Sexual Addiction

Course #96272 - $20 • 5 Hours/Credits


Study Points

  1. Compare the concepts of sexual compulsivity, sexual addiction, and sexual anorexia with identified norms for healthy sexuality.
  2. Articulate some of the controversies that exist about the concept of sexual addiction.
  3. Assess for sexual compulsivity, sexual addiction, and sexual anorexia in a presenting client.
  4. Implement basic strategies for addressing sexual compulsivity, sexual addiction, and sexual anorexia as part of a comprehensive treatment program.
  5. Identify personal barriers in clinicians that may exist to assessing or treating sexual addiction.

    1 . What is the key difference between impulsivity and compulsivity?
    A) Impulsivity leads to addiction, whereas compulsivity does not.
    B) Impulsivity refers to acting in, while compulsivity refers to acting out.
    C) Impulsivity is something that we all engage in, whereas compulsivity is a doorway to sexual addiction.
    D) Impulsivity requires little or no forethought, while compulsivity is purposely engaged in to alleviate anxiety.

    FOUNDATIONS AND DEFINITIONS

    The terms compulsivity and impulsivity are often used interchangeably in clinical settings. However, this is incorrect. The American Psychological Association defines these concepts as [3]:

    • Compulsive behavior: A behavior or a mental act engaged in to reduce anxiety or stress

    • Impulsive behavior: A behavior that displays little to no forethought, reflection, or consideration of consequences

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    2 . What is one process addiction that has its own diagnosis in the DSM-5?
    A) Sex addiction
    B) Opioid dependence
    C) Gambling disorder
    D) Alcohol dependence

    FOUNDATIONS AND DEFINITIONS

    While the DSM-5 does include a category of Substance-Related Disorders, it generally does not use the term addiction in its descriptions of individual disorders. The DSM-5 uses the label substance use disorder to identify chemical addiction [5]. Gambling addiction is referred to simply as gambling disorder, and other conditions that are often referred to as addiction could be labeled as impulse control disorders. However, addiction is used widely as an all-inclusive clinical term, and the term appears in the names of many professional associations, such as the American Society of Addiction Medicine, the National Association for Addiction Professionals, and the National Institute on Drug Addiction. For the purposes of this course, the term "addiction" will be used to describe continuing a behavior (e.g., drinking alcohol, smoking cigarettes, gambling, engaging in sexual activity) even when the activity causes repeated pain and consequences [7]. Addiction usually implies a holistic impact on an individual as a result of continuing to engage in the harmful behavior. Carnes defines sexual addiction as an entire pattern of maladaptive behaviors, cognitions, belief systems, and consequences; the behavior alone can be identified as sexual compulsivity [1]. A simple way to identify addiction compared to compulsivity is to recognize that addiction involves how compulsive behaviors impact (or are impacted by) the rest of a person's functioning.

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    3 . The entire pattern of maladaptive behaviors, cognitions, belief systems, consequences, and how behaviors impact a person's functioning best describes what concept?
    A) Anorexia
    B) Addiction
    C) Impulsivity
    D) Compulsivity

    FOUNDATIONS AND DEFINITIONS

    While the DSM-5 does include a category of Substance-Related Disorders, it generally does not use the term addiction in its descriptions of individual disorders. The DSM-5 uses the label substance use disorder to identify chemical addiction [5]. Gambling addiction is referred to simply as gambling disorder, and other conditions that are often referred to as addiction could be labeled as impulse control disorders. However, addiction is used widely as an all-inclusive clinical term, and the term appears in the names of many professional associations, such as the American Society of Addiction Medicine, the National Association for Addiction Professionals, and the National Institute on Drug Addiction. For the purposes of this course, the term "addiction" will be used to describe continuing a behavior (e.g., drinking alcohol, smoking cigarettes, gambling, engaging in sexual activity) even when the activity causes repeated pain and consequences [7]. Addiction usually implies a holistic impact on an individual as a result of continuing to engage in the harmful behavior. Carnes defines sexual addiction as an entire pattern of maladaptive behaviors, cognitions, belief systems, and consequences; the behavior alone can be identified as sexual compulsivity [1]. A simple way to identify addiction compared to compulsivity is to recognize that addiction involves how compulsive behaviors impact (or are impacted by) the rest of a person's functioning.

