Sex addiction

Sexual addiction refers to a phenomenon in which individuals report being unable to manage their sexual behavior. It has also been called "hypersexuality," "sexual dependency," and "sexual compulsivity." The existence of the condition is not universally accepted by sexologists, and there is debate about its etiology, nature, and validity. Proponents of the concept have offered varying descriptions, each according to their favored model of the putative phenomenon. Proponents of an addiction model of the phenomenon refer to it as "sexual addiction" and offer definitions based on substance addictions; proponents of lack-of-control models refer to it as "sexual compulsivity" and offer definitions based on obsessive-compulsive disorder (OCD); etc. Skeptics believe that it is a myth that the phenomenon exists as a disease or disorder at all and is instead a by-product of cultural and other influences.

Some sexual addiction proponents have commented that the concept faces many obstacles to being viewed seriously by the general public. One of these obstacles is the manner in which it is portrayed in popular media. Daily media sources sensationalize and denigrate people who are reported to be sex addicts. This portrayal typically extends into fictional television shows and movies.

Definition
Sexologists have not reached any consensus regarding whether sexual addiction exists or, if it does, how to describe the phenomenon. Some experts believe that sexual addiction is literally an addiction, directly analogous to alcohol and drug addictions. Other experts believe that sexual addiction is actually a form of obsessive compulsive disorder and refer to it as sexual compulsivity. Still other experts believe that sex addiction is itself a myth, a by-product of cultural and other influences.

Terminology
"Nymphomania" and "satyriasis" are not listed as disorders in the DSM-IV, though they remain a part of ICD-10, each listed as a subtype of "Hypersexuality."

Official status
The American Psychiatric Association publishes and periodically updates the Diagnostic and Statistical Manual of Mental Disorders (DSM), a widely recognized compendium of acknowledged mental disorders and their diagnostic criteria. The most recent version of that manual, DSM-IV-TR, was published in 2000 and does not recognize sexual addiction as a diagnosis. Some experts have expressed that excluding sexual addiction from the DSM represents a problem. The DSM does, however, include a miscellaneous diagnosis called Sexual Disorders Not Otherwise Specified, and includes as one of the examples of it: "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." Other examples include: compulsive fixation on an unattainable partner, compulsive masturbation, compulsive love relationships, and compulsive sexuality in a relationship.

The World Health Organization produces the International Classification of Diseases (ICD)), which is used globally and is not limited to mental disorders. The most recent version of that document, ICD-10, includes "Excessive sexual drive" as a diagnosis (code F52.7), subdividing it into satyriasis (for males) and nymphomania (for females).

Symptoms and proposed diagnostic criteria
An abstract on the problem of the DSM IV's exclusion of sexual compulsive behavior has been outlined by Irons and Schneider (1996).

Proposals based on addictions models
Irons and Schneider have noted that "Addictive sexual disorders which do not fit into standard DSM-IV categories can best be diagnosed using an adaptation of the DSM-IV criteria for substance dependence." Similarly, Lowinson and colleagues use the addiction model and define sexual addiction as a condition in which some form of sexual behaviour is employed in a pattern that is characterized at least by two key features: recurrent failure to control the behaviour and continuation of the behaviour despite harmful consequences. Patrick Carnes, another proponent of the addiction model of sexual addiction, argued that most professionals in the field agree with the World Health Organization's definition of addiction.

Patrick Carnes, a proponent of the idea of sexual addiction, proposed using:
 * 1) Recurrent failure (pattern) to resist impulses to engage in extreme acts of lewd sex.
 * 2) Frequent engaging in those behaviors to a greater extent or over a longer period of time than intended.
 * 3) Persistent desire or unsuccessful efforts to stop, reduce, or control those behaviors.
 * 4) Inordinate amount of time spent in obtaining sex, being sexual, or recovering from sexual experience.
 * 5) Preoccupation with the behavior or preparatory activities.
 * 6) Frequent engaging in violent sexual behavior when expected to fulfill occupational, academic, domestic, or social obligations.
 * 7) Continuation of the behavior despite knowledge of having a persistent or recurrent social, academic, financial, psychological, or physical problem that is caused or exacerbated by the behavior.
 * 8) Need to increase the intensity, frequency, number, or risk of behaviors to achieve the desired effect, or diminished effect with continued behaviors at the same level of intensity, frequency, number, or risk.
 * 9) Giving up or limiting social, occupational, or recreational activities because of the behavior.
 * 10) Resorting to distress, anxiety, restlessness, or violence if unable to engage in the behavior at times relating to SRD (Sexual Rage Disorder).

