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Sexual Addiction

Sexual Addiction
J. Robert Ross, Ph. D., LMFT

Objectives: Participants in this workshop will learn to . . .
(1) Describe the etiology, physiology and psychology of sexual addiction.
(2) Describe and diagnose the forms and level of sexual addiction.
(3) Describe the physical, psychological moral, and social damage of sexual addictions.
(4) Develop effective interventions for clients with sexual addictions.

Introduction: Definitions of Sexual Addiction
Sexual compulsivity or addiction means “engaging in persistent and escalating patterns of sexual behavior acted out despite increasing negative consequences to self and others.” – National Council on Sexual Addiction and Compulsivity
Sexual addiction is a persistent and escalating pattern or patterns of sexual behaviors acted out despite increasingly negative consequences to self or others. – The Society for the Advancement of Sexual Health
Sexual addiction is best described as a progressive intimacy disorder characterized by compulsive sexual thoughts and acts. Like all addictions, its negative impact on the addict and on family members increases as the disorder progresses. Over time, the addict usually has to intensify the addictive behavior to achieve the same results. – Michael Herkov
The DSM-IV previously described sex addiction, under the category “Sexual Disorders Not Otherwise Specified,” as “distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used.” Sex addiction might also involve, “compulsive searching for multiple partners, compulsive fixation on an unattainable partner, compulsive masturbation, compulsive love relationships and compulsive sexuality in a relationship.” However, the DSM-5 has omitted any reference to sexual addiction in any form. (It has also foregone the use of “addiction” in favor of the term “substance use disorder.”)
The only recognition of compulsive or addictive sexual behavior as a mental or emotional problem found in the DSM-V is noted under V69.9 (Z72.9) “A Problem Related to Lifestyle,” which lists as one example of a lifestyle problem “high risk sexual behavior that directly affects the course, prognosis, or treatment of a mental or other medical disorder.” For purposes of this seminar Sexual Compulsive/Addictive Behavior includes but is not limited to the following:
Masturbation w/pornography Simultaneous or repeated affairs
Compulsive cyber sex Repeated use of phone sex
Multiple anonymous partners Repeated Strip clubs
Repeated Massage Parlors Repeated Prostitution

ONE: Sexually Compulsive Behavior Compared to a Substance Disorder (Addiction)
The brain chemistry of pleasure (dopamine) is similar to substance addiction. Many of the criteria for substance use disorder in the DSM-V apply to compulsive/addictive sexual behavior. In the DSM-V an alcohol use disorder is defined as “a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:” ( Note that the symptoms in bold seem to apply also to compulsive sexual behaviors.)

1. Alcohol is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
4. Craving, or a strong desire [sexual obsessiveness?] or urge to use alcohol.
5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
8. Recurrent alcohol use in situations in which it is physically hazardous.
9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.
b. A markedly diminished effect with continued use of the same amount of alcohol.
11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal, pp. 235-236).
b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

TWO: Factors in the Development of Addiction
Biologically: Importance of the vulnerability of the physiology of pleasure in the limbic part of the brain? See
Psychologically: The need to escape or avoid emotional pain and distress
Cognitively: Sexual addiction “begins with the delusional thought processes which are rooted in the addict’s belief system” (Carnes).
Spiritually: A person fills up the God void with their sexual addiction. The addiction is their spirituality, it comforts them, celebrates them and is always available.

THREE: Levels of Addiction (Patrick Carnes)
Level One: socially tolerable sexual behavior, i.e., masturbation, promiscuous sexual relationships, pornography, and prostitution. Addicts at this level can rationalize that they are not much different from others. “While they feel unique in desperateness and obsession, the sexual behavior creates few real social consequences.”
Level Two: Exhibitionism, voyeurism, indecent phone calls, frotteurism, etc., which are criminally prosecuted and viewed by society as pitiful perverts.
Level Three: rape, incest, and child molestation, which are the most serious sexual offenses. These offenders are viewed as monsters.
Question: Does sexual addiction tend to progress from one level to the next or is there a progression of severity of addiction within each level?

