Churches, Basements and Smoky Rooms: The Many Faces of Sex Addiction

Dan Fielding on Night Court. "I think you're letting the little head think for the big head." Gotcha starring Anthony Edwards. Doug Ross on ER. Brian Kenney on Queer as Folk. The concept of sex addiction or sex being the driving force in our lives has existed for a long time. Women, while not as plentiful, also have their representatives, Samantha on "Sex and the City" and Blanche from "Golden Girls" come immediately to mind. Many theories exist as to the cause, ranging from moral weakness; the little head really is stronger than the big head, all the way to a physical disorder with a chemical imbalance. The field is new. Patrick Carnes published "Out of The Shadows" in the late eighties lifting the veil for countless people who simply thought they were failures.

Twelve Step groups sprang up - SAA, SA, SLAA, interesting that other addictions get one group, AA, NA, CA, OA, but sex addiction is so "cunning, baffling, and powerful" that multiple approaches are needed. While the fellowships share some things in common, they are distinct and meet the needs of different populations. SAA - Sex Addicts Anonymous - has no preconceived notions about sexual sobriety. Each member defines their own bottom lines. Gay addicts as well as single heterosexual people who struggle call SAA home. SA - Sexaholics Anonymous defines sobriety for its members as monogamous, heterosexual sex within marriage. Any other sex crosses bottom line boundaries. Obviously gay men and women don't find much of a home here. SLAA - Sex and Love Addicts Anonymous - is for people who connect love and sex and cannot get enough of either. For SAA and SA members, the compulsive sex act in whatever form is all that matters. In fact, addicts report having sex with strangers, friends, animals, people they would not want to be seen with otherwise, whatever is available.

SAA offers a simple twelve question survey to help people determine if they have a problem. (SAA, 1991.) The questions range from being arrested because of sexual behavior to feelings of shame and asexuality. For SAA addiction runs the entire scale of sexual responses and activity. Any sexual behavior that a person cannot manage qualifies as addiction. Pornography, masturbation, voyeurism, sex with people one doesn't like, aversion and avoidance of any sexual activity all qualify as addictive behaviors. This is not a universal definition, however. Greenburg and Bradford (1997) define paraphilic disorders as compulsive non-conventional behaviors, while compulsive culturally acceptable sex acts are considered addiction. Many addicts do not make this fine a distinction. Any out of control behavior is addiction.

One of the common causes, or at least links among sex addicts is the idea of abuse. (Kort, 2004). Carnes reported 81 percent (1991) while other studies put the number at 64 percent of sex addicts as former victims of abuse. (Blanchard, 1990). Researchers have theorized that abuse leads to compulsion as a "result of stigma and trauma to unfolding sexuality." (Kort). Abuse leads to shame, and shame often leads to compulsion and hidden activities.

Abuse generally splits into two types: contact and non-contact abuse. Contact abuse involves physical contact - touching, forced sexual activity, etc. Non-contact or covert abuse, more subtle, but perhaps more damaging due to the subtlety. Examples of covert abuse include sexualizing of language, age inappropriate conversations, exhibitionism and voyeurism and preoccupation with a child's sexual development.

Kort (2004) argues that verbal abuse aimed at a person or group due to gender or sexual orientation qualifies as sexual abuse. The gay population suffers this abuse on a regular basis and when it happens in childhood or adolescence can lead to sexual compulsivity the same as any other form of abuse.

While many experts do not consider this pressure on adolescents to be heterosexual as abuse, McNaught (1997) suggests role reversal as a way of understanding the damage that can be done to our youth.

Imagine how today's society would respond if heterosexual thirteen to nineteen year olds were forced to date someone of the same sex. What would the reaction be if they were expected to hold the hand of, slow dance with, hug, kiss and say "I love you" to someone to whom they could not be sexually attracted? Yet, that's part of the everyday life of gay teenagers.

Often this abuse becomes internalized in teenagers. The gay teenager looks inside himself and finds the target of all the insults and taunts he heard growing up. Faced with this, the future addict develops self hatred and shame just for who he is. Esther Giller (1999) reminds us that the definition of trauma is very broad. In effect, the definition of trauma is left up to each individual. In other words, the internalization of homophobic taunts and pressure creates trauma for the questioning teenager.

Thus, for many gay males, the etiology of sex addiction comes from homophobia, heterosexism, and internalized homophobia. Dissociation follows as the natural consequence of internal hatred.

Research has focused on the relationship between sexual compulsivity and dissociation as a response to previous childhood sexual abuse. (Cheney, 2005). While people of both genders and all sexual orientations suffer from sexual addiction, it seems in many ways as if society stacks the deck against gay males. The potential for abuse, shame and the need to keep themselves hidden triggers in many an impulse for uncontrollable sexual behaviors.

Other reasons have been suggested for sexual addiction. The crisis in masculinity, whatever the sexual orientation, the forcing of young boys to turn away from their mothers as a source of emotional support, as well as the idea that there is a "masculine essence" that is invariant. (Levant, 1992) leads to a "non-relational attitude toward sex." This attitude often culminates in seeking sex for sex' sake, with no thought of the partner or having any emotions involved. This unconnected lust views sexual partners as rewards or treats either for success, or as a release when struggling, either way, the partner, the act, the orgasm is an entitlement with no restrictions or consequences.

