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What You Need To Know About... Hypersexuality
What You Need To Know About... Hypersexuality
The AASECT listserv has been abuzz lately with a continuous back and forth on sex addiction. Does it exist? Are we pathologizing a symptom rather than seeking out the true cause? Is it the jargon that's most problematic? Should we be calling it hypersexuality? Impulsive or compulsive sexual behavior? Out of control sexual behavior? Something else entirely? How can we properly diagnose and treat a behavior when we can't even agree upon its existence, let alone the proper terminology?
(This issue has been so omnipresent as of late that we even touched upon it in "Exploring Evolving Clinical Models for Sex Therapy," our feature in the June 2014 issue of Contemporary Sexuality.)
The Semantics of Out of Control Sexual Behavioral
In writing this piece, it seemed important to pin down some basic terminology. After all, how does one have a conversation about a topic if they're not even sure how to refer to it? In questioning various sexologists about the language around this behavior, however, it became clear that choosing just one term would be extremely difficult.
James Cantor, PhD, CPsych, for example, a clinical psychologist and research scientist specializing in atypical sexualities, couldn't find a single term he was comfortable with. "Because we know so little about people wanting to reduce their sexual behavior," he says, "it's important to avoid terms that assume one or another theory. The term 'sex addiction' implies that it works like substance addictions, even though we have no evidence for that. The term 'compulsive sexual behavior' implies that it's related to Obsessive-Compulsive Disorder, even though we have no evidence for that either. I typically use the term 'hypersexuality' because it does not imply any theory or treatment, but that term isn't perfect either: there are people who refer themselves as 'hyper-' sexual, even though they engage in less (sometimes even much less) sexual activity than most other people."
David Ley, PhD, a clinical psychologist, is in agreement. "I don't like any of them," he says, referring to the various terms out there. "There are a plethora of terms and what that means is that nobody can agree on what we're talking about. There are no consistent, objectively agreed upon symptoms, diagnoses, or treatments. What this plethora of terms means is that the concept is inherently subjective and fluctuates in response to cultural values."
Ley references various diagnoses of both men and women throughout history, highlighting how the terminology has shifted along with cultural attitudes at the times. "Nymphomania, for example," he says, "pathologized female sexuality because of the cultural mood at the time. We are doing the same thing with these terms. I flat out disagree that this is a homogonous syndrome. It cannot be labeled with a single term."
Eli Coleman, PhD, an AASECT member, professor, and the director of the Program in Human Sexuality at the University of Minnesota, shies away from addiction-based terminology most of all. "I think the term 'addiction' is overused and implies that all behavioral excesses can be explained by some similar mechanism," he says. "What we know about alcohol and drug addictions cannot simply be transferred to other behavioral excesses. Sex is a basic appetitive drive that for some people becomes out of balance for a variety of reasons. For some it is a problem of impulse control. For others it is more like an obsession. For others, it is like a compulsion. And for others, it is a part of their personality structure and has nothing to do with impulse control, obsessions, or compulsions."
On the other hand, Paula Hall, a sexual & relationship therapist and also a sex addiction therapist, obviously prefers the term in her title. "There is growing evidence from fields of neuroscience," says Hall, "that behavioral addictions have the same impact on the brain as chemical addictions and, hence, I feel the term [sex addiction] is being proven to be accurate. But I also prefer the term because it's what the public is calling it."
But her clients' familiarity and comfort with the term aren't the only reasons she uses it. Like Cantor, she sees terms such as "hypersexuality" that presume a sexual norm as problematic. "Hypersexuality implies there is a norm for sexual thoughts, feelings, and behaviors," she says, "and I don't think that’s helpful at all."
Marcus Earle, PhD, a psychologist and marriage and family therapist, prefers to ignore the terminology entirely, focusing instead on individual clients. "Whatever clinically works best for the client is what I prefer," he says. "What they relate to and what is most helpful."