Goodman proposed: A maladaptive pattern of behavior, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
 * 1) tolerance, as defined by either of the following:
 * 2) a need for markedly increased amount or intensity of the behavior to achieve the desired effect
 * 3) markedly diminished effect with continued involvement in the behavior at the same level or intensity
 * 4) withdrawal, as manifested by either of the following:
 * 5) characteristic psychophysiological withdrawal syndrome of physiologically described changes and/or psychologically described changes upon discontinuation of the behavior
 * 6) the same {or a closely related) behavior is engaged in to relieve or avoid withdrawal symptoms
 * 7) the behavior is often engaged in over a longer period, in greater quantity, or at a higher intensity than was intended
 * 8) there is a persistent desire or unsuccessful efforts to cut down or control the behavior
 * 9) a great deal of time spent in activities necessary to prepare for the behavior, to engage in the behavior, or to recover from its effects
 * 10) important social, occupational, or recreational activities are given up or reduced because of the behavior
 * 11) the behavior continues despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the behavior

Proposals based on obsessive/compulsive models
Schneider identified three indicators of sexual addiction: compulsivity, continuation despite consequences, and obsession.
 * 1) Compulsivity: This is the loss of the ability to choose freely whether to stop or continue a behavior.
 * 2) Continuation despite consequences: When addicts take their addiction too far, it can cause negative effects in their lives. They may start withdrawing from family life to pursue sexual activity. This withdrawal may cause them to neglect their children or cause their partners to leave them. Addicts risk money, marriage, family and career in order to satisfy their sexual desires. Despite all of these consequences, they continue indulging in excessive sexual activity.
 * 3) Obsession: This is when people cannot help themselves from thinking a particular thought. Sex addicts spend whole days consumed by sexual thoughts. They develop elaborate fantasies, find new ways of obtaining sex and mentally revisit past experiences. Because their minds are so preoccupied by these thoughts, other areas of their lives that they could be thinking about are neglected.

Eli Coleman proposed:
 * 1) involves recurrent and intense normophilic (nonparaphilic) sexually arousing fantasies, sexual urges, and behaviors that cause clinically significant distress in social, occupational, or other important areas of functioning; and
 * 2) is not due simply to another medical condition, substance use disorder, or a developmental disorder

Epidemiology
Sexual addiction is hypothesized to be (but is not always) associated with Obsessive-compulsive disorder (OCD), Narcissistic personality disorder, and manic-depression. There are those who suffer from more than one condition simultaneously (known as a dual diagnosis or a co-occurring disorder), but traits of addiction are often confused with those of these disorders, often due to most clinicians not being adequately trained in diagnosis and characteristics of addictions, and many clinicians tending to avoid use of the diagnosis at all.

Specialists in obsessive-compulsive disorder (OCD) and addictions use the same terms to refer to different symptoms. In addictions, obsession is progressive and pervasive, and develops along with denial; the person usually does not see themselves as preoccupied, and simultaneously makes excuses, justifies and blames. Compulsion is present only while the addict is physically dependent on the activity for physiological stasis. Constant repetition of the activity creates a chemically dependent state. If the addict acts out when not in this state, it is seen as being spurred by the obsession only. Some addicts do have OCD as well as addiction, and the symptoms will interact.

Addicts often display narcissistic traits, which often clear as sobriety is achieved. Others do exhibit the full personality disorder even after successful addiction treatment.