FOUR: Consequences of Sexual Addiction
• Social: Addicts become lost in sexual preoccupation, which results in emotional distance from loved ones. Loss of friendship and family relationships may result.
• Emotional: Anxiety or extreme stress are common in sex addicts who live with constant fear of discovery. Shame and guilt increase, as the addict’s lifestyle is often inconsistent with the personal values, beliefs and spirituality. Boredom, pronounced fatigue, despair are inevitable as addiction progresses. The ultimate consequence may be suicide.
• Physical: Some of the diseases which may occur due to sexual addiction are genital injury, cervical cancer, HIV/AIDS, herpes, genital warts and other sexually transmitted diseases. Sex addicts may place themselves in situations of potential harm, resulting in serious physical wounding or even death.
• Legal: Many types of sexual addiction result in violation of the law, such as sexual harassment, obscene phone calls, exhibitionism, voyeurism, prostitution, rape, incest and child molestation, and other illegal activities. Loss of professional status and professional licensure may result from sexual addiction, for example, by viewing porn on a workplace computer. Sex addicts do not necessarily become sex offenders. Moreover, not all sex offenders are sex addicts. Roughly 55 percent of convicted sex offenders can be considered sex addicts, but about 71 percent of child molesters are sex addicts.
• Financial/Occupational: Indebtedness may arise directly from the cost of prostitutes, Caber-sex, phone sex and multiple affairs. Indirectly indebtedness can occur from legal fees, the cost of divorce or separation, decrease productivity or job loss.
• Spiritual: Loneliness, guilt, shame, alienation from God and intimate partner

FIVE: Diagnostic Tools
There are several assessment tools available to help determine the extent and seriousness of compulsive sexual behaviors and their impact on one’s life and the lives of people close to the addict. Following are several instruments that can assist in determining more precisely the kind of sexually compulsive behaviors that are problems in the client’s life.

PATHOS Questionnaire
Answer YES or NO:
1. Do you often find yourself preoccupied with sexual thoughts?
2. Do you hide some of your sexual behavior from others?
3. Have you ever sought help for unwanted sexual behavior?
4. Has anyone been hurt emotionally because of your sexual behavior?
5. Do you feel controlled by your sexual desire?
6. When you have sex, do you feel depressed afterwards?
Even one “yes” answer indicates a significant issue with SCB.
A Sexually Compulsive Behavior Checklist
Check all of the following types of sexual behavior you have acted out:
❒ Viewing “soft porn,” in R rated movies or internet web sites.
❒ Viewing “hard pornography” in X rated movies or on the web.
❒ Masturbation while viewing pornography.
❒ Masturbation while fantasizing about another person other than your spouse.
❒ Sexual talk with strangers in internet chat rooms.
❒ “One night stands” and/or casual sex without commitment.
❒ Phone or internet sex.
❒ Going to a massage parlor for sex.
❒ Attendance at strip clubs.
❒ Emotional sexual affairs without physical touching.
❒ Sexual affairs that involve non-genital touching (kissing, hugging)
❒ Sexual affairs that involve genital touching including mutual masturbation, oral sex or intercourse.
❒ Sex with a prostitute.
❒ Sex with an animal.
❒ Sex with a corpse.
❒ Indecent public exposure.
❒ Peeping or intrusive violation of another’s privacy.
❒ Forced sex or rape of a person not my spouse.
❒ Forced sex with my spouse.
❒ Sexual talk with a minor over the internet or otherwise.
❒ Inappropriate sexual advances toward anyone.
❒ Sex touching of a minor.
❒ Intercourse with a minor.
❒ Group sex.
❒ Sex between two persons whose relationship is defined by a significant difference in power or authority, for example, between therapist and client, pastor and parishioner, teacher and student, etc.
❒ Any other kind of sexual behavior about which you feel guilty or ashamed.

Ask the client to describe how these behaviors have effected him emotionally, spiritually and socially–i.e. the effect on family and friends, especially his relationship with an intimate partner.

Critical Diagnostic Questions
The following questions can also be helpful in assessing sexual addiction. Please answer yes or no to the following questions.
Over a period of time do you feel a need for more and more exciting, “edgy” or dangerous forms of sexual stimulation?
If you cannot find a way to act out your favorite sexual behavior, do you become anxious, nervous or unable to concentrate on other tasks?
Do you find yourself looking for more or different ways to act out sexually?
Have you had a desire to stop or cut down your sexual behavior without much success?
Do you spend a great deal of time seeking out sexual stimulation?
Have you limited or stopped any social, occupational or recreational activities because of your sexual acting out?
Do you continue your sexual behavior while realizing that it causes emotional, family, financial or health problems?

