Asking the right questions may uncover serious problems
Jennifer P. Schneider, MD, PhD
Addiction to sexual activities can be just as destructive as addiction to chemical substances. Addicts may jeopardize their marriage and family relationships, allow their job performance to deteriorate, and endanger themselves and their partner through multiple sexual exposures. Even though they realize the consequences, they cannot control their compulsions without appropriate treatment. The author explains how to spot addicts and coaddicts among your patients. For most people, sex enhances the quality of life. However, about 3% to 6% of Americans have sexual addiction(1). Through their addiction, they may injure themselves physically, experience psychological distress, lose their livelihood, and ruin meaningful relationships. Sexual addiction often coexists with chemical dependency, and untreated sexual addiction contributes to relapse to chemical use. These patients not only endanger themselves but also put their loved ones at risk for AIDS and other sexually transmitted diseases. Physicians can help by learning about this phenomenon, which is gaining increasing attention in behavioral medicine, and then educating these patients and their families.
Criteria for sexual addiction
The concept of sexual addiction was introduced less than 10 years ago(2). It not only provides an explanation for otherwise irrational behavior but also suggests effective treatment for patients who have not been helped by more traditional therapy.The Diagnostic and Statistical Manual of Mental Disorders, revised third edition (DSMIIIR)(3), lists nine criteria for chemical dependency (table 1). The presence of three establishes the diagnosis. Most of the criteria concern behavior: Two indicate decreased control, one .shows preoccupation with obtaining and using the substance, and three reflect continued use despite negative consequences. These criteria can be used to diagnose other addictions as well. Goodman(4) proposed a set of diagnostic criteria for addictive disorder that may be modified and applied to sexual behavior (table2). Any behavior that is used to produce gratification and escape internal discomfort can be engaged in compulsively and can constitute an addictive disorder. Compulsive gambling(5), spending, and overeating meet these criteria as well. Characteristic findings of any addictive disorder are the following: Compulsivity, that is, loss of the ability to choose freely whether to stop or to continue. Continuation of the behavior despite adverse consequences, such as loss of health, job, marriage, or freedom. Obsession with the activity. All of the patients in the following illustrative case reports exhibited these findings.
CASE 1: A 28yearold homosexual man spent evenings “cruising” local parks, public restrooms, and pornographic bookstores for sexual contacts. This activity consumed several hours a day. His primary outlet was sex with multiple anonymous partners. When he learned that the majority of gay men in his city had tested positive for the human immunodeficiency virus (HIV), he began to worry constantly about his risk of contracting AIDS. Still, he was unable to change his unsafe sexual practices despite repeated promises to himself to do so.
CASE 2: A 52yearold married minister had a 10year history of sexual involvement with female parishioners who came to him for counseling. He experienced marital stress because he was often away from home in the evenings “counseling” rather than spending rime with his family. Overcome by remorse and guilt, he promised to break off with the women. However, he was unable to avoid new involvements. After several women came forward with their stories, the minister was fired, evicted from his churchowned house, and publicly humiliated. He and his wife moved to another state, where she supported them with her teaching income.
CASE 3: A 32yearold woman from a rigidly religious family married an alcoholic. After 2 years of marriage, she became involved in what was to be the first of many extramarital affairs. To prevent 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. Despite feelings of guilt, she did not seek help until she cheated on her new lover.
CASE 4: A 50yearold married business executive neglected sales calls when out of town and visited massage parlors and prostitutes, despite knowledge that he was risking HIV infection. He was once an effective salesman, but his work performance suffered because of his sexual pursuits. He took alternative routes on trips in an effort to avoid massage parlors, but he was unable to control his urge to visit these establishments. His wife learned about his sexual activities when he was arrested for soliciting sex from an undercover policewoman posing as a prostitute. At that point, his marriage was in jeopardy, his children and friends shocked, and his job future uncertain.
