Addiction has been defined as a condition in which a behavior that can function both to produce pleasure and to reduce painful affects is used in a pattern that is characterized by 2 key features:
• Recurrent failure to control the behavior
• Continuation of the behavior despite significant harmful consequences
Sexual addiction is a condition in which some form of sexual behavior relates to and affects a person’s life in such a manner as to accord with the definition of addiction.
This article reviews recent developments in the diagnosis and management of sexual addiction. For more fundamental and extensive background information about sexual addiction, see the Box, “Sources for Further Information About Sexual Addiction.”
Diagnostic criteria
At this time there are no formally accepted diagnostic criteria for sexual addiction by the American Psychiatric Association. However, provisional diagnostic criteria for sexual addiction that follow DSM format have been derived from DSM-IV-TR criteria for substance dependence—the paradigmatic addictive disorder. The terms “substance” and “substance use” have been replaced by “sexual behavior,” and “characteristic withdrawal syndrome for the substance” has been replaced with a general definition of withdrawal that is applicable to all categories of behavior.
Sexual addiction is a maladaptive pattern of sexual behavior that leads to clinically significant impairment or distress, as manifested by at least 3 of the following that occur at any time in the same 12-month period1-3:
1. Markedly increased amount or intensity of the sexual behavior to achieve the desired effect or markedly diminished effect with continued involvement in the sexual behavior at the same level of intensity.
2. Characteristic psychophysiological withdrawal syndrome of physiologically described changes and/or psychologically described changes on discontinuation of the sexual behavior or engaging in the same (or a closely related) sexual behavior to relieve or avoid withdrawal symptoms.
3. The sexual behavior is often engaged in over a longer period, in greater quantity, or at a higher level of intensity than was intended.
4. There is a persistent desire, and efforts to cut down or control the sexual behavior are not successful.
5. A great deal of time is spent on activities necessary to prepare for the sexual behavior, to engage in the behavior, or to recover from its effects.
6. Important social, occupational, or recreational activities are given up or reduced because of the sexual behavior.
7. The sexual behavior continues despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the behavior.
These diagnostic criteria are not the final word on recognizing sexual addiction. They are provisional and may need to be revised in light of further developments in research or theory. At the very least, they provide a starting point for research. The research function of diagnostic criteria is critically important, particularly for newly recognized conditions. The inclusion of a condition in the next DSM depends on scientific research that documents its legitimacy. But a condition can be researched only if clear and relevant diagnostic criteria enable researchers to recognize it. Multiple varieties of diagnostic criteria limit the generalizability of research results and undermine claims that the condition is a valid diagnostic entity.
Significantly, no form of sexual behavior in itself constitutes sexual addiction. Whether a pattern of sexual behavior qualifies as sexual addiction is determined not by the type of behavior, its object, its frequency, or its social acceptability, but by how the behavior relates to and affects a person’s life. Any sexual behavior has the potential to be engaged in addictively, but it constitutes an addictive disorder only to the extent that it occurs in a pattern that meets the diagnostic criteria or accords with the definition. It is also worth noting that while sexual addiction and paraphilia overlap to some extent, they are not identical. Some sex addicts are not paraphiliacs, and some paraphiliacs are not sex addicts. A similar distinction obtains between sex addict and sex offender, where the area of overlap is considerably smaller. The key features that distinguish sexual addiction from other patterns of sexual behavior are:
• The inability to control the sexual behavior reliably.
• Continuation of the sexual behavior despite significant harmful consequences.
A few clinical examples illustrate the considerations that are involved in making a diagnosis of sexual addiction.
CASE VIGNETTES
Stan is an entrepreneur and politician in his middle 50s. He has always identified himself as heterosexual, and he embraces a religious belief system that condemns homosexuality as sin. However, since his early 20s, he has felt irresistibly drawn to gay bars where he is likely to find female impersonators. For varying periods (sometimes weeks and sometimes only minutes), Stan is able to resist such urges, but eventually, he succumbs.
He enjoys sex with his wife, but the sexual attraction, arousal, and gratification that he experiences with female impersonators is of a higher order of magnitude. Because he believes that his career depends on his public image, and also because he is ashamed of this behavior, he often travels to other cities or even other states to find female impersonators. His typical pattern is to pick up a female impersonator at a bar and bring him to a motel.
Once, in another state, he went home with a female impersonator. This man had a housemate who dealt drugs and procured adolescent prostitutes. Stan had the misfortune of arriving just an hour before a planned police raid. He was unwittingly caught in the company of heavy drugs, automatic weapons, and minors who were engaged in sexual acts with adults. By the time bail was posted, the news of Stan’s arrest had already been picked up by the local news media.
