As a playwright, my work has touched on addiction in a variety of ways. Recently in my play #Love95times, which is about a sexual assault on a college campus, the protagonist is a sober alcoholic who is a witness to the assault and goes to his sponsor about it. In one of the drafts of the play, the conversation around sex addiction comes up, and in my research and conversations, I heard a lot of misconceptions and confusion about sex addiction. “Is it even a real thing?” was a common question.
Kelly Moylan, LCSW is a psychotherapist specializing in the treatment of codependency and she consults with the Sexuality, Attachment and Trauma Project. Ms. Moylan has been a practicing clinician for 19 years in a number of mental health and medical settings. She has been in private practice for eight years working with individuals, couples and groups, treating adults as well as adolescents. I sat down with Ms. Moylan recently when she had just returned from speaking on a panel about sex addiction, asking her to clear up some of the facts and fictions of sex addiction.
First off, why is there controversy about the word “addiction” in the term sex addiction?
The term sex addiction and what it means and how it’s defined is hotly debated in the field. Many clinicians who treat sex addiction disagree about whether or not it should be considered an addiction. It’s not actually a clinical diagnosis at this point. It’s not included in the DSM (Diagnostic and Statistical Manual of Mental Disorders) which is basically the manual of all psychiatric diagnoses. There was a lot of discussion about whether to include sex addiction in the latest edition of the DSM which came out in 2013. Ultimately, it was decided not to because there is not agreement or research-based evidence to resolve the debate about the problem and its treatment.
Many clinicians feel very strongly that the term sex addiction is accurate and many others feel it is overly judgmental and pathologizing to use the term addiction. Some clinicians prefer the term Out of Control Sexual Behavior or OCSB. The question is how do you decide if a sexual behavior is problematic without running the risk of being critical of behaviors that are fine for some people but problematic for others. It’s not the therapist’s place to judge whether someone’s sexual behavior is “normal” or not. It speaks to a concern about becoming overly pathologizing and shaming about certain behaviors.
Aren’t alcoholism and sex addiction similar, yet alcoholism is in the DSM?
It’s like alcoholism in that ultimately it has to be self-diagnosed, so in that way, from a clinical perspective, OCSB is behavior that a person feels is so out of control that they seek treatment. If you hook up with someone anonymously twice a year, I wouldn’t necessarily call you a sex addict; I might say you need more sex (laughter) but if that behavior is problematic to you and feels out of control to you then you might benefit from treatment. Alcoholism is similar in that there isn’t a particular amount or type of alcohol that defines it. The individual has to determine for themselves how their drinking makes them feel and how it’s affecting their lives. Alcoholism is also a more clearly defined and researched disorder. While sex addiction or OCSB are not new problems, awareness, research and treatment of them are relatively new – certainly, in comparison to alcoholism. Another difference is that OCSB is more of a process addiction, while alcoholism is considered a substance addiction.
But even if you don’t call it an addiction, isn’t there a treatment model?
Either way there is a model for treatment. I think the debate about what terminology to use and what treatment modality to use is significant for clinicians but less so for patients. Some patients are put off by the term addict, some really identify with it and find it a useful framework for their treatment. Our perspective at the SAT Project (Sexuality, Attachment and Trauma Project) is that we treat each individual based on what they bring in. We may have 10 different patients seeking treatment for OCSB but they will all have a different set of behaviors and different reasons for acting out sexually, so we have to treat them all differently. I feel strongly that one size never fits all in psychotherapy.
If your sexual behavior has caused enough of problem in your life for you to come to treatment, your therapist’s job is to understand you as an individual and determine how you are using sexual acting out. I’d say the one common denominator among patients is that they use sexual behavior to regulate emotions, which is similar to alcoholism and other addictions, in that the behavior or substance is used in place of emotional regulation. It’s an escape that becomes habitual and self-destructive. In my mind, it almost doesn’t matter what you call it if you recognize that you’re using a self-destructive behavior to escape or regulate emotions.
Does it matter in terms of health insurance purposes?
Yep. It does! Because it’s not listed in the DSM, treatment for OCSB doesn’t have a diagnosis code for insurance reimbursement. Typically, a person with OCSB will also experience significant anxiety, depression or other symptoms as a result for the behavior. These coexisting conditions that are also being treated do have diagnosis codes covered by insurance.
What’s the difference between substance addiction and process addiction?
The easiest way to define a process addiction versus a substance addiction is that process addictions are addictions to things you can’t live without and substance addictions are addictions to things you can go through life without. With substance addiction, the solution is abstinence from the substance, but with process addiction, the goal is to develop a healthy relationship with the process. Process addictions are things like debting problems or eating disorders. Compulsive behaviors around the way you manage your money are problematic but the solution is not abstinence from money because you have to develop a relationship with money to function in the world. An eating disorder is a process addiction because you can’t live your life without food. The goal for recovery is to develop a healthy relationship with eating, not to give up food. With sex, even if you decide to become abstinent or celibate, you still have to make a choice about how you relate to your sexuality. Life does not require you to do that with something like cocaine. Substances are not necessary or essential for human life.
What are some other misconceptions around Sex Addiction?
