The Blurry Lines of Sex Addiction: Differentiating between Normal and Problematic Sexual Behaviors

A lot of us who work in addictions and mental health had hoped that the latest edition of the American Psychiatric Association's diagnostic manual (the DSM) would establish meaningful parameters for the diagnosis and treatment of sex addiction. This did not occur. While a very limited number of specific dysfunctions and behaviors are explored, our field has not yet come to an understanding of what constitutes addiction to sex/sexual behavior.

Contributors to the DSM attribute this to a lack of research. It seems more plausible that we are simply uncomfortable defining and quantifying an astounding array of behaviors and expressions into healthy and unhealthy categories. We have made grave mistakes in past editions of the DSM, including conceptualizing homosexuality as a disorder.

Sexual addiction is best understood as hyper sexuality that involves both obsessions (unwanted and recurring thoughts) and compulsions (an overwhelming urge to engage in a behavior). But for these to constitute an addiction we must also find repeated adverse affects on our health, career, relationships or other important parts of our lives as a direct result(s). In the absence of negative consequences I often give people the good news that they simply have a high libido and do not show signs of addiction.

Pathology Lies at the Extremes

In order to tell if we have a problem, we must differentiate obsession from fantasy and compulsion from desire. This is often problematic because when we are uncomfortable with our wants and wishes we tend to assume that they are things to be ashamed of. The issue is further complicated because one size does not fit all. There is tremendous diversity in every aspect of sexuality. The degree to which we are secure in ourselves impacts our perception and guides our behavior.

Daydreaming, coveting or imagining having sex with others is normal. Feeling bored with long term monogamy or sex that's become mechanical is normal. Having sex frequently is healthy unless it detracts from important areas of your life. Addiction lies at the extremes of behavior and consciousness.

Examples of Obsessions

• Recurring patterns of unwanted thoughts, imagery, or impulses that distract us for more than brief periods of time.
• Recurring thoughts regarding abusing others sexually (by definition, abuse means an unwilling participant).
• Sexual thoughts regarding children or family members.
• Thoughts in the form of self doubt that one may have committed what they would consider a heinous act and be unable to recall whether it occurred or not.

If these types of obsessions persist, it is very possible that one may live with a subtype of Obsessive Compulsive Disorder often referred to as "pure obsessions" because the person does not follow through on the ideas or imagery. In this case, treatment for anxiety is warranted but a sexual disorder/addiction is not indicated.

Examples of Compulsions

• Having sex or masturbating when it is physically painful to do so (in this context pain is not seen as pleasurable).
• Having affairs when one truly values fidelity.
• Excessively accessing prostitutes or other sex workers (excessive is defined as causing significant problems in one's life).
• Engaging in sexual behavior that is unlawful and leads to or carries a high risk of unacceptable punishment (public sexual acts/exposing oneself to others/exhibitionism with unwilling participants).

When It's Not an Addiction but Still a Problem

The most common concern I hear from those who believe they are sexually deviant is that they are ashamed of the number of partners and/or the frequency with which they have sex. For most, their "one night stands" or chronically returning to unhealthy relationships are simply a choice not to be alone. Folks tell me they fear entering into new relationships and they simply do what's expedient. This inevitably leaves an empty feeling as our true desires (companionship, love, partnership) are not met.

For those of us with low self esteem, we often feel like sex is the one thing good that we have to offer and so we engage in acts we don't want to get some instantaneous relief; only to regret it later. These patterns can be difficult to break because not only do we experience fear as we look ahead, but also shame as we look back. I remind folks that what we do is not the whole of who we are and we do not have to face out fears alone.

What's Okay & What Isn't?

The idea of something being "okay" is generally a moral judgment. People often ask clinicians, "Is it okay if..." and they go on to describe behavior they're unsure of, feel guilt over or sadly, are ashamed of. With regard to sexual behavior, whatever happens between two consenting adults is "okay."

Experimenting, fetishes, role playing, submission & dominance are all healthy and should never be viewed through a moral lens. The key to enjoyable sex is clear and direct communication with one's partner(s), comfort and knowledge of one's body, and developing a more secure sense of self holistically.

There are a plethora of taboos and topics that simply don't come up in polite conversation. Billions of dollars are spent every year on pornography in the U.S. yet folks are often loathe to admit they enjoy it. It's normal to be curious and to explore. There are many reasons why "Fifty Shades of Gray" sold over 70 million copies in the U.S. There is a wide array of great books on improving your sex life. I most often recommend "The Joy of Sex" as a fine resource.

For those in need of support with sex addictions I encourage you to check out:

• Sex Addicts Anonymous and Sex and Love Addicts Anonymous