____________________________
Steve is a software developer in his 40s who is being treated for depression, anxiety, and marital difficulties. Sex is one of the sources of tension in his marriage. He wants to have sex with his wife every day, sometimes 2 or 3 times a day, and he becomes upset when she does not comply. When his wife declines to have sex with him, he feels desperate and fears that she does not love him, that he is not good enough for her, that she is tired of him and is preparing to leave him.
On these occasions, he usually withdraws and immerses himself in work. He rarely masturbates, and he does not seek sex elsewhere. When his wife’s lupus flared up, Steve cared for her sensitively, and she expressed her appreciation and gratitude. At such times, he felt needed and valued, and he rarely thought of sex. Steve’s desire for sex occasionally offends his wife, who feels that he would rather have sex than talk with her; and sometimes, when she complies with Steve’s requests for sex, she resents him. Further inquiry does not reveal other harmful consequences from Steve’s sexual behavior, nor does it suggest any difficulty in controlling his sexual behavior.
____________________________
Jolene is an emergency room nurse in her early 30s who is “in love” with 2 men with whom she is sexually involved. She also loves her husband Ed and cannot stand the thought of leaving him. She trusts Ed and feels that he understands her. Ed knows of Jolene’s recurrent pattern of intense infatuation with a new man, resisting and then giving in to overpowering sexual attraction, and then becoming bored. When Jolene is not sexually involved with at least 1 man outside her marriage, she feels desperate, panicky, and empty. Typically, she begins a new involvement as soon as she senses that she is getting bored with her current extramarital affair.
She notes that she has tried to stop the pattern many times. Jolene recounts that her behavior has cost her 2 marriages, her kids, her place in medical school, and a lot of time, and she has gone through emotional hell. She has tried meditation, counseling, and women’s support groups, and she has joined a fundamentalist church. She had even taken excessive doses of medroxyprogesterone(Drug information on medroxyprogesterone) to decrease her sex drive, until a near-fatal pulmonary embolus developed.
She became involved with Ed while she was still married to her second husband, and she lives in constant fear that Ed, too, will get fed up with her and throw her out. Now one of her lovers is talking about killing himself if Jolene does not marry him, and the other is talking about confronting Ed. Jolene feels overwhelmed, and she is experiencing symptoms of major depression and panic disorder.
____________________________
Dale, a dealer of fine art, began psychoanalysis to help him get past his lifelong depression and his inability to sustain an intimate relationship. Ever since he quit drinking 6 years ago, he has been desperately lonely. Consciously, he wants nothing more than to find a partner, someone with whom he can share his life. However, he is anxious in social interactions and fears that he will be unable to hold up his end of a conversation and would then be humiliated.
Dale avoids situations in which conversation is likely and instead goes to parks or adult theaters where he can meet other men for anonymous sex. After these sexual encounters, he often feels dirty and disgusted with himself. He has also been beaten several times and robbed twice, and he suspects that he has contracted HIV infection. But when he is alone, or even when he anticipates being alone—when driving home or after an evening activity, for example—he experiences an intense anxiety that feels like he is “coming apart.” Dale cannot tolerate this feeling, and sexual activity relieves it.
Masturbating to pornography at home takes the edge off his anxiety and usually enables him to sleep, but he is increasingly finding that it does not work as well as it once did. On numerous occasions, he has tried to get involved in cultural or religious activities where he is more likely to meet educated, stable, gay men; however, he soon finds himself back at a park or a theater.
____________________________
Charla, a hairstylist and fashion model in her 20s, agrees to accompany her boyfriend, Mike, to a session with his psychotherapist. Mike is upset that Charla has been having sex with other men, and he thinks that she might be a sex addict. Charla says that she had told Mike shortly after they met that sex was part of her career, and that if he did not think he could stand it, they should not get involved.
Having sex with wealthy and powerful men has advanced her success as a model, she explains, and brings her money and expensive gifts. She acknowledges that what she is doing is akin to prostitution, but it is clean and legal and she is in charge. She states that she certainly does not “do it for the sex.” She is not orgasmic with these men. She likens having sex to cutting hair: her rewards are the finished product, a satisfied customer, and a nice tip. She also enjoys her sense of control over these wealthy and powerful men.
Charla states that she has never engaged in more sexual behavior than she intended, and she has never tried or wanted to decrease her sexual behavior. She also denies experiencing any kind of withdrawal symptoms or desire to engage in substitute behavior when she is not sexually active.
She recognizes that her sexual behavior bothers Mike but believes this is Mike’s problem. She makes 10 times as much money as her father ever did, and she is not about to give that up because Mike’s fragile male ego cannot deal with it. Mike acknowledges that she seems to be in control of her sexual behavior and that he is not aware of any problems that result from her sexual behavior—other than its effect on him.