In addition to using these diagnostic materials for pornography addicts you may find helpful three brief inventories in the booklet, Getting Internet Pornography Out of Your Life (
• The time porn has taken from your life (p. 4)
• The effects of porn on your character (p. 6)
• Losing control of your porn use (p. 8)

The Bible describes the compulsive, enslaving nature of sin. With Christian clients you may study Rom 7:7-25 and ask if it describes the client’s sexual behavior.

SIX: Assessment of Readiness for Treatment
The client should rate himself on a scale of 1 to 10 on each of the following statements as they apply to himself. 1 means that the assumption does not apply at all. Ten 10 means that it applies totally and without reservation.

I recognize that I have a problem with my sexual behavior that I have not been able to solve by making resolutions to change.
I accept responsibility for my sexual behavior without blaming someone else.
I am willing to examine all of my behaviors (sexual, financial, social and interpersonal) and how they have affected me and other people in my life.
I have a sincere desire to change, and there is no length to which I am not willing to go to recover from my sexually compulsive behavior.

Unless the client can rate these assumptions as a 9 or a 10, he is setting himself up for failure before beginning the recovery process.

SEVEN: Stages of Recovery
STAGE ONE: The first stage involves guilt and shame (Acts 2:37; 16:30). If you do not advance to the next stages, your guilt and shame, which in the Bible is called “worldly grief” (2 Cor 7:10), will lead to death–spiritual and emotional death and ultimately even physical death. If your guilt and shame is a “godly grief,” it will lead you to the next step and ultimately to your salvation.

STAGE TWO, OPTION A: Stage Two can take either of two directions. The first option is to make only a resolution to stop SCB. In this option you sincerely desire to change and are determined to do so. However, if this resolution is not accompanied by specific steps that facilitate a lasting recovery, it will inevitably be followed by a relapse after a period of “sobriety.” (See the Relapse Cycle.) In order for your recovery to last, the first stage of recovery described above, which you may have been repeated many times, must be followed by stage two, option B (below).

STAGE TWO, OPTION B: This option involves much more than a resolution to change. It requires a decision to stop trying to get some relief from your guilt and shame through the use of sex or using a sexual “high” to mask your spiritual and emotional pain. This option means that you not only resolve to change but that you actually commit to a program of change and recovery. This commitment is what the Bible calls a change of mind or repentance (Matt 3:2; Luke 13:3; Acts 2:38; 26:20; Rom 2:4; 2 Cor 7:9-10; Rev 2:5).
Some people struggle with this stage for years while others quickly make a decision to repent after something happens in their life that makes them realize that their SCB is leading only to death and that the way to life leads in another direction. This means realizing that “the wages of sin is death” (Rom 6:23) and that “whatever a man sows, that he will also reap” (Gal 6:7). It also means a realization that God will forgive any sin and that confession and repentance lead to forgiveness and a renewal of friendship with God (1 Jn 1:9; 2 Cor 5:18; Rom 5:10).

STAGE THREE: The third stage goes beyond quitting your SCB and involves an immersion in your recovery program (sanctification) where you learn to recognize and use the “way(s) of escape” that God will always provide when you are tempted to act out sexually (1 Cor 10:13). In this stage you will learn how to deal with the various issues faced in early recovery such as building a support system, identifying sexual triggers and high risk situations and the identification of strategies to manage these temptations.