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    4 . In the terms of Carnes' sexual addiction cycle, ritualization can be best described as
    A) obsession.
    B) sexually acting out.
    C) the chase or pursuit.
    D) systematic punishment.

    FOUNDATIONS AND DEFINITIONS

    According to this model, preoccupation is commensurate to the mental obsession. That obsession could be about using a drug or alcohol, past resentments or abuse, or simply the ruminations of a bad day. The only thing that will bring relief to the mental noise of the obsession is to begin the chase toward feeling good, defined in stage 2 as ritualization. Ritualization may be defined as the routine or the "chase" that a person engages in to obtain their addictive substance or behavior. This could be driving to a certain bar or getting ready for a night out. Many addicts describe the ritualization prior to obtaining the substance or engaging the behavior as more of a rush than engaging in the behaviors themselves.

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    5 . What concept best describes the physical, mental, and emotional task of avoiding sex?
    A) Frigidity
    B) Sexual anorexia
    C) Sexual impulsivity
    D) Sexual deprivation

    FOUNDATIONS AND DEFINITIONS

    The word anorexia is generally defined as being without appetite. Nelson has described sexual anorexia as an obsessive state in which the physical, mental, and emotional task of avoiding sex dominates one's life [6]. Sexual addiction and sexual anorexia can exist in the same person or same family at one time; extremes are the common theme. Often, a cycle of binging on sexual compulsions then abstaining entirely becomes apparent. Both conditions (addiction and anorexia) consist of an obsession with sex, but the object or manifestation of the obsession is different. In many cases, this anorexic behavior is a response to recognized addictive behavior or trauma [11].

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    6 . Sexual anorexia in the sex addict is similar to what condition in alcoholics?
    A) Tolerance
    B) Withdrawal
    C) Mental obsession
    D) "Dry drunk syndrome"

    FOUNDATIONS AND DEFINITIONS

    The idea of sexual anorexia and the addiction/anorexia cycle may be difficult to understand. However, clients who present for clinical attention are often plagued by all or nothing thinking—in this case, engaging in as much sexual activity as possible or none at all. Sexual anorexia is quite parallel to "dry drunk syndrome" seen in some chemical addicts [65]. Simply put, these individuals are abstinent but have not addressed any of the emotional issues that motivate their problem drinking or drug use (e.g., no recovery). "Dry drunks" are often impatient, depressed, irritable, impulsive, and difficult to be around as a result of the removal of their coping mechanism (e.g., drinking) without replacement with healthier coping strategies. Sexual anorexia is similar. If the core motivating issues are not addressed, a sex addict may evolve into a sexual anorectic who is depressed and difficult to be around. As such, sexual anorexia can lead to its own level of interpersonal problems. Furthermore, those who stop any addictive behavior but do not address the underlying issue(s) are at greater risk of relapse.

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    7 . The moral model views addiction as a
    A) sin.
    B) treatable disease.
    C) progressive disease.
    D) normal human condition.

    CONTROVERSIES IN THE LITERATURE

    Prior to the advent of Alcoholics Anonymous in 1935 and the American Medical Association's recognition of alcoholism as a disease in 1952, alcoholism and addiction were largely viewed as sin problems [14]. This perspective is referred to as the moral model. According to this view, alcoholics and addicts are morally flawed, and repentance, conversion, or total commitment to a religious program will address the sin and solve the problem. Interestingly, this moral model view still abounds in many circles today.

