BASICS OF SEXUAL
COMPULSIVITY
CAPTASA 2016
Mary Deitch, JD, Psy.D
DISCLOSURES
• I have no financial interests to report.
• I was an employee of Keystone Center ECU
• I was a consultant for VSC
• I am on the Board of SASH and the President elect
• The content of this program, while just an overview, may be disturbing.
OBJECTIVES
• To learn to recognize problematic sexual behaviors
• To learn the basics of assessment for sexual compulsivity/problematic sexual
behaviors
• To learn different diagnostic categories and treatment planning for problematic
sexual behaviors
WHAT ARE WE TALKING ABOUT
• Sexual addiction
• Sexual compulsivity
• Problematic sexual behavior
• Out of control sexual behavior
• Hypersexual disorder
• Impulse Control Disorder (Barth and Kinder)
• Interactive Addiction Disorder (Carnes)
• Paraphilic Disorder
SEXUAL ADDICTION
• Behaviors are engaged in for longer periods of time than intended.
• An effort or desire to cut down or stop the behavior.
• Time is spent to engage in the activity or find a way to engage in the activity or
recover from the activity.
• Important social, occupational, or recreational activities are given up or reduced
because of the behavior.
• Continue to use the behavior despite knowledge of having a persistent physical or
psychological problem.
SEXUAL ADDICTION CONT.
• Recurrent use resulting in failure to fulfill obligations.
• Continued use despite problems.
• Tolerance: Defined by increased amounts of use of behavior or increase in risk.
• Maladaptive pattern of use leading to impairment or distress.
• Withdrawal: This area is least defined in sexual addiction but there is irritability when
not able to engage in the behavior. Frequently depression, anxiety, and physical
symptoms are present.
• ASAM now includes sex as an addiction in their definition
SEXUAL COMPULSIVITY
• Behaviors are engaged in to reduce anxiety or internal states
• Behavior feels driven
• Quadland, Coleman
HYPERSEXUAL DISORDER
• Excessive time consumed by sexual fantasies, urges and planning on engaging in
sexual behaviors.
• Repetitive use of these behaviors in response to mood.
• Repetitive engagement in the behaviors in response to stressful life events.
• Attempts to control or reduce the behaviors.
• Disregard for the risk to self or others.
• Impairment in social, occupational or other functioning.
• Not due to other diagnosis.
HYPERSEXUAL DISORDER CONT
• Masturbation
• Pornography
• Sexual Behavior With Consenting Adults
• Cybersex
• Telephone Sex
• Strip Clubs
• Kafka, Reid
OUT OF CONTROL SEXUAL BEHAVIOR
• Not a diagnostic Term
• Characterized by significant problems regulated sexual behavior, thoughts or urges
• Causing negative consequences
• Significant amounts of distress, shame, worry, fear and losses
• The distress does not help regulate the sexual behaviors
• Hopelessness and helplessness
• Braun-Harvey
PARAPHILIC DISORDERS
• “Non-Normative” Sexual Behaviors
• Must rise to the level of disruptive or create victims
COMMON PARAPHILIAS
• Pedophilia (attraction to non developed minors- do not have to act on the attraction)
• Exhibitionism (sexual gratification at exposing oneself to an unsuspecting other- do
not need to agree with the diagnosis the behavior is enough for the diagnosis)
• Voyeurism (sexual gratification at seeing the sexual body parts or sexual activity of
an unsuspecting other- do not need to agree with the diagnosis the behavior is
enough)
• Sexual Sadism (sexual gratification at the idea of harming others)
COMMON PARAPHILIAS CONT.
• Sexual Masochism (sexual gratification at the idea of being harmed)
• Frotteurism (touching people for the purpose of sexual gratification while making it
appear as an accident)
• Bestiality (engaging in or being sexual aroused by sexual activity with animals)
(versus zoophilia)
• Fetishism and/or Partialism- attraction to non living objects or obsession with body
parts
AREAS OF CONSIDERATION FOR
PARAPHILIA
• A client comes to treatment and amongst other behaviors discusses that he enjoys
watching his wife have sexual activity with another person and often fantasizes about this.
What types of questions would you need to ask?
• A client comes to treatment and amongst other behaviors discusses that he enjoys looking
into the windows of his neighbors homes and then masturbates to what he sees. What
types of questions would you need to ask?
