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CBT for Compulsive Sexual
Behaviour

Increasing numbers of therapists are coming into contact with the problem of
­compulsive sexual behaviour disorders. However, it is still a relatively new field
and there is little in the current literature available that enables the therapist to
work with and treat this problem. CBT for Compulsive Sexual Behaviour: A guide
for professionals addresses this by providing a guide to cognitive-behavioural
theory and practice which includes the assessment, diagnosis and treatment of
addictive sexually compulsive disorders.
Beginning with a description of addictive sexuality and an overview of cogni-
tive behavioural therapy in which CBT is presented as the most useful response,
Thaddeus Birchard provides clear therapeutic information about the implementa-
tion of CBT treatment intervention. The chapters included cover the neuroscience
that underpins the addictive process; a ‘how to’ chapter on the use of groups;
paraphilias; trauma and attachment; comorbid disorders and cross-addictions
and analysis on the function of internet pornography, all written from a cognitive
behavioural stance.
Using case vignettes throughout, Thaddeus Birchard draws on his own expe-
rience as a psychosexual therapist, along with the latest research in the field, to
enable the therapist to treat a range of compulsive sexual problems in a way that
can be applied in individual practice or in a group setting as well as how to prevent
relapse. This book will be essential reading for psychosexual therapists, cogni-
tive behaviour therapists and other professional working with sexual compulsive
disorders.

Thaddeus Birchard is the founder of the Marylebone Centre for Psychological

Therapies and the Association for the Treatment of Sexual Addiction and
Compulsivity. He is widely acknowledged as the pioneer of all work on sexual
addiction in the UK and as an expert on working with men with out of control
sexual behaviours.
This page intentionally left blank
CBT for Compulsive
Sexual Behaviour

A guide for professionals

Thaddeus Birchard
First published 2015
by Routledge
27 Church Road, Hove, East Sussex, BN3 2FA
and by Routledge
711 Third Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2015 Thaddeus Birchard
The right of Thaddeus Birchard to be identified as author of this work
has been asserted by him in accordance with sections 77 and 78 of the
Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in
any information storage or retrieval system, without permission in writing
from the publishers.
Trademark notice: Product or corporate names may be trademarks or
registered trademarks, and are used only for identification and explanation
without intent to infringe.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
Birchard, Thaddeus, author.
CBT for compulsive sexual behaviour : a guide for professionals /
Thaddeus Birchard.
p. ; cm.
Cognitive behavior therapy for compulsive sexual behaviour
I. Title. II. Title: Cognitive behavior therapy for compulsive sexual
behaviour.
[DNLM: 1. Behavior, Addictive—therapy. 2. Sexual Dysfunctions,
Psychological—therapy. 3. Cognitive Therapy—methods. 4. Sexual
Behavior—psychology. WM 611]
RC560.S43
616.85′83306—dc23
2014043143

ISBN: 978-0-415-72379-4 (hbk)

ISBN: 978-0-415-72380-0 (pbk)
ISBN: 978-1-315-72482-9 (ebk)

Typeset in Times New Roman

by Swales & Willis Ltd, Exeter, Devon, UK
About the author

Thaddeus Birchard moved from New Orleans to the United Kingdom in 1966
to study theology at the House of the Sacred Mission, Kelham, Newark and
Nottingham University. After some years in parish ministry, he moved into psy-
chotherapy. He trained in psychosexual therapy at the Whittington Hospital and
London South Bank University. He proceeded to a Doctorate in Psychotherapy
at the Metanoia Institute and Middlesex University. He then trained in cognitive
behavioural therapy (CBT) at London Metropolitan University. First working as
Dr Thaddeus Birchard and Associates, he founded the Marylebone Centre for
Psychological Therapies in 2007. He is accredited with the College of Sexual and
Relationship Therapists and the British Association for Behavioural and Cognitive
Psychotherapies, and registered with the United Kingdom Council for Psycho-
therapy. He is the founder of the Association for the Treatment of Sexual Addic-
tion and Compulsivity. He founded the first treatment programme for sexually
compulsive men in the United Kingdom. Along with Joy Rosendale, he i­nitiated
a partners’ programme. He works in three main areas: marriage and relationships,
psychogenic sexual disorders and CBT; he works with depression, anxiety disor-
ders, obsessive compulsive disorder and trauma. His doctoral research was in the
field of hypersexuality and he has focused on sexual addiction since 1988.
This page intentionally left blank
This book is dedicated, with affection, to:
Marie Baker
Kenny, Chan and Alyssia Birchard
This page intentionally left blank
Contents