STAGE FOUR: The fourth stage involves learning to live a healthy, joyful life without using your favorite deviant or destructive sexual behavior to deal with your spiritual and emotional emptiness. In this stage you learn to face all of the moral defects in your life and to make amends for them. You also learn how to maintain the positive gains you made over time in order to reduce the likelihood of relapse. In this stage, you continue to make healthy changes in your attitudes, thinking, coping mechanisms, relationships, and lifestyle.
This means much more than not acting out sexually. It means growing into the human perfection that God desires for you. Recovery, or what the Bible calls sanctification, means much more than not sinning. It means living into holiness, becoming holy as God is holy (Lev 11:45; 1 Pet 1:16). “This is the will of God, your sanctification: that you abstain from unchastity, that each one of you know how to take a wife for himself in holiness and honor…” (1 Thess 4:3-4).
Stage four includes the rest of your life. It means using the Twelve Steps, twelve principles for living, as a practical guide to help you achieve the holiness that God desires for you. It will also mean continued, intimate contact with fellow Christians, all of whom are on the path to recovery and sanctification. One type of contact that is greatly recommended for men or women caught up in SCB is to have an accountability partner with whom you meet regularly. (A list of helpful accountability questions is found on page 47.)
Although relapse may occur at any point in recovery, the greatest risk for a relapse is the first year. Within the first year, the first few months can be the most difficult because your commitment may waver, you may have trouble adjusting to the interpersonal and mental changes that accompany a new lifestyle. Or your lifestyle may pose numerous risks and pressures to act out destructive sexual behaviors. The purpose of this workbook is to help you understand and use the “way(s) of escape” from sexual temptation that God will always make available to you.

EIGHT: TREATMENT FOR SEX ADDICTION–based on the Twelve Steps and the principles of Relapse Prevention taken from substance abuse treatment. Group treatment is recommended.
• The Relapse Cycle and Step One (acknowledgment of one’s powerlessness)
• Hope for Recovery (Step Two)
• Commitment to will of God without reservation (Step Three)
• Vulnerabilities: Triggers and High Risk Situations
• Escape from Temptation: Development of Relapse Prevention Strategies
• Self Examination (Step Four)
• Management of Anger and Resentment
• Manning Up (Step Five)
• Preparation for Recovery/Sanctification (Step Six)
• Learning to Trust God (Step Seven)
• Inventory of Victims (Step Eight)
• Making Amends (Step Nine)
• Persistence in Recovery/Sanctification (Step Ten)
• Prayer for Recovery/Sanctification (Step Eleven)
• Working the Program (Step Twelve)
• If You Slip

CONCLUSION: Help for Co-Dependents of Sex Addicts
– Appendix of Freedom from Sexually Compulsive Behavior workbook –

Addiction is a family disease. It is impossible for the addict’s behavior not to impact other members of the family. In the case of a sex addiction it is common for the spouse of the addict to become obsessed with the addict’s sexual acting out. The addict’s problem begins to be the major focus of the family’s life. The co-addict can think of nothing except the addict’s behavior, or the possibility that he will act out again. Responses of the intimate partner include:
• something she did to cause his behavior and to believe that there is something she can do to stop it
• hyper vigilant, always watching for signs of a relapse
• hypersexual, i.e. trying to provide enough sex
• distant and nonsexual, hoping that her punishing behavior will teach him a lesson.

All of these measures to “help” the addict reform are useless, even counter productive. If she wants to try to save the relationship with the addict, she should , first, expect him to enter and cooperate fully in a program for sex addicts including attendance at a group for men addicted to compulsive sexual behaviors.
The hurt felt by the co-addict because of a partner’s sexual acting out or infidelity means that she will need some time to heal sufficiently to feel like making love again. She should be free to set and enforce appropriate boundaries regarding expressions of affection until her psychic wounds have begun to heal.
It is important that the addict’s partner not become obsessed with his addiction or his recovery. Here are some signs of an unhealthy obsession with a partner’s sexual addiction:

∙ Constantly watching to see if the addict is looking at other women.
∙ Mentioning the addict’s infidelity or misbehavior in front of the children to discredit the addict.
∙ Trying to accomplish too many things in one day and thus feeling exhausted, depressed, resentful, and critical.
∙ Desperate fears and fantasies of what the addict might be doing.
∙ Setting up “tests of fidelity” to check out the addict’s commitment, love, or sexual interest.

Instead of asking the addict about his temptations or his behavior, it can be helpful to have an agreement that at the end of each day the addict volunteers the following statement without any prompting by his partner: “Today I have been completely honest and faithful to you and by God’s grace I will be faithful tomorrow.
The partner should also seek to find a group for partners of men with sexually compulsive behaviors. She should take advantage of one of the Twelve Step Groups for friends and family of sexual addicts.