Routledge International Handbook of Sexual Addiction

Thaddeus Birchard, Joanna Benfield, Thaddeus Birchard, Joanna Benfield

• Publisher: Routledge
• Year: 2017
• Print ISBN: 9781138193208
• eBook ISBN: 9781317274254
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

The concept of sexual addiction has gained increasing recognition in the academic and healthcare communities since the 1990s. It has also captured the attention of the media, where there has been much debate over whether it can truly be described as an addiction. What is certain is that many people struggle with out of control sexual behaviour, which takes over their lives and has harmful consequences for their relationships, careers and finances.

The Routledge International Handbook of Sexual Addiction brings together a comprehensive range of perspectives on sexual addiction from a worldwide selection of scholars and therapists. It sets out to define sexual addiction and to study its causes from a range of different psychological perspectives. A series of presentations of sexual addiction are outlined, including internet sexual addiction and the relationship between paraphilias and sex addiction. The handbook considers both individual and group treatment strategies, drawing on a wide range of approaches, including cognitive behavioural therapy, mindfulness and 12-step programmes. The book studies sex addiction in specific populations including women, adolescents and men who have sex with men. Finally, it considers some of the alternative discourses surrounding the concept of sexual addiction.

This is the first comprehensive reference book to bring together global viewpoints on advances in research, theory and practice in one volume. This handbook provides an essential guide for academics and students of psychotherapy, counselling, nursing, addiction, sexualities, social work and health and social care, as well as professionals in practice and in training working with sexual addiction and related issues.

SECTION 1

An introduction to sex addiction

1.1

Introduction

Joanna Benfield

Cultural developments and digital advances over the past half a century have had an enormous impact on our perceptions of sex. The so-called sexual revolution of the 1960s and 1970s challenged traditional attitudes towards sex in an unprecedented way. Many positive changes occurred in terms of attitudes towards women’s sexuality, homosexuality and different forms of sexual expression. The invention of the contraceptive pill gave women control over their own fertility, allowing them to have sex for pleasure without worrying about the reproductive implications. A fundamental shift in the relationship between men and women was also seen as more women entered the workforce and began to earn money.

Today, we have entered an era in which sex is visible and available to an extent that we have never before experienced. We need look no further than the advertisements on our televisions or on billboards to see sex being used to sell everything from cars to clothes and perfume; we are constantly bombarded with sexual imagery. The advent of the internet has made sex available in far more overt forms still, opening a whole new world of sexuality. The creation of ‘hook-up’ apps and websites offering the possibility of immediate sexual encounters has moved this new sexual world from the virtual to the real. There is a dazzling array of potential sexual partners offering many different forms of sex. The internet has created the opportunity for us to have sex with whom we want, when we want (Carnes et al., 2007).

As a result of cultural developments, we live in a far more sexually liberated society than before. A comprehensive study has shown that American adults have become far more accepting of premarital sex, adolescent sex and same-sex sexual activity since the 1970s (Twenge et al., 2015). The study also found the number of sexual partners people reported having has increased, as have rates of casual sex, showing how rising cultural individualism has produced an increasing rejection of traditional cultural rules regarding sex (Twenge et al., 2015).

The term ‘sex addiction’ has emerged in tandem with these cultural shifts. From the 1970s onwards, sexual self-help groups began to spring up, based on the 12-step model of Alcoholics Anonymous. These groups were aimed at helping individuals who felt they were no longer in control of their sexual behaviour. In addition, fears of out of control sexual behaviour intensified in the light of the AIDS epidemic in the 1980s (Irvine, 1985, in Reay et al., 2013). As awareness of sex addiction increased, counsellors and psychotherapists began to provide treatment for individuals who reported difficulties with their sexual behaviour. Dr Patrick Carnes was the therapist at the forefront of this, developing protocols and treatment strategies for both group and individual therapy. Today, there is a community of sex addiction treatment professionals throughout much of the world, serving an ever-growing population.

As awareness of the concept has grown, sex addiction has become a juicy theme for popular culture and has been explored in a number of films, such as Shame (2011) and Thanks for Sharing (2012). As the concept becomes increasingly discussed in the media it is possible that more people begin to question their own or their partner’s sexual behaviour, further increasing awareness of the problem. The media, however, remains divided on the topic. While some argue that sex addiction is the new scourge on our society, others dismiss it entirely, often critiquing it on moral grounds, arguing that it is simply being used as an excuse for bad behaviour.

