Do I have a sex addiction?
Terms & Diagnosing
Choosing the best model
Approach that work best
Clients rarely ask, “Do I have a sex addiction?” Those struggling with managing sexual urges and behaviors typically have already self-diagnosed with such. The term “sex addiction” is the common label that many within Western culture use for any patterns of sexual behavior that violate cultural values or that feel “out of control”. This term can be a starting point in improvement efforts, but is “sex addiction” really a thing, and is it a diagnostic label that is helpful? Let’s explore this terminology a bit further.
Technological advances in the 1980s and 1990s have led to greater access to information, including the greater availability of sexually stimulating online content and greater means to connect with others for sex. The resulting increase in problematic sexual behaviors led to a need to frame and diagnose this phenomenon. The term “sex addiction” took hold culturally and spurred a new label and industry. Let’s talk about the history behind this phenomenon.
“Sex Addiction”: A few key events
12 Step Groups - Twelve-step groups for sexual problems emerged in the mid-1970s. Specifically, Sex and Love Addicts Anonymous (SLAA) in 1976, and Sex Addicts Anonymous (SAA) in 1977. These programs were inspired by Alcoholics Anonymous (AA) and adapted with the assumption that the 12-step approach to substance use could be applied to problematic sexual behaviors as well.
Patrick Carnes – Later in the 1980s, Patrick Carnes popularized the “sexual addiction” model using addiction and 12-step models and terminology. Carnes' model was developed based on his work with incarcerated individuals. Carnes' work coincided with the increases in accessibility of pornography and sexual encounters, which grew exponentially with the availability of VHS tapes in the 1980s and the internet in the 1990s. The “sex addiction” industry exploded, outpacing the research needed for diagnostic criteria and evidence-based treatment.
Additional Models Introduced - With advancements in research and the testing of therapeutic models and principles, additional approaches to problematic sexual behavior have been applied. This included Doug Braun Harvey’s Out of Control Sexual Behavior model (Braun-Harvey, 2016), various research studies on ACT as a Treatment for Problematic Internet Pornography Use (Twohig, 2010), the ICD-11’s Compulsive Sexual Behavior diagnosis (World Health Organization, 2019), and Josh Grubb’s work on Moral Incongruence (Grubbs, 2018).
I am excited to see evolving research and development that addresses problematic pornography use or unwanted sexual behaviors, that also focuses on sexual health and value-based decision making. Models focused on non-shaming approaches and sex positivity are especially needed. I will be addressing these approaches and findings in future articles.
“Sex Addiction” Shortcomings
As mentioned, the “sex addiction” framework is a starting point for recognizing imbalance and identifying a problem. Here are a few shortcomings that I have discovered with the “sex addiction” diagnosis and model.
Medical Model - The medical model of mental illness (mental disorders as diseases with biological causes) has been influenced by the development of psychiatric medications and the research findings of brain science. The “sex addiction” model views these problematic sexual behaviors as a result of a chronic brain disease. This perspective is reductivistic and can undermine hope in changing habits and patterns.
Generalization - As indicated above, the 12-step and addiction models were a starting point for the treatment of problematic sexual behaviors. While there are similarities between substance abuse and problematic sexual behaviors, there are also significant differences between the two. Problematic or out-of-control sexual behaviors are more similar to compulsive overeating. Similar to food, sex is not the target problem, and abstinence from sexual expression is a misleading goal.
Lack of Consensus – There has been no professional consensus around a “sex addiction” diagnosis for inclusion in the DSM or other diagnostic manuals. Compulsive Sexual Behavior (as framed in the ICD-11) is different in symptomology and focus from an addiction model. Information and terminology are evolving, and research and discussion are moving away from an “addiction” model for problematic sexual behaviors.
Pathology & Shame - The unfortunate side effect with “addiction” approaches to problematic sexual behavior is making “sex” or “sexual imagery” the bad guy and externalizing the problem. If we saw an increase in violence with baseball bats, proclaiming baseball bats as a public health crisis would be ineffective and ridiculous. We need value-based models and personal responsibility for how we manage sexuality (baseball bats, too!).
Labeling - It’s easy to apply a simple label to complex behaviors. These labels are often, unfortunately, overused for all levels of concern or severity, vs. recognizing the different levels of use. There is also the risk of taking on this term to describe a pattern of behavior as one's identity, such as “Hi, I am Dave, and I am a sex addict”. Thus, the overgeneralization of a label can prevent and complicate healing.