List of figures and tables x

Foreword xi
Preface xii
Acknowledgements xviii

  1 Sexual addiction 1
  2 Cognitive behavioural therapy and sexual addiction 14
  3 The neuroscience of sexual addiction 31
  4 The therapeutic alliance 43
  5 The primary interventions 54
  6 The principal interventions 62
  7 The ancillary interventions 81
  8 Group work 91
 9 Paraphilias 114
10 Internet pornography addiction 131
11 Trauma and attachment 140
12 Cross addictions and comorbid disorders 150
13 Conclusion 157

Case studies 162

Appendices 174
Bibliography 184
Index 195
Figures and tables

Figures
2.1 Generic formulation 22
2.2 Sex addiction formulation 23
2.3 Two minds 25
2.4 Generic hot cross bun 28
2.5 ‘I might fail’ hot cross bun 29
2.6 ‘I am fed up’ hot cross bun 30
6.1 Trauma egg 71
8.1 Clinical outcomes in routine evaluation 105
8.2 Sexual symptom assessment scale 105
8.3 Sexual compulsivity scale 106
8.4 Sexual addiction outcomes in routine evaluation 106
8.5 Composite sexual addiction recovery scores 107
A.1 Cycle of addiction 177
A.2 Descriptive statistics 180

Tables
8.1 The primary treatment programme 97
8.2 The schedule of the women’s groups 102
Foreword

In his new book, CBT for Compulsive Sexual Behaviour: A guide for professionals,
Dr Thaddeus Birchard captures the essence of effective assessment, diagnosis and
treatment of sexually compulsive disorders in the twenty-first century. Although
the field of sexual addiction treatment is a relatively new and emerging one, indi-
viduals who currently present for treatment do so with a very different clinical
presentation from those who sought clinical intervention 20 years ago. The vast
capability of the internet continues to make our world increasingly smaller, and
contributes to those who suffer from sexual addiction having much greater access
to material that has only led them to become more captive.
Dr Birchard paints a very clear picture of sexual addiction as a disorder, cou-
pled with the neuroscientific processes that make the clinical presentation so dif-
ficult to break out of. Focus is given to the aetiology of the disorder and the role
of trauma and attachment failure in its development. He also addresses paraphilia
disorders and internet pornography, and how they sometimes fuel and are fuelled
by the addiction itself.
Ultimately, he addresses sound diagnostic principles coupled with effective
interventions that, if properly applied by the skilled clinician, will help to bring
relief to those who suffer from this illness and desire treatment. Cognitive Behav-
ioural Therapy for Compulsive Sexual Disorders: A guide for professionals will
prove to be a valuable resource to clinicians of all skill levels who are in the field
of treating sexually compulsive disorders.
Dr Matthew Hedelius
Director, Comprehensive Treatment Clinic, Logan, Utah
Preface

Introduction
This book is the product of two things: the outward journey and the inward. It is
a combination of the extrinsic and the intrinsic, the visible and the invisible, the
external and the internal. It is a fusion of these things, a composite of academic
research, clinical and pastoral care. Underneath this external journey there is a
more complicated inner journey. I will begin by writing about the outward and
then write about the inner.

The outer story

I was in pastoral ministry for many years. Most of the time was spent in a parish
in the West End of London. I had been ordained when I was 22 years old and had
served in parishes in Plymouth, Southend-on-Sea and in the East End. I felt I had
to do something else before the end. Psychotherapy seemed an obvious next, and
final, step. It fitted with a tradition of pastoral care. It also dealt with the same
issues as the faith community: meaning, purpose, suffering and transformation. I
had been drawn to Christianity, not so much by what it said about God, but what
it said about humanity. I was interested in individual and societal transformation,
even transfiguration. It came to pass that I left the parish after 21 years to set up
the Marylebone Centre for Psychological Therapies.
Before this transition, I had completed an MSc in psychosexual therapy at Lon-
don South Bank University and the Whittington Hospital. This was put together
by the redoubtable Judi Keshet-Orr. It was followed by accreditation with the
College of Sexual and Relationship Therapists and registration with the United
Kingdom Council for Psychotherapy. I went on to study for a doctorate in psycho-
therapy at the Metanoia Institute and Middlesex University. My dissertation was
on the diagnosis and treatment of hypersexual disorders. Because psychosexual
training was about a subject and not a modality, I trained as a cognitive behav-
ioural therapist and was accredited by the British Association for Behavioural and
Cognitive Psychotherapies. I then founded the Association for the Treatment of
 Preface xiii