In the past few years, a new form of sexually addictive behavior has sprung up involving the Internet. The Internet provides a forum and a place to connect for anyone lonely or looking to fill unmet needs. Three factors seem to increase the risk of compulsive behavior through the Internet: being prone to boredom, lack of social connectedness, and dissociation. (Chaney, 2005). Samuels and Samuels (1974) reported a link between boredom and substance abuse. Other studies implicate boredom in compulsive gambling and sexual addiction. Boredom is defined as experiencing monotony and lacking personal motivation. (Sundberg, 1991). Often, boredom manifests itself in men who have sex with men (MSM) due to internalized homophobia and fear of participating in regular social activities that men more comfortable with their sexual orientation may take part in such as going to bars or pride events. ( Chaney, 2005). The wide variety of behaviors available on the Internet also may compensate for monotony in the bedroom in the real world. Another aspect of boredom in compulsive behaviors is tolerance. While a man using the Internet to explore feelings of same sex attraction may start with pornographic images and pictures, the newness wears off and the "rush" disappears. (Chaney). The sexual adventurer then may move to chat rooms for explicit conversation which also wears thin quickly. Progression moves to arranging real world encounters and then unsafe sex, the use of methamphetamines, and sexual risk taking such as exhibitionism. The tolerance cycle explains the MSM approach to relieving monotony and increasing arousal. (Chaney).

Lack of social connectedness also drives people to the Internet to fill unmet needs. (Chaney 2005). Therapists need to be aware of the subjective nature of boredom and social connectedness. Evaluations need to be measured carefully to find how men who have sex with men use the Internet to fill the void.

While the debate continues as to the existence of sexual addiction, in many places the focus has shifted from yes or no to addiction or obsessive compulsive behavior. The definition of sex addiction runs the whole field. In many religious self help texts, same sex sex automatically qualifies as compulsive and unhealthy behavior. ( Beck 1990).

This new debate has led researchers to look at medication effects on paraphilic or compulsive sexual behavior. (Abouesh 1999). Psychiatrists now use SSRIs such as Paxil or Luvox to deal with compulsive behaviors. Significantly, while the research studied for this article cites success in reduction of addictive behaviors and impulses, the question of reducing the addiction, or the side effect of SSRIs of inhibiting the general sex drive with reduction of symptoms as a benefit was not addressed. Sexual compulsivity treatment and 12 Step programs have as their goal not celibacy, but healthy sexuality. Unlike alcohol or other drugs, sex serves many useful purposes in a healthy life. The use of drugs to simply reduce the sex drive does not meet this goal.

As noted in the beginning of this paper, researchers are split over the definition of addiction, but at least one study realizes that the compulsive behaviors and the paraphilias are related. (Kafka 1997). Dr. Kafka's review of the literature and research shows that male paraphilic sex offenders report multiple paraphilias as well as elevated "total sexual outlet." In other words, compulsive behaviors and paraphilias go hand in hand.

Some of the studies while valid, appear to have drawn faulty conclusions from their research. Weiss (2004). conducted research on the prevalence of depression in male sex addicts. Not surprisingly, depression is more prevalent among sex addicts than among the general population. However, Weiss tries to draw a causal conclusion that sexual addiction leads to depression. Perhaps, the opposite is true, depression leads to sexual acting out which leads to addiction, or perhaps neither is true and this is a systemic, circular issue. In any case, Weiss, while showing the link does not show cause. In addition, in an article on individualized treatment for sexual addicts, Parker (2003) argues that each sex addict must be treated individually, then proceeds with blanket recommendations of group therapy, 12 Step attendance and then slots addicts into one of four developmental stages based on Object Relations Theory. While there may be validity in Object Relations for some clients and while 12 Step groups help many people with addictions, the idea that one size therapy fits all goes contrary to the stated thesis that individualized therapies are what is needed to treat the sex addict.

Circling around treatment, definitions, causes, and therapy are individuals who suffer. Whatever the stance on the existence of addiction, or the theory held about addictions, moral, medical, or some combination of the above, the fact exists that people, addicts, family members, and victims feel pain and do not know where to turn.

A difference of opinion exists on the use of the term "sex addict" as part of the healing process. Sex Addicts Anonymous and other 12 Step groups believe the label is an important first step in recovery. For the 12 Step member, "I'm a sex addict" is a way of admitting powerlessness over the compulsive behavior. (SAA 1991). Changing old labels such as crazy, perverse, or sick to the real one of "addict" brings hope. Many 12 Step members feel relief when they discover sex addiction. They have lived their whole lives thinking they were weak or evil, now they have a name and a "disease" or disorder to put to their behavior. Walters (1996) researched the idea of labeling and the predictive effects on behavior. Relapse was most common when external agents labeled the client an addict. Walters did other research and determined that clients who believed they were agents of change were more likely to relapse the longer they held onto the addict label. Clients who viewed themselves as powerless in the face of internal and external influences did better in recovery while labeling themselves as addicts. This research coincides with the 12 Step philosophy that the addiction is more powerful than the addict and the feelings of powerlessness that go with it. Walters quotes a 1992 study relative to moderate drinking that seems to have relevance here. Clients who moderated their drinking and learned to drink responsibly were less likely to have considered themselves alcoholics in the first place. However, once again, this study makes a link but does not establish causality. Not everyone who has promiscuous sex, not every gay man who frequents parks and public restrooms, not everyone who regularly gets drunk or over-indulges is an addict. Walters sums this up well when he states:

