpatient and intensive outpatient treatment programs for compulsive sexual behaviors usually focus on helping to identify core triggers and beliefs about sexual addiction and to develop healthier choices and coping skills to minimize urges and deal with the preoccupation of sexual addiction.
Individual psychotherapy for compulsive sexual behaviors is varied but the two most common approaches are cognitive behavioral therapy (CBT) and psychodynamic psychotherapy. CBT in compulsive sexual behaviors borrows greatly from treatment with substance use disorders, focuses on identifying triggers to sexual behaviors and reshaping cognitive distortions about sexual behaviors (e.g., “I'm not really cheating on my spouse if I go to a massage parlor”), and emphasizes relapse prevention. Psychodynamic psychotherapy in compulsive sexual behaviors explores the core conflicts that drive dysfunctional sexual expression. Themes of shame, avoidance, anger, and impaired self-esteem and efficacy are common. Note that these types of therapy are not sex therapy, but individual therapy that focuses on reducing or controlling compulsive sexual behaviors.
Other forms of therapy may helpful, as well. For example, family therapy and couples therapy may restore trust, minimize shame/guilt, and establish a healthy sexual relationship between partners.
As for the assessment of treatment outcome, one of the unique difficulties in compulsive sexual behavior is determining when a patient has relapsed. Since there are no biological tests to indicate relapse, collateral history and functioning within the patient's significant relationship tends to be the most reliable markers. Despite the availability of psychosocial treatments, there are little data documenting treatment outcomes, success rates, predictors of treatment outcome.
Treatment: Pharmacotherapy
There are no US Food and Drug Administration (FDA)-approved medications for compulsive sexual behaviors. While preliminary case reports and open-label trials that have been conducted, no known randomized, double-blind placebo-controlled trials have been published.24 Various classes of medications have been tried, including antidepressants, mood stabilizers, antipsychotics, and antiandrogens. The rationales for these drugs are based on clinical phenomenology and symptoms seen in other disorders, such as substance use or obsessive compulsive disorders.
The Making of a Sex Addict
©1998 Patrick J. Carnes, PhD
Adapted from “The Obsessive Shadow,” 1998
Many readers may have also read “The Obsessive Shadow” by the author. This article is a revised and updated version of that one.
In the period from 1985 to 2003, a series of studies were performed, which gives us a profile of sex addicts. Six hundred fifty patients attended an addiction interaction workshop, which was designed to understand the patterns in the interaction of their compulsive behaviors. In order to conduct an appropriate assessment of these patients, professional helpers needed to be aware of how sex addicts come to be sex addicts, as well as of the objective criteria by which to evaluate them. Here, then, is how the data breaks down:
The Role of the Family
In studying these recovering patients and their partners, it was determined that sex addicts tended to come from families where there were addicts of all kinds. For example, mothers (25%), fathers (38%), and siblings (46%) had significant alcohol problems. Mothers (18%), fathers (38%), and siblings (50%) had similar problems with sexual acting out. Parallel patterns existed with eating disorders, pathological
gambling, and compulsive work. Only 13% of sex addicts reported coming from families with no addictions. So we know that growing up in a family with existing addictions is a factor.
Family type was also a factor. Sex addicts in the study experienced their families as rigid (77%), dogmatic, and inflexible. They also found their families to be disengaged (87%), i.e. detached, uninvolved, and emotionally absent. Thus, they came from environments in which failure to bond was the norm.
Another major area of impact was the role of child abuse. Addicts reported physical abuse (72%), sexual abuse (81%), and emotional abuse (97%). Furthermore, the more sexually and physically abused the respondents were as children, the more addictions they had as adults. Emotional abuse was a significant factor in addicts who abused children themselves.
Trauma and Sex Addiction
It is clear that for sex addicts, trauma or high stress and addiction are inextricably connected. Addiction in its various forms becomes a solution to the anxiety and stress of the trauma. In reviewing the literature and the reports of the research population, it was determined that eight different trauma responses are typically manifested by victims; and instrumentation called the Post Traumatic Stress Index was developed.
Following is a brief summary of each dimension of trauma. Percentages are those sex addicts who scored high in the category.
Trauma Reactions: Physiological/psychological alarm from unresolved trauma experiences (64%)
Trauma Pleasure: Seeking or finding pleasure in the presence of extreme danger, violence, risk, or shame (64%)
Trauma Blocking: Efforts to numb, block out, or overwhelm residual feelings due to trauma (69%)
Trauma Splitting: Blocking traumatic realities by splitting or dissociating from painful experiences and not integrating into personality or daily life (76%)
Trauma Abstinence: Compulsive deprivation that occurs especially around moments of success, high stress, shame, or anxiety (45%).
