Silva Neves Specialist Psychotherapy in Central London W1 & EC1

Out-of-control sexual behaviours. sex addiction

Compulsive Sexual Behaviours & Out-of-Control Sexual Behaviours: Important information before starting treatment

The field of 'Sex addiction' emerged in the 80’s with Dr Patrick Carnes' publications and treatment centres in the USA. The films Shame (2011), Thanks For Sharing (2012), Nymphomaniac (2013) and Don Jon (2013) brought 'sex addiction' to the awareness of the public.
More recently, the public scandals in the Hollywood film industry brought the 'sex addiction' treatment field into questioning and scrutiny. The field has been criticised to be an easy and comfortable ‘get-out-of-jail’ card for white, rich sexual offenders.

'Sex addiction' is currently the most widely used term describing sexual behaviours that have gone out of control. At the moment, many people are confused as to what 'sex addiction' actually is. If you think you are having problems controlling your sexual behaviours, you might call yourself a 'sex addict'.

There are a few important things for you to know before you engage in treatment:

  • 'Sex Addiction' is only a term coined by some treatment centres in the USA in the 80’s. It is not an approved or recognised mental health diagnosis in the DSM V (Diagnostic and Statistical Manual of Mental Disorders). It is not a recognised condition in the field of psycho-sexology either. The reason for this is that robust clinical research in the field is poor, despite what many books are preaching. These books are based on clinicians’ opinions, not clinical research. Many of these well-meaning clinicians and authors are not adequately trained in the field of human sexuality.

  • The clinical term that has been agreed by ICD-11 (International Classification of Disease) is Compulsive Sexual Behaviour Disorder. Its classification is under Impulse Control Disorder, not Addiction. The clinical criteria to meet the diagnosis for the disorder are very specific: it is rare for people to meet the disorder. Therefore, most people who struggle with their sexual behaviours do not suffer from a disorder, but they struggle with a sexual health behaviour problem.

  • The term that I believe is more appropriate if the diagnosis for the disorder cannot be formulated is out-of-control sexual behaviours or hypersexual behaviours. My opinion is based on my extensive knowledge of human sexuality and my experience of working with many clients who present with out-of-control sexual behaviours.

    Some of the issues people with hypersexual/ compulsive/ out-of-control sexual behaviours have are:

  • Using sex as a primary way of coping with the unpleasant feelings of life: feeling sad, feeling angry, feeling tired, feeling bored, etc…

  • A sexual behaviour that is compulsive and repetitive. Someone with hypersexual behaviours cannot stop their sexual behaviours despite negative consequences. They feel their sexual behaviours are out of control.

  • It makes the person feel bad. Clients often report that the sexual behaviours they engaged in was unwanted by them, and they feel bad and shame afterwards. They can also feel depressed or worthless.

  • Engaging in sexual behaviours that is against their own values and integrity. For example, having sex outside of the marriage, even though they love their spouse.

  • It is a condition that brings a lot of despair and suffering for the people with out-of-control sexual behaviours, and it has a tremendous traumatizing impact on their partner.

  • Out-of-control sexual behaviours. loneliness

    The diagnosis of 'sex addiction'

    Although the term ‘sex addiction’ is the most widely used term to describe out-of-control sexual behaviours, it is vital for you to understand the implication of a ‘sex addiction’ diagnosis so that you can make an informed choice on your treatment options:

    If a clinician diagnoses you with ‘sex addiction’, you are likely to be offered an addiction treatment, which rests upon the assumption that sex is addictive and it is a chronic illness. As mentioned above, there is no clinical evidence to support this assumption, despite many books and websites that claim otherwise.
    The typical 'sex addiction' treatment will encourage you to attend SAA meetings (Sex Addicts Anonymous) or SLAA meetings (Sex and Love Addicts Anonymous). The addiction clinician will base their treatment plans on addiction-focused treatment which will include a ‘sobriety contract’ and other addiction behavioural interventions. A sobriety contract and addiction interventions work very well for alcohol and drug addiction. However, in my clinical experience, the addiction model is not efficient with sexual behaviours because human sexuality is a completely different physiological and psychological system. In my professional opinion, in order to treat ‘sex addiction’ effectively, the clinician must have a thorough and specialist training and understanding of human sexuality.