Why and How Clients Come to Self-Identify as Sex Addicts
Which leads to the question of how clients end up self-identifying as sex addicts in the first place. Does their self-diagnosis stem from their cultural or religious backgrounds? From a problem their partner has with their sexual behavior? From the sense that their sexual choices are legitimately disrupting the normal course of their lives? The answers — once again — are as varied as the terminology. In different cases, one or more of these elements can come into play.
"One of the most difficult situations we encounter is with couples who have very different beliefs about what are acceptable kinds or amounts of sex," says Cantor. "I've seen many couples where one partner comes in as the client, not because the client has any kind of unusual behavior, but because the client's partner believes the client has a problem. Usually, this takes the form of a woman sending her husband in to fix 'his' problem (which is often just typical masturbation), when the best intervention is often to use couples' therapy with both people to help them increase healthy, assertive communications skills and psycho-education about what constitutes healthy sexual behavior."
Ley provides an example of this from his own practice. He describes the case of Philip, a 47-year-old business executive who sought out treatment with him after nine months of previous treatment in a sex addiction intensive outpatient program.
Philip entered the sex addiction treatment program following the revelation of multiple affairs and sexual infidelity. He said he accepted the sex addiction diagnosis largely because of peer pressure within the treatment group, though he never truly believed he was addicted to sex or that his sexual behaviors were out of his control. Once in treatment with Ley, it became apparent that the sex addiction label was a way for Philip's wife to understand and externalize her husband's choices. They also explored how Philip's privilege, sense of entitlement, and focus on his own needs were primary issues in his relationship decisions. Finally, they explored how the sex addiction label was a distraction from addressing many of the more global and significant issues in his relationship.
And partner perspective isn't the only thing that can lead to a sex addiction diagnosis. In other cases, says Cantor, "there are other people with strongly religious backgrounds who fear they are sex addicts because they or their partners have zero tolerance for any masturbation at all. To give them all the very same label is to look at them in only the most superficial way."
Expanding upon this, Coleman says, "I believe the term [addiction] is often used carelessly and can easily be a disguise for labeling what people see as immoral behavior. Masturbation and fantasy remain as very uncomfortable topics for many people and I see too often the term being used by some people who simply have a restrictive value system around sexuality and view this behavior as wrong."
Then there is the question — in terms of the concepts hypersexuality and out of control sexual behavior — of what a behavior is "hyper-" or "out of control" in relationship to. What is the norm against which we're supposed to be evaluating all sexual behavior?
"These concepts have more to do with level of libido and sexual desire," says Ley. "It is inherently damaging to tell people they are a sex addict, and to affirm that identity... to tell them their sexuality is something they have to fight against for the rest of their life. That creates a victim role."
Ley goes into the limitations of the current research on sex addiction. "Research shows that all people are subject to potentially making poor or impulsive decisions when they are sexually aroused," he says. "But sex addiction takes this human variable and calls it a disease."
Hall agrees that research has been limited. "The latest research in the United Kingdom was of 19 people with porn addiction, and a control group without, and brain scans showed similar cue responses to chemical addictions," she says. "There is no doubt for most people now that some people feel their sexual behavior gets out of control and they are seeking help to enjoy their sex lives more. But the science is still scant and sketchy."
Despite the lack of solid research, Hall defers to the experiences of her clients. "What we do have is an ever-growing amount of clinical evidence and experience, and we need to start listening to our clients, not just the researchers," she says.
Lawrence Siegel, MA — another AASECT member — disagrees. He puts aside the causes of such self-diagnosis entirely, bringing up an interesting point in regard to how therapists approach their clients. "This is the only area in psychotherapy where we let the patient and the client diagnose themselves," he says. "If anyone else came in saying 'I am...,' you'd want to know, 'Why do you think that? What's going on?' But with sex addiction, they come in and say, 'I'm a sex addict,' and the therapist says, 'Okay, let's go with that.'"