Criticism of the concept of sex addiction is not just confined to the media. There are many voices of dissent in both the academic and therapeutic communities. Some critics argue that the concept of sex addiction, and the accompanying treatment industry, is simply a reaction to cultural shifts of the last few decades. As Levine and Troiden write, ‘The concepts of sex addiction and compulsion constitute an attempt to repathologize forms of erotic behaviour that became acceptable in the 1960s and 1970s’ (Levine and Troiden 1998: 349, in Reay et al., 2013: 2–3). Certainly, it is true that some religious groups, who saw their values undermined by the new developments, were active participants in the sex addiction treatment movement. Critics might also assert that the sex addiction treatment industry has become lucrative, preying on the stigma attached to sexual liberation, with the emergence of expensive inpatient treatment centres.

Whether we agree with this analysis or not, there is surely a warning worth heeding in these viewpoints. As therapists, we need to be careful that, in diagnosing sexual addiction, we are not simply stigmatising a cultural shift. Sexual addiction cannot simply be diagnosed to reflect the prevailing moral standpoint. It is imperative that we are ethical in our treatment of sex addiction and that we do not stigmatise otherwise healthy sexual behaviour just because it does not conform to our own personal or cultural views of what is healthy. If we do so, we are also in danger of stigmatising certain groups for whom greater sexual freedom is considered a normal part of their lifestyle. As therapists, it is imperative that we strenuously guard against this. For example, a person who is distressed by homosexual thoughts and behaviour might seek out ‘conversion therapy’ but that in no way makes it ethical for us as therapists to try to ‘cure’ them. Equally, someone who is distressed by sexual thoughts that do not fall in line with their religious values might not need ‘curing’ per se, but may instead need an opportunity to discuss and eventually reconcile their conflicting needs and values. As Moser writes, ‘…some individuals seek help because they perceive their sexuality as out of control. It is not clear if this perception is accurate, the result of another mental disorder, a new mental disorder…, or a conflict between the individual and society (or the individual’s religious beliefs, self-imposed morality, personal expectations, or a misunderstanding of what constitutes normal sexuality)’ (Moser, 2013: 56). We must at all times remain aware of this and ensure that we are clear about what it is we are treating and why.

Most of us who work in the field of sex addiction have no wish to stigmatise sex. We see it as an enjoyable and necessary part of life, and we work from a sex-positive stance. After all, as human beings, we are biologically programmed to enjoy sex; it is a necessary design feature in the propagation of the species. It may be difficult to see how we can treat an ‘addiction’ to something we don’t necessarily want to banish from our lives. Generally, in treating alcohol or drug or gambling addiction, our aim will be to completely eradicate the use of the substance or the behaviour from the person’s life. This would not be a desirable outcome in most cases of sex addiction. The aim instead would be for sex to become an enjoyable and healthy part of the person’s life. In this respect, parallels could be drawn between the treatment goals of sex addiction and those of eating disorders. We need to eat to live, and the aim of treating eating disorders is to help the patient re-establish a healthy relationship with food.

The criticisms of sex addiction have been highlighted by its exclusion from the latest version of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders – 5^th Edition (DSM-5; American Psychiatric Association, 2013). Dr Martin Kafka, of Harvard University Medical School, made a compelling, if ultimately unsuccessful, argument for the inclusion of ‘hypersexual disorder’ in DSM-5 and proposed diagnostic criteria (Kafka, 2010). He argued that sex addiction differed from healthy sexual behaviour in that, in the case of sex addiction, sex was used to relieve negative emotional states and resulted in significant distress for the individual. Even though this was not taken up by the American Psychiatric Association, it is a useful definition for us to keep in mind when working with patients.

One of the main reasons sex addiction was not included in the DSM-5 was a lack of empirical evidence. This is perhaps strange, given the growing number of academics working in the field and individuals presenting with out of control sexual behaviours. We must question why the topic has not attracted significant research funding or interest. Some may argue that the failure to recognise sex addiction is political; after all there are no great advantages for pharmaceutical companies in its inclusion in DSM-5 and, therefore, there is no powerful industry lobby acting as its advocates.

