Sexually addicted men and women enter treatment because their addiction is destroying their lives, but once they’re in therapy they often fail to mention their out-of-control sexual activity (most often due to shame). Instead, they ask for help with their addiction’s related symptoms – depression, severe anxiety, relationship problems, co-occurring substance abuse issues, and the like. And while therapists can take these clients at their word and treat the addiction’s related and co-occurring issues, these patients can’t fully heal until their core problem is uncovered and addressed. As such, it is incumbent upon clinicians to recognize the sometimes difficult to detect signs of compulsive sexual behavior and sexual addiction. This requires close and careful (but not necessarily graphic) questions about a client’s romantic and sexual life (with self and others), along with the ability to find truth and reality in a client’s potentially evasive responses.
If you have a client entering counseling or therapy today and you hear words like infidelity, affairs, casual sex, anonymous sex, hook-ups, cyber-porn, sexting, and the like, it is best to engage that client in a broader discussion of his or her sexual/romantic history, not confining your initial assessment to the material being generated by the client. Interestingly, many clinicians are more comfortable talking with clients about past sexual abuse and trauma than they are with discussing the adult manifestations of these attachment and trauma-based challenges. Some therapists will provide full-on trauma treatment without ever even asking about the client’s adult sexual and romantic behaviors. In hopes of remedying this, I have provided below a short list of things to ask about and look for when providing psycho-sexual assessments.
- A Pattern of Out-of-Control Sexual Behavior
Clients will sometimes respond openly and honestly to direct questions about sexual behavior. If so, that is great. If not, it is up to the clinician to discern problematic patterns from indirect statements and admissions. Clients will sometimes indicate they’ve lost control over their sexual behavior by saying: “Suddenly I found myself doing…” or “I’m not even sure that I meant to go there but…” It is true that non-sex addicted clients also make regrettable sexual decisions, but non-addicts are nearly always aware of the steps that led to the event and they tend to not repeat those that caused problems, whereas sex addicted clients are typically not cognizant of the decision-making process and they will return to problematic sexual activities regardless of consequences.
- Severe, Negative Consequences Related to Romantic and Sexual Acting Out
Common negative consequences of sex addiction include relationship betrayals, living a double-life with related anxiety and depression, financial woes, lack of focus at work or in school, STD’s, social isolation, and even legal trouble. Clients reporting one or more these issues should be asked directly about porn use, digital hookups, affairs, massage parlors, strip clubs, prostitutes, and the like. Clinicians should be aware that “pre-contemplative” sexually addicted clients often have not made cognitive links between their sexual acting out and the life, work, relationship, and emotional problems they are having. This is their denial. Sometimes therapists need to read between the lines and continue to ask pertinent questions. Useful clinical questions for men and women can be found on the Sexual Recovery Institute website.
- Inability to Stop despite Adverse Consequences
Clients whose sexual/romantic behaviors have led to disciplinary measures at work, broken relationships, health risks, or legal risks and related consequences should be asked whether those sexual/romantic behaviors were repeated despite the consequences. Clinicians should be aware that sexually addicted clients will resist this line of questioning. Male sex addicts will sometimes admit to their behaviors but argue that “all men behave this way, it’s just a guy thing,” while female sex addicts may argue that they “just can’t seem to find the right guy to date” even though they are acting out sexually far more than they are actually dating. Justifying actions, deflecting blame, and minimizing consequences are part and parcel of all addictions, and therapists must be aware of this tendency in sex addicted clients.
- Loss of Interest in Important Social, Recreational, or Occupational Activities
One of the first things to disappear from the life of an active sex addict is free time. For individuals whose lives have become increasingly wrapped up in sexual fantasy and behavior there is less and less time for socializing, recreation, hobbies, and friendships. Because of this, sex addicted clients sometimes say that their lives feel small and confined, that they feel isolated and alone, and that they’ve lost interest in things they used to enjoy. (Statements to this effect are typical indicators for all forms of active addiction.)
- Seeking Sex and/or Romantic Intrigue as an Emotional Coping Strategy
Sometimes a clinician can discern sexual addiction by asking questions about when and why a client is sexual (with self or others). If clients appear to be using sexual/romantic fantasy and activity as a way to self soothe and/or manage difficult emotional triggers (including things as simple as boredom), that can be a strong indicator of sexual addiction – especially if it seems to be a client’s go-to coping mechanism.
- Anger When Questioned about Sexual Activity
Sex addicts (whether they are consciously aware of their addiction or not) nearly always experience guilt, shame, remorse, isolation, and self-loathing about their sexual behaviors and the lack of control they have over them. As such, questions about sexual behavior nearly always make them uncomfortable, sometimes to the point where they lash out in anger. Although it is more often the case that these clients are dying to talk about their history (but terrified of judgment), some do get angry or feel invaded. Should this occur, it is wise to explain that questions about sex are standard for an emotional health assessment, just like asking about eating, exercise, social habits, work, family, school, etc.
Most of the time male clients are more open to talking about their impulsive/compulsive sex lives than female clients. This is because men who have a lot of sex are culturally celebrated and may think of themselves as “studs” or “players,” whereas women who have a lot of sex are culturally shamed and may think of themselves as “whores” or “sluts.” As such, men tend to enter sexual addiction treatment through the front door, more readily admitting to their core (sexual) problem. Women, however, tend to be referred into sexual recovery after seeking treatment for related symptoms such as depression, eating disorders, or substance abuse.
If, after close questioning, you are still unsure as to whether a client may have a problem with compulsive or addictive relationships/sexuality, there are numerous screening quizzes that can help. These quizzes are similar to the 20 questions Alcoholics Anonymous provides to help people decide if they are an alcoholic. As mentioned above, excellent sex addiction screening tests for both men and women, as well as a cybersex addiction test applicable to both sexes, are available on the Sexual Recovery Institute website. The tests are comprised of no more than 25 yes/no questions. All you do is click on the yes or no button for each question and then hit the “submit” icon at the bottom of the quiz. The site provides instant (and anonymous) analysis of the situation, including a rating of how dire the situation may be.
Robert Weiss LCSW, CSAT-S is Senior Vice President of Clinical Development with Elements Behavioral Health. A licensed UCLA MSW graduate and personal trainee of Dr. Patrick Carnes, he founded The Sexual Recovery Institute in Los Angeles in 1995. He is the author of Cruise Control: Understanding Sex Addiction in Gay Men and Sex Addiction 101: A Basic Guide to Healing from Sex, Porn, and Love Addiction, and co-author with Dr. Jennifer Schneider of both Untangling the Web: Sex, Porn, and Fantasy Obsession in the Internet Age and the recently released, Closer Together, Further Apart: The Effect of Technology and the Internet on Parenting, Work, and Relationships.