Sexual Addiction and Compulsivity, an organisation to train and accredit ­people

to work with men and women with addictive compulsive patterns of sexual
behaviour.
The Marylebone Centre for Psychological Therapies focuses on four areas of
therapeutic work: marriage and relationships, psychogenic sexual disorders, sex-
ual addiction and a number of disorders treated under cognitive behavioural pro-
tocols: depression, obsessive compulsive disorder, anxiety disorders and trauma.
We developed the first United Kingdom group treatment programme for men
with sexual addiction. This treatment programme, and the subsequent training
extended to other therapists, has been the foundation for all further work on sexual
addiction in the United Kingdom. As far as I know, all the treatment programmes
operating in this country are based on the original model that we put together in
2000. This was based on a non-residential programme developed by the late Al
Cooper. I had correspondence with him and he encouraged us to use his base for
our base. There was much revision to make it compatible with British culture and
it has since, at least by us, been adapted and extended in scope and content over
the years. We now run a three-part group treatment programme. The first part
involves all the major interventions for addictive sexual behaviour; the second
part uses art therapy to further the themes of recovery; and the third part uses
straightforward cognitive behavioural exercises for the restoration of self-esteem.
I say ‘restoration’ but for many it is building self-esteem for the first time. This
three-part programme lasts 36 weeks and is followed by a rolling aftercare pro-
gramme. To date, we have run over 60 treatment groups.
We were also the first to initiate a women’s programme to meet the needs
of female partners. The design of this group was first created and developed by
Joy Rosendale, an associate of the Marylebone Centre. We were concerned that
women who were traumatised by the revelations of male sexual addiction were
receiving no help. Their needs were not met. It was clear that, while the men
were recovering from sexual addiction, the women were sitting at home without
help. Having lost their partners to sexual addiction, they lost them to addiction
recovery. The formation of these groups was a way of redressing this balance and
helping women deal with what most experienced as severe trauma. The person
who had been considered a ‘safe haven’ proved not to be a safe haven after all. I
pay tribute to Joy Rosendale whose contributions to our centre have been beyond
substantial.
All this work has been accompanied by a certain amount of direct and indirect
research. In 1998, I did a research project on the clergy and sexual misconduct
(Birchard 1998). This was a combination of interviews with professionals, focus
groups and a qualitative and quantitative random survey of serving clergy in the
Church of England. This remains the only United Kingdom research done on
this subject. We found that the clergy have higher rates of sexual misconduct
than those in other caring professions. This was matched by results reported by
a number of American researchers (Fortune 1989; Loftus 1994; Moeller 1995;
xiv Preface

Sipe 1995). I then undertook another direct research project on the presentation
of sexual addiction to psychosexual therapists in the United Kingdom (Birchard
2004). I have also published a small number of articles on religion, sexuality and
the paraphilias (Birchard 2011).
Finally, we have tried to blend a tradition of pastoral care with the therapeutic
frame. We are less scrupulous about the frame than would be normal for other
psychotherapeutic modalities. For example, I give out my personal mobile num-
ber. We are flexible about appointment times and we will often see people at
short notice. We sometimes see people individually and at the same time work
with them in a group. We also engage in email correspondence and text messages
with our patients. In addiction recovery work, there is often more self-disclosure
than would be normal in other therapeutic approaches. This self-disclosure must
be done prudently, for the benefit of the patient and not as an indulgence for the
therapist. We regard these adjustments as enlargements of the frame rather than
disruptions to it.
The Marylebone Centre started with me as sole practitioner. We now have a
psychiatrist, an existential psychotherapist, a forensic specialist, an integrative psy-
chotherapist, a psychoanalytic psychotherapist formerly from the Portman Clinic, a
specialist in eye movement desensitization and reprocessing (EMDR) and a sexual
health nurse. The clinic is located in Marylebone Lane in central London.