Criteria for chemical dependency
Substance often taken in larger amounts or for a longer period than intended (control)
Persistent desire for the substance or one or more unsuccessful efforts to reduce or control substance use (control)
Much time spent in obtaining the substance, taking it, or recovering from its effects (preoccupation)
Frequent intoxication when expected to fulfill major obligations at work, school, or home or recurrent use in physically hazardous situations (negativeconsequences)
Abandonment or restriction of important social, occupational, or recreational activities because of substance use (negative consequences)
Continued substance use despite a persistent or recurrent social, psychological, or physical problem that is caused or exacerbated by use of the substance (negative consequences)
Need for markedly increased amounts of the substance to achieve the desired effect, or markedly diminished effect withcontinued use of same amount (tolerance)
Presence of characteristic withdrawal symptoms (withdrawal)
Use of the substance to relieve or avoid withdrawal symptoms(withdrawal)
At least three criteria must be met for diagnosis, and some symptoms of the disturbance must have persisted for at least 1 month or have occurred repeatedly over a longer period.
Adapted from American Psychiatric Association(3)
Cycle of sexual addiction
When sexual behavior is compulsive and continued despite serious adverse consequences, it is addiction. Sex addicts tend to sexualize other people and situations, finding sexual connotations in the most ordinary incident or remark. They spend great amounts of time and/or money in pursuit of a “quick fix.” Any sexual behavior can be part of the addictive cycle: The context of the behavior must be considered to ascertain whether the behavior is compulsive. What is healthy sexual behavior for many people may be unhealthy for others, just as the use of alcohol causes no adverse consequences for most people but severe problems for some.
Sex addicts describe a euphoria with sex similar to that described by drug addicts with drug use. This may be an effect of endorphins and other endogenous brain chemicals, whereas the druginduced state is externally produced. Milkman and Sunderwirth(6) have classified sexual addiction as an arousal addiction because its effects on the brain are similar to the effects of cocaine, amphetamines, compulsive gambling, and risktaking behaviors. In contrast, addiction to alcohol, sedatives or hypnotics, and food are considered satiation addictions.
Like alcoholics and other drug addicts, sex addicts behavior engage in distorted thinking, rationalizing, and defending and justifying their behavior while blaming others for resulting problems. They deny having a problem and make excuses for their behavior.
On the basis of a survey of about 600 selfidentified sex addicts, Carnes(1) categorized addictive sex into 11 patterns (table 3). Sex addicts usually participate compulsively in more than one type of sexual behavior. For example, they may masturbate compulsively in addition toviewing pornography and patronizing prostitutes. Although some sex addicts are hypersexual, seeking sexual intercourse or orgasm several times daily, most are not. For the addict who has affairs, the euphoria may come from the thrill of the chase and conquest rather than £from the sexual experience itself. Many sex addicts report progression of their addiction; that is, they have to take increasing risks or try new sexual behaviors to maintain the same euphoric effect.
Sex addicts, like alcoholics and other addicts, often come from a dysfunctional family in which parents were chemically dependent, sexually addicted, abusive, or otherwise emotionally unavailable. In a survey of 75 recovering sex addicts,(7) only 15 (20%) said their parents had no addiction. At least one parent was chemically dependent in 30 (40%) of the 75 families. One or both parents were sex addicts in 27 (36%). In 25 (33%), at least one parent had an eating disorder, and in 5 (7%), one parent was a compulsive gambler. Results of Carnes(1) larger survey’ were similar.
Criteria for addictive disorder
Frequent engaging in the behavior to a greater extent or over a longer period than intended
Persistent desire for the behavior or one or more unsuccessful efforts to reduce or control the behavior
Much time spent in activities necessary for the behavior, engaging in the behavior. or recovering from its effects
Frequent preoccupation with the behavior or preparatory activities
Frequent engaging in the behavior when expected to fulfil occupational, academic, domestic, or social obligations
Giving up or limiting important social, occupational, or recreational activities because of the behavior
Continuation of the behavior despite knowledge of having a persistent or recurrent social, financial,psychological, or physical problem that is caused or exacerbated by the behavior
Need to increase the intensity or frequency of the behavior to achieve the desired effect, or diminished effect with continued behavior of the same intensity
Restlessness or irritability if unable to engage in the behavior
At least three criteria must be met for diagnosis, and some symptoms of the disturbance must have persisted for at least 1 month or have occurred repeatedly over a longer period.
