Compulsive Sexual Behaviours

A Psycho-Sexual Treatment Guide for Clinicians

Silva Neves

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000387100
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Compulsive Sexual Behaviours offers a unique approach to the struggles people face with their out-of-control sexual behaviours.

This comprehensive guide is deeply rooted in the science of sexology and psychotherapy, demonstrating why it is time to re-think the reductive concept of 'sex addiction' and move towards a more modern age of evidence-based, pluralistic and sex-positive psychotherapy. It is an important manual for ethical, safe and efficient treatment within a humanistic and relational philosophy.

This book will be an important guide in helping clients stop their compulsive sexual behaviours as well as for therapists to self-reflect on their own morals and ethics so that they can be prepared to explore their clients' erotic mind.

Part I

Understanding compulsive sexual behaviours

Chapter 1

A pluralistic perspective beyond the addiction thinking

The topic of ‘sex addiction’ is still a contentious debate amongst professionals. Whilst the ‘sex addiction’ thinking dominated the profession for many years, a growing number of clinicians are moving away from that conceptualisation as there is now a large body of clinical evidence that supports sexual compulsivity to be quite a different phenomenon (Ley, 2012; Magnanti, 2012; Bering, 2013; Donaghue, 2015; Braun-Harvey and Vigorito, 2016). As research and critical thinking goes on, the limitations of the addiction-focused model are becoming more evident. Over many years of working with clients presenting with sexual compulsivity, and studying the topic in depth, I have come to the conclusion that a pluralistic approach is essential for an effective and ethical treatment, as indicated by Cooper and McLeod:

The essence of this approach is the assumption that different clients may want different things from counselling and psychotherapy at different points in time (2011, p. 13).

It requires an understanding of multiple psychotherapeutic orientations in order to meet the needs of clients in the here-and-now. I draw my interventions from the field of sexology and various psychotherapy modalities. In my opinion, this approach has more to offer than the single framework of addiction.

It does matter what we call it

Many therapists are confused with the terms addiction and compulsivity. Some think they are the same. Some think it doesn’t matter what you call it. Some say that if a behaviour is out of control then it is an addiction. All of these thoughts are reductive and they serve the purpose of avoiding being challenged. Before I go on with the definitions and explain the distinct differences, let me tell you first that, yes, it does matter what you call it because it determines the treatment you offer to clients. A cough may be a common cold, lung cancer or a speck of dust stuck in your throat. It certainly matters what the cough is to get the right treatment. The psychotherapy field should uphold the same rigorous approach as the medical profession; a failure to do so is negligence, in my opinion.

Addiction

Addiction is a complex pathology understood in the context of substances introduced in the body that creates physiological and psychological consequences. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies the pathology under ‘Substance Use Disorders’ with the following criteria:

1. Impaired control: unsuccessful attempts to reduce or stop using the substance. Spending a lot of time obtaining, using and recovering from the substance. Intense urge to take the substance, called cravings.

2. Social impairment: failure to meet life’s obligations because of the substance use. Continued use of the substance despite negative consequences. Social activities stop or are avoided in order to continue using the substance.

3. Risky use: using the substance in a dangerous way. Unable to stop using it even when there are clear ongoing physical and psychological problems.

4. Tolerance: needs an increased dose to achieve the desired effect.

5. Withdrawal: a physical discomfort when the level of substance reduces in the blood and tissue.

It is easy to mistake sexual compulsivity for an addiction because we often hear clients struggling with impaired control and, sometimes, but not always, social impairment. However, in sexual behaviours, the elements of risky use, tolerance and withdrawal are not present.

Risky use: there is a risk of contracting a sexually transmitted infection, which is damaging, but it will not kill people. Some clients may put themselves in risky situations when engaging in compulsive sex, although it is not common or frequent.

Tolerance: implies that the sexual behaviour has to be pleasurable to start with and then stops being pleasurable, so the person needs to do more of it to achieve the same effect. This is one of the major criteria of addiction that is not present in sexual behaviours. Sexual pleasure never stops being pleasurable and people don’t need to have more sex to achieve the same pleasure. People sometimes report not feeling pleasure from their compulsive sexual behaviours. It is not because they have become desensitised to it and need more of it, it is because they have dissociated from it, which is a big difference. People mindlessly eating their favourite cheese may not feel the pleasure of the taste in that moment, but they will continue to have the same enjoyment of their cheese when they eat it mindfully.

Withdrawal: is also another major criterion that has never been observed in sexual behaviours because our body is naturally designed to sustain the brain chemicals involved in the pleasure experience of sex and orgasms.

The DSM-5 explains the phenomenon of craving as:

an intense desire or urge for the drug that may occur at any time but is more likely when in an environment where the drug previously was obtained or used (2013, p. 483).

Addiction experts call the association of an environment with the intense urge ‘cue reactivity’. This is quite confusing for addiction professionals who have no training in sexology because they can mistake the pathological addiction of cue reactivity with the normative one of sexual desire and arousal. Sexual stimuli naturally bring sexual arousal in a non-pathological way.