• A client states that he has viewed child pornography? What types of questions would you
need to ask to clarify the diagnosis?
• A client is caught in internet chat with a minor. What types of questions would you need to
ask to clarify the diagnosis?
OTHER BEHAVIORS THAT ARE OF NOTE
• clients view web cameras of unsuspecting people for voyeuristic activity
• place cameras in locations where people will be changing or otherwise unclothed
• use web cameras to expose themselves
• watch nudist sites to view children
• watch barely legal pornography
• read erotica about incest
• watch bestiality pornography
• Telephone Scatologia often comorbid with Voyeurism and Exhibitionism
• Alcoholism thought to be highly comorbid with paraphilias generally, specifically sadism
and fetishism
SUMMARY
• Sexual addiction is using a sexual behavior to cope despite the consequences.
Sexual addiction can take many forms from masturbation, pornography, affairs,
prostitution, exhibitionism, voyeurism, anonymous sex, and child pornography.
Typically, using these behaviors despite it affecting interpersonal, occupational, or
other areas of life. Typically, using these behaviors to a greater degree than intended.
Typically, have shame after or use them despite not wanting to.
• All definitions agree that it is a pattern of behavior that continues despite negative
consequences. Many include to cope with distress or other internal states.
DIAGNOSIS
• Diagnosis can inform treatment
• Paraphilic Disorder Specified/ Unspecified
• Other Disruptive, Impulse control and Conduct Disorder
• Obsessive Compulsive Disorder
SEX AND TREATMENT FACILITIES
• Why would clients use sex while in treatment?
• What are the red flags for treating providers?
• How would you handle this?
DRUGS AND SEX
• Substance abuse history is common in this population, either clients are co-occurring or switched.
• 40-60% of sexual addicts report substance use disorders
• Alcohol use to help numb before or after sexual behavior (high self monitors, other directed)
• Marijuana use was less common, on the upswing (highest age group 50-59 year olds of a normative
sample, this was also highest group to report “transactional” sex and alcohol use)
• Cocaine and the use of prostitutes
• Meth, “club drugs”, rohypnol and anonymous sex
• Poppers are still an issue
DRUGS AND SEX
• Sexual behavior during the use of drugs is common and quite frequently risky
• Higher incidence of sexual risky behavior while under the use of stimulants
• One study found that men in DA treatment stated that their drug use and sexual behaviors
were strongly intertwined
• Drug use increases the desire or preoccupation with sex
• Drug users have an expectation that drug use will enhance their sexual interactions and
performance
• Those in DA treatment without a component of reducing risky sexual behavior are more
likely to engage in substance abuse sexual activity, with casual partners and do not enjoy
sex as much as when sober
DRUGS AND SEX CONT
• Sexually addicted only versus sexually addicted and drug or alcohol addicted
clients, have not been greatly studied.
• One study found that SA only clients reported having SA longer than SASUD clients.
SASUD clients reported more treatment history.
• When treated for both, improvements in quality of life and sexual impulsivity were
shown.
• SASUD show lower rates overall of sexual compulsivity
OTHER COMORBIDITIES WITH SEX
ADDICTION
• Anxiety disorders
• Mood disorders
• ADHD
• OCD
• Impulse Control Disorders
• Social Anxiety
• PTSD
FOR YOU TO PONDER
• It you are uncomfortable with any topic, don’t do that work!
• Use preventative measures to guard against counselor burn out or PTSD,
• Participate in personal and professional development,
• Recognize and examine own biases,
• Recognize and examine own sexuality, what you have known (and done) will become an
issue!
• Be mindful that your own sexual attitudes and beliefs are not being put on the client.
Don’t work with certain populations if you disagree with their version of healthy sexuality.
• Function as a member of an interdisciplinary team
• Have a working definition of sexual health
• Need to be curious! Ask questions!
ASSESSMENT
• SAST –sexhelp.com
• Hypersexual Disorder Questionnaire
• HBI-19 (hypersexual behavior inventory)
• Sexual behavior list
• Pornography consumption inventory
• ECR-R
ASSESSMENT CONT
• Shame inventory
• Impulsivity scale
• Self-compassion scale
• Self-monitoring Scale
• MMPI-2
• AASI-3
• Polygraph
PERSONALITY FACTORS
• Lower levels of trust and empathy associated with infidelity as well as being
disorganized and unreliable.