The inner story

The previous story is the outer story. There is a more complex inner story. I was
invited to a conference in the United States, entitled ‘Healing addictive compul-
sive disorders’. This was a revelation. I became aware that I was an addict. I was
using sex, food, alcohol and religion as my addictive substances and behaviours.
Furthermore, I came to understand that my addictions were attempts to manage
the intolerable ‘burden of selfhood’ (Baumeister 1991: title page). My addictions
grew out of a sense of self that was both unacceptable and painfully experienced. I
began to know what was wrong and so the repair work began. The repair involved
psychotherapy, Twelve Step (90 days, 90 meetings), co-sponsorship and time
spent in treatment at the Meadows in Arizona. In 1988, I was a founder member
of the first Sex Addicts Anonymous meeting in London. I write all this because
my understanding of addiction is not just based on academic interest. It is based
on a personal experience of the nature of the addictive process.
I retrained as a psychotherapist and left parish ministry to undertake this new
work. My decision to move out of parish ministry and into full-time psychother-
apy has not been about the loss of a vocation but rather the fulfilment of a voca-
tion, unifying, harnessing and gathering together all that has gone before. When I
was inducted to my last parish, I knelt before the Bishop and held the seals of the
induction document as the Bishop said “receive this cure of souls which is both
yours and mine”. Psychotherapy also means ‘cure of souls’. I have not left the
ministry: this is the ministry.
 Preface xv

The story behind the story begins long ago in my family of origin. I was the
child of an unhappy, narcissistically damaged and emotionally needy mother.
She was addicted to nicotine, alcohol and prescription drugs. She lost what little
money we had. Everything was sold. Eventually she was arrested for prostitution.
She was emotionally seductive towards me in childhood and sexually seductive
towards me in adolescence.
By contrast, my father avoided me. I am not sure he was my biological father.
The family was divided but stayed together. I belonged to my mother and my
elder brother belonged to my father, thus depriving me of a father and him of
a mother. My brother became a medical doctor and then a psychiatrist. He was
eventually diagnosed with a bipolar disorder and lost his licence to practice medi-
cine. For a time, he lived on the streets. This promising psychiatrist ended up as a
yard man (not even a gardener) for the town’s medical doctor. He died in poverty.
I write about him to give an indication of the level of disturbance in the family and
the severity of the consequences.
I grew up in New Orleans in the 1950s, an uncoordinated, fat child in a slim
athletic male-dominated culture, poor in a place of competitive affluence and gay
in a violent society that hated and despised gay people. Life was experienced as
fearful and dangerous. I felt myself to be contaminating and loathsome. In con-
trast to the violence all around me, I found in the Church acceptance and refuge. A
vocation to the priesthood offered me a way out. I know now that I sought ordina-
tion to quieten the shame. At the same time, before I knew what addiction was, I
became an addict. I used substances and behaviours to anaesthetise loneliness and
self-contempt. Looking back, there were other symptoms of the damage: a need
to control others to keep myself safe, fear of exposure, a marked tendency to split
and compartmentalise, chronic low self-worth masked by grandiosity, difficulty
in setting functional boundaries or respecting the boundaries of others, cyclical
depression, sexual shame, seductiveness, a need for admiration that could not be
requited, and the capacity to manipulate and cajole. I had never been in a relation-
ship with anyone and had little capacity for intimacy. We all have a past and I
would like to apologise to anyone I dismayed during this part of my life. I was, in
the words of a colleague, “a man more driven than called”.
Alongside addiction recovery, there have been a number of startling unexpected
beneficial side effects. I lost my fear of flying, fear of public speaking, my hypo-
chondria, anorexic/bulimic eating patterns, cyclical depression and indebtedness.
Perhaps most indicative of all was the development of a capacity for ­relatedness,
evidenced by the establishment and maintenance of a first and only committed
relationship. These were the fruits of recovery, not only from addiction but also
from the damage that creates the addictive hunger.