    AASECT (American Association of Sexuality Educators, Counselors and Therapists) issued the following statement:
    1- There is no sufficient empirical evidence to support the classification of 'sex addiction' and 'porn addiction' as a mental health disorder.
    2- The sexual addiction training and treatment methods and education pedagogies are not adequately informed by accurate human sexuality knowledge.

    Based on my clinical experience, out-of-control sexual behaviours/ hypersexual behaviours/ compulsive sexual behaviours are real problems which bring a lot of distress in people's lives. But it is not an addiction or a chronic illness. You can re-organise your sexual behaviours and your relational self in a way that is fulfilling for you, permanently.

    Out-of-control sexual behaviours. Elaine purple ball flower

    My treatment of compulsive sexual behaviours: a psycho-sexological, holistic and humanistic approach

    My treatment for out-of-control sexual behaviours, hypersexual behaviours, compulsive sexual behaviours is based on specialist psychosexual training and experience, clinical research on human sexuality, clinical evidence on brain functions and neuropathways, and human psychology. I do not offer an addiction treatment to ‘sex addiction’. It means that I do not encourage clients to attend SAA or SLAA meetings. I do not ask clients to be ‘sober from sexual behaviours’. I do not prescribe clients a ‘right’ way to be sexual.

    Instead, I help my clients understand where their sexual behaviours come from, explore their sexual and relational landscape to gain a better understanding of their own individual sexual and relational system. Together, we make sense of their sexual urges and desires, their needs, their wanting, their longing. We also explore values and what their integrity is made of. With this deep understanding, clients are then able to change many different areas of their life to support a fulfilling and vibrant sex life in stable relationships. My approach is humanistic and holistic: it is a non-shaming, respectful and sex-positive approach. In my clinical experience, this approach is very effective, and supports a sustainable long-term fulfilling lifestyle.

    My treatment of hypersexual behaviours, out-of-control sexual behaviours and compulsive sexual behaviours includes:
  • Behavioural approach to help identifying the sexual behaviours that are wanted from those that are unwanted.
  • Learning new ways to self-soothe and cope with the negative feelings about life: stress, anxiety, feeling low, feeling bored, feeling unfulfilled, feeling bad.
  • A deep exploration of the sexual landscape.
  • A deep exploration of the emotional world and core beliefs.
  • An examination of cognitive processes.
  • An examination of sexual urges and desires.
  • Behavioural, psychological and emotional interventions to manage impulse control.
  • Re-instating balance in life: hobbies, positive connections with friends and loved ones, a deep sense of self, finding meaning, higher self-esteem.
  • Healing the possible trauma(s) underlying the roots of out-of-control sexual behaviours.
  • Treating the possible psychosexual dysfunctions underlying the roots of out-of-control sexual behaviours.
  • Healing the relationship that has been devastated by hypersexual behaviours, if appropriate.
  • Re-integrating vibrant, diverse and fulfilling sexuality with self and others.

    My approach of the treatment of hypersexual behaviours, out-of-control sexual behaviours and compulsive sexual behaviours is non-moralistic, non-judgmental, empathic and holistic.

    The treatment for compulsive sexual behaviours is challenging. But I do not believe in ‘once an addict, always an addict’. Using specific classic humanistic, evidence-based psychological interventions and modern psychosexual interventions, people can truly leave their out-of-control sexual behaviours behind and change their lives positively and permanently.

    The aim of the treatment of compulsive sexual behaviours is based on the six principles of sexual health (Pan America Health Organisation):
    1- Consent
    2- Non-exploitation
    3- Protection from HIV, STI and unwanted pregnancy
    4- Honesty
    5- Shared values
    6- Mutual pleasure

    Sexual Health is the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. (WHO 2006)

  • Out-of-control sexual behaviours. Sex addiction

    Therapy for partners

    The discovery or disclosure of out-of-control sexual behaviours, hypersexual behaviours or compulsive sexual behaviours brings devastating and traumatizing consequences to the partner.

    The most common impacts on the partner are:
  • Emotional turmoil, depression and feelings of despair
  • Acting like a detective
  • Obsessing about the sexual acting out which can make like hard to manage
  • Avoiding thinking or discussing the traumatizing consequences
  • Sleeplessness and nightmares
  • Feeling stupid for believing the addict's lies
  • Emotional numbness
  • Feelings of victimization
  • Fear about future relapse
  • Trust is shattered
  • Anger and hostility
  • Loss of the dream of the relationship
  • Loss of self
  • Loss of emotional and sexual safety

    It is important for the partner to engage in therapy to help with healing the trauma of compulsive sexual behaviours and the restore balance in the emotional and practical life.

