HANDBOOK OF SEXUAL and GENDER IDENTITY Disorders
DAVID L. ROWLAND
John Wiley & Sons, Inc.
Copyright © 2008 by John Wiley & Sons, Inc.
Matt O’Brien, Liam E. Marshall,
and W. L. Marshall
Sexual addiction has been described as a sexual desire that diminishes the capacity or wish to control sexual behaviors that persist despite significant harmful consequences (Carnes, 1983, 1989; Goodman, 1998). However, controversy surrounds the use of the term sexual addiction as the single descriptor for a cluster of
behaviors associated with problematic sexual behavior. Other authors, for example, have used other terms to describe similar symptoms, and the specific terminology appears to depend on personal preference and reflect preferred treatment methodologies (see Sidebar 19.1). Attempts to reach consensus among sexual ddiction researchers on the classification of sexual addiction are ongoing. To date, the main descriptors used appear to be describing a broadly similar cluster of behaviors, yet to reflect preferred treatment methodologies. These descriptors include: sexually impulsive (Barth & Kinder, 1987), sexually compulsive (Coleman, 1987), hypersexual (Kafka, 1997; Kafka & Hennen, 1999), or sexually excessive (Manley & Koehler, 2001). Still others see these behaviors as variants of obsessive-compulsive disorder (Coleman, 1990; Leedes, 2001). Despite the difference in terminology, all describe the essential sexual behavior problems referred to in Carnes’s (1983) conceptualization of sexual addiction: abrogation of control and persistence of behavior, despite harm. “Sexual addicts” view their problematic behavior as involving high rates of overt sexual contacts, excessive masturbation, or habitual use of the Internet to access sexual sites including pornography.
Terminology and Classification of Sexual Addiction
The construct of sexual addiction first appeared in the Diagnostic and Statistical Manual of Mental Disorders, third edition, revision (DSM-IIIR; American Psychiatric Association, 1987); however, it was referred to under “Sexual Disorder Not Otherwise Specified” as an example of problematic sexual behavior. Under section 320.90, DSM-III-R describes one instance of a sexual disorder not otherwise specified as “distress about a pattern of repeated sexual conquests or other forms of nonparaphilic sexual addiction, involving a succession of people who exist only as things to be used” (p. 296). No specific criteria are given for diagnosing sexual addiction in DSM III-R, nor have subsequent editions made any further or expanded reference to sexual addiction. This static description reflects not only the fact of limited empirical research, but also a conflicted political climate surrounding sexual issues (Smith, 1994). Some attempt has been made to reach consensus about descriptions among sexual addiction researchers and theorists (American Foundation for Addiction Research [AFAR], 2001) on the classification of sexual addiction. This effort led to a research project intended to develop both a standardized measure to assess the construct and to provide further information on its classification. This project, however, is still in process.
Sexual Addiction in Sexual Offenders
In our treatment programs in two Canadian federal prisons, a number of sexual offenders exhibit behaviors similar to the features described by Carnes (1983, 1989) as indicative of sexual addiction. For example, some offenders indicate they are so preoccupied with sexual thoughts that they have problems interacting appropriately with prison staff. Or they disclose being bothered by inappropriate sexual fantasies or appear to enjoy listening to the offence details of other group participants, even after receiving feedback indicating the inappropriateness of this behavior. Some sexual offender clients report having attended a community sexual addiction program.
Through work in our programs, we have found features of sexual addiction that might be relevant to the treatment of sexual offenders, such as the lack of desire, or the inability to control sexual behavior, and the persistence of these behaviors despite negative consequences, both for the offender and even more importantly, for victims. As a result, in 1997, our team began a research program to examine the features and relevance of a sexual addiction diagnosis in such offenders. The following section presents our research on sexual addiction in incarcerated sexual offenders and socioeconomically matched community comparison groups (L. E. Marshall & Marshall, 1998, 2001, in press; L. E. Marshall, Marshall, & Moulden, 2000; L. E. Marshall, Moulden, Serran, & Marshall, 2004).
We present the findings in the following order: first, the psychometric properties of the Sexual Addiction Screening Test (SAST; Carnes, 1989), including the underlying factor structure; the observed incidence of sexual addiction in incarcerated sexual offenders and in a community comparison group; the comorbidity of sexual addiction with other addictions; the relationship between sexual addiction and clients’ history of sexual outlets, as well as the inclination to use sex as a coping strategy; and finally, the possible relationship between psychopathy and sexual addiction. Unless otherwise stated, the information reported is based on the responses of the sexual offenders in our research program.