Content
Chapter 1 of this book defines and describes sexual addiction. It contains a brief
overview of the history of the concept. There is a short survey of the most recent
xvi Preface

contributions to the theory of sexual addiction. Sexual addiction is placed in its

medical context. Attention is given to aetiology, the role of shame and the regula-
tion of negative affect states. Counter-arguments and objections are cited.
This is followed by an elucidation of the underlying principles of CBT and its
relevance to working with sexual addiction. After a cursory glance at the history
of behavioural and cognitive therapies, the fundamental tenets of CBT are deline-
ated. Various assessment scales are described. The use of the formulation is given
and the role of cognitive behavioural tools described, including Socratic question-
ing and the downward arrow technique. A variety of behavioural techniques are
outlined.
In order for our therapeutic work to be well grounded, the neuroscience of
addiction is explored. Genetics are discussed. Attention is given to learning and
impaired executive function. There is reference to the brain chemistry of addic-
tion. Pharmacological interventions are assessed. A section is given over to attach-
ment and the role of neuroscience in the relationship between the patient and the
therapist. It concludes with a consideration of the addiction as a temporary escape
from an impaired sense of self.
CBT has not emphasised the therapeutic alliance. The therapeutic relationship
is seen as important but not sufficient to effect change. However, when working
with sexually addicted men, there is an emphasis on the therapeutic relationship.
There is also an introduction to schema therapy in this chapter. Attachment and
erotic transference are discussed.
The discussion on interventions for sexual addiction is divided into three chap-
ters: primary interventions, principal interventions and ancillary interventions.
The primary interventions are teaching units. The principal interventions are out-
lined and explained in detail. The ancillary interventions include sexual health and
relapse prevention.
There is a chapter on group work that includes an examination of the theory
and practice of group psychotherapy (based upon Yalom and Leszcz 2005). The
three-part group treatment programme used in our clinic is explained in detail.
The chapter includes information about our outcome studies. Attention is given to
the Twelve Step programmes.
In our experience, most paraphilic behaviour is driven by addictive processes.
Paraphilic behaviours are listed in the Diagnostic and Statistical Manual of Men-
tal Disorders (DSM-V) and designated ‘disorders’, if they cause wide-ranging
impairments or undue subjective distress (American Psychiatric Association
2013). Aetiology of paraphilic behaviour is considered and, while there are a vari-
ety of opinions, I take the view that the causes always emerge from the develop-
mental history. Consideration is given to treatment with particular reference to
CBT and pharmacological intervention.
There is a chapter on the internet. It highlights the positive contributions of
the internet to stigmatised sexual minorities. Prevalence data are made available.
Because of the rapid expansion of the internet, the statistical information will
inevitably be out of date within days of writing. The internet has an impact on
 Preface xvii

s­exuality. It allows exposure to supernormal stimuli. This chapter explores the

negative impact of internet pornography on male sexuality and provides ideas
to help internet sex addicts to manage and limit their behaviour. Attention is
given to the neuropsychology of internet addiction. A final section of this chapter
researches an interconnection between dissociation and internet overuse.
This is followed by an overview of traumatic attachment. This term is used to
note non-optimal attachment patterns that leave the individual with an inability to
internally regulate their feeling states. These individuals look to substances and
addictive behaviours to self-regulate. The standard treatment for trauma is dis-
cussed. This comprises creating the alliance, establishing safety, teaching ground-
ing techniques, re-telling the trauma with the original affect and the creation of a
coherent narrative. This treatment protocol leads to resolution. Attachment styles
are reviewed and the sequelae of traumatic attachment considered.
The final chapter before the conclusion is on cross addictions and comorbid
disorders. Cross addictions are considered not as just another addiction running
alongside the sexual addiction but rather as a package. Addictions combine in
distinctive ways. The comorbid issues that are presented are the ones most regu-
larly seen in our clinic. These include depression, loneliness, anxiety, boredom
and shame. While loneliness and shame are not ‘disorders’, they are difficult and
unmanageable feeling states that are often anaesthetised by sexual behaviour. For
this reason, I have included them in the section on comorbid disorders.
The concluding chapter considers three interrelated subjects that flow from
work on sexual addiction and CBT. The first is the pathologising of male sexu-
ality. We then consider whether the sexual addiction narrative, as I have put it
forward, is yet another attempt to police the difference between the acceptable
and unacceptable in human sexual behaviours, this time by psychologists and
psychotherapists. Finally, we consider a major paradigm shift in our understand-
ing of addiction, moving from addiction as a word only applying to substances to
a word that applies also to behaviours.
The book ends with a list for further reading and a guide to facilities and organ-
isations that might be helpful to recovering sex addicts or to therapists working
with them. The term ‘acting out’, which is used in this book, is a widely used one
to describe addictive sexual behaviour. Throughout this book, I have used the
male gender in reference to the sex addict. While there are undoubtedly women
who are sexually addicted, they rarely present at our clinic. To work with them
is outside my field of professional expertise and the scope of this book has been
limited to male sex addicts.
Acknowledgements

