Addictive Sexual Behaviors

sexual problems

Addictive Sexual Disorders: Differential Diagnosis and Treatment
Jennifer P. Schneider, MD, PhD, and Richard Irons, MD

Educational Objectives:
Visualize where addictive sexual disorders fit into the DSM-IV.
Obtain an overview of the spectrum of addictive sexual disorders.
Understand the principles of treatment of sex addiction and have access to resources for recovery.

Introduction: Patients who present with excessive and/or unusual sexual urges or behaviors are often a source of confusion to clinicians. In some cases, the diagnosis appears clear-cut: The young man who has a history of arrests for exposing his genitals to unsuspecting strangers has a paraphilia known as exhibitionism (pp525); a young woman's obsessive, intrusive, and very disturbing sexual thoughts may be one aspect of her obsessive-compulsive disorder (pp417); the 70-year-old nursing home patient who gropes any female staff member who gets within touching distance may be exhibiting a loss of judgment secondary to his Alzheimers disease (pp139); and another hypersexual patient exhibits pressured speech and grandiosity typical of the manic phase of bipolar type I or II psychosis. (pp356)

In a larger number of cases, the etiology is less obvious, and therefore the therapeutic approach is less clear. Some examples are: The computer programmer whose job and marriage suffer because he spends many hours daily viewing internet pornography and communicating online with women who have similar interests; the married woman who has multiple affairs despite her fears that the marriage will end; the gay man who has had thousands of anonymous sexual encounters in restrooms and parks with other menusually without giving any thought to "safe sex" practices until panic sets in after the encounter is over; the clinician who uses his professional practice to engage in sexual encounters with women; and the isolated consumer of home and bookstore pornography whose multiple daily episodes of masturbation have cost him excessive time, money, and injuries to his genitalia.

To complicate the picture, many people who engage in excessive sexual behavior are also pathologically indulgent in other behaviors and activities.

1. They are most commonly found to have a concurrent substance use disorder, such as alcohol dependence, an impulse control disorder such as pathological gambling, or an eating disorder.

2 The majority of people with cocaine dependence engage in compulsive sexual behavior as part of their cocaine-using lifestyle.

3 Professionals who treat chemical dependency are learning that in order to avoid relapse in chemical use among recovering addicts, all compulsive behaviors must be identified and addressed. Assessment and treatment of addictive sexual behaviors must be an integral part of chemical dependency treatment.

The goal of this article is to help the psychiatrist and the primary care physician to understand the various disease processes underlying excessive sexual behaviors and to understand the various treatment approaches which are helpful. Slide #PP4:16

Differential Diagnosis of Excessive Sexual Behaviors
Common
- Paraphilias
- Sexual disorder NOS
- Impulse control disorder NOS
- Bipolar disorder (I or II)
- Cyclothymic disorder
- Posttraumatic stress disorder
- Adjustment disorder [disturbance of conduct]

Source: Schneider JP, Irons RR. Sexual Addiction Compulsivity. 1996; 3:721.
Schneider JP, Irons RR. Primary Psychiatry. Vol. 5. No. 4. 1998.
Slide #PP4:17

Differential Diagnosis of Excessive Sexual Behaviors

Infrequent
- Substance-induced anxiety disorder [obsessive-compulsive symptoms]
- Substance-induced mood disorder [manic features]
- Dissociative disorder
- Delusional disorder [erotomania]
- Obsessive-compulsive disorders
- Gender identity disorder
- Delirium, dementia, or other cognitive disorder
Source: Schneider JP, Irons RR. Sexual Addiction Compulsivity. 1996; 3:721.
Schneider JP, Irons RR. Primary Psychiatry. Vol. 5. No. 4. 1998.

Differential Diagnosis of Addictive Sexual Disorders
The most common types of excessive sexual behaviors can be classified into three Axis I categories: paraphilias, impulse control disorder Not Otherwise Specified (NOS), or sexual disorder NOS. The paraphilias are characterized by recurrent, intense sexual urges, fantasies, or behaviors that involve unusual objects (such as animals or inanimate objects), activities or situations (for example, involving nonconsenting persons, including children, or causing humiliation or suffering). For some individuals, paraphilic fantasies or stimuli are essential for erotic arousal and are always part of sexual activity; in other cases, the paraphilic preferences occur only episodically. In contrast to sexual dysfunctions, which are associated with decreases in sexual functioning, the paraphilias are commonly associated with increases in sexual activity, often with compulsive and/or impulsive features.

While some cases of sexual excess represent impulse-control disorders, many others cannot be classified as either paraphilias or impulse-control disorders. If they cause distress to the person, they can be diagnosed as Sexual Disorder NOS. Many of these cases can be considered as addictive disorders.