Adapted from Goodman (4)
families of sex addicts. The great majority of sex addicts (82% of almost 900 addicts in Carnes’ survey(1) had been sexually abused in childhood. Among the male addicts, 3% were forced to have sex by their fathers and 11% by their mothers.(1) Others (41%) were abused by neighbors, business associates of their parents, or strangers, while 8% were molested by other adults in authority. (1)
In some families, there was no overt incest, but a heightened sense of sexuality was present. Sexually explicit material may have been available, or sexual comments (eg, a father remarking on his daughter’s anatomy) were made repeatedly. Privacy in the bathroom and bedroom may have been lacking. Children who come from families that lack emotional support and nurturing tend to be vulnerable to sexual exploitation. Children who are sexually abused may grow up fearing sex, confusing sex with love, or believing that the only way to relate to others is sexually. Others may be troubled by “repetition compulsion,” in which they become perpetrators of sexual abuse.
More than half of sex addicts surveyed come from a rigid, emotionally disengaged family.(8) In such families, discussion of sex may be taboo or sex may be considered disgusting. As a result, children grow up lacking accurate information about sex and believing that sex is powerful and dangerous.
Patterns and examples of sexual addiction
Fantasy sex: neglecting commitments because of fantasy life, masturbation
Seductive role sex: extramarital affairs (heterosexual or homosexual), flirting and seductive behavior
Anonymous sex: engaging in sex with anonymous partners, having one night stands
Paying for sex: paying prostitutes for sex, paying for sexually explicit phone calls
Trading sex: receiving money or drugs for sex
Voyeuristic sex: patronizing adult bookstores and strip shows, looking through windows of houses, having a collection of pornography at home or at work
Exhibitionist sex: exposing oneself in public places or from the home or car, wearing clothes designed to expose
Intrusive sex: touching others without permission, using position of power (eg, professional, religious) to sexually exploit another person, rape
Pain exchange: causing or receiving pain to enhance sexual pleasure
Object sex: masturbating with objects, crossdressing to add to sexual pleasure, using fetishes as part of sexual rituals, having sex with animals
Sex with children: forcing sexual activity on a child, watching child pornography
Like chemical dependency, sexual addiction is a family disease. Spouses of sex addicts, or “coaddicts,” usually grew up in a dysfunctional family, where they acquired a set of core beliefs that resulted in low selfesteem and difficulty in relationships. They may believe that they are not worthwhile, that no one could love them for themselves, that they can control and are responsible for others, and that sex is the most important sign of love.(9)
Spouses of sex addicts were often sexually abused in childhood and thus have fear or confusion about sex. They tend to be attracted to individuals who are needy, which describes most addicts. Coaddicts usually fear abandonment, often cannot imagine life without their partner, and are willing to accept behaviors that healthier persons may find unacceptable. For example, in a survey of 78 recovering coaddicts,(9) 52 (66%) said that they had participated in sexual activities that they found uncomfortable. These included viewing pornography, swapping sexual partners, and having sex in public places.
Many coaddicts fear refusing sex; others use sex to control and manipulate. Those whose sexually addicted partner prefers other sexual outlets (eg, compulsive masturbation, hiring of prostitutes) may go for years with out conjugal relations, often at great cost to their emotional wellbeing. Since the sex addict’s primary relationship is with the addiction, the partner justifiably feels unimportant and unloved.
All too often, couples who seek marriage counseling because of sexual problems are advised to add variety to their sexual repertoire or to do more to please each other sexually. Some marriage counselors may not understand that the sexual problems are an addictive pattern, not a marital issue. Often, the coaddict takes responsibility for the marital discord and fruitlessly works at finding a solution, as illustrated in the following case.
