A. Tom Horvath, Ph.D., ABPP, Kaushik Misra, Ph.D., Amy K. Epner, Ph.D., and Galen Morgan Cooper, Ph.D. , edited by C. E. Zupanick, Psy.D.
Sexual activity, like alcohol, drugs, and gambling, increases levels of dopamine in the brain. Dopamine is the primary neurotransmitter in the brain's reward system. Because sex is an activity that promotes the survival of the species, the brain rewards this activity with dopamine. Dopamine creates pleasurable feelings. However, the brain's reward system also makes us vulnerable to addiction. People are not addicted to sex. As with all addictions, people become addicted to the brain chemicals released during the substance use or activity (in this case, sex), not the substance or activity itself.
1. Using in larger amounts, or over a longer time, than intended. For example, purchasing more porn, or viewing porn for increasingly longer periods of time, or with greater frequency. 2. Unsuccessful efforts to cut down. For example, someone knows they stay up too late every night watching porn. They know they need to get to bed earlier and try to set a time limit for watching Internet porn. However, they are unsuccessful and therefore cannot meet their needs for adequate rest. 3. A great deal of time is spent in activities necessary to obtain or use. For example, a husband comes home late every night because he stops at a strip joint and masturbates afterwards. 4. Cravings such that much of the day is spent fantasizing about, and anticipating the next opportunity for sexual activity.
5. Use interferes with the ability to fulfill important responsibilities such as partner, parent, and employee. For example, lying to one's partner about where they have been; masturbating at work while on company time; coming in late to work because of staying up late to watch porn; losing a job because of inappropriate sexual behavior in the workplace. 6. Continued use despite the harm caused to social or personal relationships. For example, frequent arguments with a spouse about failing to come home at a reasonable time, or arguments about excessive pay-per-view charges on television bill due to porn, 7. Important social and recreational activities are given up or reduced. For example, not getting home before children go to bed because of hiring sex trade workers, or giving up regular basketball games with friends so that the time can now be spent at the strip club.
8. Using in situations that are dangerous. For example, a woman works head in a dangerous section of town as a sex trade worker, having multiple sex partners without practicing safe sex because her customers don't want to use condoms. Another example is a person who engages in dangerous sex practices such as autoerotic asphyxiation. 9. Continued use despite physical or psychological problems caused by use. For instance, it is quite common for someone be unable to achieve erection or arousal with real partners due to excessive porn use. As a result, they now take medication (e.g., Viagra®) to achieve an erection with their partner despite a heart condition that makes the use of this drug dangerous.
Sexual addiction also resembles the compulsive quality of many addictions. "Compulsive sexual behavior" describes acting on sexual impulses, without regard to consequences. This compulsive quality results from a need to reduce the tension of craving.
Risk factors for developing a sex addiction include being molested as a child; having bipolar disorder; and distress about one's sexual orientation.
The DSM-5 does not yet recognize sexual addiction as a distinct mental disorder. Professionals often use "Other specified sexual dysfunction." However, this diagnostic label is inaccurate because sexual addiction is not the same as sexual dysfunction. The most accurate label would be other specified disruptive, impulse-control disorder.
The possibility of repeated involvement with sex, to the detriment of other aspects of life, seems quite possible. What is confusing about "sex addiction" is that it may include behaviors that many people would not consider especially sexual or enjoyable. The pleasures of addicted sexual activity may also be short-lived. As momentary pleasure subsides, the pursuit begins again. This is similar to the pattern seen in substance addictions. Pleasure eventually gives way to compulsions in an effort to reduce the tension associated with cravings.
Some people enjoy sexual activities that are not considered average or ordinary. This does not necessarily indicate sexual addiction. For instance, sexual activity may involve multiple partners or just one. There are also people who consensually engage in polyamory. Polyamory refers to involvement with two or more partners (at the same time, or at different times). While these sexual behaviors may not follow cultural norms, they do not in themselves indicate an addiction. Conversely, there are many people who claim to be polyamorous, who meet the criteria for sexual addiction.
Likewise, a high degree of interest or enjoyment of sex doesn't necessarily indicate sexual addiction. There is quite a lot of variance among people with respect to sexual interest and appetite. Sexual activity resembles addiction when it becomes the sole source of pleasure in life, or replaces other healthy interests (work, relationships, recreation, etc.).
There may be many forms of sexual addiction. This is similar to substances addictions. There are different substances that can become addictive. The sexual activity may include things we don't ordinarily associate with sexuality. This may include things like dominance, control, or abuse of a partner. The activity may involve other people directly. It might also be a solo activity. If partners are involved, those partners may be sexually addicted themselves. On the other hand, these partners may have a healthy sexuality.
Locating sexual partners, while concealing the addictive nature of sexual involvement, may require significant deception. It also reflects a degree of predatory behavior. Sexual activity might include high levels of fantasy, which may be more important than the activity itself. There may be a form of "keeping score" about the number of sexual conquests. Sexual activities may be limited to a very narrow range of activities. These activities can interfere with other more wholesome enjoyment of sex. For instance, heavy users of pornography, coupled with masturbation, may be unable to achieve an erection or orgasm with a partner. The collection of sexual paraphernalia, clothing or pornography can be extremely costly and secretive. This is similar to the expense of obtaining many drugs. Sexual activity may be pursued in a purposeful, goal-oriented manner; e.g., going out to clubs during specific nights to pick up partners. Alternatively, it may be more impulsive; e.g., "cruising" whenever sexual cravings become strong.
Sexual addiction is often accompanied by shame and secrecy. This makes research difficult. Whatever the research reveals, it is not hard to imagine a person whose life is out of balance due to sexual pursuits. The pleasure of the activity lasts only a little while. Then, more activity is sought. The activity does not foster healthy human relationships. Rather, it replaces such relationships, or destroys them. Like all addictions, the negative consequences build up over time. These may include infections; debt; legal troubles; or impaired health (from lack of sleep, poor self-care, being beaten up); loss of important relationships; loss of job, etc.