In today’s world, almost every psychotherapeutic clinician encounters at least a few clients who are behaving in sexually compulsive ways. The first step in treating these clients, the same as with any disorder, involves proper assessment. Unfortunately, very few biopsychosocial instruments cover sexual issues in any sort of meaningful way. Thus, I suggest that clinicians routinely add a few sex related questions to their analyses. Basic questions that I typically ask include:
- Do you look at porn? If so, how often? And how do you feel about it?
- Do you engage in other forms of internet driven sex and/or romance? If so, how often? And how do you feel about it?
- Is there anything about your sexual or romantic life that troubles you or those around you? If so, what?
- Are you keeping any secrets about your sexual or romantic activities? If so, what are they, and why have you been keeping these behaviors secret?
If a client’s response to these questions indicates a potential issue, or if a client’s presenting issue centers on infidelity, compulsively hooking up, heavy porn use, or some other sexual or romantic behavior, a fuller assessment for sexual addiction is in order. An updated list of 15 questions to ask is available on my website at this link. Or, if you choose to do so, you can use a longer (and somewhat dated) sex addiction screening test, available here and in various other locations.
When a client is diagnosed as sexually addicted, the next step is getting his or her sexual behaviors under control, typically by developing a personalized plan for sexual sobriety and implementing behavioral accountability.
Later, when the client’s sexually compulsive behaviors are solidly under control, his or her related issues (depression, anxiety, shame, and the like) may or may not dissipate. If the secondary problems fade away, that’s great. If not, then further therapeutic work is needed, and that work should focus on the client’s underlying issues—the unresolved problems that drove the client toward escapist sexual behaviors in the first place.
This, of course, is the same approach we use when treating substance addicts, compulsive gamblers, and even people with eating disorders. First, we manage the out of control behavior. Then, if necessary, we attack the underlying problems. And most of the time these deeper issues center on unacknowledged, unaddressed, and/or unresolved childhood trauma.
This should not be surprising, as there is a definite and undeniable link between childhood trauma and later life addiction. For example, one study tells us that survivors of chronic childhood trauma are:
- 1.8 times as likely to smoke cigarettes
- 1.9 times as likely to become obese
- 3.6 times as likely to qualify as promiscuous
- 7.2 times as likely to become alcoholic
- 11.1 times as likely to become an intravenous drug user
Another common risk factor for addiction (of all types) is early exposure to an addictive substance or behavior. Of course, age of first use and family instability (and, therefore, early-life trauma) are generally related, as addictive substances and behaviors are often available within a dysfunctional home. Thus, trauma rather than early exposure is generally (though not always) the overarching factor.
This means that with sexual compulsivity (and other compulsions and addictions), from a longer-term treatment standpoint, resolution of early-life trauma is paramount. If these issues are not uncovered, identified, and addressed, the shame and other negative self-beliefs that drive a client toward escapist and therefore addictive behaviors remain in play, and the potential for relapsing into compulsive sexuality (or some other compulsive or addictive activity) remains high.
With early-life trauma, the only real difference between sex addicts and other addicts is that with sex addicts the early-life trauma is much more likely to be sexual in nature. This sexualized trauma may be overt (hands on) or covert (sexualized emotional partnering). Making matters worse, this inappropriate early-life sexualization is nearly always coupled with other forms of trauma, including neglect, emotional abuse, psychological abuse, physical abuse, etc. That said, sexual trauma is not a prerequisite for sexual addiction. Any form of trauma will do.
When a sexually compulsive client has an extensive trauma history, and almost every true sex addict does have such a background, his or her underlying issues with abuse and neglect must ultimately be addressed. Otherwise, the client will still feel a need to “self-soothe” and “self-medicate” via escapist and potentially addictive activities, greatly increasing the risk of relapse. Generally, early-life trauma is addressed in treatment with “exposure” and “desensitization” techniques, where clients are asked to re-experience traumatic events in the safety of a therapeutic milieu, thereby learning to cope with “in the moment” feelings in healthier ways.
For more information about trauma driven sexual addiction and how this disorder can best be identified and treated, check out my recently published book, Sex Addiction 101, and the accompanying Workbook. For sex addiction treatment referrals, click here or here. For information on trauma treatment, click 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. He is the author of several highly regarded books, including Sex Addiction 101: A Basic Guide to Healing from Sex, Love, and Porn Addiction. For more information please visit his website at robertweissmsw.com or follow him on Twitter, @RobWeissMSW.