The essential features of all substance use disorders are behavioral, consisting of: (1) loss of control
(2) preoccupation, and
(3) continuation despite adverse consequences.

These same criteria can be applied to excessive behaviors such as excessive sexual behaviors, compulsive overeating, and pathological gambling. This analysis suggests that an addiction-sensitive treatment model might be effective in treating disorders of excess involving sex, food, and gambling.

(4) Other psychiatric disorders can also be associated with sexual excesses.

In addition, Axis II characterological disorders (eg, antisocial personality disorder, narcissistic personality disorder) are often contributory, or may be the primary cause of paraphiliac or nonparaphiliac excessive sexual behavior. The frequent and infrequent Diagnostic and Statistical Manual of Mental Disorders Axis I diagnoses associated with sexual excesses are presented in (PP4:16,17).5

The word "excessive," as used in this article, does not specify a particular quantity, frequency, or type of sexual behavior. Rather, what makes these behaviors addictive disorders is that the patient has expended much time and mental energy in connection with the behavior, and has incurred distressing life consequences as a result of the behavior yet has been unable to stop.

Among 1,000 patients admitted for inpatient treatment of addictive sexual disorders, Carnes2 discerned 10 patterns of behavior, summarized in (PP4:18). Five of the categories covered in (PP4:18) constitute specific DSM-IV paraphilias: voyeuristic sex, exhibitionistic sex, pain exchange (sexual sadism, sexual masochism), some types of intrusive sex (frotteurism), and exploitative sex (pedophilia).

Four of the remaining categories may be correlated with paraphilias as follows:

1. fantasy sex may be associated with paraphiliac urges not acted upon;
2. anonymous sex may be used to permit expression of paraphiliac behavior with decreased risk of consequences; and
3. paying for sex and
4. trading sex are means by which a partner who may permit paraphiliac activities may be purchased.

Whether the specific pattern is diagnosed as paraphiliac or nonparaphiliac, its compulsive nature often leads to a failure of traditional psychotherapeutic techniques to cure it, and success with addiction-based approaches.

Gender Differences
Significant gender differences have been observed in the prevalence of various patterns of addictive sexual behaviors.

(6) Men tend to engage in behavioral excesses that objectify their partners and require little emotional involvement (voyeuristic sex, paying for sex, anonymous sex, and exploitative sex). A trend toward emotional isolation is clear. Women tend to be excessive in behaviors that distort power either by gaining control over others or being a victim (fantasy sex, seductive role sex, trading sex, and pain exchange).

Women sex addicts use sex for power, control, and attention. 6,7

Case 1: A 34-year-old woman from a rigidly religious family married an alcoholic. After 2 years of marriage, she became involved in the first of many extramarital affairs. To avoid detection by her husband, she withdrew from him emotionally and neglected the marital relationship. She recognized that she was not spending enough time with her children, but felt powerless to change. Despite feelings of guilt, she did not seek help until she cheated on her new lover. Slide #PP4:18

Patterns of Addictive Sexual Behaviors

1. Fantasy sex: Person is obsessed with a sexual fantasy life. Fantasy and obsession are all-consuming.
2. Seductive role sex: Seduction and conquest are the key. Multiple relationships, affairs, and/or unsuccessful serial relationships are present.
3. Anonymous sex: Engaging in sex with anonymous partners, or having one-night stands.
4. Paying for sex: Paying for prostitutes or for sexually explicit phone calls.
5. Trading sex: Receiving money or drugs for sex or using sex as a business.
6. Voyeuristic sex: Visual sex: Use of pornographic pictures in books, magazines, computer, pornographic films, peep-shope. Window-peeping and secret observation. Highly correlated with excessive masturbation, even to the point of injury.
7. Exhibitionistic sex: Exposing oneself in public places or from the home or car; wearing clothes designed to expose.
8. Intrusive sex: Touching others without permission. Use of position or power (eg, religious, professional) to sexually exploit another person.
9. Pain exchange: Causing or receiving pain to enhance sexual pleasure.
10. Exploitative sex: Use of force or vulnerable partner to gain sexual access. Sex with children.

Source: Carnes PJ. Don't Call it Love: Recovery from Sexual Addiction. New York, NY: Bantam Books. 1991;35:42- ­44.
Schneider JP, Irons RR. Primary Psychiatry. Vol. 5. No. 4. 1998.

Multiple Addictions
Addictive disorders tend to coexist. Nicotine dependency, for example, is highly correlated with alcohol dependence. The same is true of sex and drugs. Addictive sexual disorders often coexist with substance-use disorders and are frequently an unrecognized cause of relapse. In an anonymous survey of 75 self-identified sex addicts,9 39% were also recovering from chemical dependency and 32% had an eating disorder. In another study,3 70% of cocaine addicts entering an outpatient treatment program were also found to be engaging in compulsive sex. In Irons and Schneiders8 population of health professionals assessed for sexual impropriety, those with addictive sexual disorders were almost twice as likely to have concurrent chemical dependency (38% prevalence) as those who were not sexually addicted (21%). Thus, the presence of sexual compulsivity was a comorbid marker for chemical dependency.

