By Ralph Earle (PhD, ABPP) and Rick Isenberg (MD, CSAT)
In the human experience, sexual expression takes a myriad of forms, limited only by the bounds of imagination. As the field of human sexuality progresses, more and more sexual behaviours have been catalogued and acknowledged as normal variants. As myriad as the range of sexual behaviours are the various manifestations of sexual addiction. Addiction, with its obsession, compulsion, tolerance, cravings and withdrawal, may distort any form of human sexual and romantic expression, and turn what is potentially joyful and intimate into something compulsive and problematic.
Much work has been done to understand the various manifestations of sexual addiction. It is apparent that certain behaviours present in clusters that may accompany specific forms of psychopathology. In this chapter, we review the various common presentations of the disorder, considering first those medical and psychological disorders that present similarly and must be ruled out before making the diagnosis of sexual addiction.
Differential Diagnosis of Sexual Addiction
In the field of mental health, despite our reliance on the Diagnostic and Statistical Manual (DSM) (American Psychiatric Association, 2013), not everything that quacks like a duck is truly a duck. We learn from our colleagues in medicine that a practitioner must always consider a differential diagnosis before making and acting upon a diagnosis. We have come to understand that when presented with depression, for instance, we must rule out hypothyroidism, syphilis, Lyme disease, post-concussion syndrome and drug effects, among many other disorders. So it is, too, with patients presenting with problematic, compulsive sexual behaviour. Especially in light of the shame, discrimination and contempt showered by our society on men and women with sexual addiction, we as clinicians must be discerning in our application of the label. Not all that quacks like a sexual addict is a sexual addict.
Definition of Sexual Addiction
In keeping with the nomenclature applied to substance use disorders and gambling disorder, Carnes has proposed ten criteria for the diagnosis of sexual addiction, which include elements of obsession, compulsion, risk-taking, tolerance, withdrawal, cravings, unsuccessful efforts to stop and social impairment. It is important to recognize that there are conditions that present with only some of the diagnostic criteria that must be separated from the rubric of sexual addiction, and other medical and psychological disorders that largely mimic sexual addiction and must be excluded before a diagnosis is made. We next explore these ‘rule out’ conditions.
Medical Conditions that May Mimic Sexual Addiction
Hypersexual behaviour has been associated with a range of neurological and psychiatric disorders. Before making a diagnosis of sexual addiction, consideration must be given to these medical disorders that are associated with sexual behaviour that is compulsive, inappropriate, uncharacteristic or excessive: Traumatic Brain Injury, Stroke and Neurosurgical Injury, Dementia, Autism Spectrum Disorder, Parkinson’s Disease, Bipolar Disorder, and Substance Abuse. The diagnosis of sexual addiction should not be made when these disorders are present without extensive consideration.
In this discussion of conditions subject to misdiagnosis as sexual addiction, it is important to emphasize that the concept of healthy sexuality may include sexual behaviours that are frequent or different from the norms of the prevailing culture (such as homosexuality, BDSM, polyamory, etc). The clinician would do a disservice by reflexively labelling such behaviour as addictive. Such behaviors would not qualify as addictions unless all the criteria of obsession, compulsion, risk-taking, tolerance, withdrawal, cravings, unsuccessful efforts to stop and social impairment are present.
The Clinical Presentations of Sexual Addiction
In recent years, multiple typologies have been proposed for sexual addiction.
The most extensive characterization of the phenotypes of sexual addiction has been performed using latent profile analysis of a large database of patient self-reported data obtained through use of the Sexual Dependency Inventory (SDI-4.0).
As described by Carnes, close to two hundred different sexual behaviours have been catalogued as part of the development of the SDI. Using the statistical technique of factor analysis, these behaviours are found to cluster in distinct types, each with characteristic acting-out behavioural patterns. In the derivation of the SDI-4.0, 20 behavioural clusters were identified. It is common for sexual addicts to endorse behaviours in multiple categories. Details are provided in the book chapter.
These behavioral clusters include:
- Fantasy Sex
- Pornography Use
- Phone Sex
- Use of Inanimate Objects
- Anonymous Sex
- Conquest and Seduction
- Group Sex
- Relationship Addiction
- Humiliation & Domination
- Pain-Exchange Sex
- Paying for Sex
- Power Exchange Sex
- Intrusive Sex
- Voyeurism & Covert Intrusions
- Exploitation of Trust
- Sexual Exploitation of Children
- Production of Pornography
- Compulsive Sexuality with Drug Use
Sexual addiction presents in a myriad of ways with recognizable clusters of behaviour. The clinician facing a client with problematic, compulsive or excessive sexual behaviours must be mindful of the medical and psychological conditions which resemble sexual addiction and must be differentiated, with appropriate specific treatment provided. Multicultural sensitivity is necessary, especially when working with sexual minorities.
About the authors:
Ralph Earle is a noted marriage and family therapist and psychologist, author and lecturer. He holds a Masters of Divinity from Harvard Divinity School, and a PhD in Pastoral Psychology. He is a Diplomate of the American Board of Professional Psychology (ABPP) and a Licensed Marriage and Family Therapist, as well as a Certified Sex Addiction Therapist. He is a past national President of the American Association for Marriage and Family Therapy (AAMFT). He is a national authority on sexual addiction with over 40 years’ experience working with sexual problems. Dr. Earle is an ordained minister and served on the Board of Directors of the Interfaith Sexual Trauma Institute of St John’s University, Minneapolis. He has numerous media credits and is the author of several books, including Lonely All the time: Recognising, Understanding and Overcoming Sex Addiction and Come Here, Go Away. He is he co-author of Sex Addiction: Case Studies and Management, and Healing Conversations: Therapy and Spiritual Growth, and The Pornography Trap: Setting Pastors and Laypersons Free from Sexual Addiction. He is the founder of Psychological Counselling Services (PCS) in Scottsdale Arizona that specialises in the PCS intensive Outpatient Therapy Program model. He is a Certified Supervisor of Sex Therapy for the American Association of Sexuality Educators, Counsellors and therapists (AASECT) and a Certified Supervisor for AAMFT.
Rick Isenberg serves as medical director at Psychological Counselling Services, a premier outpatient treatment centre for sexual and other process addictions. He is also the executive director of the American Foundation for Addiction Research (AFAR) and a certified sex addiction therapist (CSAT). Dr. Isenberg is pursuing a Master’s degree in clinical counseling. Dr Isenberg is a licensed obstetrician/gynaecologist. He has 16 year’s experience in clinical research, having directed research programmes and Johnson & Johnson, Wyeth Pharmaceuticals, Ventana Medical Systems and Regenesis Biomedical. Dr Isenberg has served on the medical faculties of the University of Pennsylvania and Thomas Jefferson University. He has authored original research and review articles in the medical literature on subjects including addiction, pain management, wound healing and complications of surgery.