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«ABSTRACT The management of patients with compulsive sexual behavior requires an understanding of the profile of the sexually compulsive or addicted ...»

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by Patrick J. Carnes, PhD

CNS Spectrums 2000; 5(10): 63-72


The management of patients with compulsive sexual behavior requires an understanding of

the profile of the sexually compulsive or addicted patient. This article summarizes patient

characteristics and their implications for treatment. Data from a study of the recovery of 957 patients who had problematic, sexually excessive behavior are presented. Spanning 5 years, the study shows six distinct stages patients experience and the clinical activities that were most useful to them. A trajectory of a typical diagnosis and treatment path is provided, as well as important resources for physicians and patients.

CNS Spectrums 2000; 5(10): 63-72


With greater awareness of sexual exploitation, sexual misconduct in the workplace and public attention regarding sexual disorders, more cases of sexual compulsivity will be brought to the attention of physicians. Thus, physicians ought to have an understanding of addictive/compulsive problematic sex in order to make appropriate management decisions and to evaluate clinical approaches. The purpose of the article is to review the nature of the problem, the typical course of treatment and recovery, and critical factors for monitoring a patient’s progress.

During the last three decades, professionals have acknowledged that some people have uncontrolled sexual behavior. People with sexual compulsivity are similar to compulsive gamblers, compulsive overeaters, or alcoholics in that they are not able to contain their impulses, which lead to destructive results. For this reason, they are often referred to as sexual addicts. Depending on one’s professional framework. The words addiction or compulsions have been used to describe the disorder.1 In the field of addiction medicine, one of the signs of addiction is compulsive use. Some professionals may make distinctions between addiction and compulsion; others may use them interchangeably. There is, however, a growing common understanding of the problem and how it occurs. Great progress is also being made in treatment.

Advances in neurochemistry may soon redefine our terminology as we understand more clearly the biology of the disorder.2


The first issue for clinicians is recognition of the problem. Typically, persons with problematic sexual compulsivity are not candid about their behavior, nor are they likely to reveal that the specific behavior is actually part of consistent selfdestructive pattern. The nature of this illness causes patients to hide the severity of the problem from others to delude themselves about their ability to control their behavior and to minimize their impact on others.3 This includes being deceptive with their physician because of their immense shame. If they hold any type of leadership position (e.g., church, business, community, or political), the fact that they are to be

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Often, some event may precipitate a visit to the physician. The incident will be presented as a onetime event or simply as a moral lapse, and may lead to marital therapy. However, if a sexual compulsion is present the problem will not disappear without more specific therapy. A wide range of behaviors can be problematic, including compulsive masturbation, extramarital affairs, pornography use, and use of prostitutes, voyeurism, exhibitionism, sexual harassment and criminal sexual misconduct. Patients with problematic sexual compulsivity seldom have just problem behavior, but rather show a variety of problem behaviors that often cluster together.4 For example, in addition to multiple extramarital affairs, there might also be use of prostitutes, pornography, and cybersex as well as masturbation. The following situations should prompt the clinician to assess a patient for the presence of sexual


• The patient volunteers that there is a long-term pattern of problematic sexual behavior. There are occasions when the person will give in to despair and let others know about the extent of his or her troubles.

• The clinician has evidence that there is a pattern of behavior. For example, if the clinician knows there is a pattern of extramarital affairs and hears reports from the spouse that there is evidence that the patient uses a massage parlor or prostitute, a pattern starts to emerge. A history of sexual issues over time also indicates a problem.

• There is a sexual incident and the clinician knows that other excessive, uncontrolled behaviors also exist, such as alcoholism, compulsive eating, compulsive working, or compulsive gambling (or a history of these behaviors exists), in addition to evidence of a sexual problem. Most often, compulsive behaviors occur together and amplify each other.7 8

• The behavior involves the abuse of power, including sex with children, congregants, employees, patients, or other persons under the authority of the affected person. Any exploitation of power or complaint of exploitation should immediately trigger an assessment and temporary removal from duties.

(Evidence of child abuse or dependent adult abuse may be required to be reported in many jurisdictions.)

• There are unexplained problems coupled with a sexual behavior. Unexplained absences, failure to perform expected tasks, and the disappearance of large sums of money could all be part of a compulsive pattern (e.g., compulsive affairs or sue of prostitutes could be the issue).

The discovery of an inappropriate sexual incident does not always indicate an addictive illness. A long-term extramarital affair, for example, may be a problem for a spouse, but does not represent a compulsive pattern. Likewise, exploitive or even violent behavior does not indicate a sexually addictive illness. For example, in a recent study of sex offenders, only 72% of pedophiles and 38% of rapists fit the criteria for sexual compulsivity.9 Task-Centered Competency-Based Approach to Treatment Page 2 of 16 CNS SPECTRUMS ● Volume 5 – Number 10 ● October 2000 ©1998 Patrick J. Carnes, PhD Finally, it is important to note that women can have the problem too. In fact, for every three men with sexual compulsivity, there is one woman with the disorder.

This ratio parallels the gender ratios of compulsive gambling and alcoholism. The expectation of many that women (especially moral or religious women) do not have this problem helps keep it secret. A female patient suffers the shame of having a sexual disorder and also from being a woman who has lost control.

The following examples illustrate the diversity and complexity of sexual


• A parish pastor had a $1,000/weekprostitution habit, after depleting his family inheritance, he started to use parish funds by removing loose cash in the parish collections and making out false payroll checks for staffing who did not exist.

