Sex Addiction

The human brain has a circuitry of nerve cells and their connections that is concerned with feeling pleasure when we do certain activities, like eating, having sex, achieving in sports, studies or work. A neurotransmitter called dopamine is being released at such times, acting on the receptors in the synapses (space between nerve cells) to produce pleasure. This is the reward system of our brain.

Human beings are wired to like pleasure and to avoid pain. For example, six year-old John liked chocolates. His mother encouraged him to finish his homework before watching the children’s TV program by rewarding him with two pieces of chocolates. Since he liked chocolates, John complied. Two years later, John did quite well at school and was especially good in mathematics. One day, his teacher praised him for getting the highest mark in the mathematics test. His friends pat him on the back and the girls looked at him with admiration in their eyes. Ever since that day, John did not need any more rewards from his mother to finish his homework quickly after school. He already had his reward ---- the praise from the teacher and the recognition from his classmates. He continued to work hard at mathematics and excelled in that subject. This being so because researchers found out that the reward system in our brain is also closely linked with the motivation system. Having experienced pleasure, a person is motivated to repeat the activity in order to have more pleasure.

However, alcohol and drugs of abuse like heroin also activate the same reward system, releasing large amounts of dopamine. Besides producing intense pleasure, this large amount of dopamine causes the brain to down regulate the dopamine receptors, i.e. to decrease the number of dopamine receptors. Consequently, the individual requires a larger amount of dopamine to experience the same amount of pleasure. Such substances, therefore, can predispose a person to want more and more of it, gradually resulting in addiction to that particular substance.

Sexual activity also produces pleasure. During orgasm, large amounts of dopamine, serotonin, noradrenaline, oxytocin and endorphins (all neurotransmitters) are being released, bringing feelings of intense pleasure, excitement and control. For some individuals, these feelings can also serve as a means of distraction and emotional escape from the unhappiness and frustrations of life. If the sexual activity is being paired with watching pornography, like when the individual masturbates to online pornography, the intense pleasure of orgasm puts a seal, as it were, onto the sexual activity, predisposing the individual to repeat the coupled behavior again and again, especially in times of stress and frustration. By and by, the individual learns to engage in such activities to avoid stress and emotional discomfort. This is the beginning of a sexual addiction.

So addictions can result from ingesting a particular substance or engaging in a particular behavior that produces intense pleasure, relief of anxiety, or sense of control. Of course, not everyone who drinks alcohol or watches pornography or masturbates will end up in an addiction. It is estimated that about 1 to 2% of the population may be prone to such a condition. Robert, for example, was having problems with his marital relationship because of his sexual addiction. His wife, Helen, told the doctor that they had been married for four years. Robert had never been enthusiastic about sex. Helen attributed this to his long working hours as an accountant. But sex gradually turned from an occasional activity to a scarce one, and the last time they had sex was two years ago. Robert usually returned home at 9 to 10p.m. after work, and then he still had to work in his study till 2 to 3a.m. Naturally he was always too tired for sex.

Helen was very frustrated. She often complained about the emptiness of their marriage and their lack of shared activities and communication. But things did not improve. She suspected that her husband was having an affair. After struggling with her conscience for many days, Helen finally checked Robert’s computer for clues. It so happened that she was a computer expert, and it did not take her long to hit on the password and open the many encrypted files. To her great dismay, she found out that instead of working on clients’ financial matters, Robert had been watching tons and tons of pornography every night. And recently, there were pictures of women whom Robert had cybersex with ---- and all these happened while she herself was feeling lonely and sad in the bedroom next door.

Helen did not want her husband to think that she was a thief, so she waited until 1a.m. that night and walked into the study. Robert was masturbating in front of the computer, and to Helen’s horror, the computer monitor was not showing a pornographic strip but a real, nude woman masturbating in front of the webcam on the other end.

Helen was deeply hurt and felt betrayed. However, Robert blamed Helen for refusing oral sex with him or being reluctant to try new positions in sex. It took many days of reasoning and arguing, with an ultimatum of filing for divorce before Robert finally admitted having the problem of sexual addiction and agreed to go for therapy. He told the doctor that he started reading pornographic magazines and comics when he was sixteen. That was the time when he immigrated to Canada with his mother and younger sister. His English was way below what was expected of a grade 11 student. Besides having to cope with the academic work and culture shock, he had few friends. His mother was too busy coping with her own problems of managing a household without the domestic helpers whom she used to have in Hong Kong. His father stayed in Hong Kong to attend to his profitable business and to support the family. Then a classmate passed around some pornographic magazines, and he was hooked ever since.

After entering university, Robert spent more and more time everyday on pornography. Sometimes masturbation was not enough to satisfy him and he had to visit prostitutes. His problem escalated further after graduation when he was working in an accounting firm. It was actually easier then to access pornographic material because of the sudden boom on the internet. Whenever his job was becoming very complicated and difficult, he had to watch pornography in the office and then go to the men’s room to masturbate. Even after marriage, he would stay behind in the office after work for pornography and masturbation, sometimes visiting prostitutes before going home. Then there would be four to five hours more of pornography and masturbation in his study till the early hours of the next day.

