The concept of sexual addiction was introduced less than 10 years ago.
It not only provides an explanation for otherwise irrational behavior but
also suggests effective treatment for patients who have not been helped by
more traditional therapy.

The Diagnostic and Statistical Manual of Mental Disorders, revised third
edition, lists nine criteria for chemical dependency. The
presence of three establishes the diagnosis. Most of the criteria concern
behavior: Two indicate decreased control, one .shows preoccupation with
obtaining and using the substance, and three reflect continued use despite
negative consequences. These criteria can be used to diagnose other
addictions as well.

Goodman proposed a set of diagnostic criteria for addictive disorder
that may be modified and applied to sexual behavior. Any behavior
that is used to produce gratification and escape internal discomfort can be
engaged in compulsively and can constitute an addictive disorder.
Compulsive gambling, spending, and overeating meet these criteria as
well.

Characteristic findings of any addictive disorder are the following:

1) Compulsivity, that is, loss of the ability to choosefreely whether to
stop or to continue.
2) Continuation of the behavior despite adverse consequences, such as loss
of health, job, marriage, or freedom
3) Obsession with the activity

All of the patients in the following illustrative case reports exhibited
these findings.

CASE 1: A 28 year old homosexual man spent evenings "cruising" local parks,
public restrooms, and pornographic bookstores for sexual contacts. This
activity consumed several hours a day. His primary outlet was sex with
multiple anonymous partners. When he learned that the majority of gay men
in his city had tested positive for the human immunodeficiency virus (HIV),
he began to worry constantly about his risk of contracting AIDS. Still, he
was unable to change his unsafe sexual practices despite repeated promises
to himself to do so.

CASE 2:A 52 year old married minister had a 10 year history of sexual
involvement with female parishioners who came to him for counseling. He
experienced marital stress because he was often away from home in the
evenings "counseling" rather than spending rime with his family. Overcome
by remorse and guilt, he promised to break off with the women. However, he
was unable to avoid new involvements. After several women came forward with
their stories, the minister was fired, evicted from his church­owned house,
and publicly humiliated. He and his wife moved to another state, where she
supported them with her teaching income.

CASE 3: A 32 year old woman from a rigidly religious family married an
alcoholic. After 2 years of marriage, she became involved in what was to be
the first of many extramarital affairs. To prevent detection by her
husband, she withdrew from him emotionally and neglected the marital
relationship. She recognized that she was not spending enough time with her
children. Despite feelings of guilt, she did not seek help until she
cheated on her new lover.

CASE 4:A 50 year old married business executive neglected sales calls when
out of town and visited massage parlors and prostitutes, despite knowledge
that he was risking HIV infection. He was once an effective salesman, but
his work performance suffered because of his sexual pursuits. He took
alternative routes on trips in an effort to avoid massage parlors, but he
was unable to control his urge to visit these establishments. His wife
learned about his sexual activities when he was arrested for soliciting sex
from an undercover policewoman posing as a prostitute. At that point, his
marriage was in jeopardy, his children and friends shocked, and his job
future uncertain.

Cycle of sexual addiction

When sexual behavior is compulsive and continued despite serious adverse
consequences, it is addiction. Sex addicts tend to sexualize other people
and situations, finding sexual connotations in the most ordinary incident
or remark. They spend great amounts of time and/or money in pursuit of a
"quick fix." Any sexual behavior can be part of the addictive cycle: The
context of the behavior must be considered to ascertain whether the
behavior is compulsive. What is healthy sexual behavior for many people may
be unhealthy for others, just as the use of alcohol causes no adverse
consequences for most people but severe problems for some.

Sex addicts describe a euphoria with sex similar to that described by drug
addicts with drug use. This may be an effect of endorphins and other
endogenous brain chemicals, whereas the drug induced state is externally
produced. Milkman and Sunderwirth have classified sexual addiction as an
arousal addiction because its effects on the brain are similar to the
effects of cocaine, amphetamines, compulsive gambling, and risk taking
behaviors. In contrast, addiction to alcohol, sedatives or hypnotics, and
food are considered satiation addictions.

Like alcoholics and other drug addicts, sex addicts behavior engage in
distorted thinking, rationalizing, and defending and justifying their
behavior while blaming others for resulting problems. They deny having a
problem and make excuses for their behavior.