    I do not offer therapy for both the person with compulsive sexual behaviours and the partner. If I engage in therapy with the partner, I refer the person with compulsive sexual behaviours to one of my trusted colleagues, and vice versa.
    I do offer couples therapy for couples who have been wounded by compulsive sexual behaviours.

  • Out-of-control sexual behaviours. iceberg

    ICD-11 Classification: Compulsive Sexual Behaviour Disorder. My analysis: information for clinicians and the public: How to diagnose and its implication for treatment change.

    Many patients report negative consequences as a result of repetitive consensual sexual behaviours. In their initial consultation, they often use a ‘sex addiction’ language as it is the most known language: their behaviour feels like an addiction because they can’t stop it.

    For years, clinicians have been in strong disagreement between those believing in ‘sex addiction’ and offering an addiction treatment to such problematic sexual behaviours and those who refused the theory that sex can be addictive and therefore offering a non-addiction treatment. There has been much debate on how to call this condition: ‘sex addiction’?, compulsive sexual behaviour? Hypersexual behaviour? Out-of-control sexual behaviour?

    From June 2018, the ICD-11 (International Classification of Disease), included Compulsive Sexual Behaviour as a disorder.
    The description of the disorder is:
    ‘Compulsive sexual behaviour disorder is characterized by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it. The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g. 6 months or more), and causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement.’

    It is an interesting set of criteria which brings forth important clinical considerations for both therapists and patients.

    The purpose of my analysis is two-fold: to understand the diagnosis and its exclusions, and its implication on treatment change. I will highlight the therapeutic methods that are traditionally practiced under the umbrella of ‘sex addiction’ and my recommendations on how treatment may now develop and change.

    Firstly, one of the good outcome of such classification is that the psychotherapeutic community can now stop fighting over what terms to use. We can use Compulsive Sexual Behaviour Disorder, not ‘sex addiction’. WHO (World Health Organisation) clearly states that there is no clinical evidence of an addictive component to sex therefore the disorder is classified under Impulse Control Disorder, which is very different from addiction. From now on, we can confidently put the term ‘sex addiction’ in inverted comas, as it is not a clinical term. In fact, it never was a clinical term: the words ‘sex addiction’ were coined in the late 70’s. The diagnosis classification makes ‘sex addiction’ an outdated and old fashion term. Just the same as we used to call female anxiety ‘hysteria’ or people suffering from bipolar disorder ‘manic depressive’: there are thousands of examples of old fashioned terms that disappear when we acquire more knowledge on the problems. This is good, because it means that the field of sexual health behaviours can finally be updated to fit with 2018.

    Secondly, it is important that a disorder is diligently diagnosed. For example, most people have heard the term PTSD (Post-Traumatic Stress Disorder), however only a few people use this diagnosis accurately. For the disorder to be diagnosed, the symptoms have to be so elevated that the patient cannot function in normal life. Most patients who experience terrible flashbacks as a result of a trauma who can also go to work and turn up to therapy with good hygiene are less likely to fit the criteria for the disorder. Such people would be classified as PTS (Post-Traumatic Stress), which is also a condition that can be treated with therapy, but is not a disorder. A patient not meeting the criteria for PTSD does not negate their suffering with flashback symptoms, which are very distressing. Therapy helps treating the symptoms for PTS for a better quality of life, without calling it a disorder. It is the clinician’s duty to inform the patient about how severe a condition is based on diagnostic criteria. Patients can then agree or disagree, they can be free to go to another clinician for a second opinion, or they can agree on their treatment plan.

    If a patient comes to a doctor’s office with stomach pain and fearing it is cancer. It is the doctor’s responsibility to do all the tests required and diligently diagnose or undiagnose conditions and inform the patient what condition they will be treated for. This is the expectations of all patients when seeing a medical doctor. We, psychotherapists, have to be as diligent with diagnosis.

    So let’s see how we can diagnose Compulsive Sexual Behaviour Disorder:

    1-‘A persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities.’
    Under ICD-11, the sexual behaviour that is problematic has to be evaluated by the patients themselves. A client may say that their repetitive visits to sex workers is a problem but their pornography use is not. We, clinicians, are not to tell patients what is problematic or not.