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    8 . Some argue against the existence of sex addiction, reasoning that
    A) the sex addiction concept has been employed to oppose equal rights for gays and lesbians.
    B) sex addiction is a pseudoscientific cover-up to eliminate sex education and birth control clinics.
    C) sex addicts just enjoy sex a lot and the label is only used when an individual is faced with the consequences of their sexual behaviors.
    D) All of the above

    CONTROVERSIES IN THE LITERATURE

    On the other end of the spectrum from the moral model is the notion that sexual addiction does not exist at all. Some professionals argue that sex addiction is a pseudoscientific cover-up to promote puritanical moral values by the mainstream establishment. One such critic contends that "sex addiction has also been used as a political justification for censorship, eliminating sex education and birth control clinics, and opposing equal rights for gays and lesbians" [18]. Others in the general public believe sex addicts just enjoy sex; the addiction label is only used when they face consequences of their sexual behaviors. Indeed, using addiction as an excuse for poor behavior is not a new concept.

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    9 . What neurotransmitter has been identified as a brain chemical involved in sex addiction?
    A) GABA
    B) Glucose
    C) Dopamine
    D) Amitriptyline

    CONTROVERSIES IN THE LITERATURE

    Several theorists suggest that ingestion or reliance on a physical substance is needed to truly justify addiction or dependence. These theorists argue that forms of sexual activities are interactions, not substances [1]. In response, Weiss notes that "acting out sexually becomes the primary way to meet the chemical needs of the brain" [9]. Indeed, anyone who takes an introductory course in addiction learns that it is the dopaminergic response in the brain that makes an experience addicting. Sexual arousal can trigger the release of dopamine and other hormones, including endorphins, which are neurotransmitters in the brain with properties similar to morphine. Some studies have indicated that viewing sexually explicit images can induce the same dopamine response as heroin in addicts [19]. However, a study published in 2013 found that neural responsivity to visual sexual stimuli did not significantly differ in persons with hypersexuality issues compared to healthy controls [85]. Some argue that this lack of verifiable biologic response (as seen in persons with substance dependence) is evidence that sexual addiction is not a real clinical entity.

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    10 . What are two examples of process addictions?
    A) Heroin and sex
    B) Sex and gambling
    C) Alcohol and drugs
    D) Smoking and alcohol

    ISSUES IN THE ASSESSMENT OF SEX ADDICTION

    High comorbidity exists between substance use disorders and sexual addiction. Hagedorn and Juhnke contend that those trained to treat chemical dependency should also be trained to treat the commonly comorbid sexual addiction [1]. Part of meeting this challenge is recognizing the reality of process addictions. Process addictions are often referred to as behavioral addictions and include such addictions as sex, gambling, shopping, Internet use, sports, and eating. The term suggests that the behavioral act, or process, is the most addictive aspect, not necessarily the result of engaging in that activity. O'Brien has suggested that a good starting point for conducting assessments is the exploration of out-of-control behaviors and their consequences, even more so than physical tolerance and withdrawal [1]. O'Brien's contention stems from the idea that any substance and any behavior can become addictive as long as it has the potential to create debilitating behavioral consequences.

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    11 . In conducting addiction assessments, what needs to be considered even more than tolerance and withdrawal?
    A) Family history
    B) Physical health
    C) Emotional problems
    D) Behavior and consequences

    ISSUES IN THE ASSESSMENT OF SEX ADDICTION

    High comorbidity exists between substance use disorders and sexual addiction. Hagedorn and Juhnke contend that those trained to treat chemical dependency should also be trained to treat the commonly comorbid sexual addiction [1]. Part of meeting this challenge is recognizing the reality of process addictions. Process addictions are often referred to as behavioral addictions and include such addictions as sex, gambling, shopping, Internet use, sports, and eating. The term suggests that the behavioral act, or process, is the most addictive aspect, not necessarily the result of engaging in that activity. O'Brien has suggested that a good starting point for conducting assessments is the exploration of out-of-control behaviors and their consequences, even more so than physical tolerance and withdrawal [1]. O'Brien's contention stems from the idea that any substance and any behavior can become addictive as long as it has the potential to create debilitating behavioral consequences.

