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Sex Addiction

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Stephanie Savage

on 14 December 2013

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Transcript of Sex Addiction

Sex Addiction
Sex Addiction and the DSM-5
Treating Sex Addiction
Lack of substantive research
Conceptualization similar to compulsive overeating
Balance between gaining client's trust and holding client accountable
Provide clients with tools for managing stress, reducing shame, and relapse prevention
Let's Talk About...
What is Sex Addiction?
Sex Addiction and the DSM-5
Treatment of Sex Addiction
Let's Put it To Vote
Do you believe Sex Addiction is really an addiction?

"With the stress I'm under, I deserve it"
"I couldn't help it, given how she acted"
"It's my way of relaxing"
"My husband is not sensitive to my needs"
"I am oversexed and have to meet my needs"

out-of-control sexual behaviour
Don Juanism
hypersexual disorder
compulsive sexual behaviour
impulsive-complusive sexual behaviour
Sexual Addiction
You Should Know...
Diagnosis and Treatment (Carnes, 2000)
Conduct a sexual history
Involve family members, if possible
Decide if client's behaviour is indicative of a pattern or is situational
Phases of Treatment
Initial phase: Intervention
Confront areas of denial
Second Phase: Initial Treatment
12-step program mandatory
Trauma assessment
Third Phase: Extended therapy
Focus is on underlying family-of-origin issues
Couples Therapy
Sex addiction is often undetected in therapy
The addict should be engaging in activities supportive of recovery
E.g. Sexaholics Anonymous, Sex Addicts Anonymous, Sex and Love Addicts Anonymous, Recovering Couples Anonymous
Relational-Cultural Theory (RCT) activities for couples
Role Reversal
Relational Awareness Activity
Psychodrama: The supporter and the voice
Relationship Tracking
Authentic Connection Activity
CBT is the most recommended psychological treatment for excessive sexual behaviour
Techniques can be used to disrupt cognitive distortions and dysfunctional beliefs
Behavioural therapy helps to decrease excessive sexual activity, helps to improve self-esteem, and may also help to decrease symptoms of anxiety or depression

Carnes's 6 Stages of Recovery
Developing Stage
(up to 2 years)
Problems mount, awareness builds
Clients often not ready to change
Clients may minimize problem
Crisis/Decision Stage
Change often precipitated by a personal crisis
Shock Stage
(first 6-8 months after crisis stage)
Disbelief & numbness, feelings of hopelessness & despair
Reactive to limits set by therapist
Grief Stage
Client becomes aware of losses caused by the sex addiction
Carnes's 6 Stages of Recovery
Repair Stage
Clients move from pain to a deep internal restructuring
Clients have a new ability to express their needs
Growth Stage
Clients have a greater understanding of themselves
Clients are not more available to others, are more compassionate, and have a new trust for their own boundaries
Therapist Considerations
Consider the role your personal needs might play in the therapy room
E.g. "What is my capacity for victimizing my clients?"
Consider clients' boundary issues
Blindness to pathology
Clients who present with anger
Therapist Considerations
Client's fear of abandonment
Power/control issues
Treatment of sexuality cross-culturally
Media and society
Cognitive-Behavioural Therapy for sex addiction
Sex Addiction Behaviours
Common behaviours reported include:
Compulsive use of pornography
Multiple relationships
Fixation on unattainable partners
Paying for sex
Having affairs
Sexual harassment
Fantasy sex.
Lack of codification for specific behaviours
Estimated that 3-6% of population is affected.
On-set is often in late adolescence.
Majority are male. There is a lack of empirical research regarding females and sex addiction.
High rates of comorbidity with other psychological disorders including mood disorders, affective disorders, substance abuse, anxiety, personality disorders, paraphilia and ADHD.
The cause(s) of sexual addiction are unknown.
Diagnosis of Sex Addiction
First included in DSM-III-R
Changes in DSM-5 including behavioural addictions
What are behavioural addictions?
Consideration of the inclusion of hypersexual disorder
What is hypersexual disorder?
DSM-5 Work Group on Sexual and Gender Identity Disorders
Controversies surrounding diagnositic criteria and conceptualization of disorder
lack of support for original operationalization of hypersexual behaviour
Hypersexuality as a symptom of Axis I disorder (Moser 2010; Winters 2010)
addiction verus compulsion
Cultural norms
Methodological flaws in research
Arguments Against Inclusion
Proposed Criteria
DSM-5 proposed criteria for hypersexual disorder
A. Over a period of at least 6 months, recurrent and intense sexual fantasies, sexual urges, and sexual behavior in association with four or more of the following five criteria:
1. Excessive time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior.
2. Repetitively engaging in these sexual fantasies, urges, and behavior in response to dysphoric mood states (e.g., anxiety, depression, boredom, and irritability).
3. Repetitively engaging in sexual fantasies, urges, and behavior in response to stressful life events.
4. Repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, and behavior.
5. Repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others.
B. There is clinically significant personal distress or impairment in social, occupational, or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges, and behavior.
C. These sexual fantasies, urges, and behavior are not due to direct physiological effects of exogenous substances (e.g., drugs of abuse or medications), a co-occurring general medical condition, or to manic episodes.
D. The person is at least 18 years of age.
Specify if masturbation, pornography, sexual behavior with
consenting adults, cybersex, telephone sex, and strip clubs
Support For Inclusion
expert opinion and perceived need
research support
increased expressions of normative sexual desire (Kafta, 2010)
Wines’ (1997) study offering empirical support for the addiction model.
comorbidity with Axis I disorders (Raymond, Coleman & Miner, 2003)
DSM-5 field trial findings show reliability, validity, and significant consequences (Reid et al., 2012)
Decision and Impacts
“the group recognized that, anecdotally, many people meet most of the criteria for addiction to these behaviors. But the DSM-5 emphasis on scientific justification precluded listing them...We looked at sex addiction, but there was no science at all. None.”
– working group chairman Charles O'Brien

