Is sex addiction real? Despite the prevalence of the addiction model as a treatment plan for those struggling with unwanted sexual behavior, this is actually a very controversial question.
According to a national survey in 2018, 10% of men and 7% of women say they “suffer from significant levels of distress and dysfunction associated with difficulty controlling sexual feelings, urges, and behavior.”
The history of sex addiction being acknowledged as a real thing starts with the work of Patrick Carnes. Carnes worked through his own sexual addictive behavior in the 1960’s and 70’s by getting involved with AA twelve step meetings. He pursued a PhD in counseling, published a book on sex addiction called “Out of the Shadows: Understanding Sexual Addiction” in 1983, and created a therapeutic treatment plan for treating sex addiction based heavily in the 12 step model. This treatment plan is taught through the Carnes-created institution IITAP where the certification CSAT (certified sex addiction therapist) is granted. This approach grew and became more popular until by the 2000’s, the CSAT approach has by and large the default approach to problematic sexual behavior.
The most respected organizing body for sexual education and health in America is the American Association of Sexuality Educators, Counselors, and Therapists (AASECT). AASECT offers a certification called a certified sex therapist CST. CST’s and CSAT’s argue over the appropriateness of the CSAT approach to problematic sexual behavior. The gist of the argument by the CST’s:
- Research especially recent work headed by Josh Grubbs shows that when someone self-identifies as a sex addict and seeks treatment for sex addiction, the highest correlated variable is not the degree of sexual acting out, but the person’s moral beliefs about sexually acting out. Religious Americans and Non-religious Americans both watch porn and cheat on their partners with about the same frequency. But religious Americans are much more likely to self-identify as porn addicts and seek treatment. CSATs would likely label them as sex addicts. CST’s would likely say they are not addicts but there is a moral incongruence that needs to be worked out.
- Some pro-addiction model experts argue the neuroscience of sex addiction is similar to drug addiction. However this opinion is divided. Neuroscientist Nikki Prause has done research (for example this article titled “Data do not support sex as addictive”) which she claims debunks some of the scientific claims made about sex and porn addiction.
- Some CST’s criticize the addiction model treatment as ineffective and in many cases detrimental as it increases the anxiety the behaviors cause and reinforces the toxic shame that self-identified sex addicts internalize.
- David Ley, CST and former CSAT, author of the book “The Myth of Sex Addiction”, and strong detractor of the concept of sex addiction summarizes a view that many have that sex addiction is an excuse for some people to act badly: “I am not sure when being a selfish, misogynistic jerk became a medical disorder. This is a concept that has been used to explain selfish, powerful, wealthy men engaging in irresponsible impulsive sexual behavior for a long time.”
This conflict between CST’s and CSAT’s came to a head in 2016, when AASECT published a formal position on sex addiction. You can read an interesting back story from CST Michael Aaron on Psychology Today.
Founded in 1967, the American Association of Sexuality Educators, Counselors and Therapists (AASECT) is devoted to the promotion of sexual health by the development and advancement of the fields of sexuality education, counseling and therapy. With this mission, AASECT accepts the responsibility of training, certifying and advancing high standards in the practice of sexuality education services, counseling and therapy. When contentious topics and cultural conflicts impede sexuality education and health care, AASECT may publish position statements to clarify standards to protect consumer sexual health and sexual rights.
AASECT recognizes that people may experience significant physical, psychological, spiritual and sexual health consequences related to their sexual urges, thoughts or behaviors. AASECT recommends that its members utilize models that do not unduly pathologize consensual sexual behaviors. AASECT 1) does not find sufficient empirical evidence to support the classification of sex addiction or porn addiction as a mental health disorder, and 2) does not find the sexual addiction training and treatment methods and educational pedagogies to be adequately informed by accurate human sexuality knowledge. Therefore, it is the position of AASECT that linking problems related to sexual urges, thoughts or behaviors to a porn/sexual addiction process cannot be advanced by AASECT as a standard of practice for sexuality education delivery, counseling or therapy.
AASECT advocates for a collaborative movement to establish standards of care supported by science, public health consensus and the rigorous protection of sexual rights for consumers seeking treatment for problems related to consensual sexual urges, thoughts or behaviors.
UCLA professor Rory Reid is the most published researcher in the sex addiction field. A US News article from 2013 titled “Study: Sex May Not Be Addictive” summarized Reid’s view that brain studies do not show connection between brain chemistry and sex addiction. Reid, who formerly did believe sex addiction was an accurate term, now believes we should call it “hypersexuality disorder” because though we shouldn’t call it addiction, some people’s sexual behaviors clearly cause them severe consequences and personal distress.
