Having worked with clients with out of control sexual behavior (OCSB), and having spent several years during my training working with clients with chemical addictions, I have found the term sexual addiction is at best a misnomer and at worst a mistake.

Sex Addiction V. High Sex Drive

One challenge with the term sex addiction is that it is very hard to objectively differentiate sex addiction from high sex drive. Most human behaviors and characteristics from IQ to physical skill are distributed in normal populations along a bell-curve. So when a characteristic is distributed along a bell-curve in a population, who gets to decide where the cut of line is between “normal” and “abnormal”. Clinically, the distinction between “functional” and “impairing function” are a little more useful but in the area of sexuality the features that define whether a behavior is functional is a complex mix of the individual’s behavior, the social-relational response from others, and the emotional response from the individual. I will use the example of two vignettes to illustrate the impact of these factors.

Imagine Farrukh and Cheng both 32-year old males. Barring partnered sexual activity both men report masturbating twice a day. Both present for therapy saying that their partner has asked them to come to therapy for sex addiction. Both report significant shame at their behavior.

Farrukh

Farrukh masturbates once in the morning. Sometimes this is after his alarm goes off, at other times, he might masturbate in the shower. Farrukh is never late to work and has enough time in his morning routine for this masturbation habit. Farrukh uses a lubricant at times and reports that he hasn’t hurt his penis with his masturbation since he was a teenager and still figuring out how to do it without hurting the skin. In the evening he masturbates again. Sometimes, this is right after work and sometimes before falling asleep in bed. He sometimes watches pornography while he masturbates in the evening. He has no trouble with foregoing masturbation in lieu of partnered sexual activity though he says that sometimes he prefers to orgasm by masturbation because his orgasms are stronger that way. His partner is disgusted by Farrukh’s “compulsive” masturbation and feels that he is out of control. She caught him in a lie recently when he told her that he wasn’t masturbating as much but she found evidence that he had been. Questions in the intake interview reveal that Farrukh does not masturbate at work or other compromising settings, does not view pornography that is outside his values, he goes to the same site every day and has so far not found that he is searching for more intense pornography. Farrukh is also able to identify the differences between porn and real sex. Yet, Farrukh feels ashamed of his behavior, that it is hurting his partner, and that he is bad for masturbating. Consequently, he tries to hide his masturbation from his partner and feels even worse when he is caught.

Cheng

Cheng experiences a very different pattern for his masturbation. He masturbates whenever he can during the day, sometimes to orgasm and sometimes not. In addition to masturbating in his home in many different locations, he also reports masturbating in his car, in bathrooms at work, sometimes in secluded public spaces if he thinks he can get away with it. He reports that he has had some close calls and nearly been caught masturbating in public before. In addition, he reports watching pornography that he says is sometimes shocking to him. He says he gets bored of seeing the same old stuff. Cheng is willing to have partnered sex but says his partner is boring and not adventurous enough for him. Cheng’s descriptions show that he is clearly comparing real sex to pornography. Cheng also reports that he has injured his penis a couple of years ago by masturbating in such a way that he tore his frenulum. Cheng’s partner is scared that he will get caught but also reports being humiliated by the fact that Cheng prefers porn to partnered sex. Cheng feels very ashamed of his behavior, says that he can stop masturbating for periods of time but always seems to return to it, and that because he fears the reactions from others, that he continues to try to hide his behavior at home and at work.

Check your own assumptions at this point. Which of these men is a sex addict? Neither? Only one? Both? Both men have several signs that are supposed to indicate sex addiction including frequently seeking sexual activity, negative impacts on the relationship, secretive sexual behavior, lying, and shame.  Yet for each person, I can identify several possible explanations for the behavior that might mitigate the impulse to call the behavior addiction.

Why Farrukh Might not be a Sex Addict

Farrukh has had enough education or self-awareness to make sure that his masturbation doesn’t hurt his body. Second, though Farrukh hides and lies about his behavior this is in response to a critical partner. If his partner wasn’t critical, he might continue to masturbate as a matter of daily life without hiding it. Farrukh’s shame seems to come more from believing that he shouldn’t do what he is doing than from any ability on his part to identify what the negative impact of his masturbation might be. Finally, though Farrukh masturbates more frequently than many men, I see no reason to believe that I have a right to label him an “addict” just because he occupies a certain location on the bell-curve distribution of sexual desire frequency.

Are you expecting that I will now identify all the reason that I think Cheng is a sex addict in contrast to Farrukh?

Why Cheng Might not be a Sex Addict

Cheng has also learned that he needs to hide his masturbation. Given that he is masturbating in public, in his car, and at work, it might be easy to label his behavior as out-of-control or potentially impairing functioning. But before I come to that conclusion I might first explore whether he has tried to limit his masturbation to his home and what if anything prohibited that. I would also want to find out how the thrill of forbidden sexual activity is a part of his erotic landscape. If it plays an important role, I might inquire about whether he has ever gotten creative about how to include playing with the forbidden in safer ways.

Cheng reports that he is bored with pornography and looks for things that are exciting and shocking. This could be seen as an indicator of sex addition because it suggests that he has developed tolerance, one hallmark of addiction. Other possible explanations include that Cheng is intelligent enough to be easily bored, has ADHD, that most porn is repetitive, or that Cheng lacks the skills or knowledge to cultivate other ways to bring variety into his sex life. Cheng is certainly comparing his real sex life to pornography and this is indeed a real problem with porn. But where else could Cheng learn about real sex? Who taught him about real sex? About the difference between pornography and real sex? If therapy teaches that to him, will his behavior persist in the same way?