Many of the studies are deficient in at least two key respects. First, the majority of studies addressing the addiction-identity connection have relied on poorly specified definitions and measures that are of unknown reliability and validity. Greater precision in defining and assessing addiction and identity is therefore required in future research.

While not all sex addicts are sex offenders, many times the two populations go hand in hand. To date, treatment programs for offenders have followed a patriarchal paradigm. (Williams 2004). Like most offender rehabilitation and punishment programs, offenders are not consulted. The goal so far in offender treatment has been complete relapse prevention. Miller (2000) points out that the basic approach to treatment has been medical. This includes clinician centeredness, emphasis on credentials, super valuation on science and intolerance of alternative treatment approaches.

Williams (2004) did the unthinkable. He surveyed offenders to find out what worked in their treatment and what did not. While the study included only nine offenders, they each had attended multiple programs and presented with different paraphilias and offenses. While limited in scope, the results still have value. Relationships, not program content carried more weight with the participants. There appears to be an inherent conflict between the correctional and the therapeutic processes and this conflict affected the offenders in the study. Being able to trust the therapist, feeling cared for and supported as opposed to punitive carried much weight in the feelings of efficacy in treatment.

Participants felt they could not trust probation officers. One survey used the phrase "schoolyard bully" to describe the officer. Threats did not work for this population. "Threat and fear do not effect lasting change." (Williams 2004). Confrontation similar to what is used in other addictive treatments does not seem effective. It has a "damaging effect on clients" and should be avoided. Punishment is part of the correctional atmosphere. However, if the goal of corrections and sex offender treatment is to produce functioning citizens, perhaps, more focus on the therapeutic approach would yield better results than a punitive approach.

While the review of literature shows great strides in understanding and treating sexual addiction, and progress from the late eighties when Carnes was publishing his revolutionary work and a small group of addicts gathered in the basement of a church in Minnesota to form what later became SAA, much still needs to be done. Sexual addiction as a concept or even a theory remains unknown to society at large, many clergy and even to some in the helping professions.

The addiction field cannot settle for anything less than the integration of this topic into the fundamental cultural perspective of contemporary society. (Herring, 2004). This is the main goal of the National Council on Sexual Addiction and Compulsivity (NC-SAC). In 2001 experts from many fields attended a conference in Nashville, TN to begin the organized effort to include sexually compulsive behavior in the next edition of the DSM. Herring argues effectively that at this young point in the development of the field, a wide ranging philosophical base is needed to absorb the many competing theories that vie for attention and funding.

In an ideal world, the following fields, among others, would all be represented in a drive to understand and treat people whose sexual behavior is out of control: mental health, addiction medicine, sex therapy, sex education, medical providers, public health, sexual offender and victim groups, morality based groups, the gay community, the business community, the sex and pornography industry and sex addicts and their families. (Herring 2004). Each group brings something unique to the table, a unique viewpoint or worldview that must be represented if the field is to flourish. The idea of sexual health is too varied to permit one philosophy such as 12 Steps, abstinence, or harm reduction, religious caveats or total hedonism to dominate and lock providers into a rigid orthodoxy when it comes to treatment. However, according to Herring, all these viewpoints have a place to be expressed, and the proponents of each of these factions share interest in "obsessive hypersexual desire." All sides have in common reducing disease, unwanted pregnancies, exploitation of children and the myriad other consequences that flow from out of control sexual behavior.

Herring (2004) would have the NC-SAC seek out and actively develop theories that are non-conventional and even controversial. The most important growth is the growth that requires controversy. Two fields Herring especially wants in the discussion may raise some eyebrows, but his reasons are sound. Sex therapists belong - obviously they are the sex experts. However, as he notes, they have a history of "privileging" robust sexuality, something Herring states is vital to avoid subtle bias against sexual deviance or even against sex itself.

In addition, the sex industry needs to be involved, much as the gambling, alcohol, and tobacco industries are involved in preventing irresponsible usage of their products and services. Herring (2004) believes that not only does the sex industry have a right to be involved, they have a responsibility to be involved and help support studies in sexual compulsivity. Rejecting funding from pornography companies, or others in the sex industry reinforces the ideas of shame and guilt that have made sexually obsessive behavior such a difficult area to study and treat already.

The field of sex addiction remains wide open. Over the past twenty years a basic groundwork has been laid, but much work needs to be done to develop better understanding of etiology and treatments. Both clinicians and researchers will be pushed to discard pre-conceptions about addicts and about the nature of sex itself. Advances come when clinicians are willing to stand on the shoulders of those who have gone before and jump. It is time to make that jump now.

References

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