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    12 . Which of the following areas are NOT included in the WASTE-Time screening tool for sexual addiction?
    A) Withdrawal
    B) Adverse consequences
    C) Time spent on sexual activity
    D) Ability to control sexual behaviors for long periods of time

    ISSUES IN THE ASSESSMENT OF SEX ADDICTION

    THE WASTE-TIME SCREENING TOOL FOR SEXUAL ADDICTION

    Withdrawal: "Have you experienced any withdrawal symptoms when you are unable to engage in sexual activities?"

    (Typical responses: Irritability, anxiety, depression, anger, negative mood states, using chemicals to substitute)

    Adverse: "Have you ever experienced any negative or adverse consequences as a result of your sexual behaviors?"

    (Typical responses: Broken relationships, lost career opportunities, financial difficulties, physical injury, and/or psychologic trauma)

    Stop (inability to): "Have you attempted to cut back, control, or stop your sexual behaviors without success, even when you know that continuing will cause you harm?" (Typical responses: Multiple attempts at stopping, controlling the addictive behavior without success, even when faced with the knowledge that continuing poses a physical or psychologic problem)

    Tolerance or intensity: "Have you found it necessary to increase the amount or intensity of your sexual behaviors to achieve the same effect?"

    Escape: "Do you use sexual activity as an escape from negative mood states, such as stress, anxiety, depression, sadness, loneliness or anger?" (Typical responses: Any negative mood state)

    Time: "Have you found yourself spending a lot of time preparing for, engaging in, or recovering from sexual activity?" Or, "Have you been spending more time and/or more resources on your sexual activities than you intended?"

    A "yes" answer to 1 item indicates a strong possibility that a sexual addiction is present; further assessment needed. A "yes" answer to two or more items indicates a high probability of sexual addiction; immediate intervention by a trained counselor is needed.

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    13 . A general guiding principle for sexual addiction treatment is to help addicts put their sexuality into proper perspective and to
    A) cease all acting out behaviors.
    B) learn how to maintain a monogamous relationship.
    C) obtain a spiritual connection with a higher power.
    D) learn how to use it in a way that respects themselves and others.

    TREATMENT

    As previously discussed, the goal of recovery from sexual addiction is never the extreme of deprivation or sexual anorexia. Rather, the general guiding principle is to have recovering individuals put their sexuality into perspective and to learn how to use it in a way that respects themselves and others.

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    14 . The Carnes model for the treatment of sexual addiction can be best described as
    A) eclectic.
    B) 12-step.
    C) cognitive.
    D) psychodynamic.

    TREATMENT

    As noted, many who are addicted to both drugs/alcohol and sex have identified sexual addiction as the most difficult recovery [9]. When sex addicts attempt to control their disease by "white knuckling," they can be successful for various lengths of time, but this is in essence acting in rather than acting out [26]. Therefore, the basis of sex addiction treatment is similar to the traditional basis for treatment of chemical addictions; quitting "cold turkey," and without help, is never recommended. The Carnes model of sex addiction treatment is eclectic, incorporating educational, behavioral, and psychodynamic components. This will be the model discussed in this course.

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    15 . The first major aim of sex addiction treatment is to get the addict to
    A) refrain from having sex all together.
    B) commit to a relapse prevention plan.
    C) refrain from having sex in the short term.
    D) cease acting out behaviors that are causing problems.

    TREATMENT

    Whereas total abstinence from the chemical is recommended in traditional chemical addiction treatment and certain behavioral addiction treatments (e.g., gambling), total abstinence from sex is not necessarily a part of the treatment of sexual addiction. The first part of a successful treatment program for sexual addiction is to cease the acting out behaviors that are causing the most pervasive problems (e.g., compulsive masturbation, contact with prostitutes, voyeurism, affairs with people other than the spouse). These problems should, of course, be identified in the initial assessment or shortly thereafter. Contracts are often used as part of the treatment process [6]. This is a close parallel to chemical addiction treatment, in which the client is asked to abstain from mood/mind-altering drugs to optimize the effectiveness of the treatment.