• Higher levels of extraversion and neuroticism associated with promiscuity and risky
sex
• Higher levels of psychopathy associated with unprotected sex and paying for sex
• Uncertain of MMPI-2 results as sex addiction is a heterogeneous group. Some
evidence for higher levels of Pd scale, Anxiety. However, can be useful in treatment
planning
CLINICAL INTAKE
• Family history
• Substance abuse
• Disordered eating
• Gambling/ debting/ stealing
• Gaming
• Relationship history
CLINICAL INTAKE CONT
• Treatment history
• Medical history
• Legal history
• Religion/spirituality
• Recovery history
• General Internet use
• History of Violence
CLINICAL SEXUAL INTAKE
• Need to do a complete sexual history
• First time, last time, frequency over time
• Who, what, when, where, why, how
• For all sexual behaviors not just “problematic”
• Where did they learn about sex?
• What were their families attitudes about sex?
SEXUAL BEHAVIORS CONT
• What are their thoughts about sex/sexuality?
• What is their view on their sexual health and satisfaction?
• How often do they have sex with their current partner?
• At the end of the interview- is there anything I have not asked you that I should have?
Is there anything that you were worried I was going to ask you about?
• Consequences due to sexual behaviors
COMMON SEXUAL BEHAVIORS FOR CHECKLIST
Masturbation
Use of singles ads/singles cites
Masturbation in car
Cyber sex/webcams
Masturbation to the point of injury
Sex with patients/ clients/ parishioners
Sexual obsession/Fantasy
Sex with employers
Pornography in any form
Sex with employees/coworkers
Child Sexual Abuse images (child pornography)
Use of drugs with sex
Romantic Involvements
Use of drugs to obtain sex
Sex outside your primary relationship
Use of sex to obtain drugs
Paying for sex
Sex with animals
Strip Clubs
Group sex/ Swingers clubs
Bathhouses
Use of urination or feces for sexual arousal
Adult bookstores
Phone Sex
Sex in public places
Obscene calls
Anonymous Sex
Dangerous sex (asphyxiation, sadism, masochism)
One Night Stands
Sex with minor
Sex with family members
Exhibitionism
Voyeurism
Cross-dressing
EXAMPLE OF QUESTIONS FOR
PORNOGRAPHY USE
• First time
• Last time
• Frequency (both how many times a day/week/month but how many hours)
• What do they view? Who are the people? Age, race, gender, ethnicity. Who are they
in the pornography? What are the people (or non-people as the case may be) doing?
• Where do they watch? (please remember phones and there is still paper).
• Who is around while they watch?
• How do they access it? (e.g. Search terms, pay for, different types of sites)
INTERCOURSE
• First time/Last Time/Frequency?
• Who with? Age, Race, Gender, Frequency (note to ask about sex outside orientation)? How long do
they know the person?
• Pay for? Paid to? “Barter”?
• Protected/unprotected?
• Where?
• Drugs and Alcohol?
• What do they do? What would they like to do?
• How do they find people? (some studies suggest that online sexual encounters are less likely to be
protected).
MASTURBATION
• First time, how learned, frequency, thoughts about, last time
• What are the doing while masturbating? Mindful? Fantasizing? Viewing? With
partner?
• Where are they?
• Have they ever masturbated to injury?
• Have they ever masturbated in their car? In Public? At work?
TREATMENT PLANNING
• There is no one way to treat a sex addict!
• Presentations are wide and varied
• Its not just about stopping the behaviors
• Group versus Individual
• A few notes
•
•
•
•
•
•
•
Mindfulness
ACT
Trauma Informed Care
CBT/Relapse Prevention
Schema Informed Therapy
Co-Occuring Issues
Motivational Interviewing
TREATMENT PLANNING CONT
• Start with your history
• What are most risky issues right now? Legal, Medical, Substances, Sexually, Family
• What coping mechanisms do they have in place and how to build on that?
• What areas of accountability are needed?
• What are the mental health concerns that need to be addressed and monitored?
• What sexual education has to be done?
• What more “digging” needs to be done in sexual behaviors?
• What Personality Disorder Traits are there?
• What interpersonal skills need to be built?
TREATMENT PLANNING CONT
• What supports are needed (consider 12-step)
• What emotional intelligence work?
• What is the clients shame?