Rigid Moral Frame - Within conservative and religious communities, there can be a heightened moral and cultural discomfort attached to sexuality. This can lead to sexual exceptionalism (viewing sexual behaviors with greater shame and scorn than other problems). While a moral foundation is crucial, a rigid application of morality can lead to a stronger negative and shameful focus on sexual problems due to this discomfort and cultural disapproval.
Risk of Harm - Multiple studies have now shown that identifying as a “sex addict”, independent of the severity of the behavioral problem itself, can be correlated with multiple negative outcomes, including depression, suicide ideation, communication discomfort about pornography, and higher odds of having a relationship end. The words that we use can significantly support or deter healing (see Dover et al, 2024 for one example).
Industry Branding - While I trust that most therapists treating sexual problems have client interests at heart, the sex addiction industry is also focused on making money. Given the investment in the model and the support of the cultural narrative around “sex addiction”, therapy with sex addiction industries can be prolonged and expensive. The financial benefits of such can lead to resistance to new research and models.
What I Recommend
So, what do I recommend and what have I found helpful in addressing these problematic sexual behaviors? Here are a few characteristics of my approach.
Hope - Do the terms that you use to describe yourself motivate you to change and instill a sense of hope and self-love? Or do you get stuck in hopelessness and shame? I use empowering language.
Acceptance - Acceptance is the gateway to agency. Taking a humble and honest view of our weaknesses provides the foundation for value-based changes. I support starting with acceptance.
Education - Utilizing current research and evidence-based models supports learning, growing, and change. Cultural assumptions and traditions not grounded in values or research can keep one stuck. I review research broadly and learn from different models and findings.
Holistism - Beyond a narrow focus on eliminating problematic behaviors, taking a multifactorial approach allows for a comprehensive view of a complex issue. Looking broadly, we can better see problems, solutions, and the end from the beginning. I focus on the full person and a comprehensive view of aspects of self.
Sense of Self - Positive and progressive beliefs flow from a healthy identity and view of self, vs. seeing through the lens of our weaknesses. I encourage connection to values, principles of sexual health, and affirmations as foundational to healing. I seek to connect clients with strengths, goals, and the best of themselves.
Emotional Regulation - Compulsive behaviors suggest underlying emotions that are being avoided, buffered, and coped with. I focus more on emotional awareness and regulation as a core skill in managing urges.
Solutions - Focusing on the solution is more likely to yield results than tracking, calendaring, and shaming the problem. I focus on what works to align clients with their values and sexual health, and creating a plan to implement and maintain.
The word “addiction” was a starting point in understanding problematic sexual behavior, but has become a stumbling block for many individuals, partners, and family members. With ongoing research, more holistic and evidence-based models are being developed to help find balance and health in our sexual expression. As a sex-positive advocate and proponent of a balanced approach to health, I believe we can hold the boundaries that can keep us aligned with values and also enjoy sexual expression in a way that brings joy and fulfillment to our lives.
References
Braun-Harvey, D., & Vigorito, M. A. (2016). Treating out-of-control sexual behavior: Rethinking sex addiction. Springer Publishing Company.
Dover C. R, Leonhardt N. D, Edwards MH. Labels Are For Soup Cans: How Self-Labeling as "Addicted" to Pornography Is Associated with Negative Outcomes. Arch Sex Behav. 2024 Oct;53(9):3461-3474. doi: 10.1007/s10508-024-02966-7. Epub 2024 Aug 12. PMID: 39134735.
Grubbs J. B, Perry S. L. Moral Incongruence and Pornography Use: A Critical Review and Integration. J Sex Res. 2019 Jan;56(1):29-37. doi: 10.1080/00224499.2018.1427204. Epub 2018 Feb 7. PMID: 29412013.
Twohig, M. P., Crosby, J. M., Acceptance and Commitment Therapy as a Treatment for Problematic Internet Pornography Viewing, Behavior Therapy, Volume 41, Issue 3, 2010, Pages 285-295, ISSN 0005-7894
World Health Organization. (2019). International statistical classification of diseases and related health problems (11th ed.). https://icd.who.int/".
Recommended Reading
The Myth of Sex Addiction - David J. Ley
Treating Out of Control Sexual Behavior: Rethinking Sexual Addiction - Douglas Braun-Harvey, Michael A. Vigorito
Compulsive Sexual Behavior: A Psycho-Sexual Treatment Guide for Clinicians - Silva Neeves
Unwanted: How Sexual Brokenness Reveals Our Way to Healing - Jay Stringer
Faith, Sexuality, Science, Diversity: Confessions of an LDS Sex Researcher - Cameron Staley
Sex Addiction: A Critical History - Barry Reay, Nina Attwood & Claire Gooder
