Sex Addiction 101 – Definition of Addiction – Differentiating Between Disorders
In another blog post, Addiction as Construct, I introduced the notion of a construct. In this article, we examine addiction in clinical terms and move toward definitions. We do this to tell the difference between addiction and other constructs.
The person addicted to sexual acting out comes in many personality types, cultural backgrounds, beliefs, and behaviors. Common to all sex addicts, however, are elements that distinguish their struggle from other types of distressing syndromes or behaviors. These other disorders might appear identical to Sex Addiction but are not, such as Hypersexuality, Obsessive-Compuslive Disorder (OCD), and Impulse-Control Disorder.
As we will discover, Hypersexuality, OCD involving sexual acting out, and impulse control are along the same dimension as sex addiction but are not identical to it. Similarity does not equal identity.
The Orthodox Church, of course, has a lot to say about sex and the relations of the two genders in her teaching tradition. The clinical triage to tell the difference between one kind of behavior and another, however, is not opposed to that.
Hypersexuality
Hypersexuality is marked by the felt need for frequent relational sex. One female client I treated for anxiety linked to religious trauma felt the need for sex on a daily basis. Daily seems to meet a reasonable definition of frequency, especially considering her gender. For her, she sought out a network of relationships, chiefly an ex-husband. Only when she was unable to have relational sex with a man she had a personal connection with would she resort to other means to satiate the craving (e.g. masturbation).
Hypersexuality involves sexual craving but is linked to a spouse or partner or other relational sex. The sex partner is not necessarily objectified, not just a means of gratification, although gratification as a goal seems to be involved. This is what I mean by “dimension”, that these distressing syndromes are along a dimension and not simply categorical as if you have absolutely all of one disorder and absolutely none of another. It is not a light switch but like a dimmer switch. There is overlap—namely, dimensionality.
There are explanations for hypersexuality, but addiction is perhaps not one of them. Addiction seems to be somewhere else in the dimension of sexual syndromes.
Obsessive-Compulsive Disorder
Obsessive-compulsive disorders involving sexual acting out is another dimension. It most often comes about when someone has unwanted, intrusive thoughts and then makes attempts to avoid the anxiety associated with the thoughts. Sexual obsessions can and do develop, and the person feels an uncontrollable compulsion to act out so the intrusive thoughts die down and anxiety, eased.
One example may be the man who feared that he would get erectile dysfunction (ED) unless he masturbates every day and “keeps himself in shape.” This is an irrational fear compounded with guilt because this man believed masturbation to be a sin. He does not want to do it but feels compelled even against his desires to avoid a feared, disastrous outcome. Giving into the compulsion relieved the anxiety about ED, despite feelings of inferiority about his OCD. Someone afflicted with obsessions feels forced to do something he may not even like to do as if against his own desires. Guilt may oppose the impulse, but he goes through with the act to avoid a dreaded event, i.e. to ease anxieties.
Impulse Control Disorder
What about impulse control disorder? It depends on how “impulse” is defined. Impulses certainly accompany many aspect of life, including already-acknowledged addictions, such as substance abuses. The alcoholic may impulsively drink the next beer, despite being well aware of his limits. And the next, and the next. And yet, we would not say he is not addicted, just recognize the role of impulsivity in the addiction. Also, there may be a significant time gap between the impulse and the action. The alcoholic may have the impulse to drink but not he means (say he is at work). So, on the way home hours later, he swings into the corner store. Is this an impulse, or a planned action that looks less and less like impulse?
The same goes for any addiction, such as with sexual addiction. Yes, there may be relief from anxiety or pleasure derived from acting on an impulse. But impulse control impairment does not seem to be a separate category from addiction, but a feature of addiction.
Genuine impulse control disorders will have divergent features from addiction disorders, which is another topic for another time.
Can sexual problems really be an addiction?