He fancied himself as having a ministry to the prostitutes he used. He also did not see himself as violating his vow of celibacy, since he was an emotional virgin with no relationship commitments.

• A 37-year-old social worker had been married for 13 years. Yet even on the day she married, she was having an affair. Her unusual pattern was to have two or three affairs at a time. She was confronted by her therapist about her compulsive affairs, but she dismissed the therapist saying that the problem was her marriage. She then discovered the Internet and chat rooms. While her husband slept, she repeatedly engaged in romantic, sexual talk with many men

simultaneously throughout the night. Romanic intrigue escalated to phone sex:

phone sex led to her meeting with men in hotels. She finally was beaten and left for dead in a hotel room by a man she met through the Internet.

• A 71-year-old chief executive officer of a very successful office products manufacturing company received two sexual harassment complaints in a matter of a few weeks. The company hired an investigator to do a company audit of sexual harassment. More than 70 women (past and current employees) came forward with stories of constant propositions, fondling, and affairs. The investigation further revealed similar stories among vendors. Trades people, family friends, and very unfortunate incident with his daughter-in-law.

• A 40-year-old married gynecologist had a pattern of initiation relationships with his patients after he conducted examinations of them. He also had a history of relationships with nurses both at the hospital and in his own staff. His current affair with his own staff member involved extensive financial support of a person who was clearly not competent to do assigned work. What precipitated the crisis that brought him to treatment, however, was a hospital audit of computer usage, which revealed this physician was extensively downloading pornography, particularly of young and adolescent women.

• A 35-year-old chemical dependency counselor had a severe problem with pornography and strip bars. He also masturbated six to eight times a day, sometimes in unsafe situations such as in his car. He was married to a woman to whom he was attracted and whom he said he deeply loved; however, he was sexually avoidant with her.

Task-Centered Competency-Based Approach to Treatment Page 3 of 16 CNS SPECTRUMS ● Volume 5 – Number 10 ● October 2000 ©1998 Patrick J. Carnes, PhD

• A successful businessman had problems with both sexual compulsivity and substance abuse. When he drank, he liked to arrange threesomes with prostitutes and was very directive as to what they should do. When he used cocaine, he was very passive and would masturbate for up to 15 hours without stopping. Sometimes on his cocaine/masturbation binges, he would also crossdress and hire a prostitute to assist with the masturbation.

The common theme in these examples is sexually compulsive behavior. These individuals have reached a level of sexual frequency and loss of control that is selfdestructive. Like compulsive gamblers, compulsive overeaters, or alcoholics, they will make repeated efforts to stop but are unsuccessful. They know that to continue will bring disaster; yet, they continue the behavior.

Table 1 lists criteria some clinicians use to diagnose this condition. The second column shows how patients rated themselves initially, and the third column shows how they viewed themselves after long-term treatment, averaging 2½ years.12

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A review of the characteristics of those affected by compulsive sexual behavior will help clinicians understand the requirements of treatment. These traits are mainly from a study of nearly 1,000 sex addicts.13 Critical characteristics include the


• Distrust of authority. Most patients are from dysfunctional families who have a significant problem with addictive and compulsive disorders. Only 13% of the families of origin have no addictions or compulsive disorders reported. Children who grow up in dysfunctional families are extremely rigid and controlling.

Children from these families tend not to develop normal abilities of selflimitation and responsibility, To comply with authority means an essential loss of self. As adults, they are comfortable hiding things from those in authority and are resistant to accountability.

• Intimacy deficit. More than 87% of these patients come from disengaged family environment in which family members are detached, uninvolved, or emotionally absent. Compulsive sexual behavior is a sign of a significant intimacy disorder and the inability to meet emotional needs.

• Post-traumatic stress disorder. Sexually compulsive patient often have a history of sexual abuse, physical abuse, and emotional abuse. Addictions become a way to manage their stress disorder and may include repeating the trauma compulsively.

• Extreme eroticization. One of the effects of abusive families and childhood sexual abuse is that, as adults, survivors sexualize all interactions. They often sense that other people do not have the same relationship filters they do, which adds to their sense of shame.

• Shame-based sense of self. Shame stems from a failure to achieve a positive sense of self and profound belief in one’s lack of worth. The constant failure to stop the behavior you hate confirms your belief that you are fundamentally flawed and unlovable.

• Compartmentalization. A survival mechanism for abused children is to compartmentalize in order to avoid reality. For adults this means dividing up life into compartments. This explains both a person who believes that no none will discover their sexual behavior as well as a person who can lie to others without distress.14

• Compulsive cycles. Most addicts (72%) binge and then feel despair-much like a person with bulimia will binge and purge. For example, a number of clergymen preach against promiscuity or some sexual behavior only to be discovered engaging in or arrested for that behavior. In their public pronouncements they were purging, while privately they were clearly binging. These cycles add to both shame and compartmentalizing.

Task-Centered Competency-Based Approach to Treatment Page 5 of 16 CNS SPECTRUMS ● Volume 5 – Number 10 ● October 2000 ©1998 Patrick J. Carnes, PhD

• Self-destructive behavior. Many patients report high-risk behaviors, which result in severe consequences, such as loss of career or arrest. Children who are sexually abused often integrate fear into their arousal patterns. For sex to work for these adults, it has to have a fear component, which results in riskseeking sex. Frequently, these patients reported knowing their behavior would be disastrous, but engaged in it anyways.

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