Prominent addiction expert Gabor Maté defines addiction more broadly incorporating ‘behavioural addiction’, also called ‘process addiction’:

Addiction is any repeated behaviour, substance-related or not, in which a person feels compelled to persist, regardless of its negative impact on his life and the lives of others (2018, p. 128).

Neuroscientist Marc Lewis refers to sex as an addiction too but argues that addictions should not be conceptualised as a disease:

If addiction is a disease, then so, apparently, is love (2015, p. 168).

Lewis makes the analogy of addiction as ‘false advertising’:

The striatum responds with eager anticipation to the glitter bestowed by our wishes and fantasies. But the high is never as good as promised and, worse, it doesn’t last (2015, p. 171).

The American Psychiatric Association, however, excludes ‘sex addiction’ and ‘behavioural addiction’ from the DSM-5:

groups of repetitive behaviors, which some term behavioral addiction, with such subcategories as “sex addiction”, “exercise addiction”, or “shopping addiction”, are not included because at this time there is insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions needed to identify these behaviors as mental disorders (2013, p. 481).

Neuroscientists who are sex researchers concur with the DSM-5:

To date, research on the effects of sex on glutamate function and its modulation of dopamine pathways is scarce. Sex is primary reward, with unique peripheral representation. Engagement in sex is positively associated with health and life satisfaction. Sex does not allow for supraphysiological stimulation (Prause et al., 2017).

The American Association of Sexuality Educators, Counselors and Therapists (AASECT) made a clear statement on their website regarding ‘sex addiction’:

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.

The World Health Organisation (WHO) and the International Classification of Disease (ICD-11) classified the condition as ‘Compulsive Sexual Behaviour Disorder’ (CSBD), under the impulse control category, not addiction. The Medical Services Advisory Committee, whose role it is to advise WHO in the development of the ICD-11, states:

materials in the ICD-11 make very clear that CSBD is not intended to be interchangeable with sex addiction, but rather is a substantially different diagnostic framework

Compulsivity and impulsivity

Berlin and Hollander (2008) summarise impulsivity as a:

tendency to act prematurely and without foresight for the purpose to increase arousal.

They define compulsivity as:​​​​

a tendency to repeat the same, often purposeless acts, which are sometimes associated with undesirable consequences for the purpose of relief of tension.

A compulsive behaviour aims to reduce unpleasant emotions. People with compulsivity are fully aware that their behaviours are irrational because they do not have any links to the unpleasant emotions they are trying to reduce, yet, they can’t stop the behaviours. For example, someone compulsively washing their hands knows that they won’t be able to irradicate germs. Someone compulsively eating biscuits knows that the biscuits won’t fix their anxiety. But the stress and anxiety that these people feel is relieved temporarily at the moment of the compulsive behaviour. Crucially, there is no pleasure experienced with compulsive behaviours. We can understand compulsive sexual behaviours’ undercurrent purpose as both an attempt to increase arousal as well as relieving tension. Both are good strategies to manage emotional disturbances if the client doesn’t have other strategies for emotional resilience. Increasing arousal and relieving tension can also be a normal function of sex that doesn’t necessarily respond to emotional disturbances.

In contrast, some people find impulsivity exciting because they enjoy the thrill despite the possible negative consequences. For example the impulse of ‘I might get caught having sex in the woods’ may produce a thrill-seeking excitement. In other words, impulsivity is an active going towards pleasure and compulsivity is an active moving away from unpleasant emotions. It is important to consider the function of impulsivity and compulsivity with each client to help them understand how they can regulate them better, like driving a car, with a consistent balance between acceleration and braking.

However, both the pathology of addiction and the understanding of compulsivity assume that sex stops feeling good. This is where the two models fail to fully describe people’s sexual behaviour problems. It is very rare to meet someone who likes sex experiencing no pleasure from it.

The problems with the ‘sex addiction’ approach

As mentioned earlier, what we call it determines the treatment. ‘Sex addiction’ therapists are congruent with their beliefs and their treatment. The typical addiction treatment primarily focuses on stopping behaviours and avoiding ‘triggers’. In the ‘sex addiction’ thinking, it translates into avoiding anything that has the potential of being sexual or arousing: attractive people, posters showing models in bikinis, sexual scenes on television or movies, sexual jokes, any sexual stimuli, including sexual fantasies!

The simplest and most effective strategy is simply to look away (…) Other strategies include making sure you’re facing the wall in public places so you’re less likely to notice people or scan on the off chance (Hall, 2019, p. 146).

These types of typical addiction strategies are problematic because they encourage clients to be erotically avoidant, which is not a sustainable outcome. Being that avoidant makes for a pretty miserable life of deprivation; it’s like being on a spinach diet, with no dressing.

Although there have never been any reports of death from orgasm overdose, ‘sex addiction’ professionals try very hard to apply the addiction definition to sex, making clients believe that there is a tolerance to these behaviours which escalate to unmanageable levels. The ‘sex addiction’ field tries to instil fear of the addiction by discussing the dangers of contracting sexually-transmitted infections or the sexual behaviours escalating to illegal territory, confusing sexual compulsivity with sexual offending, which are, in fact, two distinctly different clinical presentations. Carnes (2001) erroneously classifies sexual offending under what he calls the ‘Leve...