A client comes to you in great distress. She has discovered she is pregnant but is unsure of the identity of the father because of the multiple anonymous sexual encounters she has had. With tears in her eyes she says she has no idea how she got to this place in her life, and is struggling with the life-changing decision of how to proceed with the pregnancy.
Later that day you meet a new client referred through an employee assistance program (EAP). He fears that he is on the verge of being terminated. His supervisor is questioning him about his poor attendance. He tells you he is ashamed to admit that he is often late for work because of the amount of time he spends viewing pornography online. He reports that he also has started to masturbate almost daily in the men’s restroom at work to get him through the day.
Where do you begin in the counseling process with each client? At what point do you address your client’s compulsive sexual behavior, and how would you plan on doing so? If you feel unsure about how to proceed clinically, you are not alone. A survey of certified addiction counselors found that 92.5% indicated they did not receive formal education on working with sexual addiction while in graduate school.1 Despite the high likelihood of encountering clients with sexually compulsive behaviors, many addiction professionals do not feel competently trained to treat sexual addiction.
It remains unclear if feeling underqualified to treat sexual addiction is related to the fact that sexual addiction is not a formal diagnosis in the DSM-5. There are valid reasons for this lack of inclusion, as the etiology of sexual addiction is unsubstantiated:
No single biological cause has yet been identified to explain hypersexual behavior.
Symptoms verified in chemical addiction, such as tolerance and withdrawal, are not yet validated for sexual addiction.
Limitations exist regarding correlating hypersexual behavior with addiction using neuroimaging, bio-physiology and genetics.2
However, lack of formal inclusion in the DSM-5 does not mean that compulsive sexual behavior lacks legitimacy as a concern or disorder. Public acceptance of sexual addiction is evident in the establishment of 12-Step support groups such as Sex Addicts Anonymous, founded in 1977.
Furthermore, sexual addiction continues to be researched within scholarly literature. A recent search of “sexual addiction” within the PsycInfo and SocIndex research databases garnered more results than searches using the keywords “cocaine addiction,” “marijuana addiction,” or “gambling addiction,” all of which are formal diagnoses in the DSM-5.
Treatment modalities for sexually compulsive behavior have been developed for use within the context of individual, group, and marriage and family therapy environments.3,4,5 Treatment methodologies have been developed for use with a variety of theoretical orientations such as cognitive-behavioral, structural, and motivational-enhancement.5,6,7 As technology has created channels to obtain easy, affordable and anonymous access to sexually arousing stimuli, research is trending toward developing a greater understanding of compulsive Internet-based sexual behavior.8
Despite therapies being in place for treatment of sexual addiction, many programs depend on a DSM diagnosis for insurance reimbursement. Self-pay offers an option, but some clients may not be able to pay for treatment even with sliding scale fees. Some mandated clients may have treatment for sexually compulsive behavior reimbursed by the referring agency, such as a court system, but court-ordered treatment only addresses sexual addiction after a crime has been committed. It does not target prevention and it does not assist the larger percentage of individuals who experience sexually compulsive behavior but do not engage in illegal activity.
Disorders pertaining to sex have been documented in psychological literature for hundreds of years. For example, Michael Ryan, MD, wrote in the 19th century, “Satyriasis and nymphomania are diseases in which the sufferers evince an irresistible desire for copulation, as well as abuse of the reproductive functions. The first disease attacks the male, the second the female … there is no real difference between these diseases and unbridled masturbation; and that both ought to be considered species of insanity.”9
While issues involving unmanageable or problematic sexual behavior may not be new, the stigma evident from Ryan’s writing remains. Individuals struggling with sexual addiction may feel stigmatized or shamed and therefore not present for treatment. Garcia and Thibaut state, “Due to the embarrassment that sexual addiction patients may suffer, they rarely spontaneously seek medical advices. Usually the patient is referred to the psychiatrist for a suicide attempt or for depressive or anxiety symptoms.”10
The stigma, secrecy and shame surrounding sexual addiction may lead clients to think they are incompetent, weak or full of character flaws. They may develop feelings of low self-worth and become unwilling to obtain or adhere to treatment. Clients may fear being ridiculed, embarrassed or discriminated against, and therefore isolate themselves.
The call to action is threefold:
1. Treatment providers need options to obtain education and training to develop competency to identify, assess and plan treatment for clients presenting with issues related to sexual compulsivity.
2. Individuals struggling with sexual addictions who cannot afford to self-pay or who are not court-involved need options for accessing effective treatment.
3. We as a community have an obligation to work proactively toward eliminating stigma.