The Sex Addiction Myth

The sex addict diagnosis is problematic and obscures instead of elucidates a person’s struggles. Sex addiction (hypersexual disorder) is not a recognized diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 2013) and was rejected by the DSM5 task force due to a lack of empirical evidence. Compulsive Sexual Behavior Disorder (CSBD) is an impulse control disorder that was included in the International Classification of Diseases (ICD-11, 2019) but according to Sassover and Weinstein (2022), there is not enough data supporting CSBD as a behavioral addiction due to anecdotal scholarship and a lack of empiricism. CSBD is described as:

Compulsive sexual behavior disorder is characterized by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behavior.

Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behavior; and continued repetitive sexual behavior despite adverse consequences or deriving little or no satisfaction from it.

Criteria:

1.     The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behavior

2.     Manifested over an extended period of time (e.g., 6 months or more)

3.     Causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviors is not sufficient to meet this requirement.

Sex addict has become part of the American lexicon to describe secrets that revolve around one’s erotic conflicts. Patrick Carnes (1983) coined the term sexual addiction (SA) which gained traction during the AIDS epidemic. The label and the myth of an increasing problem was bolstered by media coverage and increased access to pornography (i.e., sexually explicit imagery) along with the emergence of a heteronormative self-help system (e.g., 12-step program) and a privately paid therapy industry in the U.S. Moreover, the term sexual compulsivity was coined by Quadland (1985) and used to describe gay and bisexual men from New York City who sought treatment. The sex addiction label has continued to proliferate popular culture through the news and media and the obsession with celebrities and media personalities.     

Compulsive sexual behavior is often thought to primarily afflict males, but Marchetti (2023) found no significant differences between males and females and across age which dispels common patriarchal myths regarding male and female sexuality. But women may report compulsive sexual behavior less than men due to the stigma associated with women’s sexual behavior.

Sexual behavior is fundamentally different than substance use and gambling as it is informed by different moral and cultural conditions including other forms of shame. The label sex addict is frequently used to describe individuals grappling with internal moral conflicts, characterized by intrapsychic distress stemming from moral incongruence, self-discrepancies, and competing internal motivations. These conflicts may be influenced by factors such as religiosity, puritanical socialization, or imbalances in excitatory and inhibitory processes. Consequently, individuals may experience a sense of being out of control, manifesting as compulsive sexual behavior driven by difficulties in emotion regulation, preoccupation with sexual thoughts, attempts to seek out sexual partners, or perceived lack of impulse control.

CSBD is often comorbid with mood disorders, anxiety disorders, substance abuse, personality disorders, ADHD, and obsessive-compulsive disorders. In addition, it is not uncommon among many who identify with CSBD to have had early past experiences of sexual victimization and abandonment that produced an avoidant-attachment style that resembles superficial relationships with others that can be primarily sex-focused.    

In many cases, men accept a sex addict label from their partners due to concerns about pornography consumption or infidelity. Many partners can feel threatened by their partner’s porn viewership as porn viewership often involves masturbation (solo sex) and fantasy. Many people believe myths that indicate that a partner watching porn means that they desire something or someone else which is not accurate as a person’s erotic fantasies don’t necessarily indicate a desire in real-life, but it could indicate a preference that they would like in their romantic relationship that they are apprehensive to disclose. Moreover, the other myth that many people believe is that their partner masturbating is indicative of their failure to please their partner. Solo sex is actually more common than partnered sex. In addition, the sex addict label is used by individuals and their partners as an explanation for infidelity or an excuse for one’s decision to engage in an affair or multiple affairs and to avoid accountability (externalized responsibility).  

Problems are not disorders and it is imperative that CSBD is thoroughly assessed by therapists which includes whether various domains of a person’s life has been affected (e.g., dropping out of school, losing jobs, unwanted financial losses, social isolation, marital adversities, and mental health distress) including assessing for co-occurring disorders before diagnosing their client with CSBD.  

Treatment for CSBD include groups designed to specifically address CSBD, individual therapy, couples therapy, and any co-occurring disorders would need to be addressed. Group therapy typically is 6-months of weekly group meetings and include assessing for motivation, sexual health principles, and the goals of accountability for behavior change, self/attachment emotion regulation, emotional intimacy, authenticity (e.g., the development of a positive sexual/erotic identity), and vulnerability with others. A 12-step program (12-step groups/addiction model) is not recommended as they have a religious foundation that can increase feelings of addiction to sex and pornography due to moral incongruence between beliefs and behaviors. Further, a person’s ability and self-efficacy can be diminished due to responsibility being placed on a higher power. Lastly, moral incongruence can be increased due to the promotion of abstinence-celibacy.

References

Braun-Harvey, D., & Vigorito, M. A. (2015). Treating out of control sexual behavior: Rethinking sex addiction. Springer Publishing Company.

Briken, P., & Turner, D. (2022). What does “Sexual” mean in compulsive sexual behavior disorder?•: Commentary to the debate: “Behavioral addictions in the ICD-11”. Journal of Behavioral Addictions, 11(2), 222-225.

Briken, P. (2020). An integrated model to assess and treat compulsive sexual behaviour disorder. Nature Reviews Urology, 17(7), 391-406.

Carnes, P. (1983). Out of the shadows: Understanding sexual addiction. Minneapolis: CompCare Publications.

Fuss, J., Briken, P., Stein, D. J., & Lochner, C. (2019). Compulsive sexual behavior disorder in obsessive–compulsive disorder: Prevalence and associated comorbidity. Journal of Behavioral Addictions, 8(2), 242-248.

Grubbs, J. B., Grant, J. T., & Engelman, J. (2018). Self-identification as a pornography addict: Examining the roles of pornography use, religiousness, and moral incongruence. Sexual Addiction & Compulsivity, 25(4), 269-292.

Herbenick, D., Fu, T. C., Wasata, R., & Coleman, E. (2023). Masturbation prevalence, frequency, reasons, and associations with partnered sex in the midst of the COVID-19 pandemic: Findings from a US nationally representative survey. Archives of sexual behavior, 52(3), 1317-1331.

Kraus, S. W., Krueger, R. B., Briken, P., First, M. B., Stein, D. J., Kaplan, M. S., Voon, V., Abdo, C. H., Grant, J. E., Atalla, E. & Reed, G. M. (2018). Compulsive sexual behaviour disorder in the ICD‐11. World Psychiatry, 17(1), 109-110.

Marchetti, I. (2023). The structure of compulsive sexual behavior: A network analysis study. Archives of Sexual Behavior, 52(3), 1271-1284.

Munns, R., Dickenson, J., Candelario-Perez, L., Kovic, A., Rider, N., Berg, D., Coleman, E., Girard, A. (2020). Psychotherapies in the treatment of CSBD. In P. Briken, & R. Balon (Eds.), Compulsive sexual behavior disorder: Understanding, assessment and treatment (pp. 109–128). Washington DC, USA: American Psychiatric Association Publishing.

Quadland, M. C. (1985). Compulsive sexual behavior: Definition of a problem and an approach to treatment. Journal of Sex & Marital Therapy, 11(2), 121-132.

Sassover, E., & Weinstein, A. (2022). Should compulsive sexual behavior (CSB) be considered as a behavioral addiction? A debate paper presenting the opposing view. Journal of Behavioral Addictions, 11(2), 166-179.

Thompson, D. (2010, May 12). The “reality” of sex addiction stirs debate. https://www.healthday.com/health-news/sexual-health/the-reality-of-sex-addiction-stirs-debate-636637.html