How Strong Is the Sex Addiction Research?
Returning to the issue of current research on sex addiction, Ley says, "In over 30 years, the sex addiction industry has never published or conducted research not limited by extreme sample bias. Seventy-five percent of the stuff written on it is off-the-cuff, anecdotal, theoretical writing."
He then mentions some startling research on the efficacy of addiction treatment programs in general. Just this past March, Lance Dodes, PhD, published The Sober Truth: Debunking the Science Behind 12-Step Programs in the Rehab Industry. This book contains research showing that 12-step treatment programs are effective for only five to 10 percent of those seeking treatment for alcohol or drug addiction. "Sex addiction treatment is based upon this," says Ley.
Then there is the 2008 paper written by Jason Winters, BSc, MA, showing that self-identified sex addicts have just as much ability to be in control of their sexual arousal as non-sex addicts.
In addition, Ley found in his own investigations of existing research (his review article was published earlier this year in the journal Current Sexual Health Reports) that self-identification as a sex or porn addict was predicted by an individual's level of religiosity. Joshua Grubbs led a similar study this year titled "Transgression as Addiction: Religiosity and Moral Disapproval as Predictors of Perceived Addiction to Pornography," published in the journal Archives of Sexual Behavior.
Ley explains that the degree to which these individuals grew up in religious, highly moral households predicted the likelihood of a self-diagnosis as a sex addict, as having a high level of sexual arousal or desire conflicted with their internal morals.
"Good, current research is happening," says Ley, "and it is not going in [sex addiction treatment advocates'] favor."
Coleman mentions similar shortcomings when it comes to hypersexuality. "There is a paucity of rigorous science on the topic of 'hypersexuality,'" says Coleman. "While the American Psychiatric Association's (APA) Task Force on the revision of the Diagnostic and Statistical Manual of Mental Disorders section on sexual disorders recommended the inclusion of 'Hypersexual Disorder,' the APA was not convinced that there was enough science to support its inclusion."
Is Sex Addiction the Cause... or the Symptom?
Then there is the concern that "sex addiction" is merely a symptom of what may be, in most individuals' cases, a larger problem. "Depression and negative life events come first," says Ley. "People sometimes use sex and porn as coping strategies. That's healthy."
"Sometimes we have jumped too quickly into diagnosing people with sex addiction," adds Earle. "I think the field is maturing now, and people are paying more attention to distinctions."
In reference to the addiction model, Earle concedes that "this model continues to be very helpful to a very large group of people, but it's not the only model."
He goes on to say that clinicians tend to function from where they're most comfortable. "But if someone comes in not wanting to work from that model," says Earle, "check to see where their resistance comes from. The therapist can refer them to someone else who works with another model. I think we can do a better job of finding fits for clients. With all these terms and treatment models floating around, what we're really talking about, for an individual, is a behavior they're finding disruptive in their lives, a behavior that's creating pain for them, that they've been hiding and that's worsened with time."
Hall advocates for greater acceptance of the addiction model, echoing Earle's message about the fact that — terminology aside — clients are seeking out help for a behavior that is proving troublesome. "Sex addiction is about addiction, not about sex," she insists. "It's about the function of the behavior and the dependency on it — not about the behavior itself. Too many people focus on the morality of the sexual behavior, but that’s a red herring. Whether you're pro- or anti-alcohol, some people use alcohol as a primary coping mechanism in spite of the damage it is doing to their lives, and they can't stop. That's called alcoholism. The same is true of sex addiction."
She shares a case study from her practice:
"Martin, 52, had been visiting sex workers since the age of 18 but didn’t feel his behavior was out of his control," says Hall. "He knew his wife would be devastated if she found out, but he was sure he could keep it hidden, and justified it by saying he was meeting sexual needs for variety that she wasn't able to provide, and that it strengthened his marriage and ensured he would not have an affair."