• What trauma/abuse history needs to be addressed?
• What are their sexual health goals?
• What empathy work needs to be done?
• What family/couples work needs to be done? Disclosure?
• What grieving work needs to occur?
• What areas do you need education?
WORKING WITH SPOUSES/PARTNERS
• Most clients had encouragement from loved ones to come to treatment.
• It is very important, yet very difficult, to establish rapport with spouses/partners, without
going to far.
• The spouse will need help with education on the disease, recovery, relapse prevention.
However you need to ensure you maintain boundaries.
• Spouses often feel a level of trauma, mistrust, abuse and have resultant symptoms. Be
mindful of labeling them either traumatized or coaddicted/codependant.
• Except in very rare instances, there should be 3 clinicians involved with clear roles,
boundaries and systems in place.
• Boundaries, boundaries, boundaries, boundaries (yours, hers, his and theirs!)
DISCLOSURE
• Disclosure is very important but delicate, spouses/partners are getting informed consent.
• Not the 8th and 9th step, if clients try to avoid using this.
• Careful planning and work with the client is needed and many drafts might done.
• Do not rush this process as it will add more issues to the table! It might be tempting but take your
time.
• Make sure the disclosure is to your best ability as the clinician a true and honest account. Watch your
integrity.
• Make sure to plan for after the process and where will everyone go.
• Work with spouses therapist to ensure the most stability and support in place.
WORKING WITH PARENTS
• Crucial work! Very fine line between support, good parenting and smothering or
sponsoring.
• First work with your client to gauge their perspective of what might be useful,
beneficial, supportive.
• Many clients don’t want to nor need to tell their parents about their trauma history or
to express how it was growing up in the household. Some may need to and have to
be okay without validation.
• Have to help the whole system look at the system dysfunction and where to go while
honoring the system’s fears and hurts due to our clients behaviors.
CONTACT INFO FOR
QUESTIONS
Mary Deitch, JD, Psy.D
Deitch Therapy and Consulting
www.deitchtherapyandconsulting.com
mary@deitchtherapyandconsulting.com
610-945-8021
1112 MacDade Blvd
Woodlyn PA 19094
REFERENCES/RESOURCES
• www.sash.net
• www.rory.net
• www.iitap.com
• Multiple Authors (2010). Findings from the National Survey of Sexual Health and Behavior
(NSSHB) Center for Sexual Health Promotion Indiana University. The Journal of Sexual
Medicine. 7(5)
• Allnutt, S. H., Bradford, J. M. W., Greenberg, D. M., and Curry, S., "Co-Morbidity of
Alcoholism and the Paraphilias," Journal of Forensic Sciences, JFSCA, Vol. 41, No.2, March
1996, pp. 234-239. (online)
• Bancroft, J., Vukadinovic, Z., (2004). Sexual Addiction, Sexual Compulsivity, Sexual
Impulsivity, or What? Toward a Theoretical Model. Journal of Sex Research 4(3). (Online)
REFERENCES CONT.
• Bowen S., Chawla, N., Marlatt, G.A. Mindfulness Based Relapse Prevention for Addictive
Behaviors. (2011) Guilford Press.
• Braun-Harvey, Douglas. (2010) Sexual Health in Recovery: A Professional Counselors
Manual. Springer Publishing
• Calsyn, DA., Critis-Christoph, P., Hatch-Maillett, MA., Doyle, S., Song, Y., Coyer, S., Pelta, S.
(2010). Reducing Sex under the Influence of Drugs and Alcohol for Patients in Substance
Abuse Treatment. Addiction 105(1), 100-108. (online).
• Carnes, P., Murray, R., Charpentier, L., (2005). Bargains with Chaos: Sex Addicts and
Addiction Interaction Disorder. Sexual Addiction and Compulsivity. 12.
• Cooper, A., Griffin-Shelley, E., Delmonio, D., Mathy, R. (2001) Online Sexual Problems,
Assessment and Predictive Variables. Sexual Addiction and Compulsivity. 8:267-285
(online)
REFERENCES CONT
• Garcia, F., Thibaut, F., (2010) Sexual Addictions. The American Journal of Drug and Alcohol
Abuse. 36. online
• Hartman, L., Ho, V., Arbour, S., Hambley, J.M., Lawson, P. (2012). Sexual Addiction and
Substance Addiction: Comparing Sexual Addiction treatment Outcomes Among Clients
with and Without Comorbid Substance Use Disorders. Sexual Addiction and Compulsivity:
The Journal of Treatment and Prevention. 19:4, 284-309.
