Written by Munis Topcuoglu, Editor at EHN Canada.
A valid definition and diagnostic criteria for “sex addiction” have long eluded experts because, historically, definitions and diagnostic criteria have either represented sexually oppressive cultural norms, or they have been vague and imprecise, requiring too much subjective interpretation. Cultural norms, oppressive or otherwise, are not valid bases for diagnostic criteria, because they have no scientific justification. The definition of “too much sex” has varied widely throughout history and currently varies widely throughout the world, and none of the definitions are supported by scientific evidence.
The following excerpt from the book Nymphomania: A History describes a historical example of the problem of diagnosing sex addiction based on cultural norms:
In the Victorian period, both doctors and patients who sought medical help believed that strong sexual desire in a woman was a symptom of disease. Self-control and moderation were central to the health of both men and women, but women’s presumably milder sexual appetite meant that any signs of excess might signal that she was dangerously close to the edge of sexual madness.
Another excerpt from Nymphomania: A History, illustrates the absurdity of Victorian doctors’ culturally biased understanding of the etiology of “nymphomania”:
Eating rich food, consuming too much chocolate, dwelling on impure thoughts, reading novels, or performing ‘secret pollutions’ [i.e. masturbation]… overstimulated women’s delicate nerve fibers and led to nymphomania.
Interesting to note, is that in the Victorian era, the male equivalent of nymphomania “satyriasis” existed in medical textbooks, but was almost never diagnosed in practice—because “a man wanting too much sex” was not really considered a thing. Fortunately, both science and culture have come a long way since then, and we are now able to understand sex addiction in more functional and less sexist terms.
Evidence-Based Definition and Diagnosis of Sex Addiction
If we make the effort, we can minimize cultural bias, and define and diagnose sex addiction based on evidence. The key element for deciding whether or not a person’s sexual behavior is problematic is determining whether or not their sexual behavior results in real negative outcomes. This is the most effective approach for identifying genuinely problematic sexual behaviors and it lays the groundwork for creating effective treatment programs for the people who have them.
Required criterion: negative consequences or endangerment
The necessary criterion for identifying sex addiction is that the person’s sexual behavior actually results in negative consequences or endangerment in one or more of the following ways:
- Physical or psychological harm to the person or to his or her sexual partners
- Endangering the person’s health or safety, or endangering the health or safety of the person’s sexual partners (especially if done without partners’ knowledge and consent)
- Functional impairment in an important area of life such as health, relationships, family, work, education, etc.
Other signs of sex addiction: loss of control, frequency, consuming focus, and mood regulation
The following features can be signs of sex addiction when they result in negative consequences or endangerment:
- Irresistable or uncontrollable sexual urges
- Frequent or repetitive sexual behaviors
- Inability to reduce or stop sexual behaviors
- Sex becomes a central focus in the person’s life, to the point that he or she neglects other important areas such as health, relationships, family, work, education, etc.
- Increasing need for frequency, intensity, or variety of sexual experiences
- Sex is used to regulate mood or emotions, or in response to stress
The “other signs” by themselves are too subjective for diagnosis
The inability to control, reduce, or stop sexual behavior is only a sign of sex addiction when the person recognizes that the behavior has negative consequences or is unacceptably dangerous. Similarly, excessive frequency and repetition of sexual behaviors, or excessive focus on sex, can only be signs of sex addiction when the individual recognizes the negative consequences or dangers because, otherwise, “excessive” is merely cultural and subjective. It’s also important to note that, for similar reasons, engaging in sexual behaviors that others find offensive or disturbing does not, per se, indicate sex addiction.
What Is the Underlying Disorder?
Experts tend to agree that the problematic and uncontrollable sexual behaviors associated with sex addiction are usually the result of an underlying mental health disorder. They do not agree on which disorder is most often the cause, but the following is a list of possibilities:
- Anxiety
- Attachment
- Bipolar (a.k.a. manic depressive)
- Depression
- Impulse control
- Hormonal (i.e. primarily biological, not psychosocial)
- Obsessive-compulsive
Consequently, there does not exist an established standard process for how to treat sex addiction.
Understanding sex addiction as an attachment disorder
At EHN Canada, we find that nearly all of our sex addiction patients have underlying attachment disorders. Our experience has shown us that treating a patient’s attachment disorder is essential for helping the patient to overcome sex addiction, regain control of their sexual behavior, and have healthy and satisfying intimate relationships.
In adults, attachment disorders usually result in problems with intimate relationships that can include any of the following:
- Discomfort or anxiety associated with intimacy
- Seeking intimacy, approval, or responsiveness from partners: either too much or too little
- Being excessively dependent on partners, or alternatively, being excessively independent
- Having difficulty trusting partners
- Having negative opinions of oneself or of one’s partners
- Suppressing one’s emotions
Hence, we understand that sex addiction is a relational and intimacy disorder and this understanding informs our approach to designing the most effective treatment programs to help patients overcome sex addiction.
Interactions with concurrent substance use disorders
Sex addiction and concurrent substance use disorders can interact in a number of different ways including the following:
- “Alternating” is when a person shows a pattern of moving back and forth between two addictions.