There’s a lot of public attention around sex addiction in recent years and in some way, I think that’s positive because it has existed for a long time, but it hasn’t been addressed and treated. Instead it was seen as “bad behavior” that should either be shamed, or hidden and tolerated. But all the attention that celebrities and athletes are bringing to the issue can be problematic too. I do think some high-profile people may use “sex addiction” to justify “bad behavior.” Some people who get caught have a real problem and it’s a very painful, horrible experience. If it gets them into treatment, it could have a positive outcome for them. But if you’re in a position of power or fame and you get caught and you don’t have a real problem, and all you’re trying to do is improve your reputation by going into treatment, then that’s something else.
I think a lot of the general public are suspicious that claiming “sex addiction” is just a way to fix a tarnished image. Since sex addiction has largely come into the public conversation through famous people who are invested financially and ego-wise in portraying a certain image, it’s hard to know if a story of sex addiction treatment is a beautiful story of recovery, or a story of someone using sex addiction as a way to sidestep the consequences for their behavior. So this plays into the ‘facts and fictions of Sex Addiction.’ People who have not been affected by sex addiction may only read about it in a magazine and it’s easy to wonder if this is a real thing. The fact is that even though the psychiatric community hasn’t come to a consensus on what to call it, it is a real, excruciating problem that can be treated.
I also think gender stereotypes in our culture make the realities of sex addiction hard to understand as well. We see that men have this problem, but men are not the only people that suffer from this addiction. Women do as well. Woman traditionally are shamed for sexual activity while men are encouraged to be sexually active and are frequently excused for acting out sexually, even for sexual harassment and assault. Many people might say “How can a guy be a sex addict? All guys are sex addicts! Guys want sex all the time. Boys will be boys,” while at the same time, be more critical of a female sex addict, as behaving like a “slut.” This is another reason why assessing each patient individually is essential to good treatment. We can’t assume anything about sexual behavior based on gender.
The difference between a healthy sex drive and compulsive sexual behavior is that compulsive sexual behavior feels out of control and has negative consequences in your life. Women have traditionally received excessively negative consequences for even very normal sexual activity. Many men have not experienced negative consequences for problematic sexual activity. I do think men are experiencing more consequences now. JFK didn’t have to go to rehab to clean up his image, right? Everyone knew that he was sleeping around but then flash forward to Bill Clinton’s impeachment trial over an affair. It’s indicative of a shift in gender roles that is part of what has brought sex addiction into the light. But let me be clear, if someone is unfaithful to a partner, that’s not sex addiction, but if someone is unfaithful because they can’t control their behavior, then that might be sex addiction. But in the past men cheating was more tolerated. Women aren’t accepting it as often anymore.
Does sex addiction come into play with behavior that we’re hearing about with Bill O’Reilly, as an example, or the high incidence of sexual assault on college campuses?
It might fall within that definition but you can’t say for sure. It’s certainly possible but people who have sex addiction or OCSB aren’t necessarily sexually harassing in their behavior or sexually violent, just as an alcoholic may be violent or may not be. But there are ways our society is enabling sexual harassment or violence by not ensuring consequences. The good news is that when there are not consequences, there is a lot of outcry from a lot of different people and organizations in the country. Part of what gets people sober is experiencing negative consequences. Men acting out gets swept under the rug more often than not. Some of those men may be in pain and some of them may be entitled assholes (and ‘entitled assholes’ is also not a clinical diagnosis) (laughter). Either way, lack of consequences is not acceptable.
I think it’s important not to take consequences from an addict; say, hypothetically, if someone has out of control sex behavior and the compulsivity is manifesting as sex assault, the person does have a problem that can be treated, and there is room for empathy but there is also no reason to mitigate the consequences. You don’t forgive the behavior because of an addiction. You can forgive the person and they can get treatment, but they may still be convicted of a crime with consequences. That would be my opinion on that anyway.
I heard a therapist say that she thought Sex Addiction was one of the most difficult addictions and the hardest to recover from. Do you agree?
I think it’s treatable but the patient needs to want to change. I think that is the prime predictor of success. How much the person wants to change, how much pain they’re in, how willing they are to break the denial and invest themselves in treatment and recovery. We’ve definitely seen in our practice people get better. They can have healthier relationships. Calmer, less distracted experiences. Sex Addiction is all-consuming – like all addictions, but you can get your life back for sure.
Is porn addiction the same as sex addiction?
I think they’re related. I would consider it a form of sex addiction simply in the sense that if it’s dominating your life and you can’t stop using it, and it’s affecting your job and relationships and quality of life, then it’s a problem. Also, as with sex addition or OCSB, it’s hard to define. Some people would define using porn in any capacity as a shameful thing, (i.e., you shouldn’t do it, so if you do, it’s a problem). But then there’s the reality of the vast prevalence and use of it on the internet by a wide variety of people, so how do you define what is problematic without making value judgements? There’s a lot of denial and secrecy around porn use and a lot of cultural enabling around it, but if it’s problematic for aspects of your life, then it could be an addiction. Another great question is – should porn addiction be considered a process or substance addiction? You can live your life without porn….or is that just a judgment I’m making? Is porn-use part of normal sexuality? And is that true in all cases or in only some cases?
If a person thinks they are having a problem with sex or porn what should they do?
They should get help. They don’t need to suffer alone in silence. There is help, empathy, treatment and relief for them. Contact a therapist, a treatment center or consider attending a 12-step meeting. Don’t obsess about whether or not you are an addict and what that might mean; there is hope for change. The SAT Project website: sexualityproject.org has informational reading about sex addiction and OCSB, as well as resources for treatment.