Cheng states that his partner is boring and not adventurous but why is he necessarily the problem? From a more kind perspective, why is this not simply a case of sexual desire discrepancy in a couple?

It is also true that Cheng harmed himself with his masturbation process. But who taught Cheng to masturbate? Who taught him how to care for his penis or warned him of the risks of tearing his frenulum? Who taught him to use lubricants when masturbating?  If he had better sexual health education would these negative consequences have come to him? Given that he didn’t have that education, does that make him an addict?

One hallmark of addiction is that a person tries to quit but returns to the behavior. But sexuality can’t simply be eliminated. It is true that some aspects of Cheng’s behavior are challenging in his relationship but trying to make him eliminate his sexual expression will not be a sustainable solution that allows him to retain his sexuality. This is true because it is impossible to eliminate his sexuality from him. And that fact illustrates a key difference between sexual behavior and substance use. The substance can be eliminated from the person’s life but our sexuality goes with us everywhere

Finally, it is not only Cheng who needs to come to terms with the existence of his sexuality. His partner will also need to do that if they are to stay together. While there may be many ruptures in this relationship because of Cheng’s history of lying, secrets, and their mutual lack of sex positives attitudes, repairing those bonds will not be complete in my opinion unless they find a way to accept Cheng’s sexuality (with more sustainable expressions) as one part of the relationship between them.

As you can see, in Cheng’s case I would certainly recommend treatment to help him make a lot of changes to improve his mental health and relational satisfaction. But is this an addiction? The treatments I would primarily offer include education, acceptance, skill building, finding paths for expression, and open discussion with his partner. These are not hallmarks of addiction treatment. I might use some tools that I learned when I did treatment for addictions like encouraging him to have a plan for how to channel his sexuality into healthier avenues if he is inclined to repeat behaviors that could get him arrested like masturbating in public. Yet I might also use these tools when I have clients with other challenges that have nothing to do with sexuality or addiction.

Conclusion

Clients like Farrukh and Cheng come to treatment because something about their sexuality is not bringing them joy. Can treatment help? Yes, I believe it can. Does it matter whether we say that the treatment is for Sex Addiction or Out-of-Control Sexual Behavior (OCSB)? I believe that it does. When we talk about addiction, we think that recovery means abstinence, yet recovery from Sex Addiction does not mean abstinence from sex, though it might mean abstinence from specific sexual behaviors. In addition, because shame and self-loathing are such a toxic component of the OCSB process, I am cautious about using a label that might contribute to someone with this experience considering their body or the body of their lovers to be the “substance” of addiction and therefore a source of anxiety. I want my clients to walk out of my office embracing their sexuality in joy-generating ways.

Links for Critical Thinking About Sex Addiction

My view on Sex Addiction is not the only one among therapists who work with sexual issues or among researchers about sexuality. There are plenty of professionals who feel that sex addiction should be a recognized diagnostic disorder. To support critical thinking on this issue, I offer the following links in support of the Sex Addiction label and those like me cautious about Sex Addiction or in favor of the Out-of-Control Sexual Behavior label.

 

In Favor of “Sex Addiction”:

• http://www.rehabs.com/pro-talk-articles/new-research-supports-sexual-addiction-as-a-legitimate-diagnosis/
• http://www.discoverandrecover.org/2014/10/13/another-study-links-compulsive-sexual-behavior-to-other-forms-of-addiction/
• http://www.rehabs.com/pro-talk-articles/new-research-supports-sexual-addiction-as-a-legitimate-diagnosis/

In Favor of “Out-of-Control Sexual Behavior” or cautious about the label “Sex Addiction”:

• http://www.ucsf-ahp.org/wp-content/uploads/2012/11/FOCUS-V24-N1-Winter-2009.pdf
• http://www.crsh.com/control-sexual-behaviors/
• http://www.psychologytoday.com/files/attachments/882/challenginglandscapechapter.pdf

2019 Update:

A consensus is emerging the field of sex therapy against the sex addiction model. As one example witness this statement from the American Association of Sex Educator, Counselors, and Therapists:

Founded in 1967, the American Association of Sexuality Educators, Counselors and Therapists (AASECT) is devoted to the promotion of sexual health by the development and advancement of the fields of sexuality education, counseling and therapy. With this mission, AASECT accepts the responsibility of training, certifying and advancing high standards in the practice of sexuality education services, counseling and therapy. When contentious topics and cultural conflicts impede sexuality education and health care, AASECT may publish position statements to clarify standards to protect consumer sexual health and sexual rights.

AASECT recognizes that people may experience significant physical, psychological, spiritual and sexual health consequences related to their sexual urges, thoughts or behaviors. AASECT recommends that its members utilize models that do not unduly pathologize consensual sexual behaviors. AASECT 1) does not find sufficient empirical evidence to support the classification of sex addiction or porn addiction as a mental health disorder, and 2) does not find the sexual addiction training and treatment methods and educational pedagogies to be adequately informed by accurate human sexuality knowledge. Therefore, it is the position of AASECT that linking problems related to sexual urges, thoughts or behaviors to a porn/sexual addiction process cannot be advanced by AASECT as a standard of practice for sexuality education delivery, counseling or therapy.

AASECT advocates for a collaborative movement to establish standards of care supported by science, public health consensus and the rigorous protection of sexual rights for consumers seeking treatment for problems related to consensual sexual urges, thoughts or behaviors.