Trauma Shame: Profound sense of unworthiness and self-hatred rooted in traumatic experience (72%)
Trauma Repetition: Repeating behaviors and/or seeking situations or persons that re-create the trauma experience (69%)
Trauma Bonding: Dysfunctional attachments that occur in the presence of danger, shame, or exploitation (69%)
These early data point to a day when we will be able to correlate trauma profiles with patterns of dependent, compulsive and obsessive behaviors. Therapists will predictably see traumatic experiences as a factor in compulsive sexual behavior.
Sex Addiction Criteria
In keeping with the guidelines used to assess pathological gambling, alcoholism, and substance abuse, the following criteria for diagnosing sex addiction have been established:
Recurrent failure to resist sexual impulses to engage in specific sexual behavior;
Frequently engaging in those behaviors to a greater extent, or over a longer period of time, than intended;
Persistent desire or unsuccessful efforts to stop, reduce, or control those behaviors;
Inordinate amounts of time spent in obtaining sex, being sexual, or recovering from sexual experiences;
Preoccupation with sexual behavior or preparatory activities;
Frequent engaging in the behavior when expected to fulfill occupational, academic, domestic, or social obligations.
Continuation of the behavior despite knowledge of having a persistent or recurrent social, financial, psychological or physical problem that is caused or exacerbated by the behavior.
Need to increase the intensity, frequency, number, or risk level of behaviors to achieve the desired effect; or diminished effect with continued behaviors at the same level of intensity, frequency, number, or risk.
Giving up or limiting social, occupational, or recreational activities because of the behavior.
Distress, anxiety, restlessness, or irritability if unable to engage in the behavior.
In a research study that David Wines conducted on recovering sex addicts, 85% of his subjects met at least five of the criteria and 52% met seven or more. In the American Psychiatric Association’s Diagnostic and Statistical Manual, only three criteria must be met in order to quality for compulsive gambling or substance abuse. Thus, we are beginning to see an emerging profile of diagnosis in the field of sex addiction.
Sexual Behaviors
While the process of addiction is common for all those with sexual compulsion, the focus of the behaviors will vary. Through a series of studies using hundreds of specific behaviors, we found that certain behaviors emerged that were commonly found together. These are:
Fantasy Sex: Becoming lost in sexual obsession and intrigue, including behaviors that support preoccupation, such as stalking, compulsive masturbation, or being a “romance junkie”
Voyeurism: Visually-oriented behaviors, including pornography, strip shows, and peeping
Exhibitionism: Exposing oneself inappropriate or in self-destructive ways
Seductive Role Sex: Serial or concurrent exploitation of relationships, usually in pursuit of power and conquest
Intrusive Sex: Violating boundaries as a high arousal experience, such as obscene phone calls or frotteurism
Anonymous Sex: Compulsive sex, often in high-risk circumstances, with people one does not know
Trading Sex: Using sex as part of a business transaction. This is addictive because of the risk, cost, or repetition of early trauma.
Paying for Sex: Purchasing sex as in compulsive prostitution or phone sex services
Pain Exchange: Sex that is most pleasurable when one is hurt physically and diminished personally
Exploitive Sex: Serious sexual misconduct at the expense of vulnerable persons.
Addiction Interaction Disorder
In studies conducted by the author, many facts have been discovered:
Less than 13% of addicts have only one addiction
Sustained recovery is more successful when all addictions present are addressed
Addictions do not merely coexist, but actually interact with each other. Furthermore, there are ten dimensions in which addictions impacted or in some way related to one another. They are:
Cross tolerance: a simultaneous increase in addictive behavior in two or more addictions
Withdrawal mediation: one addiction serves to moderate, relieve, or avoid physical withdrawal from another.
Replacement: one addiction replaces another with a majority of the emotional and behavioral features of the first.
Alternating Addiction Cycles: addictions cycle back and forth in a patterned systemic way.
Masking: An addict uses one addiction to cover up for another, perhaps more substantive addiction.
Ritualizing: Addictive rituals of behavior of one addiction serves as a ritual pattern to engage another addiction
ntensification: One addiction is used to accelerate, augment or refine the other addiction through simultaneous use
Numbing: An addiction is used to medicate shame or pain caused by other addiction or addictive binging.
Disinhibiting: One addiction is used frequently to chronically lower inhibitions for other forms of acting out.
Combining: Addictive behaviors are used to achieve certain effects that can only be achieved in combination.