Case 5: A 36yearold woman, the mother of three small children, was raised by a rageful alcoholic father and a dependent mother. She married a man who also had an alcoholic parent. Over the course of their marriage, he had multiple affairs. He denied the most blatant evidence of his philandering until she at times doubted her own sanity. Although she knew he was having sex with other women, she did not dare deny him sex for fear he would leave.
Frightened of confronting her husband and expressing her anger, she had bouts of depression and periods of overeating. During her second pregnancy, she contracted gonorrhea from her husband. Although she felt intense guilt about risking her fetus’s health, she continued having sex with her husband. She expressed intense shame when she disclosed her home situation to her physician.
She became progressively obsessed with her husband’s infidelity and would drive around town at night, with her three small children, looking for her husband’s car. When she found his car-at a girlfriend’s house-she would send one of the children to ring the doorbell and ask daddy to come home.Despite her recognition of how hurtful this behavior was to her children, she was unable to stop.
Eventually she sought counseling, joined a selfhelp group for spouses of sex addicts, and later divorced her husband.
Sexual addiction is of en accompanied by other addictions. Physicians’ understanding of this fact is important because sexual addiction contributes significantly to the AIDS epidemic and because efforts control sexual addiction are often confounded by coexistent problems.
A recent survey of 823 homosexuals or bisexual men seeking primary care(10) showed that 527 (64%) had engaged in at least one unsafe sexual practice in the previous 2 months even though most of them understood the elements of safe sex. Compared with the safesex group, men who engaged in riskier sexual activities had more partners, used more drugs, and felt they had less control over their sexual activities. The investigators conducted, “It appears that many gay and bisexual men may be faced with multiple addiction problems related to sex, drugs, and alcohol. Further changes in sexual behavior are not likely to occur unless the compulsive nature of their sexual behavior and polydrug use are dealt with more directly.”
Sexual addiction often coexists with chemical dependency and is frequently an unrecognized cause of relapse. This is particularly true with cocaine addiction. In one study,” about 70% of cocaine addicts entering an outpatient treatment program were found to be addicted to sex as well. Many patients had become trapped in a “reciprocalrelapse” pattern, in which compulsive sexual behavior precipitates relapse to cocaine use and vice versa.
In an anonymous written survey of 75 recovering sex addicts,(7) I found that 29 (39%) were also recovering from chemical dependency, 28 (38%) were workaholics, 24 (32%) had an eating disorder, 10 (13%) characterized themselves as compulsive spenders, and 4 (5%) were compulsive gamblers. Only 13 (17%) believed they had no other addiction. It is clear that clinicians who treat addicts need to assess them for multiple addictions and recognize that an addict who stops one addictive behavior (eg, excessive drinking) may substitute another addictive behavior (eg, multiple affairs, overeating) as a means of mood alteration and escape.
The following case histories illustrate the relationship between sexual addiction and chemical dependency.
Case 6: A 30yearold salesman who was addicted to cocaine and sex left work early many days to go to his dealer’s house, where he would inhale cocaine and drink beer. He then spent hours in a cycle of visiting pornographic bookstores to masturbate and snort cocaine and then driving around while drinking beer and inhaling cocaine until he had recovered enough to visit the next pornographic bookstore.
When he finally sought help for his cocaine addiction, he found himself relapsing repeatedly until he finally addressed his sexual addiction. He related, “The sex addiction came first, but cocaine was like pouring gave line on a fire. My relapses began with sexual behaviors, but because the sex and drugs were so interrelated and were part of the ritual, the sex served as a potent trigger for the cocaine, so I would end up doing that too.” To stay dean and sober, he had to avoid both drugs and compulsive sex.
Case 7: A 40yearold physician was actively involved in Alcoholics Anonymous and appeared to be doing well until one day when he did not appear at work and was found at home, intoxicated. Remorseful and depressed, he explained to his therapist that drinking was not the problem. He had been engaging in anonymous sex in public restrooms and felt such anguish about his sexual behavior that he thought his only choices were suicide and drinking; he chose alcohol. Sexual issues had not been addressed during his prior treatment for alcoholism.