It is clear that for sex addiction to be considered for future versions of the DSM, there would need to be clear agreement about its definition, as well as a set of clear criteria for diagnosis. Equally, until we can establish how many people suffer from sex addiction, it is unlikely to be universally accepted as a clinical disorder. Without greater certainty about the prevalence of sex addiction, we cannot definitively argue that it is increasing, even if anecdotally this seems to be the case. As Moser writes, ‘The current state of our knowledge about individuals who are seeking help for purported “hypersexual behaviour” appears to be superficial and characterized by subjective interpretations and preconceptions of the nature of this disorder’ (Moser, 2013: 56). Such criticism, hard as it may be to hear, is surely valid at the current point in time. As therapists, researchers and scientists we need to take responsibility for addressing this lack of information and knowledge in order to make a definitive case for the disorder. As editors of this handbook, we hope that it can be a small step in the right direction of encouraging an increase in research into the causes, symptoms, affects and treatments for sex addiction.

Recent developments in neuroscience may soon help to resolve some of the arguments as to whether or not sex addiction should be recognised as a disorder. MRI scans are beginning to show how out of control sexual behaviour impacts the brain, and similarities in this regard are emerging with other addictive processes, such as drug addiction (Voon et al., 2014), internet addiction and gambling (Love et al., 2015). However, further neurobiological research is needed to strengthen the evidence-base for sex addiction.

For the moment, as therapists, we face a diagnostic challenge: can we definitively diagnose an individual as having a disorder that does not appear in the DSM? Without definitive diagnostic criteria, we perhaps run the risk of what Hall describes as ‘loitering in the shallows of unconscious incompetence’ (Hall, 2013: 2), lacking the appropriate map and compass for our work. Does this mean that, as a sex addiction treatment community, we should stop treating individuals presenting with out of control sexual behaviour until we have definitive criteria? Personally, I firmly believe this would be a dangerous path to take.

Most of us who work as therapists in this field are aware that, whatever name we give to sex addiction, time and again individuals walk through our consulting room doors who are experiencing marked distress as a result of their sexual behaviour. They tell us they no longer feel their sexual behaviour is within their control, relationships with their partners have broken down and, in some cases, they have experienced severe financial consequences, such as losing jobs or homes. Whatever label we give it, therapists should be able to offer help and solace to an individual in distress. As Reid writes, ‘Clinically speaking, a patient’s subjective description of sexual fantasies, urges, and behaviors combined with their personal distress, feelings of diminished control, and negative consequences, is likely more meaningful for treatment purposes than the label given to these characteristics’ (Reid, 2013: 5). Each of us will have a different approach to working with these patients. We may not all choose to ‘diagnose’ a patient with sex addiction but we will do our best to alleviate difficulties and help them overcome distress. Often, it is the patient themselves that uses the term and, as therapists, we need to explore what the label means to them. In other cases, it may be the partner who has labelled the problem as sex addiction and sent the ‘errant’ spouse for treatment. In such cases, we will want to explore whether the patient sees their behaviour as problematic. Whichever approach we take, it is ethical to work with the patient to help them understand and alleviate their distress, even if we cannot offer them a DSM-approved diagnosis.

As a result of the exclusion of sex addiction in the DSM-5, it is perhaps even more important to have a comprehensive handbook on the issue. Therapists lack guidance on how to recognise and treat the disorder, and it is hoped this handbook might fill the gap somewhat. It is aimed at therapists, researchers and others interested in the field of sexual addiction. The book gathers together a comprehensive range of perspectives on sexual addiction from a worldwide selection of scholars and clinical practitioners. It sets out to try to define sex addiction, to study its causes and to propose effective treatment strategies. The handbook also considers sex addiction in specific populations and looks at some of the alternative discourses surrounding the concept.

The handbook is structured to make it easily accessible to the reader and is divided into seven sections. Section one provides an overview of the concept of sexual addiction. The authors in this section examine classic and contemporary approaches to aetiology and diagnosis. The topic of definitions is explored, even though sex addiction is by no means a universally accepted concept. A biopsychosocial lens is used to encourage practitioners to adopt a comprehensive approach for both diagnosis and treatment that addresses the complexities of individual cases. Section two explores some of the main forms in which sex addiction presents, including internet sex addiction, and the use of fantasy. It also covers paraphilic disorders, which are oft...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• About the Editors
• List of Contributors
• Foreword by Dr Stefanie Carnes and Dr Patrick Carnes
• SECTION 1 An introduction to sex addiction
• SECTION 2 Presentations of sex addiction
• SECTION 3 The aetiology of sex addiction
• SECTION 4 The treatment of sex addiction
• SECTION 5 Sex addiction in specific populations
• SECTION 6 Alternative discourses on sex addiction
• SECTION 7 Conclusion
• Index