Problematic 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 compulsive behaviors that usually have 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.
There is no need to label
There are different ways in which people refer to problematic or compulsive sexual behavior; some of these ways remain controversial in the mental health community. The way that this type of issue is usually portrayed in the media has made this situation more confusing, and created more stigma around it.
Different terms have pros and cons. Some labels (such as “sex addiction”) can offer people a way to understand and make sense of their patterns of behavior, but they can also feel moralistic, sex-negative, and pathologizing of whatever falls outside of social norms. Some therapists prefer to use the term "Out of Control Sexual Behavior," in order to describe and emphasize how the experience of these behaviors feels. The term "compulsive sexual behavior" was recognized in 2018 by the International Classification of Diseases (ICD) as diagnosable mental health condition. One limitation of this term is the emphasis on the nature of the behavior, which does not describe the different issues that might be behind.
Regardless of how we call it, 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, 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
Problematic sexual behavior is rarely sex, but about the individual’s relationship with sex and the meaning that sex has (consciously and unconsciously) in a person’s life. 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.
Does someone who wants to have sex “all the time”, has an affair, or visits strip clubs someone with a “disorder”? Is watching porn, having a foot fetish, wanting an open relationship, or having same-sex fantasies a sign that there is a problem? At best, the answer is “it depends.” The behaviors themselves might not be problematic, but we might feel there is a problem if these things create emotional, psychological, or relational distress. Instead of judging the behaviors, however, what matters is to understand the meaning that they have and the reason behind the feelings they trigger.
Why does it happen?
Everyone is different, our experiences are unique, and the meaning we give to them is very specific. Our relationship with sex and sexuality is extremely complex, and it involves characteristics of our upbringing, our earlier attachments, what and how we learned about sex, possible traumatic experiences, our feelings towards emotional intimacy, among many other things.
Sometimes, problematic sexual behavior develops as a result of chronic complex trauma, including experiences of neglect, rejection, lack of safety, inconsistency, or physical or emotional abandonment during childhood. We develop a "relationship" with our sexuality and our behaviors that serves a purpose, like self-soothing after an injury, avoiding fear or anxiety, coping with fear of rejection, re-establish a sense of self-worth, feel powerful to counteract feelings of powerlessness, etc.
Trauma may or may not be part of the causes of problematic sexual behavior, but one thing remains true: those behaviors are but a symptom of deeper underlying issues, related to our conscious and unconscious views about ourselves and others. Unless we understand, make sense, and address what is at the root, we won’t be addressing the real issue. 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.
Some researchers suggest that some people have developed a compulsive, and sometimes exclusive, use of online pornography as a result of the unprecedented overstimulation available online, anywhere, anytime. For example, the amount, variety, and intensity of sexual acts that a person can watch in 10 minutes online, dramatically exceeds the amount of porn a person would see in a lifetime only a couple of generations ago. When pornography overstimulates our brain’s capacity, its chemistry might change by “hijacking” the mechanisms that make us repeat (and stop) pleasurable behaviors. This is a bigger problem when we’re younger, because our brains are still in development. Real life is just no match for the "high" of porn.
How can Fermata Psychotherapy help?
Many people seek help for problematic sexual behavior when their life is in disarray. Their spouse found out, they lost their jobs, or got in legal problems. 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 to the experience of their own sexuality.
There is not only one path to working through these issues. Depending on how the problem is conceptualized, there might be different alternatives (for example, peer support programs based on the 12 steps) that can be a complement to psychotherapy, and provide a space for people to open up and connect with others who have similar experiences. That said, there is not one “program” that is for everyone and is a necessary requirement to address these issues.
Problematic sexual behaviors usually trigger painful shame for the people who engage in 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 generally 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.
Our belief is that therapy is not only about modifying behaviors. Treatment is also about understanding why the behaviors became a way to cope with reality, becoming aware of the role they play in 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.
Banner photo credit: Matteo Vistocco