Since many patients are reluctant to talk about sexual problems, primary care physicians are not likely to suspect sexual addiction unless they ask the right questions. In this age of AIDS, obtaining a sexual history from every patient is desirable. If initial questioning suggests compulsive sexual behavior, the 25question self-administered test shown in table 4 is a useful diagnostic tool.(8) If 13 of the 25 questions are answered in the affirmative, in about 96% of cases the respondent is sexually addicted. This tool must be used with caution in homosexuals, whose behavior can involve secrecy and shame even though most are not addicts. Also, the test’s validity has not been established for women or adolescents. Even though sexual addiction is not currently recognized in the DSMIIIR, application of its criteria for chemical dependency as adapted for sexual behaviors and a score of 13 or more on this test suggest the diagnosis.
Sexual addiction screening test *
Were you sexually abused as a child or adolescent?
Have you subscribed to or regularly purchased sexually explicit magazines?
Did your parents have trouble with sexual behavior?
Do you often find yourself preoccupied with sexual thoughts?
Do you feel that your sexual behavior is not normal?
Does your spouse (or significant other) ever worry or complain about your sexual behavior?
Do you have trouble stopping your sexual behavior when you know it is inappropriate?
Do you ever feel bad about your sexual behavior?
Has your sexual behavior ever created problems for you or your family?
Have you ever sought help for sexual behavior that you did not like?
Have you ever worried about people finding out about Your sexual activities?
Has anyone been hurt emotionally because of your sexual behavior?
Are any of your sexual activities against the law?
Have you made promises to yourself to quit some aspect of your sexual behavior?
Have you made efforts to quit a type of sexual behavior and failed?
Do you have to hide some aspects of your sexual behavior from others?
Have you attempted to stop some parts of your sexual activities?
Have you ever felt degraded by your sexual behavior?
Has sex been a way for you to escape your Problems?
When you have sex, do you feel depressed afterward?
Have you felt the need to discontinue a certain form of sexual activity?
Has your sexual activity interfered with your family life?
Have you been sexual with minors?
Do you feel controlled by yoursexual desire?
Do you everthink that your sexual desire is stronger than you are?
* Affirmative answers to 13 questions strongly suggest addiction.
Reprinted, with permission, from Carnes.(8)
When patients present with multiple somatic complaints, depression, dependency on tranquilizers, or compulsive behaviors, asking about the family situation may be extremely productive. Obtaining a thorough sexual history and asking questions about addiction problems in the patient’s family of origin are helpful. A few minutes of empathetic conversation can lead to clues that suggest addiction or coaddiction. Physicians can then recommend specific treatment and attendance at a support group for addicts or coaddicts.
In coaddicts, stressrelated symptoms (eg, headache, backache, insomnia, lack of energy, gastrointestinal disturbances) are often present. Depression is even more common among spouses of sex addicts than among spouses of alcoholics. To mask painful feelings, many coaddicts turn to overeating or bulimia, dependency on tranquilizers, overworking, or compulsive housecleaning. Those who were sexually abused may have recurrent abdominal or pelvic pain that defies diagnosis.
Unlike the goal in treatment of chemical dependency, which is abstinence from use of all psychoactive substances, the therapeutic goal in sexual addiction is abstinence only from compulsive sexual behavior with adaptation of healthy sexuality. Sexual addiction treatment programs suggest that patients abstain from all sexual activities, including masturbation, for 30 to 90 days to demonstrate that they can live without sex. When they stop all sexual activity, some sex addias report withdrawal symptoms similar to those experienced by cocaine addias. Involvement of the partner in the treatment program is highly desirable. In fact, the most important predictor of relapse after treatment of sexual addiction is failure of the spouse to be involved in the treatment program.(1)
Because sex addicts were of en sexually abused as children and because they have distorted ideas about sex, they frequency lack information about healthy sexuality. In the early recovery period, sex addicts and their partners frequency have sexual difficulties, often to a greater degree than they had during the active addiction phase.(12)
Therapists can provide reassurance during this phase. If the compulsive sexual behavior was samesex, as is surprisingly common even among men who identify themselves as heterosexual,(13) therapists can help patients work through issues of sexual identity. Shame, a major issue for sex addicts, is often addressed best in group therapy, where other recovering addicts can provide both support and confrontation.