Robert found that he seldom talked to his wife and almost never had any shared activities with her in the weekends because he had to catch up on his sleep. He had to lie to Helen for coming home late and for not going to bed together with her. He was sick of himself and did try to stop this shameful behavior. He tried several times, but the longest time that he could stay away from pornography was four days. He could not sleep and felt so miserable that he just slipped back to his previous behavior. Recently he was on to having cybersex with women whom he met on line. In the past six months, he had twice dated these women and had real sex with them in a hotel.

Robert’s story is a very common one. He manifested a number of the features of sexual addiction, which are:-

1. Obsessive sexual fantasies and preoccupation with sexual activity, spending hours and days fantasizing, planning, pursuing and engaging in it.

2. The person has loss of control over his ability to choose not to engage in such fantasies and behavior.

3. Continuation of the behavior even in the face of adverse consequences, such as loss of job or relationship, poor performance in work or studies, poor self-esteem, financial losses, and infringement of the law etc.

4. Tolerance and escalation of the behavior, meaning the individual has to increase the intensity or frequency of the behavior in order to attain the same amount of pleasure and satisfaction. In time, more and more novelty of the behavior is demanded, so that personal moral codes may be violated, and acts done against the law etc.

5. Stopping the behavior may elicit withdrawal symptoms like feeling depressed, restless, lonely, irritable and discontented.

6. The individual denies that he has a problem. He is out of touch with reality and the costs. He ignores warning signs and would only blame other people or the circumstances for his plight.

In recent years, sexual addiction has been a controversial topic. On the one hand, some experts deny that such a condition exists, stating that it is only a flaw in some people’s personality that they make a choice to behave like this. On the other hand, some celebrities overuse this term to excuse their acts of infidelity and to lessen their responsibility when there are legal issues. The DSM 5 issued in 2013 by the American Association of Psychiatrists does not contain such a diagnostic category, whereas the previous edition, DSM 4, put sexual addiction under the category of “Hypersexuality”. However, to the many therapists who treat such unfortunate and unhappy people, this condition is very real.

The American Society of Addiction Medicine states that, “ Addiction is a primary, chronic disease of the brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors......Addiction also affects neurotransmssion and interaction between ...... structures, such that the memory of previous exposures to rewards (such as food, sex, alcohol and other drugs) leads to a biological and behavioral response to external cues, in turn triggering craving and/or engagement in addictive behaviors.”

Addictive behaviors usually go through a cycle. The cycle begins when situations occur that produce blame, shame, guilt, stress and other strong, negative emotions, and these feelings act as “triggers” to start the behavior. The individual then employs the problematic sexual behavior to bring about a neurobiological state of distraction and emotional escape. He fantasizes about the sexual act, bringing great pleasure to him. Then he will enter the stage of ritualization, in which he exists “in a trance”, planning the whole sexual behavior. Then comes the stage of sexual acting out. After that, he becomes numb, self-justifying and minimizing his behavior. This denial allows him to be emotionally distant from his act and protects him from despair. Finally, reality returns with all the undesirable feelings of despair, anxiety, depression and most of all, shame. However, the individual feels powerless to stop his problematic behavior, and these negative feelings will act as triggers, leading him back to stage one.

Sexual addiction is not the same as having a paraphilia. If a person has recurrent and persistent sexual fantasies relating to high heel shoes and masturbates to such images or fantasies, but has no interest to build an intimate and sexual relatioship with a mature woman, he has a paraphilia. However, there is no sexual addiction if he does not exhibit the characteristics of sexual addiction mentioned above. Sexual addictions can be paraphilic or nonparaphilic.

People who have sexually addictive behavior are unhappy people who live in great shame and who are very preoccupied with sex in their daily lives. They may have a history of emotional and/or sexual abuse in childhood, and are more prone to depression and suicide. The good news is that sexual addiction can be treated.

The first step in treatment is for the individual to admit that he has a problem. It is only then that he can look at his problematic behavior in the right perspective and stop all the strategies that he has used in the past, such as denial, self-justification, minimization and blaming the victim. He has to stop the behavior altogether. Therapy for sexual addiction, however, is not celibacy for life. It is about learning healthy sexuality. Take the example of Robert mentioned earlier. After a sobriety period of three months, during which he has to learn about the normal human sexual response cycle and healthy attitudes of sexual relationship, he can then start to have sexual intimacy with his wife based on love and mutual respect. He has to discard the impersonal sex (and possibly sexual violence) depicted in pornography where women are treated as sexual objects only.

Treatment also includes how to face his own shame and guilt, learning problem solving skills, identifying triggers for the problematic behavior, screening and treating any sexually transmitted infections, treating anxiety and depression if present, as well as resolving issues of childhood trauma. Success in treatment is greatly increased if the partner is supportive and understanding. The partner may also be very traumatized by the discovery of the addiction, and may need to be treated too. The couple may also need treatment to improve their relationship. Relapse prevention is very important and such individuals need to be followed up for some time even after treatment has been successfully completed. Having someone (not the sexual partner) to act as an accountability partner or mentor throughout the treatment period and afterwards will greatly increase the chance of success of treatment and the effectiveness of relapse prevention.

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Dr. Angela Ng

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