Manifestation
According to the book Synopsis of Psychiatry, sex addicts are unable to control their sexual impulses, which can involve the entire spectrum of sexual fantasy or behavior. Eventually, the need for sexual activity increases, and the person's behavior is motivated solely by the persistent desire to experience the sex act and the history usually reveals a long-standing pattern of such behavior, which the person repeatedly has tried to stop, but without success. Although a patient may have feeling of guilt and remorse after the act, these feelings do not suffice to prevent its recurrence and the patient may report that the need to act out is most severe during stressful periods or when angry, depressed, anxious, or otherwise dysphoric. Eventually, the sexual activity interferes with the person's social, vocational, or marital life, which begins to deteriorate.

Etiology
Proponents of the concept have described sufferers as repeatedly and compulsively attempting to escape emotional or physical discomfort by using ritualized, sexualized behaviors such as masturbation, pornography, including obsessive thoughts. Some individuals try to connect with others through highly impersonal intimate behaviors: empty affairs, frequent visits to prostitutes, voyeurism, exhibitionism, frotteurism, cybersex, and the like.

Neurochemical theories
Earle has argued that neurochemical changes, similar to an adrenaline rush in the brain, temporarily reduce the discomfort an individual experiences with urges and cravings for sexualized behaviors that can be achieved through obsessive, highly ritualized patterns of sexual behavior.

Psychological distress theories
Patrick Carnes (2001, p.40) argues that when children are growing up, they develop “core beliefs” through the way that their family functions and treats them. If a child is brought up in a family where his or her parents take proper care of him or her, he or she has good chances of growing up, having faith in other people and having self worth. On the other hand, if a child grows up in a family where he or she is neglected by his or her parents he or she will develop unhealthy and negative core beliefs. He or she will grow up to believe that people in the world do not care about him or her. Later on in life, the person will have trouble keeping stable relationships and will experience feelings of isolation. Generally, addicts do not perceive themselves as worthwhile human beings (Carnes, Delmonico and Griffin, 2001, p. 40). They cope with these feelings of isolation and weakness by engaging in excessive sex (Poudat, 2005, p.121).

Addiction theories
According to Patrick Carnes the cycle begins with the "Core Beliefs" that sex addicts hold:
 * 1) "I am basically a bad, unworthy person."
 * 2) "No one would love me as I am."
 * 3) "My needs are never going to be met if I have to depend on others."
 * 4) "Sex is my most important need."

These beliefs drive the addiction on its progressive and destructive course:
 * Pain agent — First a pain agent is triggered / emotional discomfort (e.g. shame, anger, unresolved conflict). A sex addict is not able to take care of the pain agent in a healthy way.


 * Dissociation — Prior to acting out sexually, the sex addict goes through a period of mental preoccupation or obsession. Sex addict begins to dissociate (moves away from his or her feelings). A separation begins to take place between his or her mind and his or her emotional self.


 * Altered state of consciousness / a trance state / bubble of euphoric fantasized experience — Sex addict is disconnected from his or her emotions and he or she becomes pre-occupied with acting out behaviours. The reality becomes blocked out/distorted.


 * Preoccupation or "sexual pressure" — involves obsessing about being sexual or romantic. Fantasy becomes an obsession that serves in some way to avoid life. The addict's thoughts become focused on reaching a mood-altering high without actually acting-out sexually. He or she thinks about sex to produce a trance-like state of arousal in order to fully eliminate feelings of the current pain of reality. Thinking about sex and planning out how to reach orgasm can continue for minutes or hours before moving into the next stage of the cycle.


 * Ritualization or "acting out." — These obsessions are intensified through the use of ritualization or acting out. A sex addict first cruises and then goes to a strip show to heighten his or her arousal until he or she is beyond the point of saying no. Ritualization helps to put distance between reality and sexual obsession. Rituals are a way to induce trance and further separate oneself from reality. Once the addict has begun his or her ritual, the chances of stopping that cycle diminish greatly. He or she is giving into the pull of the compelling sex act.


 * Sexual compulsivity — The next phase of the cycle is sexual compulsivity or "sex act". The tensions that the addict feels are reduced by acting on their sexual feelings. They feel better for the moment, thanks to the release that occurs.  Compulsivity simply means that addicts regularly get to the point where sex becomes inevitable, no matter what the circumstances or the consequences. The compulsive act, which normally ends in orgasm, is perhaps the starkest reminder of the degradation involved in the addiction as the person realizes that he or she has become nothing more than a slave to the addiction.


