Sex Addiction 101

While the problem of substance use and addiction has gained cultural notoriety as an individual, social, and healthcare problem worldwide, behavioral-based addictions such as sex addiction have had a much harder time gaining acceptance within the medical, therapeutic and cultural communities. Thanks to an increase in evidence-based research studies, sex addiction is gaining acceptance as a legitimate mental health problem that has a defined set of diagnostic criteria and pattern of behaviors. Additionally, recent research has begun to identify the link between sex addiction and past trauma in the life of the addicted person. The purpose of this web page is to provide a basic understanding of a definition of addiction and specifically, sex addiction, the different forms of sexually addictive behavior, the diagnostic criteria for both substance use and sex addictions, and the pattern of sex addiction known as the addiction cycle.

I. What is Addiction in general, and Sex Addiction in particular?

According to the short definition of the American Society of Addiction Medicine (ASAM), Addiction is defined as…

A primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to a characteristic biological, psychological, social, and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain (from substance use or other addictive behaviors), impairment in behavioral control, craving diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and result in premature death. 

A striking part of the ASAM definition is the acknowledgement that addiction is a disease of the brain. The impaired brain function produces the symptoms of obsessive use and/or behaviors, impaired intellectual functioning in the areas of problem recognition, emotional and behavioral response, and interpersonal relationship functioning. As with any disease, addiction is progressive in nature and left untreated, will result in premature death. To learn more about how the brain is altered by addiction and fits the disease criteria, an excellent resource is the video, Pleasure Unwoven: An Explanation of the Brain Disease of Addiction by Kevin McCauley.

The National Council on Sex Addiction and Compulsivity has defined Sex Addiction as….

Engaging in persistent and escalating patterns of sexual behavior acted out despite increasing Negative consequences to self and others. 

Michael Herkov, a clinical forensic psychologist in Florida who specializes in working with behavioral and substance abuse, says sex addiction is a progressive intimacy disorder characterized by compulsive sexual thoughts and acts. Like all addictions, its negative impact increases as the disorder progresses. Over time, the addict usually must intensify the addictive behavior to achieve the same results. 

II. The Ten Types of Sexually Addictive Behavior

Patrick Carnes has been considered one of the pioneers in the field of sex addiction research. He has written numerous books on the topic (including Contrary to Love (1994), Out of the Shadows (1983), and Don’t Call It Love (1992)), which are considered seminal reading for therapists, researchers, and individuals who are providing care for sex addicts or are struggling with sex addiction themselves. In preparation for writing the book Don’t Call It Love, Carnes and others conducted research with over a 1000 sex addicts and their partners, analyzing 114 different sexual behaviors. Carnes and his team identified 10 categories of compulsive sexual behaviors patterns in the participants surveyed. Those ten types are: fantasy sex, seductive role sex, voyeuristic sex, exhibitionistic sex, paying for sex, trading sex, intrusive sex, anonymous sex, pain exchange sex and exploitive sex.

III. The Ten Criteria/Symptoms of Sex Addiction 

– Am I an addict? Am I a sex addict? 

It is important to note that addictions of ten travel in pairs or groups. In other words, being cross-addicted (having co-occurring addictive behaviors at the same time) is a common occurrence.  The symptoms may be the same, but the behaviors can be very different. For example, sex addicts in treatment have also acknowledged struggling with the following addictive behaviors:

• Chemical Dependency 42%

• Eating Disorders 38%

• Compulsive Working 28%

• Compulsive Spending 26%

• Compulsive Gambling 5%

Treating one addiction without treating another often will lead to a relapse in the addiction that a person is being treated for. For example, alcoholics have reported that getting sober from alcohol revealed that their drinking was covering up their compulsive paying for sex with prostitutes. Seeing how their addictions are connected is important in treating both addictions. Seen side by side, the diagnostic criteria for both a substance use addiction (from the American Psychological Association’s Diagnostic and Statistical Manual-version 5) and a sex addiction (developed by Patrick Carnes) are virtually identical:

1. Loss of Control: Engaging in clear behaviors more frequently that you intend or want. 

The old substance use adage, “One is never enough, and a thousand is never too many” applies here. The addict has lost the ability to stop their behavior.

2. Compulsive Behavior: Over time, a pattern of out-of-control behavior emerges. 

The addicted person has a set of behaviors that taken together, provide a sense of relief (albeit temporary) for the addict. Once the uncomfortable emotional state returns, the addict automatically returns to the addictive behavior for relief.