That leads us back to the CST complaint that the personal distress and consequences are many times tied to religious or moral perspectives. A comparison: a Vegan who keeps backsliding on his commitment not to eat meat might experience severe personal shame over this shortcoming and even relationship consequences if he were in a relationship with another strict Vegan. Yet, no one would say this person is a hamburger addict.
Why does it matter?
Both CSAT’s and CST’s would agree that the reason this debate matters is that the treatment follows the diagnosis.
CSAT’s follow an addiction model. Twelve Step programs are highly recommended and absolutely mandatory per most CSAT’s. Sobriety of sexual behavior is paramount. Some CSAT’s make dogmatic assertions like complete abstinence from masturbation and pornography is required by their clients. Good CSAT’s will assess and treat a client for depression, anxiety, trauma, relationship problems, and mental health disorders that could be contributing to the sexual addiction problem. Many CSAT’s go deep with therapies like EMDR and IFS, but stopping the sexual behavior is commonly the primary emphasis.
CST’s have varied approaches to problematic sexual behavior. Some CST’s take a very permissive approach to sexual behavior. If you’re concerned about your sexual behavior, the easiest solution is to stop worrying, accept yourself, nothing is wrong. This is appropriate in some cases. But in some cases it leads clients to stay stuck in behavior that is hurting themselves and their partners.
In 2015, CST Douglas Braun-Harvey published the book Treating Out of Control Sexual Behavior: Rethinking Sex Addiction. This has now become the default approach for most CST’s. In it he defines principles of sexual health, outlines a process for working out moral conflicts with the client, and encourages the therapist to help the client align his behavior to those values. He stresses the importance of treating anxiety, depression, attachment insecurity, mental health disorders, and other issues that could be the underlying cause and think about problematic sexual behavior as a symptom.
I’m trained in both CSAT and OCSB. I believe both models have strengths and weaknesses. I try to take the best of both worlds when I work with clients.
According to the National Institute of Drug Abuse:
Addiction is defined as a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. It is considered a brain disorder, because it involves functional changes to brain circuits involved in reward, stress, and self-control. Those changes may last a long time after a person has stopped taking drugs.
The primary indicators of addiction are:
- declining grades or difficulty at school or poor performance at work
- relationship difficulties, which often involve lashing out at people who identify the addiction
- an inability to stop using a substance even though it may be causing health problems or personal problems, such as issues with employment or relationships
- a noticeable lack of energy in daily activities
- profound changes in appearance, including weight loss and a noticeable abandonment of hygiene
- appearing defensive when asked about substance use
Yes, this seems to definitely supports sex as an addiction. I like this definition. But as an aside, as a former “sex addict”, the circular logic of an addiction being defined as defensiveness to being called an addict was very frustrating to me. “You’re a sex addict.” “No, I’m not, stop saying that.” “See, defensiveness is one of the indicators.”
Tolerance is when you take a substance, your body gets used to it, so the next time you use it, you need a higher dose to get the same effect. Over time, with drug addiction, you might be taking an amount that will barely get you high that previously might have sent you into overdose. Dependence is when you become reliant on the drug. Many people can’t function properly in the morning without a cup of coffee. This is an example of dependence on a drug. Withdrawal is when you have serious physical and emotional consequences when you try to quit the drug.
Proponents and detractors of the idea of sex as an addiction will argue whether this fits for sex addiction. There is an idea that sex addiction is escalating. The person doesn’t get the same rush with porn, so he goes from softcore to hardcore porn to fetish porn. Or a person will graduate from porn consumption to affairs and prostitution. This does happen. But in many cases it doesn’t happen. Some people struggle with compulsive behavior that doesn’t ever escalate. Additionally, there is a component of escalation that has to do with a person exploring boundaries that is in common without a lot of human behavior. It’s a good question, whether one’s behavior exhibits an addictive, escalating quality or one’s behavior exhibits a somewhat natural exploration of one’s sexuality.
Robert Weiss, a well-known CSAT, and author of the book Sex Addiction 101: A Basic Guide to Healing from Sex, Porn, and Love Addiction, defines addiction as behavior that meets three criteria;
- Preoccupation to the point of obsession with the substance or behavior of choice
- Loss of control over use of the substance or behavior, typically evidenced by failed attempts to quit or cut back
- Directly related negative consequences: relationship trouble, issues at work or in school, declining physical health, depression, anxiety, diminished self-esteem, isolation, financial woes, loss of interest in previously enjoyable activities, legal trouble, etc.
Compulsive sexual behavior
The word compulsive in psychology has an element of doing it against your will and is usually reserved for activities that don’t provide any direct pleasure, such as compulsive hand washing. It has a broader meaning of doing something in an impulsive manner, repeatedly in a way that is distressing to the individual. But some people don’t like this term due to the technicality that sexual behavior does provide pleasure so doesn’t fit that model exactly.
