Compulsive sexual behavior is a rarely understood and usually stigmatized phenomenon. It is experienced by people of all genders and sexual orientations, and often involves a pattern of sexual obsessions and behaviors with the following characteristics:
- They continue despite their negative consequences (e.g., shame, isolation, lost relationships, legal or health issues).
- They typically increase in frequency, duration, intensity, or severity.
- They continue despite repeated attempts to stop.
- They are often used as a coping mechanism to deal with overwhelming emotions, negative and positive.
These patterns are sometimes connected to difficulties with emotional intimacy, which usually interferes with the capacity to trust and be vulnerable in relationships. Impaired relationships are oftentimes a cause and it is almost always a consequence.
Is it Sex Addiction?
Sex addiction is a relatively young and controversial field in the mental health community. It stirs passionate debates between clinicians, unfortunately not always helpful or productive. The way the term has been usually portrayed in the media has made this situation more confusing, and created more stigma around it.
The term “sex addiction” itself has pros and cons. On one hand, it offers people a way to understand and make sense of their patterns of behavior. It can also offer, through multiple self-help programs supporting sex addiction recovery, a community of peers who share similar experiences and are struggling with similar challenges.
On the other hand, some therapists believe that the term "addiction" is moralistic and can pathologize certain behaviors (i.e., whatever is not the "norm," sexually speaking), or be misused to label as “addicts" people with non-mainstream sexual preferences. Some of these therapists prefer to use the term "Out of Control Sexual Behavior," in order to describe and emphasize how the experience of these behaviors feels, without labeling as an "addiction" or a "disorder."
The term "compulsive sexual behavior" was recognized in 2018 by the International Classification of Diseases (ICD) as diagnosable mental health condition (they do not use the term "sex addiction" or "out of control sexual behavior"). One limitation of this term -and of diagnoses in general- is the emphasis on the nature of the behavior, which does not describe the different issues that might be behind.
Whether we call it sex addiction (SA), out of control sexual behavior (OCSB), compulsive sexual behavior (CSB), or something else, the fact of the matter is that many people are affected by it, living a double life, overwhelmed with shame and hopelessness, and making their lives and the lives of the ones they love unmanageable. What is behind these behaviors is usually pain, sadness, grief, or anger. Because of this, I think what is most important is not the term we use, but what is the pain underlying these issues, whether it is trauma in our family of origin, disconnection from or judgement toward our sexual preferences, or feeling that sex is the only way we can feel alive or validated.
It is not about sex
SA/OCSB/CSB is not about sex, but about the individual’s relationship with sex and with their own sexuality. It is not defined by specific behaviors, but by the relationship the person has with those behaviors. Common behaviors such as masturbation can generate a compulsive dependence, while less common preferences such as BDSM can be practiced in a healthy and trusting way.
Is someone who wants to have sex “all the time”, has an affair, or visits strip clubs a sex addict? Not necessarily. Is watching porn, having a foot fetish, wanting an open relationship, or having same-sex fantasies a sign that there is a problem? There might be a problem if these things create emotional distress, but that doesn’t mean that the problem is sex addiction but not having come to terms with parts of their own sexuality.
It is not about sexual assault
Because of the way it is portrayed in the media, some people might believe that "sex addiction" is only an excuse for people who have committed sexual assault. The fact that high-profile sexual offenders seek "sex addiction treatment" has the unfortunate result of conflating both issues, but they are not the same. Make no mistake: an addiction is never an excuse for criminal behavior. There is no cause-effect relationship between sex addiction and sex assault, even if many people are attached to the wrong idea that mental health issues cause criminal behavior.
Two types of issues
It is important to distinguish two types of SA/OCSB/CSB:
- Issues rooted in attachment and early trauma issues. This means that it is a response to patterns of neglect, rejection, lack of safety, inconsistency, or physical or emotional abandonment during childhood. In these cases, sex addiction is often rooted in traumatic experiences and could be considered an attachment disorder. We have a "relationship" with the addiction that serves a purpose, like self-soothing after an injury, avoiding fear or anxiety, or coping with fear of rejection (read more about addiction and relationships in this post and this paper). Therefore, the addiction is a symptom of deeper underlying issues, related to our conscious and unconscious views about ourselves and others. The specific behaviors involved can be very diverse, and may include anything from sexual fantasies and compulsive masturbation to pornography, to serial extramarital affairs, paying for sex, manipulating others for sex, or engaging in exhibitionistic behavior.
- In recent decades, with the advances of technology, many people have developed a compulsive, and sometimes exclusive, use of online pornography. While sexual imagery has been part of our culture for centuries, our brains are not prepared for the unprecedented overstimulation available online. For example, the amount, variety, and intensity of sexual acts that a person can watch in 10 minutes online, dramatically exceeds what a person could see in a lifetime only a couple of generations ago. When pornography overstimulates our brain, its chemistry changes in ways similar to other addictions, by “hijacking” the mechanisms that make us repeat pleasurable behaviors. This is a bigger problem when the person exposed to excessive porn is a child or a teenager, because their brain is still in development. As a result, it becomes more difficult to connect and engage sexually in real life, resulting in shame and intimacy issues. For our brains, real life is just no match for the "high" of porn.
What can be done?
Many people seek help for sex addiction when their life is in disarray. Their spouse found out about their multiple affairs, they lost their jobs for watching pornography at work, or were arrested for solicitation. Others are not in crisis, but feel tired of living a double life, don't understand why they can't stop certain behaviors, or just want to make changes in their life.
I do not think there is only one path to healing. For example, there are multiple 12-step programs (based on the principles of Alcoholics Anonymous) that help thousands of people around the world. They can be a great complement to psychotherapy, and provide a space for people to open up and connect with others who have similar experiences. That said, 12-step programs are not for everyone and are not always a necessary requirement to address these issues.
While the addiction is not defined by the behaviors themselves, these behaviors can be problematic. They usually create painful shame for the people who engage in them, and immense suffering for those who love them. Shame is a feeling that thrives in the darkness, so shedding light on it is a big part of the process. This needs to happen in a sex-positive environment, free of any moral judgements, open to the person's experiences, and attentive to their wishes, preferences, and vision for themselves.
The behaviors are usually the symptom of something else, so focusing on them can be necessary but it is not enough. It is equally important to address the underlying issues. These might include shame about our sexual preferences or behaviors, identity and orientation issues, unprocessed traumatic experiences, mistrust or fear of others, and difficulties with intimacy in relationships.
Therapy is not only about modifying certain behaviors. Treatment is also about understanding why the addictive behaviors became a way to cope with reality, becoming aware of the role they play in the our life, letting go of shame and hopelessness, and regaining our capacity to have intimate relationships. Recovery does not mean not having sex, or having only a specific kind of sex. The goal is to work through the relationship we have with sex and develop a lasting understanding and experience of healthy sexuality.