Addiction is different and distinct from all the above syndromes. Addiction is not primarily relational sex, although relationships may be involved. Addiction is not the primary relief of a dreaded outcome, although stress and anxiety may be a contributing factor. Addiction, rather, seeks gratification or pleasure to meet some perceived, underlying need (whether or not the addict is fully conscious of the need). Sex addiction has its own elements, which hypersexuality and obsession-compulsion does not necessarily share. Impulsivity is also involved in addiction, but seems to be a feature of addiction and not a good, stand-alone explanation.
Now, there are many who believe sex addiction does not exist. Why? Perhaps some fear the concept of sex addiction implies a condemnation of their desires, orientations, attractions, paraphilias, and behaviors. This is likely based in shame, which should be addressed in therapy. A definition of addiction can be behaviorally non-specific and not automatically condemn anything. In other words, such a definition may provide guidance to understand the right dimension or clinical framework for a set of behaviors but have no specific content about the exact behaviors.
Such non-specific definition of addiction is a clinical definition. It is not a moral evaluation. The moral evaluation of the behaviors must rest on other-than-clinical foundations, such as religious convictions and one’s ethical worldview. The Orthodox Church, of course, has a lot to say about sex and the relations of the two genders in her teaching tradition. The clinical triage to tell the difference between one kind of behavior and another, however, is not opposed to that, but it is a separate issue (although directly relevant, obviously).
Also, being a linguistic effort at defining a construct, a behaviorally non-specific definition of addiction rests on a series of word definitions of words that “stack,” so to speak, to create the sum of the concept.
One leading author offers the following clinical approach to sex addiction.
A maladaptive pattern of behavior leading to clinically significant impairment or distress as manifested by three (or more) of the following, occurring at any time in the same 12-month period…
Goodman, A. (1998) Sexual addiction: An integrated approach. International Universities Press, Inc., p. 17.
Goodman goes on to detail seven specific criteria, but this will do for now to approach a definition of addiction. Notice he does not specify any sexual behavior or anything else at all. He does not mention masturbation, oral sex, viewing internet pornography, sexual orientation—nothing. It is behaviorally non-specific, only a framework. It is a clinical guide. The key words whose meanings stack up are the following: maladaptive, clinically significant, impairment, and distress. And then there is the time frame of 12 months that matters.
Maladaptive. This relies on pre-committments to what is adaptive in society, in one’s personal context or social sphere. Mal-adaptive means bad-adaptive, or not properly formed for one’s environment or social context. There is a measure of objectivity here. What type of sexual behavior counts as adaptive versus maladaptive? It involves, as I said, one’s psycho-social context, religious convictions, and ethical worldview.
Clinically significant impairment. This has to do with functioning in one’s ordinary life. Does the behavior interfere with work? With responsibilities at home? Has it cost excessive amounts of money, risking financial ruin? Has the behavior hurt relationships? Does it result in culpability according to the client’s religious convictions? There is a measure of objectivity here, also. The client usually has reached out to a therapist by the time enough areas of life have been impacted.
Clinically significant distress. If one’s behavior is maladaptive, meaning it does not match one’s social context or ethical beliefs, then the behavior will cause distress. Beliefs are in conflict with behavior, producing distressing results for one’s mood. Clinically significant distress usually means (in practice) that the distress was bad enough the person decided to find a therapist to reduce or resolve the distress.
12 months. This is the most debatable aspect of the definition, in my opinion. Any timeframe will be somewhat arbitrary. It is important, however, to have some idea that the problem is ongoing or chronic in some form or fashion, that it has gotten “stuck,” as in a rut one cannot get out of. Otherwise, it may not be addiction at all, but an occasional binge. Not all bingers are addicts, although some addicts are bingers. There is wisdom and clinical prudence needed here to determine the role of timeframe, which is not an exact science.
Conclusion
There are other criteria to help determine whether someone struggles with an addiction or some other affliction. There are also formal tests or clinical assessments, which are helpful in this effort. You should not try to make this determination on your own. Being an active member in your local Church community, especially in a brotherhood of like-minded men, is critical. Regular confession to your priest is non-negotiable, as are the other spiritual disciplines and Mysteries of the Church.
Contact me today if you would like to talk about these issues and want an informal conversation with a brother in Christ.