• Holmes, W.C., Foa, E., Sammel M.D., (2005) Men’s Pathways to Risky Sexual Behavior: Role
of Co-Occurring Childhood Sexual Abuse, Posttraumatic Stress Disorder, and Depression
Histories. Journal of Urban Health, Bulliten of the New York Academy of Medicine. 82(1).
Online
• Hook ,JP., Hook, JN., Davis D., Worthington, E., Penberthy, J.K., (2010). Measuring Sexual
Addiction and Compulsivity, a Critical Review of the Instruments. Journal of Sex and
Marital Therapy. 36.
REFERENCES CONT.
• Kafka, M. (2009). The DSM Diagnostic Criteria for Paraphilia Not Otherwise Specified.
Archives of Sexual Behavior. Doi: 10.1007/s10508-009-9552-0
• Kafka, M., Hennen. J., (1999). The Paraphilia-Related Disorders: An Empirical Investigation
of Nonparaphilic Hypersexuality Disorders in Outpatient Males. Journal of Sex and Marital
Therapy. 25: 305-319. online
• Kafka, M., Hennen, J. (2002). A DSM-IV Axis I Comorbidity Study of Males (n = 120) With
Paraphilias and Paraphilia-Related Disorders. Sexual Abuse: A Journal of Research and
Treatment. 14(4).
• Levine, M., Dalrymple, K., Zimmerman, M., (2013). Which Facets of Mindfulness Predict the
Presence of Substance Use Disorders in an Outpatient Psychiatric Sample? Psychology of
Addictive Behaviors. Advance online publication. doi: 10.1037/a0034706
REFERENCES CONT.
• Liau, A., Millett, G., Marks, G., (2006). Meta-analytic Examination of Online Sex Seeking
and Sexual Risk Behavior Among Men who Have Sex with Men. Sexually Transmitted
Diseases. 33(9): 576-584. Online.
• Luoma, J.B., Kohlenberg, B.S.., Hayes, S., Fletcher, L. (2012). Slow and Steady Wins the Race:
A Randomized Clinical Trial of Acceptance and Commitment Therapy Targeting Shame in
Substance Use Disorders. Journal of Consulting and Clinical Psychology. 80(1)
• Motoharu, T., Takihashi, S., Kitamura, M. (2009). Addictive Personality and Problematic
Mobile Phone Use. CyberPsychology and Behavior. 12(X). Online
• Parsons et al (2010). Explanations for the Origins of Sexual Compulsivity Among Gay and
Bisexual Men. Archives of Sexual Behavior. http://rd.springer.com/article/10.1007/s10508007-9218-8/fulltext.html
• Reid, R., Carpenter, B.N. (2009). Exploring Relationships of Psychopathology in
Hypersexual Patients Using the MMPI-2. Journal of Sex and Marital Therapy. 35(4).
REFERENCES CONT.
• Reid, R., Cyders, M.A., Moghaddan, JF., Fong, T.W., (2014). Psychometric properties of
the Barratt Impulsiveness Scale in patients with gambling disorders, hypersexuality, and
methamphetamine dependence. Addictive Behaviors. 39(11).
• Schmitt, D.P. (2004). The Big Five Related to Risky Sexual Behaviour Across 10 World
Regions: Differential Personality Associations of Sexual Promiscuity and Relationship
Infidelity. European Journal of Personality. 18:301-319. (online)
• Skegg. S., Nada-Raja, S., Dickson, N., Paul, C., (2010). Perceived ‘‘Out of Control’’
Sexual Behavior in a Cohort of Young Adults from the Dunedin Multidisciplinary Health
and Development Study. Archives of Sexual Behavior. 39:968-978. online.
• Michael P. Twohig, Jesse M. Crosby, Acceptance and Commitment Therapy as a Treatment
for Problematic Internet Pornography Viewing, Behavior Therapy (2010),
10.1016/j.beth.2009.06.002
• Wetterneck, C.T., et al (2012). The Role of Sexual Compulsivity, Impulsivity and
Experiential Avoidance in Internet Pornography Use. The Psychology Record. 62.