Some controversy remains around intimacy disorders as sex addiction has yet to be included in the Diagnostic and Statistical Manual of Mental Disorders, which American clinicians use to diagnose mental health conditions. Its latest update in 2013, the DSM-5, did not list sex addiction as a specific psychiatric diagnosis. This may change in the next edition.
In 2018, the World Health Organization (WHO) included “compulsive sexual behavior” as a mental health disorder in its update of the International Classification of Diseases list. In January 2022, the latest edition, ICD-11, will officially replace the ICD-10 as the global standard for coding health information and causes of death.
In the ICD-11, sex addiction is described as “a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behavior.”
Sex addiction was first recognized as an intimacy disorder in the 1980s by one of the “founding fathers” of sexual addiction therapy, Patrick Carnes, Ph.D. In his book Out of the Shadows, he suggested that not only substances like drugs and alcohol can drive an addiction but also certain behaviors like eating, gambling, exercising, or sexual activity.
Similar to a substance use disorder (SUD), “for sex addicts, sex becomes the priority for which they sacrifice everything,” wrote Dr. Carnes in Facing the Shadow. “They put sex before their children, spouses, and friends, despite great cost to themselves. Just as an alcoholic has an affair with the bottle, the sex addict’s relationship is with sex and romance.”
The recently updated definition of addiction provided by the American Society of Addiction Medicine states that “people with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences.” Sexual activity can be one of those behaviors.
Sex addiction may be present if three of the following signs are present:
- Tolerance, defined as needing more of the behavior or more explicit behavior to feel the same
- Withdrawal symptoms such as irritability, difficulty concentrating, or sleep disruption
- Failed attempts to stop the behavior
- Increased behavior during use
- More time spent pursuing or participating in the behavior than intended
- Negative impact on family dynamic or work performance
- Continuing the behavior despite negative consequences
Many of these are very similar to the DSM-5 criteria for substance use disorders, confirming the assertion that compulsive sexual behavior is indeed comparable to an alcohol or drug addiction.
Carnes views all addictions primarily as intimacy disorders since “distorted relationships lie at the center of the addictive process.” Just like people with SUD, sex addicts engage the reward cycle of the human brain. Chronic and excessive activation of certain pathways within the reward system has long been implicated in the development of compulsive behaviors that characterize addiction. Craving is a central feature of the disease of addiction.
In his 2017 book The Craving Mind, addiction psychiatrist Judson Brewer explored the central role craving plays in developing a variety of addictive behaviors. Like other experts, Dr. Brewer views addiction as a maladaptive use of the reward-based learning process. “I could line up their habit loop in my head. Trigger. Behavior. Reward. Repeat.”
In the case of sex addiction, “the addiction cycle is embedded in a larger addictive system, and this starts with a belief system,” wrote Dr. Carnes in Facing the Shadow. Sex addicts believe they are unworthy people, that no one would love them as they are. “The addiction cycle becomes the driving force in the addict’s life,” Carnes wrote. “Bad things start to happen. We call this unmanageability. Consequences start to occur.”
Feelings of despair resulting from the inevitable consequences of the compulsive behavior then confirm the dysfunctional belief about being an unlovable person. “Thus, the belief system perpetuates itself.” Since sex addicts feel unworthy of actual intimacy they continue to act out. “Sex becomes an end in itself,” says Carnes.
As is the case with other addictions, the sex addict may be genetically predisposed or may have experienced deep trauma that is driving attempts to self-medicate intolerable emotional pain. “Addiction often begins simply: reality becomes too much to bear, so we try to escape through drugs, alcohol, or sex. Escaping reality for even the briefest time brings some relief. When escaping becomes habitual, we have a mental illness known as addiction,” Carnes wrote.
Recovery from Sex Addiction
Treatment for sex addiction needs to address any underlying conditions and expose the nature of the addiction cycle to the patient. Carnes emphasizes the importance of helping addicted people tell their stories. “Those who tell their story admit that they have a problem,” wrote Dr. Carnes. They need “a safe place with other people who know their story before it is told.”
This is the power of peer support in addiction recovery. In one of the most popular TED Talks, addiction and mental health journalist Johann Hari discussed the underlying causes of addiction and famously concluded that the opposite of addiction is not sobriety but connection. “Recovery is more than a shift of emphasis. It is a series of internal movements that alter one’s life,” wrote Dr. Carnes.
“Sobriety” is different in recovery from sex addiction. Changing your behavior does not mean giving up sex altogether. In fact, sexual anorexia—the compulsive denial of one’s natural sex drive—is a maladaptive coping mechanism frequently embraced by sex addicts who are desperately trying to regain control over their behavior. Instead, Carnes views sexual sobriety as developing appropriate boundaries.
Sobriety may be established with a period of celibacy, however. “The goal of celibacy is not to create sexual anorexia, but rather to provide important perspective on reclaiming sexuality, which has been lost amid the cycles of addiction and anorexia.” As part of a treatment plan, celibacy can help set boundaries, experience new feelings, and work on achieving real intimacy with a partner or spouse.
The recovery process for intimacy disorders can involve many different avenues with varying results. At Valiant Living, we provide personalized recovery plans to create the most helpful recovery process for each person.
The process may involve weekly individual therapy in addition to weekly therapy groups and highly encouraged participation in a Twelve-step group. Our center provides the highest level of treatment for sexual addiction recovery. Therefore, our program involves a high level of commitment for true recovery. It is our philosophy that true recovery comes from a deep desire to change and grow, manifested through a strong commitment to recovery.