For patients who are suicidal or who need a change of environment to begin their recovery, several inpatient treatment programs for sexual addiction are available in the United States. Most are located in hospitals that treat chemical dependency. with the increasing awareness of multiple addictions, more chemical dependency treatment centers are adding programs for compulsive sexual behavior. Facilities that do not address sexual addiction may refer patients to other centers or to therapists if sexual issues are detected during treatment for chemical dependency.
The 12 steps of Alcoholics Anonymous have been adapted for use in programs for eating disorders, compulsive gambling, sexual addiction, and other addictions. Attendance at a program dealing with sexual addiction can be extremely helpful in the recovery process. Programs modeled after AlAnon (the selfhelp program for families and friends of alcoholics) are also available, and attendance by sex coaddicts is highly recommended. Group support can be a powerful tool for overcoming the shame that most sex addicts and coaddicts feel. We provide addresses of the national offices of 12step programs for sex addicts and their families.
By the time sex addicts seek help, their marriage or relationship is often in great distress. Communication is lacking, and distrust, anger, and resentment are the hallmarks of the relationship. Couples counseling by a therapist who is knowledgeable about sexual addiction can be of great help. The therapist can facilitate forgiveness and rebuilding of trust(14) and can also help the couple deal with the sexual problems that often occur during recovery.(12) For couples who are willing to work on their individual recovery and on their relationship, the prognosis for survival and improvement of the relationship is surprisingly good.(7)
Sex addiction, like other addictions, cannot be “cured” and relapse is always a possibility. To prevent this, recovering sex addicts learn to avoid particular people and situations that can trigger old urges and behaviors. Some recovering addicts find that they need to avoid masturbation as well.
Some sex addicts benefit from pharmacotherapy. Coleman,(15) who views compulsive sexual behavior as a variant of obsessivecompulsive disorder, reported that some patients respond dramatically to specific drugs, such as fluoxetine hydrochloride (Prozac) and domipramine hydrochloride (Anafranil).
The sexual addiction model enables physicians to understand the selfdestructive behavior of patients whose actions may otherwise appear inexplicable. When a person is preoccupied with sex and continues to engage in compulsive sexual activity despite adverse consequences (eg, loss of marriage, job, health, freedom), he or she is a sex addict. Treatment allows sex addicts eo stop their compulsive behavior and improve their relationships. Preferred treatment includes professional counseling and attendance at selfhelp programs based on the Alcoholics Anonymous model. Partners of sex addicts, whose coaddiction may manifest itself through various physical symptoms, depression, or compulsions, can benefit from the same treatment approach.
Address for correspondence:
Jennifer P. Schneider, MD, PhD,
1500 N Wilmot, Suite B25O.
Tucson, AZ 85712
Carnes PJ. Don’t call it love: recovery from sexual addiction. New York: Bantam Books, 1991 42-4
Carnes P. Out of the shadows: understanding sexual addiction. Minneapolis: CompCare Publishers, 1983
American Psychiatric Association. Diagnostics and statistical manual of mental disorders. 3d ed, rev. Washington, DC: Am Psychiatric Assn, 1987
Goodman A. Addiction defined: diagnostic criteria for addictive disorder. Am J Prev Psychiatr Nuerol 1989;2(1):12-5
Daghestani AN. Why should physicians recognize compulsive gambling? Postgrad Med 1987; 82(5):25363
Milkman HB, Sunderwirth SG. Craving for ecstasy: the consciousness and chemistry of escape. Lexington, MA; Lexington Books 1987:40
Schneider JP, Schneider B. Sex, lies, and forgiveness: couples speaking out on healing from sex addiction. Center City, MN: Hazleden
Educational Materials, 1991
Carnes P. Contrary to love: helping the sexual addict. Minneapolis: CompCare Publishers, 1989:218-9