Particular thanks go to Dr Neema Chudasama, Dr Matthew Hedelius, Dr Dean

Krechevsky, Dr Robin Lawrence, Dr Stirling Moorey and Dr Bhaskar Punukollu.
Thanks to our associates, Sarah Alpert, Victoria Appleyard, Leigh Brown, How-
ard Martin, Joy Rosendale and Alex Smith. Thanks to Pavlo Kanellakis and Geor-
gia Masters. Special thanks to our practice manager, Raj Khera.
I wish to thank Francesca Hall, an art therapist, for designing part of our treat-
ment programme for men with sexually addictive behaviours.
Warm thanks to Wiktor Kumala.
The writing of this book would have been impossible without the help of my
researcher and personal editor, Jo Benfield. Her meticulous attention to detail and
useful advice on the content have been invaluable. I hold her in the highest regard.
In memoriam Giles and Cecilia.
The author and publishers would like to thank the following for granting per-
mission to reproduce material in this work:
Alcoholics Anonymous: the Twelve Steps are reprinted with permission of
Alcoholics Anonymous World Services, Inc. (AAWS). Permission to reprint the
Twelve Steps does not mean that AAWS has reviewed or approved the contents
of this publication, or that AAWS necessarily agrees with the views expressed
herein. Alcoholics Anonymous is a programme of recovery from alcoholism only;
use of the Twelve Steps in connection with programmes and activities that are
patterned on Alcoholics Anonymous but which address other problems, or in any
other non-Alcoholics Anonymous context, does not imply otherwise. In addition,
while Alcoholics Anonymous is a spiritual programme, it is not a religious pro-
gramme. It is not affiliated or allied with any sect, denomination or specific reli-
gious belief.
Every effort has been made to contact copyright holders for their permission
to reprint material in this book. The publishers would be grateful to hear from any
copyright holder who is not acknowledged here, so that they can rectify any errors
or omissions in future editions of the book.
Chapter 1

Sexual addiction

Introduction
The term ‘addiction’ comes from the Latin addicare, which means ‘to be bound
over by judicial decree’. It suggests a loss of will. It describes a state or condition
that seems beyond individual control. There are overtones of slavery to a substance
or a behaviour that is outside volition or personal determination. This chapter will
describe and define sexual addiction. It will outline the historical antecedents and
explore nomenclature. The aetiology of sexual addiction will be considered and
the concept will be located in a variety of contexts. The chapter will examine the
drivers for sexually compulsive behaviour and briefly explore addiction as a means
of affect regulation, as well as considering comorbid conditions. The objections to
the concept of sexual addiction will be considered. The chapter will end with two
illustrative case studies of sexually addicted men. I will use the following terms
interchangeably: sexual addiction, sexual compulsivity, hypersexuality and ‘out of
control’ sexual behaviour. By this use, I attribute no particular preference for one
term over another and no term implies any particular aetiology.

Definitions
Sexual addiction is the label given to a pattern of sexual behaviour that is compul-
sive and preoccupies, that is difficult to stop and stay stopped, and that brings with
it harmful consequences. The behaviour is continued in spite of these harmful
consequences. It is largely used to anaesthetise intolerable affect states. It emerges
from the life story of the addicted individual.
Goodman gives the following definition of sexual addiction: ‘A condition
exists in which the subject engages in some form of sexual behaviour in a pattern
that is characterised by two key features: recurrent failure to control the behaviour
and the continuation of the behaviour despite significant harmful consequences’
(Goodman 1998: 9).
Kingston and Firestone (2008) cite Goodman as writing that the function
of excessive sexual behaviour is to produce pleasure and provide escape from
pain. Carnes and Wilson (2002) propose that a process would be considered an
­addiction when the behaviours fulfil the following three criteria: 1) loss of control
2  Sexual addiction

2) continuation in spite of harmful consequences, and 3) obsession/­preoccupation.

