‘In the beginning, we thought this was curable. We didn’t realize that this was a compulsion.’ Cardinal Theodore McCarrick, Archbishop of Washington, DC, in a televised interview April 21, 2002.
Sex is in the news. From pedophilic priests to philandering politicians, people at every level of society get into trouble over their sexual behavior. Among clinical disciplines, psychiatry has a celebrated tradition of addressing sexual problems (Box 1).1-4 We can therefore expect to be asked for help when a person’s inappropriate sexual behavior brings him into conflict, whether with his internal values or with society.
Are we prepared to treat these predatory patients and protect their potential victims? As the U.S. Catholic church has clearly demonstrated, many approaches to prevention and treatment—moral, medical, and traditional—are often ineffective. Rather than viewing compulsive sexual behaviors as moral failures, it may be time to conceptualize and treat them as addictions.
PSYCHIATRY’S VIEWS OF SEXUALITY
Among modern clinical disciplines, psychiatry has one of the more celebrated traditions of addressing sexual problems.
In Three Essays on the Theory of Sexuality,1 Freud identified problem areas as “deviations with respect of the sexual object” and “deviations in respect of the sexual aim.” This early focus on physiologic function as a model of “normal” was succeeded by psychoanalytic attempts to address otherwise normal sexual behavior that was compulsive and, arguably, at odds with societal values.2
Masters and Johnson3 weighed in with Human Sexual Response, physiologically interesting studies of sexual behavior that raised many questions about ethics and underlying psychological processes. Finally, psychiatry’s interest in the subject may have peaked with the publication of Helen Singer Kaplan’s The New Sex Therapy,4 which integrated findings and practices from a number of disciplines.
Sexual addiction as a diagnosis
Patrick Carnes popularized the concept of addictive sexual behavior in the consumer self-help book, Out of the Shadows,5 and in Contrary to Love,6 a volume aimed at clinicians. In characterizing addictive sexual behavior, Carnes cast a large net to include masturbation, heterosexual sex, pornography, prostitution, homosexuality, exhibitionism, voyeurism, and other practices that may be associated with sexual excitement.
The unifying quality was the habitual or compulsive nature of the behavior with the goal of altering mood, regardless of its social, legal, medical, emotional, or other maladaptive consequences (Box 2). As common as these cases are, they tend not to reach the mainstream psychiatry literature until a pharmaceutical treatment is tried.7,8
DSM-IV-TR provides diagnostic criteria for paraphilias such as exhibitionism, fetishism, voyeurism, pedophilia, and sexual masochism or sadism. These are descriptions of behavior, whereas sexual addiction is a cycle of mental and emotional experiences that may have a behavior phase.
CASE STUDY THE WANDERING PASTOR
A middle-aged clergyman presents for counseling due to repeated heterosexual affairs that have been reported to the head of his district and are a potential cause for dismissal. While the affairs have been largely ego-dystonic, he cannot overcome the compulsion to repeatedly seek and become involved in these superficial relationships.
His job offers him much unstructured time, which he frequently fills with fantasies of pursuing sexual experiences. He uses his pulpit, family visits, counseling sessions, and public service activities to make new sexual contacts. He notes that he is more likely to become preoccupied with such relationships when he is distressed or depressed, and he is aware of craving or feeling states that predispose him to looking for such relationships.
The clergyman has tried prayer, counseling, psychoanalytic psychotherapy, brief courses of cognitive-behavioral therapy (weeks to months), and medication trials with various antidepressant and antianxiety agents. These treatments have been unsuccessful.
The addictive behavior may or may not be legal, and it may or may not involve a victim. The common denominator is that the addictive behavior attempts, in a chronically ineffective way, to upregulate mood and sense of self.
DSM-IV may not recognize the term “sexual addiction,” but many patients will recognize the addiction concept, identify with it, and find it useful to understand their compulsive sexual behaviors. An addiction model is already being used by a variety of 12-step and self-help approaches to sexual addiction that have spun off of the success of Alcoholics Anonymous. This model accepts the unlikelihood of cure while offering hope for rehabilitation.
Advantages As a diagnosis, sexual addiction offers patients and psychiatrists two advantages:
- It recognizes a series of temporal mental, emotional, and behavioral events with which sufferers can identify without prohibitive pain and unbearable damage to self-concept.
- It leads to a potential treatment solution that is widely available, relatively inexpensive, and addresses the volition paradox (controlling the uncontrollable) that confounds other approaches.