- “Disinhibiting” is when one addiction lowers a person’s inhibitions so that the problematic behaviors associated with another addiction can occur. For example, when consuming alcohol lowers a person’s inhibitions enough that they will have unprotected sex.
- “Intensifying” is when two addictions are indulged at the same time to create an even more intense experience. For example, when a person uses methamphetamine to intensify the experience of having sex with strangers.
- “Masking” is when one addiction is used to hide or deny the existence of another. For example, when a person denies sex addiction by stating that they only engage in problematic sexual behaviors when they are intoxicated.
- “Numbing” is when one addiction is used to numb the feelings of shame that result from another addiction. For example, when a person uses benzodiazepines to numb the shame they feel due to their sex addiction.
At EHN Canada, we believe that it’s essential to understand how each patient’s sex addiction interacts with any substance use disorders that they may have. We address these interactions in the individualized treatment programs that we design for each patient. This approach allows us to create the most effective treatment programs according to each patient’s unique needs.
EHN Canada’s Sex Addiction Treatment Programs
Patients are admitted to our treatment programs based on screenings that evaluate the negative outcomes of their sexual behaviors and their persistence in engaging in those behaviors. Since we expect that problematic sexual behavior usually stems from an underlying attachment disorder, we analyze each new patient’s history of family relationships and family dynamics to learn about their attachment style. To allow us to further individualize our treatment programs to address each patient’s particular needs, we also screen for the following:
- Past trauma or abuse: the majority of our sex addiction patients have a history of abuse or interpersonal trauma (though not necessarily sexual)
- Substance use disorders: the majority of our sex addiction patients have concurrent substance use disorders
Ultimately, our goal is to develop a deep understanding of what the problematic sexual behaviors mean and signify personally for each patient, rather than try to understand the sexual behaviors in terms of any standard typology. We believe that this understanding allows us to design the most effective treatment program for each patient and reduces the influence of cultural bias.
Helping patients regain control of their sexual behaviors
EHN Canada treatment programs are designed to help patients regain control of their sexual behaviors. This begins with helping patients recognize and fully acknowledge the consequences of their problematic sexual behaviors. Next, we teach them how to identify and predict situations in which their sexual behaviors might have negative outcomes. We also teach patients how to identify triggers for their problematic sexual behaviors and how to address them in healthy ways. Throughout the process, we help patients with concurrent substance use disorders understand how their substance use disorders interact with their problematic sexual behaviors.
Whenever applicable, group education and therapy activities are conducted in small, intimate groups where patients can learn from each other in an environment free of shame and judgment. The following are some of the activities that help patients regain control of their sexual behaviors:
- Creating an addiction timeline that helps visualize life events and how the patient’s sex addiction developed
- Examining and understanding core beliefs and rationale that support the patient’s problematic sexual behaviors
- Identifying particular sexual behaviors that are especially problematic for each patient and from which each patient should, perhaps, abstain indefinitely
- Identifying possible relapse scenarios and designing mitigation strategies
- Creating a long-term recovery and aftercare plan
Teaching patients how to build healthy and satisfying relationships
Since we view sex addiction as a relational and intimacy disorder, our treatment programs include substantial education and therapy components focusing on interpersonal work such as effective communication, relationship building, and developing healthy attachments. Due to their interpersonal and experiential emphasis, our sex addiction programs involve more in-the-moment behavioral interventions compared to our other addiction and trauma programs.
Again, whenever applicable, group education and therapy activities are conducted in small, intimate groups where patients can learn from each other in an environment free of shame and judgment. The following are some of the activities that teach patients how to have healthier and more satisfying relationships:
- Exploring and processing core interpersonal traumas
- Education regarding how to enter and build healthy and satisfying intimate relationships
- Education regarding healthy and satisfying sexuality
Other elements of treatment programs
The following elements are included in some of our treatment programs or may be optional for patients:
- Mindfulness, meditation, and yoga
- Individualized nutrition and exercise plans
- Expressive arts therapy
Full recovery takes much longer than other addictions
A full recovery from sex addiction can take three-to-five years after completion of a treatment program. Therefore, long-term success depends on a patient’s commitment to participating in aftercare programs and to continue working on themselves after they complete one of our residential treatment programs.
EHN Canada Sex Addiction Treatment Programs
If you or someone you love needs help with sex addiction, please call us at one of our numbers below for more information or to enrol in one of our programs.
- 1-800-387-6198 for Bellwood Health Services in Toronto, ON
- 1-800-683-0111 for Edgewood Treatment Centre in Nanaimo, BC
References
Groneman, C. (2000). Nymphomania: A History. New York, NY: Norton.
Krueger, R. B. (2016). Diagnosis of hypersexual or compulsive sexual behavior can be made using ICD‐10 and DSM‐5 despite rejection of this diagnosis by the American Psychiatric Association. Addiction, 111(12), 2110-2111.
Ley, D.J. (2012). The Myth of Sex Addiction. London, England: Rowman & Littlefield.