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    16 . Two of the four major goals that should be included on sex addiction treatment plans are to
    A) stop having sex and prevent relapse.
    B) stop having sex and improve the addict's overall lifestyle.
    C) resolve all core issues about self and improve lifestyle.
    D) improve the addict's overall lifestyle and address core beliefs about self.

    TREATMENT

    Four basic components should be addressed in a treatment plan for sexual addiction. As long as these four components are included, the individualized aims for abstinence of problematic behaviors and resumption (or attainment) of healthy sexuality can be worked in. Clinical discretion regarding how these behaviors are addressed is a must. The four major goals of sex addiction treatment are [1,6]:

    • Improving an addict's overall lifestyle

    • Addressing core beliefs about self

    • Evaluating core beliefs about sexuality

    • Reducing the risk of relapse

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    17 . What is one major similarity found among the multitude of approaches to addiction treatment?
    A) Lifestyle change
    B) Spiritual connection
    C) Attitude adjustment
    D) Resolving core issues

    TREATMENT

    The importance of lifestyle change for the addict cannot be overestimated. In 12-step recovery, there is an axiom that an addict must change people, places, and things in order to recover. These are all facets of an individual's lifestyle. In much of the available research of treatment models for recovery (e.g., 12-step, religious, spiritual, rational), there is one major similarity: the necessity of lifestyle change.

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    18 . Which of the following statements is TRUE regarding relapse prevention plans?
    A) Relapse prevention has been shown to be more effective than recovery enhancement for sex addicts.
    B) Relapse prevention plans should be very specific, as general plans tend to leave room for client interpretation.
    C) Relapse prevention plans are essentially proactive steps identified by the client and counselor to maintain gains in recovery.
    D) When clients have used the relapse prevention plan to successfully prevent relapse, they are usually advised that they may discontinue using the plan.

    TREATMENT

    For the purposes of this course, relapse refers to any resumption of the primary addictive behavior(s) that cause significant functional impairment in the individual's life. This concept has been defined in numerous ways in the published literature, which has often led to problems in studying the phenomenon [46]. Relapse prevention plans are often discussed as elements of addiction treatment and are essentially proactive steps identified by the client and counselor that the client will take to maintain gains in recovery. Some treatment professionals prefer to refer to these steps as recovery enhancement rather than relapse prevention. While the two terms are basically synonymous, the former reminds recovering individuals that the stronger the recovery system they have in place, the less likely that relapse will occur.

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    19 . According to Hagedorn and Juhnke, if counselors do not receive the proper training in the treatment of sexual addiction,
    A) the family unit in America will continue to collapse.
    B) then they should enroll in a graduate level course in human sexuality.
    C) alcoholism relapse rates are bound to increase because of co-addiction.
    D) clients, and those affected by their addicted behaviors, will be adversely affected.

    ISSUES FOR CLINICIANS

    Graduate study in human sexuality is encouraged for counselors, and an understanding of healthy sexuality is vital for those treating sexual addiction. Sadly, most graduate programs do not include coursework on healthy sexuality or sexual addiction [1]. As Hagedorn and Juhnke cautioned, "If counselors do not receive the proper training in the treatment of sexual addiction, clients, and those affected by their addicted behaviors, will be the ones adversely affected" [1].

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    20 . Which of the following clinician behaviors can assist in the successful treatment of a client presenting with sexual addiction?
    A) Networking with other professionals in the community
    B) Identifying colleagues and treatment centers equipped to address sex addiction
    C) Additional education in human sexuality, including an understanding of healthy sexuality
    D) All of the above

    ISSUES FOR CLINICIANS

    In addition to more extensive education, clinicians may benefit from networking with other professionals in the community. This networking is especially important for clinicians who make referrals for specific treatment. Colleagues who are comfortable treating sexual addiction and local treatment centers equipped to address sex addiction can be identified, allowing for better referral and education for clients.

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