In today’s world, all sorts of people are misdiagnosed, by self or others, as sexually addicted. This occurs for any number of reasons. Recognizing this, it is imperative that addiction therapists and other clinicians learn to differentiate between those who are and those who are not sexually addicted. Otherwise, we risk over-treating and/or mistreating clients—either of which can be incredibly damaging.
In general, sexual addiction is diagnosed based on the following three criteria:
- Preoccupation to the point of obsession with sexual fantasies, imagery, and/or activity
- Loss of control over the use of sexual imagery and/or activity, typically evidenced by multiple failed attempts to cut back or quit
- Directly related negative life consequences, such as ruined romances, problems at work or in school, anxiety, depression, social/emotional isolation, physical ailments, loss of interest in previously enjoyable activities, financial woes, legal entanglements, etc.
It is important to state here that sexual addiction is not in any way defined by who or what it is that turns a person on. As such, homosexuality, bisexuality, kinks, fetishes, and the like are not a consideration when diagnosing sexual addiction, even if those attractions and behaviors are ego-dystonic. Certainly people with these attractions and behaviors can be sex addicts, but they should only be diagnosed as such if they meet the benchmarks listed above.
Consider the criteria for sexual addiction in relation to the following three clients, asking yourself which of the young men are sexually addicted.
Max is a 22-year-old college senior. Until a few months ago he had a steady girlfriend, but when he told her that he didn’t want to get married after graduation, she broke up with him. Now he is experiencing significant anxiety about his life and has started seeing a therapist. In his first session, he tells his therapist he is actually relieved that his two-year relationship is over because he’s known for a long time that his former girlfriend isn’t “the one.” He also says that ever since the breakup he’s been looking at porn “a lot,” using it as a substitute for the time and sexual energy once spent with his girlfriend. He says that he first discovered Internet porn at age 15, and he has used it off and on ever since. He is still keeping up with his schoolwork—in fact, his grades have improved since the breakup—and he socializes at least a few times per week with his friends, either playing video games in his dorm suite or going to a local bar for beers and foosball. As of now, he has no real interest in dating, nor does he want to have casual sex. He says he is bothered by the anxiety he feels about his life, and he is worried that online pornography has taken precedence over real world sex and relationships. He asks his therapist if he might be a sex addict.
Kevin is a 22-year-old sales associate for a major cellphone carrier. Two nights per week he takes classes at the local community college, though he has no declared major and needs to focus on a particular subject before he can hope to graduate. In high school he had a girlfriend, but he broke up with her during his senior year because she was pushing him to be more sexual, and that did not mesh with his conservative religious upbringing. Since that time he has gotten his sexual needs met a few times per week via porn, even though porn use also doesn’t mesh with his religion. He says he started looking at porn after high school, and nowadays he finds himself looking at gay porn. This occurs even though he continually tells himself, “This time I won’t look at men.” He feels very ashamed about his attraction to men, and he says that he does not want to be gay because “it’s a sin.” Beyond his issues with sexuality, he does not have any serious life problems. His work life is fine, his grades are decent, and he gets along with his family. However, he feels very depressed, emotionally isolated, and ashamed about his online sexual activity. A month ago, Kevin spoke to his pastor about his porn use, including the fact that he was looking at men, and his pastor suggested he seek treatment for sexual addiction. His pastor seemed to think that if a nice, normal boy like Kevin was looking at porn, especially gay porn, the only plausible explanation was addiction. So now Kevin is in treatment, thinking he is sexually addicted and hoping he can stop fantasizing about sex with men.
James is a 22-year-old college dropout. His is depressed, he feels as if his life is going nowhere, and he has started seeing a therapist. In therapy, he says that he started looking at online pornography when he was 11, after his father left to be with another woman, and by the time he finished high school he was using porn daily—often for several hours a day, despite many attempts to cut back. He says that he has lost interest in nearly all of the activities he once enjoyed—sports, school, video games, and just plain hanging out with his friends—preferring instead to view porn and have webcam sex with anyone who’s willing. Once an excellent student, his grades dropped steadily throughout high school to the point where he was barely accepted into college. And he dropped out of college after his second semester because dropping out seemed like a better option than failing out. He says, “If I’d done my homework instead of fooling around online, I might have done a lot better.” Since then, he has held several menial jobs, none for more than a few months. He now lives with his parents. Every time he goes online he tells himself he’ll only look at porn for a few minutes, but his sessions almost always last several hours. He has not had a girlfriend since his sophomore year of high school, even though he wants one. He tells his therapist that he views cybersex as a solution to his problems (depression, anxiety, loneliness), and not a potential cause. He says he does not want to even discuss the concept of sexual addiction, and that he only wants to treat his depression and anxiety.