What impact does its exclusion have?
"Excessive" or Out of Control Sexual Behaviour
No Laughing Matter
Talking about sexual behaviour so "out of control" it constitutes a mental illness.
Potential to:
Destroy relationships
Create financial difficulties
Cost people their jobs
Cause health concerns for individuals and public
Ruin lives
No uniform definition of excessive, interfering, or out of control sexual behaviour.
Typically interferes significantly with life functions (e.g. work and social relations)

No standardized diagnosis criteria.
Lack of consensus and scientific data.
Researchers have taken different approaches to create diagnostic criteria, some based on substance addiction.
Lack of evidence-based assessment/screening measures.
One of the most widely used assessment tools is the Sexual Addiction Screening Test (SAST),

What's in a Name?
Therapist Considerations?
Do you believe Sex Addiction is really an addiction?

Raymond, N. C., Coleman, E., & Miner, M. H. (2003). Psychiatric comorbidity and compulsive/impulsive traits in compulsive sexual behavior. Comprehensive Psychiatry,
44, 370-380.

Reid, R. C., Carpenter, B. N., Hook, J. N., Garos, S., Manning, J. C., Gilliland, R., ... & Fong, T. (2012). Report of Findings in a DSM‐5 Field Trial for Hypersexual Disorder. The Journal of Sexual Medicine, 9(11), 2868-2877.

Turner, M. (2009). Uncovering and treating sex addiction in couples therapy. Journal of Family Psychotherapy, 20, 283-302.

Vogel, J.E. 2007. Using Relational-Cultural Theory to conceptualize couple interventions in the treatment of sex addiction. Journal of Creativity in Mental Health, 4, 3-16.

Wilson, M. (2000). Creativity and shame reduction in sex addiction treatment. Sexual Addiction & Compulsivity, 7, 229-248.

Wines, D. (1997). Exploring the applicability of criteria for substance dependence to sexual addiction. Sexual Addiction & Compulsivity, 4,195-220.

Winters, J. (2010). Hypersexual disorder: A more cautious approach. Archives of Sexual Behaviour, 39, 594-596.
Is this Hypersexual Disorder?
Carnes, P.H., Green, B.A., Merlo, L.J., Polles, A., Carnes, S., & Gold, M.S. (2012). PATHOS: A brief screening application for assessing sexual addiction.
Journal of Addiction Medicine.
6(1), 29-34.

De Visser, R. O., Smith, A. M. A., Richters, J., & Rissel, C. E. (2007). Association between religiosity and sexuality in a representative sample of Australian adults. Archives of Sexual Behaviour, 36, 33-46.

Garcia, F.D. & Thibaut, F. (2010). Sexual Addictions.
The American Journal of Drug and Alcohol Abuse
, 36, 254-260.

Griffin-Shelley, E. (2009). Ethical issues in sex and love addiction treatment.
Sexual Addiction & Compulsivity
, 16, 32-54.

Kafka, M. P. (2010). Hypersexual disorder: A proposed diagnosis for DSM-V. A
rchives of Sexual Behavior,
39(2), 377-400.

Kaplan, M.S., & Krueger, R. B. (2010). Diagnosis, assessment, and treatment of hypersexuality. Journal of Sex Research, 47, 181-198.

Kor, A., Fogel, Y.A.,Reid, R.C., & Potenza, M.N. (2013). Should Hypersexual Disorder be Classified as an Addiction?.
Sexual Addiction & Compulsivity,
20(1-2), 27-47.

Mental health; how to prove a sexual addiction. (2012). NewsRx Health & Science, 103. Retrieved from http://search.proquest.com/docview/1125264241?accountid=14771.
Break up into pairs: one therapist client
You have a new client, Henry. Henry has mentioned that he has been using phone sex lines when he is distressed.
Please role play the interaction you would have as client and therapist.
Let's Put it to a Vote Again...
Full transcript