 * Despair — Almost immediately reality sets in and the addict begins to feel ashamed. This point of the cycle is a painful place where the Addict has been many, many times. The last time the Addict was at this low point, they probably promised to never do it again. Yet once again, they act out and that leads to despair. He or she may feel he or she has betrayed spiritual beliefs, possibly a partner, and his or her own sense of integrity. At a superficial level, the addict hopes that this will be the last battle.

According to Carnes, for many addicts, this dark emotion brings on depression and feelings of hopelessness. One easy way to cure feelings of despair is to start obsessing all over again. The cycle then perpetuates itself.

Treatment
Self-help groups such as Sex Addicts Anonymous, Sexaholics Anonymous, Masturbators Anonymous and Sex and Love Addicts Anonymous are popular with proponents of the sexual addiction concept. These are large groups based on the 12-step system of Alcoholics Anonymous. There are various online support forums as well as real-life help through an out- or in-patient program or private counselor.

Portrayal in popular culture

 * In the television show, Nip/Tuck, one of the main characters in some seasons, Gina Russo is portrayed as being a sex addict. She meets Christian Troy, who also has been diagnosed as having a sexual addiction by psychologist Grace Santiago, at a sexaholics anonomyous meeting, after which he sleeps with her after she was 8 months celibate.  She later contracts HIV.
 * In The L Word, the lesbian character Bette Porter, played by Jennifer Beals, is portrayed as a sex-addict who will use any woman she pleases to fulfill her sexual desires if she cannot do so with her on-off girlfriend (and apparent one true love), Tina Kennard.
 * Caveh Zahedi's documentary film I Am A Sex Addict addresses, as the title implies, his personal obsession with prostitutes and the subsequent destruction of short-term relationships that initiate in bar/club scenes. In the film Zahedi re-enacts and reminisces on his struggles with sex addiction and his recovery from it.
 * Brenda, a character from HBO's Six Feet Under, was a sex addict, and while the portrayal may seem to be accurate to a point, the problem also seemed to disappear almost as fast as it appeared.
 * A Dirty Shame starring Tracey Ullman as Sylvia Stickles is about a conservative housewife, to husband Vaughn Stickles (Chris Isaak), who suffers a concussion and is passed "the gift of sex addiction" by Ray Ray Perkins (Johnny Knoxville). While the movie refers directly to Sylvia as being a sex addict, the movie does not accurately represent sexual addiction and rather mocks the stereotype of the condition.
 * Choke, a novel by Chuck Palahniuk, shows how the main character, Victor Mancini, snoops around groups similar to Sexaholics Anonymous, not only recovering from his own sex addiction, but also to find possible sex partners.
 * Love Creeps, a novel by Amanda Filipacchi, describes the romantic relationship between a stalker and a sex addict.
 * Slaughter Disc, written and directed by David Quitmeyer, is a modern horror film where the main character is a college-aged porn addict. The ghost of a murdered porn star seeks revenge by using a porn addict's gravitation towards explicit sexual content to kill them off and enslave their souls. This film has caused controversy amongst horror film fans as it depicts gore, graphic violence and actual explicit hardcore sex acts.
 * Blades of Glory, a 2007 film, features Will Ferrell as Chazz Michael Michaels, who repeatedly claims to suffer the burden of sex addiction and attends a meeting of Sex Addicts Anonymous.
 * ~The Bill~ DS Phil Hunter of the UK television show The Bill confesses he is a sex addict and secretly picks up a pamphlet during one of his work visits to a doctor.
 * Black Snake Moan Black Snake Moan, a 2007 film directed by Craig Brewer, tells the story of how a Southern farmer named Lazarus, played by Samuel L. Jackson, takes in and looks after a young woman name Rae, played by Christina Ricci, in order to cure her of her sexual addiction
 * Brand's My Booky Wook In My Booky Wook by Russell Brand, the first and later chapters detail his time in a Sex Addiction clinic
 * Californication: David Duchovny plays a sex-addicted writer in the TV series "Californication." Duchovny himself was treated for sex addiction in August 2008.