    The ‘sex addiction’ practice: In the traditional ‘sex addiction’ model as well as in 12-steps programmes (such as SLAA and SAA), patients are commonly told to stop all forms of sexual behaviours, including those which the client hasn’t mentioned as problematic. There is no clinical evidence that this intervention has any benefits. However there is evidence that it exponentially increases sexual shame. I often hear some people say: ‘it is a way to ‘re-boot’ the brain. Our brain is an organ that is intelligent and alive, not a computer. There is no such thing as ‘re-booting’ a brain. Doing this unnecessary intervention also makes the therapist’s ideas and opinions the standard of ‘success’ rather that the client’s goal of what they want to achieve. It creates a power imbalance so great that it impairs the therapeutic collaboration.

    The new diagnosis: This criteria focuses on the link between the intense impulses and urges and the repetitive behaviours. It does not include intense urges and impulses that do not result to repetitive unwanted behaviours nor wanted repetitive behaviours nor behaviours that are not the effect of uncontrolled intense sexual urges and impulses. It is quite specific. Also, the symptoms have to be significant enough for the person to struggle with looking after their health, personal care or other interests. This is when we need to be diligent as much as we are with making the difference between PTSD and PTS. If a patient presents in our consulting room with good hygiene, able to hold a job with responsibilities, feed themselves, and get on with life, the criteria for the disorder cannot be formulated. I work in private practice: most of my clients can hold their job and meet their needs for health and personal care. Although, I frequently hear clients say that they are so preoccupied by their sexual urges that they don’t have a hobby. It is something that can be addressed in therapy, for sure, but not having a hobby or having a lot of sexual preoccupation is not sufficient for a disorder if they can manage other areas of their life.

    2-‘Numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it’
    This is a crucial part of the disorder diagnosis which is usually overlooked in the traditional ‘sex addiction’ assessment. Many people do not attempt to reduce their repetitive sexual behaviours until after they are caught by their partner or at high risk of being caught. For these people, if there were no risk of getting caught they would continue their sexual behaviour, indicating that they derive enough satisfaction from such behaviour. They may think ‘I shouldn’t be doing this’ but they do it anyway because the motivation to meet their sexual needs trumps the motivation to keep to their agreed relationship boundaries with their partner. If this is the case, it is not a disorder, it is a sexual health conflict between what they want sexually and what is permissible or not within their relationship. However, some people do try very hard to stop their repetitive sexual behaviours without success before they are at high risk of being caught: for these people, important questions need to be asked before we prematurely assume that it is part of the disorder: for example, do they want to stop because they perceive that others (society, religious groups, etc.) would disapprove? If so, it is not a disorder (I explain more about that below). Most people would stop behaviours that do not produce any satisfaction, any pleasure or do not interest or arouse them in any way. The diagnostic criteria for the disorder would only apply to people who do a repetitive sexual behaviour for which they derive almost no pleasure and cannot stop that behaviour. For example, the most common story is a problematic sexual behaviour that provides a sense of feeling connected and loved. Although such behaviour can be destructive if it is outside of their committed relationship, it also provides the satisfaction of connection: this means that the disorder diagnosis must be ruled out. Instead, the patient’s problem can be understood, and treated, as a sexual health behaviour problem. Let’s think about this: meeting this diagnostic criteria is very rare.

    3-‘The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g. 6 months or more), and causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning’.
    This is another important criteria to explore. People’s sexual behaviour is usually different before and after they get caught by their partner. In fact, it is very rare for patients to come to therapy before they get caught. There is a question over inability to control those urges resulting in repetitive sexual behaviours and choosing not to control them because they produce much pleasure. I think that ‘the pattern of failure to control’ refers to an inability to control sexual impulses and urges (as the disorder is under Impulse Control Disorder). If people can have continued repetitive sexual behaviours over an extended period of six months or more and not get caught, it means they are highly functioning and very much in control: it takes much planning and organization to hide such behaviours from your partner. After they get caught, it is often when patients report marked distress and significant impairment in personal areas: they have to deal with the consequences of being caught, the intense emotions that their partner feels faced with the discovery of the enormous betrayal, chaos in all areas of their life trying to deal with the fall out of the discovery. People who have not been caught, or those who are single and do not breach any relationship agreements usually do not report marked distress or impairment in their life functioning. The exception is if patients have strong moralistic or religious views over some sexual activities, which is excluded from the diagnosis criteria (see below). Just like the last diagnostic criteria, meeting this criteria for the disorder is very rare.