Problematic sexual behavior or Out of Control Sexual behavior
For some, these terms don’t give the problem the proper seriousness that the term addiction conveys. Some professionals don’t even like these terms because they imply that someone is declaring the behavior as problematic or out of control, with the implication that these are moral judgments and the existence of morality is what is actually causing the problem not the behavior. There is the common saying “a sex addict is someone whose sexual behavior isn’t in line with the morals of his therapist.”
Sex Addict Label
I use the term “sex addiction”. It’s a common usage for we talk about many behavioral addictions: gambling, food, shopping, video gaming. But I prefer not to use the term “sex addict”. If I see a client who believes this label is helpful, I don’t make a big deal of it, but I don’t like it for many reasons.
In addiction recovery and 12 steps there is this idea that there are two types of people: “addicts” and “non-addicts”. I hear so many dogmatic statements made by both recovering addicts and professionals in the recovery industry that I think are very shaming and damaging. “Once an addict, always an addict.” “An addict’s mind is a dangerous place.” “It’s impossible for a sex addict to be emotionally intimate.” “Sex addicts can’t do ______ or can’t be _______ (fill in the blank).” Often I hear statements like “well that’s fine for normal people but not for sex addicts”. I believe these blanket statements are a) usually always not true b) often inherently shaming and c) make recovery more difficult. I invite my clients to reject these blanket statements if they are not helpful.
Good and Bad of 12 Steps
Twelve Step programs can do great with shame reduction and getting support from others. When you meet with other people with a common goal of recovery, and you can share your story and not feel judged and shamed, this can be very helpful for a person trying to overcome addictive behavior. SA (Sexaholics Anonymous), SAA (Sex Addicts Anonymous), and SLAA (Sex and Love Addicts Anonymous) are well established programs where people can find a meeting in their city and find like-minded people all working for a common goal of recovery.
I see sex addiction as a symptom of mental health issues like anxiety, depression, CPTSD, ADHD, or insecure attachment. Twelve Steps is not therapy. The first recommendation for someone experiencing sex addiction is usually to go to 12 Steps. In my opinion, for most people struggling with unwanted sexual behaviors 12 Steps is secondary in importance to therapy to undo cognitive distortions, learn emotion regulation skills, resolve trauma, and heal toxic internalized shame. If this work is not done, it is difficult to obtain long-term “sobriety” (I would prefer to say “aligning one’s sexual behaviors with one’s values” over the term “sobriety”). And even when long-term sobriety is attained, if this deeper healing is not done, they will likely be what is known as a “dry drunk”, white knuckling their sobriety, and usually replacing their sex addiction behaviors with other addictive behaviors or constantly on edge with anxiety, anger, and frustration. The Karuna Healing method to treat addiction puts an emphasis on this deeper work.
Focus on length of sobriety can cause two serious problems. 1) The idea that all types of breaking sobriety are equal. “I watched porn and lost my sobriety, I might as well call an escort.” Sexual behaviors, especially when in a relationship, have a significant range of seriousness level of consequences. Harm reduction principles should be used. If I “give in” to the desires I have to act out sexually, it’s better to choose to act out in a way that minimizes consequences for myself and my loved ones. 2) Length of sobriety can become a source of anxiety. Slips and relapses can carry enormous weight in shame when I’m tied too closely to sobriety length as source of worth.
Some people feel like 12 Step programs have too much of a focus on God and feels too religious, especially those with religious trauma. For some, the dogmatic approach feels too limiting and narrow. If it works for you, then use it for your benefit. If it doesn’t, you shouldn’t feel it’s the only way to recover from this problem.
I support 12 Step programs, but I advise my clients to keep these principles in mind when engaging in sobriety-based recovery programs.
Is Sex Addiction Real? It would be offensive to the people suffering with sex addiction and their betrayed partners to say there is no such thing as sex addiction, but if you want to call it something else, I can agree with that. Whether we call it sexual compulsivity, sex addiction, or out-of-control sexual behavior, it doesn’t seem to matter. It’s a serious problem for many that requires significant effort to heal and recover.
This article was written by Robert Terry, a Certified Sex Addiction Therapist (CSAT-C), practicing in St. George, Utah. He can be reached through his website at www.karunahealing.org.
Rob Terry is a therapist for clients in Utah and coach for clients outside of Utah and across the globe. He specializes in sex addiction recovery for individuals and couples. He integrates the CSAT, OCSB, and Minwalla models for individual recovery and Gottman Method, RLT, and ERCEM for couples recovery. He is betrayal trauma informed. His therapy modalities are IFS, ACT, CBT, EMDR, and Attachment Theory.