3. Efforts to Stop: Repeated failed attempts to reduce, control, or stop the behavior.

Even the best of intentions, serious negative consequences, or even a renewed commitment to their spiritual life cannot keep the addict from returning to the addictive behavior. Relapse often occurs, and failure to understand that it is often part of the healing process of recovery can serve to only deepen feelings of guilt and shame, keeping the addict stuck in their addiction.

4. Loss of Time: Significant amounts of time lost due to preparing to/engaging in and/or recovering from the behavior. 

This is one symptom that demonstrates how the brain has become altered or damaged by the addiction process. It is an example of diminished intellectual functioning. The addict suddenly becomes like a racehorse with blinders on. They lose complete track of time, often becomes unaware of their surroundings or what they were doing. The only thing they can see is how they can get a fix.

5. Preoccupation: Obsessing about or because of the behavior.

This is the “Marination Stage”. The addict may have a seemingly random thought like, “I made a sale today. Let’s go celebrate at the strip club”, or, “I have a few minutes of downtime before anyone gets home. Let’s see what or who’s online?”. Often those thoughts can be diverted and will pass through a person’s consciousness with little or no effect. For the addict, if they don’t dismiss the thought immediately, they begin to “marinate” or obsess on the thought, which creates a physical change in their body chemistry, creating a strong urge or craving, which in turn puts them into a state of diminished intellectually functioning. The blinders come on, and they are off to the races.

6. Inability to Fulfill Obligations: The behavior interferes with work, school, family, and other social relationships. 

As the addiction grows and takes root, the addictive thinking is constantly operating in the addict’s mind (often below the conscious level). They are easily diverted and unable to give their full attention or best efforts at home, work, or in important relationships. 

7. Continuation Despite Consequences: Failure to stop the behavior even though you have experiences serious negative consequences because of it (social, legal, financial, physical, and spiritual).

Just as an alcoholic will continue drinking after several DWI’s the sex addict will continue to act out even though they may be on the verge of losing their family, job, or even going to jail. They are no longer in control. The addictive behavior is now calling the shots.

8. Escalation: Need to make behavior more intense, riskier, and more frequent.

With substance users, tolerance is when they need to use greater and greater amounts of their drug to get the same effect. With sex addicts, tolerance is classified by the increasing severity and type of behavior the addict engages in. It is a downward spiral into more risky behaviors that directly involve and/or violates the boundaries of other people. In his book Out of the Shadows, Patrick Carnes breaks down tolerance into three levels of severity based on the level of victimization that the behavior involves:

9. Losses: Losing, limiting, or sacrificing valued parts of life such as hobbies, family, relationships and work.

As the addiction escalates and become more entrenched, the person’s life becomes smaller without them realizing. Unintentionally, the addict’s behavior causes them to lose important relationships that once filled their life. Ironically it is the loss of these connections to the real world that could have helped the addict see that they were on shaky ground. Now that important relationships are no longer important or are totally absent, the addictive behavior rushes in to fill the vacuum. The addict comes to think of their behavior as the only trusted friend they have. This complete nonsense of course, but the addicts brain has become so altered that they cannot see the reality of the situation. Denial is the addiction’s most powerful weapon against reality, and the addict, now isolated from their support system, is virtually incapable of breaking free on their own.

10. Withdrawal: Stopping behavior causes considerable distress, anxiety, restlessness, irritability and physical discomfort.  

While withdrawal from alcohol and drugs like Xanax and Klonopin can be life-threatening, withdrawal from sex addiction involves experiencing uncomfortable levels of anxiety, irritability, and restlessness. Their craving response may seem unbearable, and it may be difficult to control racing thoughts. During withdrawal, the addict my feel like “I’m going to die if I don’t act out or have sex”. Note: In all of recorded history, no man, woman, or other animal species has ever died from being deprived of sex. During withdrawal, denial is especially active because the mind and body have become dependent on the chemical release in the brain that the addictive behavior produces. In short, the brain will say, “I gotta have it”, and provide an excuse like the one mentioned above as justification for acting out again. 

With substance use, a person who has two to three of the criteria listed on the left meets criteria for what is called a Substance Use Disorder Mild. This used to be classified in the DSM as Substance Abuse, which meant that the person could act, behave, and look like an addict, but if the consequences were severe enough (a DUI, death of a friend due to an overdose, etc.) the person is able to quit their drug habit and not pick up again, or are able to severely limit their use. 

