Development and Overview of Sex Addiction Therapy
Dr. Patrick Carnes is credited with igniting the Sex Addiction movement (Siegel & Siegel, 2007). In 1983, Carnes published, “The Sexual Addiction”, which defined sex addiction and proposed methods of treating it. Shortly after this book was published, it was renamed “Out of the Shadows: Understanding Sexual Addiction”. Carnes (2001) uses the Addictive System to model the phases of addiction. These phases include: Belief Systems, Impaired Thinking, the Addiction Cycle (a subsystem of The Addictive System), and Unmanageability (ch. 1, The Addictive System).
Carnes (2001) asserts that addiction begins with the addict’s core beliefs, which oftentimes are not grounded in reality (ch.1, The Addict’s Belief System). He believes that “addicts do not perceive themselves as worthwhile persons, nor do they believe that other people would care for them or meet their needs if everything was known about them, including the addiction” (Carnes, 2001, ch.1, The Addict’s Belief System, para. 4). As a result, they believe that “sex is their most important need, and sex is what makes isolation bearable” (Carnes, 2001, ch.1, The Addict’s Belief System, para. 4). It is from this distorted reality that impaired thinking–denial, blaming others, minimizing behaviors, etc.–arises and perpetuates the addiction (Carnes, 2001, ch. 1, Impaired Thinking).
Carnes (2001) uses the Addiction Cycle to model the addictive experience of a sex addict, the four phases of which are: (1) Preoccupation, (2) Ritualization, (3) Compulsive Sexual Behavior, and (4) Despair. Preoccupation is the mental state that fuels the obsessive search for sex. This is then followed by ritualistic and patterned behavior that leads up to the sexual behavior itself, which then becomes difficult to control or stop due to its compulsive quality. It is the feeling of despair about their behavior and their powerlessness that both ends and begins the Addiction Cycle (ch. 1, The Addiction Cycle).
Finally, each pass through the Addiction Cycle requires greater and greater energy (e.g., stress, anxiety/depression, fear, etc.) to manage the addictive behaviors and resulting consequences (e.g., ruptured relationships, venereal disease, pregnancy, financial/work-related difficulties, legal problems, etc.). This level of unmanageability leads to further hopelessness and entrenchment in the Addictive System (Carnes, 2001, ch. 1, Unmanageability).
Assessment and Symptoms in Sex Addiction Therapy
Based on his research, Carnes (1992) has identified ten symptoms and behaviors that he believes indicate the presence of sexual addiction: (1) a pattern of out of control behavior, (2) severe consequences due to sexual behavior, (3) inability to stop despite adverse consequences, (4) persistent pursuit of self-destructive or high-risk behavior, (5) ongoing desire or effort to limit sexual behavior, (6) sexual obsession and fantasy as a primary coping strategy, (7) increasing amounts of sexual experience (because the current level of activity is no longer sufficient), (8) severe mood changes around sexual activity, (9) inordinate amounts of time spent in obtaining sex, being sexual, or recovering from sexual experience, and (10) neglect of important social, occupational, or recreational activities due to sexual behavior (ch.1, para. 4). In addition, Carnes and his team created the Sex Addiction Screening Test (SAST) that attempts to distinguish addictive from non-addictive behaviors, which he purports indicates the presence of sex addiction; many professionals, including myself, would argue this assessment is not grounded in reliable research and pathologizes many sexual behaviors based on judgments, morals/values, and beliefs of the SAST designers.
Treatment in Sex Addiction Therapy
Carnes’ (2001) treatment of Sex Addiction is based on and employs the Twelve Steps and Twelve Traditions of Alcoholics Anonymous (ch. 7). Carnes (2001) explains that the “Twelve Steps can fundamentally interrupt and alter the addictive system” (ch. 7, Transforming Beliefs Through the Twelve Steps, para. 1) and that they “can restore the capacity for meaningful relationships by developing in addicts and co-addicts new beliefs to replace dysfunctional or faulty beliefs” (ch. 7, Transforming Believes Through the Twelve Steps, para. 1). As a result, the primary support and resource for treating sex addiction are attending a Twelve Step group–such as Sexaholics Anonymous, Sex Addicts Anonymous, and Sex and Love Addicts–working with a sponsor from that group, and progressing through the Twelve Steps of the program as outlined in the program’s literature (e.g., Sex Addicts Anonymous (Green) book).
Strengths and Limitations of Sex Addiction Therapy
Strengths of this model that I observe are that for some, the Sex Addiction model provides relief in knowing their experience has been named, a language to describe and communicate their experience, a discovery that others share their experience, and resources for education, support, and treatment. In addition, Twelve Step groups can be found in most urban areas and are very affordable (i.e., group members are only asked to donate what they can).
However, there are those who are critical of this model (including myself). Klein (2003) observes that the Sex Addiction model is based on assumptions that many in the field do not share, including: sex and sexual desire is dangerous, there is only one best way to express sexuality, sex that enhances intimacy is the best sex, people need to be told what kinds of sex are wrong/bad, and laws and social norms define sexual health (p. 77). As a result, Klein argues that the Sex Addiction model bears crucial limitations: it is pathologically oriented, pathologizes non-problematic behaviors, is clinically incomplete, lacks context (both individual and situational), is culturally bound, and is politically exploitative (2003, p. 77).