    4-‘Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement’.
    This is a crucial component of the diagnosis. It is not possible to diagnose Compulsive Sexual Behaviour Disorder if the patient feels much sexual shame, moral judgement or disapproval from society, families, religious groups, etc. about their sexual impulse, urges or behaviour. It is very common for people to feel distress at their behaviour after they get caught by their partner, the distress coming from their partner disapproving with their illicit sexual activities. For example, a man repetitively seeing a Dominatrix sex worker because he derives much pleasure from BDSM practice is found out by partner who doesn’t practice BDSM: she may feel disgusted by what he had been doing and highly disapproving: the patient then feels great distress at his behaviour and wants to stop: this patient cannot be diagnosed with the disorder. Or a gay man having frequent anonymous sex in sex clubs and feeling his behaviour is ‘wrong’ because of the societal judgement that frequent anonymous sex is undesirable or that his thinking about the behaviour is homonegative cannot be diagnosed with the disorder. If somebody feels bad about their sexual behaviour because they have read a book or a website that is sex-shaming or sex-negative: the diagnosis for the disorder is ruled out.

    Why this last diagnostic component is essential: At the time when the ‘sex addiction’ theories flourished, it was also the time of the AIDS epidemic. Many people were afraid of sex, and the public latched onto the notion that there was much darkness in human sexuality and that the safest way to be was the heterosexual, monogamous way: there was much fear that too much lust can cause harm and disease. I’m not surprised that it was a popular notion then. However, the ‘sex addiction’ model emerged without knowledge or specific training in human sexuality. The people who coined the term ‘sex addiction’ based their understanding of the problem on what they already knew: the 12-step programme which had great success with people suffering from alcoholism. Because compulsive sexual behaviours can feel like an addiction, they assumed it was an addiction and didn’t pay attention to the human sexuality part of the equation: the erotic works in very different ways from alcohol.

    Changing the term is important because the diagnosis informs the treatment. If clinicians continue to call the problem ‘sex addiction’, they are likely to treat their patients with an addiction treatment, which is now clinically unfit as the proper clinical diagnosis refute the addiction element. It is not the faults of clinicians. Most ‘sex addiction’ therapists are well-meaning. But they have been trained in a model that is outdated.

    Now that the notion of addiction is refuted, we can finally open our understanding to other ways of looking at the problem. It means new, updated training that is psycho-sexologically based rather than addiction based, as well as incorporating the impulse control element to it, rather than the addiction methods. It will take some time for clinicians to have their skills upgraded, but we can now have hope that the field is going to move on.

    As explained above, the diagnostic criteria for Compulsive Sexual Behaviour Disorder are very specific: many people will not meet the criteria. It doesn’t mean they don’t have a problem, but it means they don’t have a disorder. We can stop the fear-mongering rhetoric that ‘sex addiction’ is a terrible chronic disease on the rise causing chaos in our neighbourhoods. It is not. And 12-step meetings are not recommended now that we know the problem is not an addiction.

    Most patients that we are likely to see in our consulting room will not have the disorder. They will struggle with competing motivations between sexual urges, needs and gratifications and honouring their relationship agreements. Much like many people have competing motivations between eating a chocolate cake and not wanting to put on weight.

    Now that the ICD-11 has formulated strict diagnostic criteria, the window for clinicians to prematurely and inadequately pathologise sexual behaviours has become much narrower, thankfully. I’m hoping there will be less opportunity for clinician’s own bias and personal opinions about human sexuality poluting their clinical judgements.

    Given the strict criteria to diagnose Compulsive Sexual Behaviour as a disorder, the clinician’s role is more about undiagnosing than diagnosing: reassuring the public that they do not have a disorder. The sexual health behaviour problem can feel out of control, and it can feel like an addiction which can be treated appropriately with the right therapy. Patients are likely to come in their initial consultation with a ‘sex addiction’ language: it is ok. It is not their job to be educated with the right language and their suffering needs to be validated. But it is our job, as clinicians, to explain to them that they do not suffer a disorder. Just the same way that a doctor might explain that your worrying stomach pain feel frightening but it is not stomach cancer, after a proper assessment and carefully ruling out diagnostic criteria.

    Silva Neves

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