So who is the sexual addict: Max, who is worried he might be; Kevin, whose pastor says he is; or James, who insists he’s not?
- Criterion Number One—Preoccupation to the Point of Obsession: All three young men are at least somewhat preoccupied with sexual fantasy, imagery, and activity. Max’s preoccupation may be temporary and situational (a reaction to his breakup). Kevin’s preoccupation seems relatively minimal, as he’s only looking at porn a few times per week. Meanwhile, James’s obsession seems much deeper and longer-lasting.
- Criterion Number Two—Loss of Control: Until now, Max has never attempted to quit or curtail his porn usage. The idea has simply never crossed his mind, as porn never seemed like a problem that needed to be addressed. Kevin only wants to control the type of porn that he looks at, not the amount. James, on the other hand, reports multiple failed attempts to either cut back or quit entirely.
- Criterion Number Three—Negative Life Consequences: Max is dealing with anxiety and a lack of interest in dating, both of which may be situational (related to his breakup and his impending graduation from college). Kevin’s life seems to be going fine, except he’s directionless in school and troubled by his attraction to men. Meanwhile, James is depressed and stuck and failing on many levels. In a nutshell, he has withdrawn from life, and he is feeling pretty hopeless about his circumstances.
A simple fact in today’s increasingly digital world is that there are multiple, often very different populations seeking treatment for sex/porn addiction and related symptoms. As with Max, some clients seek help because they’re situationally depressed and choosing to “numb out” with sexual behaviors (just as others might numb out with a cocktail). These individuals may or may not be sexually addicted. Either way, the basics of sex addiction treatment—stopping compulsive behaviors and learning healthier coping mechanisms—tends to significantly help this cohort. If they struggle with this early stage of treatment, a continued focus on sexual addiction may be in order. If they don’t struggle, then working on depression, anxiety, and social skills development tends to be more useful moving forward.
Other clients seek treatment because they’re engaging in sexual behaviors they find shameful or that the people around them find shameful, and they hope that sex addiction treatment will help them stop. This seems to be the case with Kevin. If, however, these clients do not meet the diagnostic criteria outlined above, they should not be treated as sexually addicted. In other words, ego dystonic sexual attraction and behaviors should not be misinterpreted as sexual addiction.
Still other clients seek treatment for the symptoms of sexual addiction, a la James, with no interest whatsoever in changing their sexual behaviors. If they truly are sexually addicted, as seems likely with James, these clients can be difficult to work with, as they’re not yet willing to address the underlying driver of their symptoms. In such cases, psychoeducation about the nature and consequences of sexual addiction is necessary, as is therapy geared toward breaking down denial. Sometimes sex addiction focused group treatment can be helpful in this regard, as the client may see his or her own behaviors and denial mirrored in other group members.
For more information about sexual addiction, check out my recently published books, Sex Addiction 101 and Sex Addiction 101, The Workbook. I also conduct an open-ended discussion about sex addiction on InTheRooms.com, Friday nights at 6 p.m. PST. If you have a client needing clinical assistance with sex addiction that you don’t feel qualified to provide, therapist and treatment referrals can be found here and here.
Robert Weiss LCSW, CSAT-S is Senior Vice President of National Clinical Development for Elements Behavioral Health, creating and overseeing addiction and mental health treatment programs for more than a dozen high-end treatment facilities, including Promises Treatment Centers in Malibu, The Ranch in rural Tennessee, and The Right Step in Texas. An internationally acknowledged clinician, Rob has served as a subject expert for multiple media outlets including The Oprah Winfrey Network, The New York Times, The Los Angeles Times, The Daily Beast, and CNN, among many others. He is also the author of several highly regarded books. For more information please visit his website at robertweissmsw.com or follow him on Twitter, @RobWeissMSW.