Case 2: A 40-year-old physician was actively involved in Alcoholics Anonymous and appeared to be doing well until the day he did not appear at work and was found at home, intoxicated and suicidal. He explained to his therapist that drinking was not the real problemhe had been engaging in anonymous unsafe sex with men in public restrooms, and could not stop. He felt such fear and anguish that his only options seemed to be suicide or drinking; he chose alcohol. Sexual issues had not been addressed during his prior inpatient treatment for alcoholism.10

Professional Sexual Exploitation
Sexual contact between a helping professional (eg, physician, counselor, or minister) and their patients or clients is condemned by professional organizations and licensing bodies, and is considered to be sexual exploitation.

Professionals may be sexually exploitative on the basis of

1. naivety and lack of knowledge of appropriate boundaries,
2. circumstances which for a time increase the professionals vulnerability,
3. the presence of one or more Axis I addictive disorders, or
4. the presence of Axis I mental illness or Axis II character pathology such as antisocial personality disorder. In many cases, the professional has a repetitive pattern of sexual exploitation of clients, and actually has an addictive sexual disorder.

Irons and Schneider reported the results of an intensive inpatient assessment of 137 health care professionals referred because of allegations of personal or professional sexual impropriety. After assessment, half (54%) were found to have a sexual disorder NOS with addictive features (ie, to be sexually addicted). Two thirds (66%) of the entire group were found to have engaged in professional sexual exploitation, and of this subpopulation, two thirds (66%) were sexually addicted. Thus, addictive sexual disorders are a common feature of sex offending by professionals. In addition, 31% of the entire group was incidentally found to be chemically dependenta condition for which many had not previously been treated.

Case 3: A 52-year-old married minister had a long history of sexual involvement with female parishioners who came to him for counseling. His family relationships were distant, because he was often away from home in the evenings "counseling" rather than spending time with his family. After several women came forward with their stories, the minister was fired, evicted from his church-owned house, and publicly humiliated. He resigned from his ministerial duties and changed his profession.

Table 1: Twelve-Step Program for Sex Addiction
For the Addict
Sexaholics Anonymous (SA). P.O. Box 111910,Nashville, TN 37222-6910, (615) 331-6230

Sex Addicts Anonymous (SAA), P.O. Box 70949, Houston, TX 77270, (713) 869-4902

Sex and Love Addicts Anonymous (SLAA)
P.O. Box 119, New Town Branch, Boston, MA 02258, (617) 332-1845
For the Partner
S-Anon, P.O. Box 111242, Nashville, TN 37222-1242, (615) 833-3152

Codependents of Sex Addicts (CoSA)
9337 B Katy Fwy #142, Houston, TX 77204, (612) 537-6904
For Couples
Recovering Couples Anonymous, P.O. Box 11872, St. Louis, MO 63105, (314) 830-2600

Professionals and interested patients can also write for information to:
National Council on Sexual Addiction and Compulsivity (NCSAC)
1090 S. Northchase Parkway, Suite 200 South, Atlanta, GA 30067, e-mail: ncsac@mindspring.com
website: http://www.ncsac.org

Source: Irons RR, Schneider JP. Addictive sexual disorders. In: Miller NS, ed. Principles and Practice of Addictions in Psychiatry. Philadelphia, Pa: Saunders; 1997:441-457.
Schneider JP, Irons RR. Primary Psychiatry. Vol. 5. No. 4. 1998.

Treatment
Unlike the goal in treatment of substance use disorders, which is abstinence from use of all psychoactive substances, the therapeutic goal for sex addicts is abstinence only from compulsive sexual behavior. The counselor can help the client identify which sexual behaviors are best avoided. For many sex addicts, masturbation is analogous to the "first drink" which can lead to relapse. Some recovering sex addicts can eventually resume this practice if they restrict their sexual fantasies to "healthy" themes, whereas others must continue to avoid it.

Because sex addicts were often sexually abused as children (83% according to Carnes2), and because they have distorted ideas about sex, they frequently lack information about healthy sexuality. Education about this subject is highly desirable. In the early recovery period, sex addicts and their partners frequently have sexual difficulties, often to a greater degree than during the active addiction phase. Therapists can provide reassurance during this phase. If the compulsive sexual behavior was same-sex, as is surprisingly common even among men who identify themselves as heterosexual,9 therapists can help patients work through issues of sexual identity.