Cannon (2015) contends that because many of the treatment providers of this approach are unlicensed addiction counselors (CSAT) as opposed to licensed psychotherapists, underlying causes of compulsive sexual behavior, such as trauma, abuse, and other mental health issues, go undiagnosed and untreated (p. 17). In addition, he argues that treatment can be punitive and shameful; for example, the label of “addict” maybe shaming to some, the addict is often banished from the marital bed, and couples are not permitted to have sex of any kind for 90 days at the beginning of treatment (Cannon, 2015, p.17). He also argues that treatment can be judgmental and moralistic; for example, sexual expression such as fetishes, cross-dressing, bondage/discipline and sadism/masochism (BDSM), and (in the most rigid of groups) homosexuality, are considered part of the addiction (Cannon, 2015, p.17). As a point of reference, Sexaholics Anonymous considers “any form of sex with one’s self or with partners other than the spouse is progressively addictive and destructive” (“What is a Sexaholic and What is Sexual Sobriety?”, n.d.).
Not only is there criticism of how unhealthy sex is defined, but Ley (2012) argues that even the definition of healthy sex in the field of sex addiction is problematic, in that “they mostly boil down to subjective assessments that make broad generalizations, sometimes addressing intent and motivation, sometimes focusing on the relational aspects of sex, and other times focusing on certain behaviors, or amounts of behaviors” (p. 61).
Concluding Thoughts on Sex Addiction Therapy
I believe the greatest limitations of the Sex Addiction model are: it pathologizes sexuality and sexual behaviors based on subjective values and moral judgments; it does not address potential underlying causes of the sexual behavior; and it is focused on refrainment from unwanted sexual behavior rather than organizing around and encouraging the individual’s unique expression of sexual health through wanted sexual behavior.
The way the Sex Addiction model pathologizes sexual behavior is evident in the questions asked and the meaning made of the responses on the Sexual Addiction Screening Test (SAST) used to diagnose Sex Addiction. Many of the questions asked on the SAST are related to thoughts, feelings, and behaviors that I do not believe are problematic in and of themselves. For example, I do not agree that because someone has sought therapy for sexual problems, feels bad about or worries their sexual behavior is abnormal (whatever that means to an individual), maintains multiple emotional or sexual relationships, hides their sexual behaviors from others, joins online dating services, frequents pornographic websites, or visits bathhouses or sex clubs means they are (or are likely to be) a sex addict. I have worked with many people who have sought therapy about sexual problems, felt bad about sexual behaviors, or engaged in emotional and sexual affairs and did not consider themselves sex addicts (nor did I). I believe that many people who do not identify as heterosexual have hidden their sexuality and sexual behaviors from others. I know many people who have enjoyed healthy sexual encounters or began intimate relationships as a result of dating (and even hook-up) websites. For some communities, frequenting bathhouses and sex clubs are normative parts of the culture. Nonetheless, affirmative responses to too many questions like these result in being diagnosed as a Sex Addict. Their message is: “You've taken the test and it confirmed your fears. You're probably frightened, confused, and overwhelmed. Where do you go? Whom can you trust?” (“Sexual Addiction Screening Test”, n.d.).
In addition to the bias implied in the questions featured on the SAST, which is based on the subjective values and moral judgments of the creators of the Sex Addiction model, I have found this bias to be present in the Twelve Step programs designed to treat Sex Addiction. For example, some Twelve Step groups pathologize and prohibit the use of pornography, regardless of whether the usage is compulsive or not. My own experience (which may be different from others) attending Sex Addicts Anonymous is that a judgmental and shaming culture had developed within the group. I regularly observed the shaming of group members by other group members (and themselves) when they relapsed in their recovery. I was often told that “working the Steps” was the only way to sexual sobriety and that than any other approach was only “managing” my addiction rather than “treating” it. Rather than subscribe to this belief, I ultimately sought out a therapist that could work with my challenges around compulsive sexual behavior in a more holistic and sex-positive way, and I have offered the same to the clients I have privilege of working with.
Cannon, N. (2015). A strength based approach to treating out of control sexual behavior (ocsb) [Presentation by Dr. Neil Cannon on February 6, 2015 at the Buehler Institute].
Carnes, P. (1992). Don’t call it love: Recovery from sexual addiction [Kindle Edition]. New York, NY: Bantam Books.
Carnes, P. (2001). Out of the shadows: Understanding sexual addiction (3rd ed.) [Kindle Edition]. Center City, MN: Hazelden.
Klein, M. (2003) Sex addiction: A dangerous clinical concept. SIECUS Report, Vol. 31, No. 5, 77-80.
Ley, D. J. (2012). The myth of sex addiction [Kindle Edition]. Plymouth, United Kingdom: Rowman and Littlefield Publishers.
Sex Addicts Anonymous. (2005). Sex addicts anonymous. Houston, TX: International Service Organization of SAA.
Sexual Addiction Screening Test (n.d.). Retrieved March 1, 2015, from http://www.sexhelp.com/am-i-a-sex-addict/sex-addiction-test
What is a Sexaholic and What is Sexual Sobriety? (n.d.). Retrieved March 1, 2015, from http://www.sa.org/sexaholic.php