But when his wife developed breast cancer, he found himself getting more involved with Internet pornography and cybersex. His behavior escalated and continued even when his wife was in full remission, and he found himself withdrawing from the sexual relationship he'd had with his wife.
Martin eventually realized he had an addiction that was out of his control. He joined a group with other men who had been through similar experiences. He developed practical relapse prevention strategies and a long-term support network. He also paired this with individual therapy to work on childhood attachment issues, and couple therapy to help him and his wife work through the trauma of her cancer and rebuild their sex life.
"It took a full five years for cravings to reduce and for him to feel as if he could release the reins on his recovery," says Hall.
How Should We Handle Contentious Issues Such As This One?
In talking to all of these sexuality professionals, I only found myself further away from a definitive answer on how we should be talking about problematic sexual behavior. When I ask how we should be handling contentious issues such as this, Earle expresses sadness that we even have to ask that question.
"Some can get real defensive when the topic comes up," says Earle, "and that doesn't help dialogue. Some are dismissive, and that doesn't help conversation. What I hope would happen is that we talk about where we agree on things: that this behavior is leading to pain for an individual."
He explains, "We've had a lot of experiences with clients coming in who felt they weren't taken seriously by their sex therapist, or that their behavior was minimized. They walk away feeling something's wrong with them and that what they're struggling with and unable to get a handle on, well, it's not a problem. It's part of being a normal male and they should just change how they think about it. This approach helps some but, for others, it just doesn't fit for them or their value system. They walk away feeling discouraged and a little more helpless."
"I wholeheartedly believe we're doing a disservice to clients by fighting battles where there really aren't battles to be fought," continues Earle. "Rather than trying to force people to see things from our perspective, we should make referrals. Being open to other forms of treatment will help us learn how to do our jobs better, and will be immensely more helpful to clients."
As for how educators should field questions on this issue in the midst of such confusion, Cantor says, "I have found it helpful to be a tour guide, to explain to audiences what the major 'camps' are, the nature of the disagreements among them, and what kinds of future evidence might help decide things. It can work out very well to offer one's own opinions," he says, "but only while acknowledging them as mere opinion."
Says Coleman, "I think the most important thing is to recognize that someone is distressed and that there is a need for careful listening. The next is not to assume anything. The educator needs to explore what [the student] means by that term and what behaviors they are concerned about. They should be alert to the possibility of over-pathologizing sexual behavior that can be caused by sex-negative attitudes and a failure to recognize the wide range of normal human sexual expression."
Earle agrees. "Even if you disagree that it's an out of control or problematic behavior," he says, "it's still a behavior experienced by individuals as out of their control. It's causing incredible pain for them. They feel really trapped in the behavior. They may have lost numerous relationships or lost jobs. They may experience a great deal of isolation in their lives and are looking for a way through what they're experiencing."
In the end, it appears best to avoid big-picture generalizing over various diagnosis terminology and to stick to treating the individual.
For further reading:
"Harvard Doctor Debunks ‘Bad Science’ Behind 12-Step Programs," Radio Boston.
Abel, Jennifer, Researchers: pornography addiction isn't real. Consumer Affairs. February 13, 2014.
James M. Cantor, Carolin Klein, Amy Lykins, Jordan E. Rullo, Lea Thaler, Bobbi R. Walling. A Treatment-Oriented Typology of Self-Identified Hypersexuality Referrals. Archives of Sexual Behavior, July 2013, Volume 42, Issue 5, pp 883-893.
Ley, D. et al. (2014). The Emperor Has No Clothes: A Review of the "Pornography Addiction" Model, Current Sexual Health Reports. DOI 10.1007/s11930-014-0016-8.
Moos, R., & Timko, C. (2008). Outcome research on twelve-step and other self-help programs. In M. Galanter, & H. O. Kleber (Eds.), Textbook of substance abuse treatment (4th ed. pp. 511-521). Washington, DC: American Psychiatric Press.