No longer sufficiently excited by his fantasies, Joe began to purchase pornography and pornographic videos. He received a second warning about tardiness and inattentiveness at work, and he felt disgusted with himself; but each time he tried to stop masturbating, he would fail. Sexual fantasies accompanied by arousal would intrude into his consciousness throughout the day, and he would feel as though he was going to explode.
When he began a new romantic relationship, he threw away his collection of pornography and resolved to quit masturbating. Within a few months, though, he lost control of his masturbation and the relationship soon fell apart. He started using telephone sex services, and before long had "maxed-out" his credit cards. Socially isolated, deeply in debt and about to lose his job, Joe realized that his preoccupation with masturbation and pornography was ruining his life, but he felt powerless.
Case 3: Steve. Steve was a neurologist in his 40s who sought treatment for depression, anxiety and marital difficulties. Sex was among the sources of tension in his marriage. Steve wanted to have sex with his wife every day, sometimes two or three times a day. Steve's wife wondered if he were a sex addict.
When she declined to have sex with Steve, he felt desperate and feared that she did not love him, that he was not good enough for her, that she was tired of him and was preparing to leave him. On such occasions, he usually withdrew to his study and immersed himself in work. He rarely masturbated, and did not seek sex elsewhere. When his wife's inflammatory bowel disease flared up, Steve cared for her sensitively, and she expressed her appreciation and gratitude. At such times, Steve felt needed and valued, and he rarely thought of sex. Steve's desire for sex occasionally offended his wife, who felt then that he would rather have sex than talk with her. Sometimes, when Steve's wife complied with his requests for sex, she resented him. Further inquiry did not reveal other harmful consequences from Steve's sexual behavior nor did it suggest that Steve had any difficulty controlling his sexual behavior.
The first two clinical examples, Harold and Joe, meet 4, 5 and 7 of the diagnostic criteria for sexual addiction and perhaps also criterion 6. Joe, in addition, meets criteria 1, 3 and probably 2. The third example, Steve, might meet criterion 5, but does not seem to meet any of the other criteria. Hence, Harold and Joe merit diagnoses of sexual addiction, according to the diagnostic criteria, while Steve does not.
An informal assessment that is based on the definition of sexual addiction reaches the same conclusions. Harold and Joe demonstrate patterns of sexual behavior that are characterized by recurrent failure to control and continuation of such behavior despite significant harmful consequences, while Steve does not. (Five detailed clinical vignettes, which include each patient's personal history, case formulations and course of treatment are presented in Goodman, 1998a.)
Treatment for sexual addiction is most likely to be effective when it emerges from an integrated approach that brings together a range of therapeutic modalities, is individually tailored and evolves as the patient progresses.
The approach to treatment described here was developed (Goodman, 1997, 1998a) in the context of the theory that sexual addiction represents an expression through sexual behavior of the addictive process: an enduring, inordinately strong tendency to engage in some form of pleasure-producing behavior as a means of regulating affects or self-states that are painful and potentially overwhelming due to impaired self-regulation. Consequently, treatment for sexual addiction should address both the addictive sexual behavior and the underlying addictive process.