What is sex addiction?

Causes

The causes of sex addiction are not known. Nevertheless, as with substance addictions, most research focuses on the structures of the brain’s mesolimbic reward system and the neurotransmitter (chemical messenger) dopamine . Most researchers believe that the mesolimbic reward system evolved to sustain behaviors that are necessary for survival and reproduction—namely, the pursuit of food, water, and sex.

Normal sexual arousal and orgasm involve excitation in the mesolimbic reward system. In sex addiction, repeated sexual behavior is hypothesized to result in excessive stimulation of dopamine pathways in structures of the mesolimbic reward system (for example, the striatum), thereby causing changes at the cellular level (fewer dopamine receptors) that lead to even greater desire and cravings to engage in the behavior.

As in substance addictions, classical conditioning appears to play a role in the development and maintenance of many sexually addictive behaviors. Stimuli that are present when an addict engages in the problem behavior, such as a computer that the person uses to view pornography or a street where the person has often visited a strip club, can become powerful triggers for the desire to engage in the addictive behavior.

Risk Factors

Men are at higher risk than women for sex addiction. Although high-quality epidemiological data are lacking, the substantial majority (80 percent or more) of sex addicts addressed in published work are male. Access to numerous sexual partners also may be a risk factor. Thus, men who are famous or socially powerful may be at especially heightened risk for sex addiction.

In 2010, tremendous media attention focused on the alleged sex addiction of golf superstar Tiger Woods, who was reportedly treated for the condition. In 2011, Anthony Weiner resigned from the US House of Representatives because of his alleged involvement in a sexting scandal. Although both Woods and Weiner and numerous other high-profile persons with “excessive” sexual activity were labeled as “sex addicts” by much of the popular media, it is not known whether either men met any formal or informal criteria for sex addiction.

Some experts have suggested that childhood sexual abuse may play an important role in the development of sex addiction. Nevertheless, available research suggests that childhood sexual abuse is a nonspecific risk factor for a broad range of mental health difficulties during adulthood rather than a specific risk factor for sex addiction.

Although pornography viewing and masturbation are common manifestations of sex addiction, these behaviors are common among adult men, and the vast majority of these men will never develop behaviors that are compulsive or otherwise problematic. Thus, masturbation and pornography are not considered risk factors for sex addiction.

Some clinicians believe rates of sex addiction have increased in recent years because of the Internet. They argue that the Internet has made pornography, and connection with casual sex partners and prostitutes, far more accessible, anonymous, and affordable than ever before. This claim is plausible, but there is no firm data to support or refute it.

Symptoms

The manifestations of sex addiction are diverse. Nevertheless, all manifestations involve a preoccupation with sexual thoughts, fantasies, or urges and sexual activity that is excessive in frequency or duration. The behavior is pursued despite obvious costs and consequences, such as loss of a job or relationship or getting a sexually transmitted disease. Many sex addicts have repeatedly attempted to discontinue or curb their behavior unsuccessfully.

There is controversy concerning whether sex addicts exhibit tolerance and withdrawal. In support of the view that tolerance develops, some have observed that many sex addicts take greater risks over time and engage in increasingly extreme or unusual sex acts. Similarly, some argue that withdrawal is evident in the frustration and anger sex addicts experience when they cannot engage in the desired sexual behaviors.

Many clinicians have reported that sex addicts use sexual behavior as a way to cope with unpleasant emotions; this possibility needs to be examined in systematic research. Data are limited, but preliminary information suggests that sex addiction is highly comorbid (overlapping), not only with substance addictions but also with anxiety and mood disorders.

Sex addiction may manifest differently in women than in men. Rather than focusing on fantasies and behaviors associated with sexual gratification, as do most men with sex addiction, some women who self-identify as sex addicts appear to experience an ongoing series of intense romantic attachments toward new partners. The romantic attachments may develop toward inappropriate persons (such as a coworker or boss) and despite possible negative consequences (such as the loss of one’s marriage). Although no systematic data are available, there have been occasional reports of men who experience such a series of attachments to many partners over time. Some authors refer to this ongoing pattern of new romantic attachments as love addiction.

Screening and Diagnosis

As noted, sex addiction is not recognized as a formal mental health diagnosis. However, because of the need for a diagnosis for sexual behavior (intercourse or masturbation) that is excessive in frequency or duration and causes subjective distress or impairment in social or occupational functioning, a related diagnosis of hypersexual disorder was considered for inclusion in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) but later rejected.

Hypersexual disorder has a narrower focus than does sex addiction. Whereas the former refers only to “normal” sexual behaviors that are habitual and cause distress or impairment, sex addiction refers either to such normal sexual behaviors or to deviant sexual behaviors (such as exhibitionism and fetishes) that are habitual and cause distress or impairment.

A clinician who suspects sex addiction should conduct a thorough interview, inquiring about the person’s sexual behaviors, urges, and fantasies and their frequency, duration, and consequences. Clinicians also may screen for sex addiction using various checklists and questionnaires.

Treatment and Therapy

Little research has been conducted on the efficacy of treatments for sex addiction. However, most treatment approaches for sex addiction parallel effective treatments for substance addictions. These approaches include behavioral therapy and cognitive-behavioral therapy. Such treatments teach addicts how to recognize and avoid stimuli that increase the risk of engaging in sexually inappropriate behavior. Such stimuli generally include people, places, and Internet sites associated with the addict’s previous maladaptive sexual behavior.

Because many sex addicts engage in sexually inappropriate behaviors in response to negative emotions, sex addicts may be taught skills that enable them to cope with negative feelings more adaptively and to identify situations that may trigger unpleasant emotions, such as anger or feelings of loneliness. Cognitive-behavioral therapy interventions also seek to identify and correct erroneous beliefs (for example, “I will be miserable if I cannot have sex when I have the urge to do so”) that the addict maintains about sex or romantic relationships.

In addition to embracing traditional psychotherapy, many clinicians and recovering sex addicts believe twelve-step programs (support groups modeled after Alcoholics Anonymous, or AA) are helpful to recovering sex addicts. Note, however, that whereas AA promotes complete abstinence from alcohol, twelve-step groups for sex addicts promote responsible sexual behavior rather than abstinence. Inpatient treatment programs for sex addiction exist and are typically used when outpatient treatments fail to curb life-threatening behaviors, such as frequent unprotected sex with strangers.

In extreme cases in which a sex addict’s behavior is illegal or harmful to others (such as with exhibitionism), antiandrogen medications (including Depo-Provera, or depot medroxyprogesterone acetate) are sometimes prescribed to reduce the person’s sex drive. Nevertheless, controlled studies to ascertain whether these medications are effective for sex addiction are lacking.

Prevention

No research has been conducted on the prevention of sex addiction.

Bibliography

Carnes, Patrick J. Don’t Call It Love: Recovery from Sexual Addiction. New York: Bantam, 1991. Print.

Cooper, Alvin. “Sexuality and the Internet: Surfing into the New Millennium.” Cyberpsychology and Behavior 1.2 (1998): 187–93. Print.

Kafka, Martin P. “Hypersexual Disorder: A Proposed Diagnosis for DSM-V.” Archives of Sexual Behavior 39.2 (2010): 377–400. Print.

Reid, Rory C., and Martin P. Kafka. “Controversies about Hypersexual Disorder and the DSM-5.” Current Sexual Health Reports 6.4 (2014): 259–64. PDF file.

Rosenberg, Kenneth Paul, Patrick Carnes, and Suzanne O'Connor. “Evaluation and Treatment of Sex Addiction.” Journal of Sex & Marital Therapy 40.2 (2014): 77–91. Academic Search Complete. Web. 28 Oct. 2015.