If a person meets four to five of the criteria on the left, this person meets criteria for Substance Use Disorder Moderate. Anyone who meets six or more of the criteria has a Substance Use Disorder Severe. Both a moderate and serve diagnosis were formerly classified as Substance Dependence. At this stage, the person has lost the ability to stop their addictive. They may make multiple attempts, or have several DUI’s, lost jobs or marriages, but continue in their addictive behavior. It is important thing to remember that the same concept applies to behavioral addiction like sex and gambling; the disease of addiction is progressive. There comes a point where the person loses the ability to not only stand by their choice to quit, but to actually quit the behavior itself.

Unlike a substance use disorder, there are no varying degrees of sex addiction. If a person meets six or more of the criteria on the right side of the diagram above, they meet criteria for sex addiction. 

IV. The Addiction Cycle – Do I live like this?

An important part of understanding sex addiction is learning how the addiction shapes our thinking and behavior. By understanding your pattern or cycle of behavior you can learn to make changes in your pattern of addiction. Patrick Carnes developed the Sex Addiction Cycle to illustrate how a person organizes their sexually addictive behavior into a lifestyle. The diagram below illustrates the Cycle of Sex Addiction.

 The Cycle involves two parts; an internal cycle that involves the addicts inner thought world. It begins with the addicts wounds from childhood, as well as any other traumatic events they have experienced. These wounds shape the addicts underlying belief system. This belief system, which was developed since our childhood, also carries faulty or Impaired Thinking. Impaired thinking is made up of our beliefs (good or bad) about ourselves, our own worth, the world around us, attitudes about women, men or sex, some past trauma, and many other things. You may have learned early on how to medicate your painful feelings by being sexual. Even though the relief from the pain may be temporary, the imprint it leaves on the brain is a powerful reminder. When stress or emotional pain becomes difficult, we remember the high from our sexual behavior and think of it as the best (and only) alternative to cope with or medicate our feelings. 

The second part is external in nature and is reflected in the addicts behavior. The first part of this behavioral part is  Preoccupation, which only fuels the desire. Mentioned above, this is the phase where the addict marinates on the thoughts of behaviors or fantasy patterns that serve to heighten arousal.  This leads directly into the Ritualization stage. Here the addict begins to engage in those behaviors that set the stage to engage in the compulsive behavior. For the addict who goes to prostitutes, part of the ritual may be going to an ATM machine and hearing the dollar bills being counted in the machine. These experiences begin to ramp up the excitement level. This is the early stages of engaging in the acting out behavior. As the addict progresses through each stage, it becomes more and more difficult to make the choice to not act out. By the time the addict is in the ritualization stage, it becomes virtually impossible to change course. 

The next stage is where the Compulsive Sexual Behavior is acted upon. An addict’s behavior can fall into any number of different behaviors, including but not limited to those listed in the chart above. This is where they receive the ultimate fix. They are numb to their emotions. They have short-term relief from their pain. Once the relief has ended, their intellectual functioning begins to be restored, which leads them to feel the emotion of Despair. “Why did I do this again?” is a common question asked at this point. They once again fell for the false sales pitch the addiction offered. Additionally, feelings of self-loathing, Guilt and Shame return with a vengeance. “I am no good”, “I’ll never change”, I don’t deserve to be happy” are all standard songs that play continuously on the internal tape of the addict. Life is truly unmanageable for them, but they see no escape. This serves to set them up for the next time they face an uncomfortable situation or feeling, which starts them in the cycle all over again. They feel like guinea pigs on a wheel with no chance of ever exiting the ride and finding solid ground again.

V. What can I do to get help?

Step One of Alcoholics Anonymous says that “We admitted that we were powerless over alcohol – that our lives had become unmanageable”. The first step in recovery is to admit that you have a problem. Recovery is different from sobriety; it not only includes stopping a self-destructive behavior (sobriety), but involves developing the skills and strength to live life each day taking the good with bad, and still being able to find the joy of living amid life’s trials. Often, our addictive behaviors developed over time to help us cope with another, deeper problem. Talking with a trained therapist is a very helpful step in helping a person identify the problem and develop goals and strategies to regain control of their lives. I would consider it an honor and a privilege to speak with you further and hopefully walk with you as you seek a life of recovery.

By Scott Smith, MA, LCMHC, LCAS, CSAT