Carnes expands this definition by drawing up what he calls the ‘Ten signs of
sexual addiction’:

  1 A pattern of out-of-control behaviour.

  2 Severe consequences due to sexual behaviour.
  3 Inability to stop despite adverse consequences.
  4 Persistent pursuit of self-destructive or high risk behaviour.
  5 Ongoing desire or effort to limit sexual behaviour.
  6 Sexual obsession and fantasy as a primary coping strategy.
  7 Increasing amounts of sexual experience because the current level of
activity is no longer sufficient.
  8 Severe mood changes around sexual activity.
  9 Inordinate amounts of time spent in obtaining sex, being sexual or recov-
ering from sexual experience.
10 Neglect of important social, occupational or recreational activities
because of sexual behaviour.
(1991: 11–12)

According to Carnes, sexual preoccupation becomes an ‘analgesic fix for the sex
addict’ (1991: 21). He asserts that ‘sex addicts use their sexuality as a medica-
tion for sleep, anxiety, pain and family and life problems’ (1991: 23). This self-
medication view of sexual addiction has also been proposed in other forms by
many researchers from different perspectives (Bader 2008; Fenichel 1946,
reprinted 1996; Kahr 2007; Weisse and Mirin, 1997).
I define sexual addiction as a pattern of sexual behaviour that is made up of
four components:

1 It is experienced as out of control and preoccupying.

2 People try to stop but they cannot remain stopped.
3 The sexual behaviour brings with it harmful consequences.
4 It is primarily used to anaesthetise some negative feeling state.

There is increasing information that some people wander into sexual addiction
by experimentation. They opportunistically look at sexual sites and, by the strong
reinforcement provided by arousal and orgasm, find that they become addicted
(Hall 2013). However, in my clinical experience, I am not persuaded that this
is just a matter of opportunity, but rather a case of opportunity meeting a pre-
existing need.

Descriptive examples
It may be useful to illustrate the concept of sexual addiction with a range of
descriptive examples of the behaviours of clients with whom I have worked on
 Sexual addiction  3

an individual basis and in a group setting. Additional material, in the form of two
case studies, is provided at the end of this chapter to further illustrate the concept
of sexual addiction. In each case, both the patient and I have come to the conclu-
sion that the behaviour fits the description of sexual addiction. The cases cited are
composite examples and do not represent any one patient. In my individual work,
I have witnessed the following:

• A young heterosexual male with a female partner and three children exhibited
‘addictive’ behaviours involving exhibitionist homoerotic masturbation in
showers and changing rooms and other public places.
• A middle-aged married heterosexual male had little control over his use
of internet pornography. He would go online for half an hour and then
compulsively masturbate for much of the night while on the internet.
Sometimes this would go on for several days.
• A young gay man took pictures on his phone, at the gym, of men in the
shower without their permission.
• An extremely able young male medical doctor had ritualised telephone sex
while talking through a fantasy of innocence and seduction. He told me that
he wanted a normal married life and a family.

Each of these patients reported some, or all, of the following harmful conse-
quences: powerlessness, self-contempt, personal danger, health risks, loss of
creative time and career opportunities, financial loss and impaired capacity for
intimate relations with a domestic partner.
Within my group treatment programme, participants have revealed the follow-
ing behaviours: one man having anonymous sex with men in public places, one
masturbating to pornography of women being beaten, another masturbating over a
mixed repertory of images of bondage and domination, two men using sex work-
ers in spite of being committed to fidelity in long-term relationships, and two
others compulsively masturbating over heterosexual pornography. In all but one
case, these men have problems with emotional intimacy and being sexual with
significant others. It is important to emphasise that this is not about heterosexual,
homosexual or solitary behaviours. The issue of concern here is not the type of
behaviour, or the amount of time it consumes, but rather the experience, function
and consequences of that behaviour in the life of the individual.

A historical perspective on sexual addiction

The notion of addiction starts deep in the Judeo-Christian tradition, with the
movement of the Hebrew people out of slavery into the Promised Land. Addic-
tion has overtones of slavery. This theme is taken up in the Christian tradition. In
a chapter referring to slavery, Paul writes: ‘For what I do is not the good I want to
do; no, the evil I do not want to do, this I keep on doing’ (Romans 7:19). This is
the language of addiction.