Group therapy is the cornerstone of sex addiction treatment. Shame, a major issue for sex addicts, is often addressed best in group therapy, where other recovering addicts can provide both support and confrontation. Education about sex addiction is a major component of all treatment programs.7,12,13,14

For patients who are suicidal or have other comorbid psychiatric or addictive disorders, or who are unable to recover in an outpatient setting, several inpatient treatment programs are available in the United States. Most are located in hospitals that also treat substance use disorders. Increasingly, treatment programs for substance use disorders are now assessing for the presence of sex addiction and other addictive disorders, and are either treating the problem themselves or referring out for such treatment.

Because a large percentage of people with addictive sexual disorders are also chemically dependent, the initial decision often facing a treatment professional is which addiction to treat first. By the time sex addicts seek help for this disorder, many are already in recovery from their substance dependence. If not regardless of which addiction is primary the drug dependence must be treated first if sex addiction treatment is to succeed.

The 12 steps of Alcoholics Anonymous have been adapted for use in programs for eating disorders, compulsive gambling, sexual addiction, and other addictions. For those with addictive sexual disorders, attendance at a program dealing with sexual addiction is highly recommended. Several fellowships have evolved, which differ primarily in their definitions of "sexual sobriety." Programs modeled after Al-Anon (the mutual-help program for families and friends of alcoholics) are also available, and attendance by spouses of sex addicts can be very helpful both for the spouse and for the relationship. The two major fellowships have no significant differences. Group support can be a powerful tool for overcoming the shame that most sex addicts and their partners feel. For information about the nearest meetings available in the United States and Canada, contact the fellowships listed in Table 1.

In cases of professional sexual exploitation, it is important to have a thorough assessment to determine the cause. Some exploitative professionals have a better prognosis than others for return to professional practice. In contrast to those who exploit primarily as an expression of an Axis II characterological disorder, sexually addicted professionals who have successfully completed comprehensive assessment and primary treatment can often return to work without compromising public health and safety. Irons11 devised a set of proposed contractual provisions for reentry. Such a contract can be part of a binding legal stipulation between the professional and a state professional licensing board and can define a standard of care for potentially impaired health care professionals.

Conclusion
Addictive sexual disorders have distinct parallels with other addictive disorders. They commonly coexist with substance-related disorders, may themselves have features associated with addiction, and may respond to an addiction model of treatment and therapy. Unrecognized and untreated symptoms of these sexual disorders are significant factors that lead to a return to substance use in substance-related disorders. Compulsive sexual behavior has significantly contributed to the growth of the current epidemic of acquired immunodeficiency syndrome. A more detailed discussion of diagnostic and treatment issues and resources may be found in our chapter in a recently published addiction psychiatry textbook.5

next: Four Perspectives on Sex Problems

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association. 1994.

Carnes PJ. Don't Call it Love: Recovery from Sexual Addiction. New York, NY: Bantam Books. 1991; 35:42-44.

Washton AM. Cocaine may trigger sexual compulsivity. US J Drug Alcohol Depend. 1989;149:1690-2685.

Schneider J, Irons R. Treatment of gambling, eating, and sex addictions. In: Miller NS, Gold MS, Smith DE, eds. Manual of Therapeutics for Addictions. New York, NY: John Wiley Sons. 1997:225-245.

Irons RR, Schneider JP. Addictive sexual disorders. In: Miller NS, ed. Principles and Practice of Addictions in Psychiatry. Philadelphia, PA: Saunders; 1997:441-457.

Carnes P, Nonemaker D, Skilling N. Gender differences in normal and sexually addicted populations. Am J Prev Psychiatr Neurol. 1991;3:16-23.
Kasl CD. Women, Sex, and Addiction. New York, NY: Ticknor Fields. 1989.

Irons RR, Schneider JP. Sexual addiction: significant factor in sexual exploitation by health care professionals. Sexual Addiction Compulsivity. 1994;1:198-214.

Schneider JP, Schneider BH. Sex, Lies, and Forgiveness: Couples Speak on Healing from Sex Addiction. Center City, Minn: Hazelden Educational Materials; 1991:17.

Schneider JP. How to recognize the signs of sexual addiction. Postgrad Med. 1991;90:171-182.

Irons RR. Sexually addicted professionals: contractual provisions for re-entry. American Journal of Preventive Psychiatry Neurology. 1991;307:57-59.

Carnes, PJ. Out of the Shadows: Understanding Sexual Addiction. Minneapolis, Minn: CompCare Publications; 1983.

Schneider JP. Back From Betrayal: Recovering From His Affairs. New York, NY: Ballantine;1988.

Earle R, Crow G. Lonely All the Time. New York, NY: Pocket Books;1989.

next: Four Perspectives on Sex Problems