On the basis of a survey of about 600 self identified sex addicts,
Carnes categorized addictive sex into 11 patterns (table 3). Sex addicts
usually participate compulsively in more than one type of sexual behavior.
For example, they may masturbate compulsively in addition to viewing
pornography and patronizing prostitutes. Although some sex addicts are
hypersexual, seeking sexual intercourse or orgasm several times daily, most
are not. For the addict who has affairs, the euphoria may come from the
thrill of the chase and conquest rather than from the sexual experience
itself Many sex addicts report progression of their addiction; that is,
they have to take increasing risks or try new sexual behaviors to maintain
the same euphoric effect.

Family history
Sex addicts, like alcoholics and other addicts, often come from a
dysfunctional family in which parents were chemically dependent, sexually
addicted, abusive, or otherwise emotionally unavailable. In a survey of 75
recovering sex addicts,(7) only 15 families of sex addicts. The great
majority of sex addicts (82% of almost 900 addicts in Carnes' survey(1)
had been sexually abused in childhood. Among the male addicts, 3% were
forced to have sex by their fathers and 11% by their mothers.(1) Others
(41%) were abused by neighbors, business associates of their parents, or
strangers, while 8% were molested by other adults in authority. (1)In some
families, there was no overt incest, but a heightened sense of sexuality
was present. Sexually explicit material may have been available, or sexual
comments (eg, a father remarking on his daughter's anatomy) were made
repeatedly. Privacy in the bathroom and bedroom may have been lacking. ­
Children who come from families that lack emotional support and nurturing
tend to be vulnerable to sexual exploitation. Children who are sexually
abused may grow up fearing sex, confusing sex with love, or believing that
the only way to relate to others is sexually. Others may be troubled by
"repetition compulsion," in which they become perpetrators of sexual abuse.

More than half of sex addicts surveyed come from a rigid, emotionally
disengaged family.(8) In such families, discussion of sex may be taboo or
sex may be considered disgusting. As a result, children grow up lacking
accurate information about sex and believing that sex is powerful and
dangerous.

Coaddiction

Like chemical dependency, sexual addiction is a family disease. Spouses of
sex addicts, or "coaddicts," usually grew up in a dysfunctional family,
where they acquired a set of core beliefs that resulted in low self­esteem
and difficulty in relationships. They may believe that they are not
worthwhile, that no one could love them for themselves, that they can
control and are responsible for others, and that sex is the most important
sign of love.(9)

Table 3. Patterns and examples of sexual addiction

1.Fantasy sex: neglecting commitments because of fantasy life, masturbation
2.Seductive role sex: extramarital affairs (heterosexual or homosexual),
flirting and seductive behavior
3.Anonymous sex: engaging in sex with anonymous partners, having one night
stands
4.Paying for sex: paying prostitutes for sex, paying for sexually explicit
phone calls
5.Trading sex: receiving money or drugs for sex
6.Voyeuristic sex: patronizing adult bookstores and strip shows, looking
through windows of houses, having a collection of pornography at home or at
work
7.Exhibitionist sex: exposing oneself in public places or from the home or
car, wearing clothes designed to expose
8.Intrusive sex: touching others without permission, using position of
power (eg, professional, religious) to sexually exploit another person,
rape
9.Pain exchange: causing or receiving pain to enhance sexual pleasure
10.Object sex: masturbating with objects, cross­dressing to add to sexual
pleasure, using fetishes as part of sexual rituals, having sex with animals
11.Sex with children: forcing sexual activity on a child, watching child
pornography

SUMMARY
The sexual addiction model enables physicians to understand the self
destructive behavior of patients whose actions may otherwise appear
inexplicable. When a person is preoccupied with sex and continues to engage
in compulsive sexual activity despite adverse consequences (eg, loss of
marriage, job, health, freedom), he or she is a sex addict. Treatment
allows sex addicts eo stop their compulsive behavior and improve their
relationships. Preferred treatment includes professional counseling and
attendance at self help programs based on the Alcoholics Anonymous model.
Partners of sex addicts, whose coaddiction may manifest itself through
various physical symptoms, depression, or compulsions, can benefit from the
same treatment approach.

Address for correspondence:
Jennifer P. Schneider, MD, PhD,
1500 N Wilmot, Suite B­25O.
Tucson, AZ 85712
USA