Measure of Sexual Addiction
The SAST (Carnes, 1989) has been used to measure sexual addiction in our research. In that research (L. E. Marshall & Marshall, 2001; in press; L. E. Marshall, Marshall, & Moulden, 2000), the SAST demonstrated good internal consistency, with alpha coefficients ranging from .89 to .93. We subjected the SAST to both an exploratory factor analysis, using principal axis factoring, and then a confirmatory factor analysis using the maximum likelihood method with promax rotation. Three-, two-, and one-factor solutions were tested for improvement of fit using Root Mean Square Error of Approximation (RMSEA; Steiger & Lind, 1980) and the Proportional Reduction in Error (PRE) method. These analyses revealed a one factor solution as the most satisfactory representation of our data, accounting for 39% of the variance in SAST scores. We concluded that the SAST measures a single latent factor that Carnes (1989) calls “sexual addiction” (but that might be described by any number of the other terms listed earlier). Consequently, any relationships found in our research ought to be indicative of sexual addiction as well as its correlates. Carnes (1989) reports that scores on the SAST do not predict dangerousness, or the consequences for either the addict or others. As a result, any over-representation of sexual addicts among sexual offenders will be a function of their responses to the SAST and not a result of their offending behavior.
Prevalence of Sexual Addiction
Based on clinical work with these problems, Carnes (1989) estimated the prevalence of sexual addiction in a middle-class community to be between 3% and 6%. Regrettably, little research has addressed important questions about the prevalence rates of sexual addiction, either in the general community or in special populations. In their study on sexual addiction using the Sexual Dependency Inventory-Revised (SDI-R), Delmonico, Bubenzer, and West (1998) reported that 33 (19.4%) of 170 respondents were sexually addicted. This study included self-identified sexual addicts (N = 73, 43%), sexual offenders (N = 55, 32%), and a comparison group that was identified neither as sexual offenders nor sexual addicts (N = 42, 25%). The specific distribution of sexual addicts within each of the three groups was unfortunately not reported. However, fewer subjects (19.4%) were classified as sexual addicts by the SDI-R than actually self-reported being a sexual addict (43%), indicating disparity between the assessment tool and self-report. This finding reinforced our decision to use the SAST rather than the SDI as the measure of sexual addiction in our research.
In our studies, matched community samples reported significantly lower rates of sexual addiction (12% to 15%) than did samples of sexual offenders (35% to 43%). Clearly then, the behaviors described in the SAST present a greater problem for incarcerated sexual offenders than for nonoffenders (see Sidebar 19.2). Another interesting feature about these findings was the higher rate of sexual addiction in our nonoffender, lower-socioeconomic comparison group relative to the rate of middle-class, nonoffenders estimated by Carnes. It is unknown whether this reflects a socioeconomic cohort difference or an underestimate by Carnes.
Sexual Addiction Prevalence and Comorbidity
Incarcerated sexual offenders reported higher rates of sexual addiction (35% to 43%) than did matched community controls (12% to Sexual Addiction 591 15%) as measured using the Sexual Addiction Screening Test (SAST; Carnes, 1989).
Carnes (1989) hypothesized that sexual addiction would be comorbid with other addictive behaviors. Schneider and Schneider (1991) did find comorbidity, with sexual addicts at greater risk for pathological gambling and eating disorders. Our studies, however, did not support comorbidity of sexual addiction with either drug or alcohol problems. Measures of alcohol (Michigan Alcoholism Screening Test [MAST], Selzer, 1971) and drug (Drug Abuse Screening Test [DAST], Skinner, 1982, 1998) problems were highly correlated with each other but not significantly related to sexual addiction. This finding was particularly surprising since other researchers have reported greater alcohol problems in sexual offenders than either nonsexual offenders or community comparison groups (Abracen, Looman, & Anderson, 2000; Looman, Abracen, DiFazio, & Maillet, 2004). In our studies, community respondents reported greater problems with nonalcohol drugs than did incarcerated sexual offenders, a finding supported by other research (Looman et al., 2004) in which sexual offenders had fewer problems with such drugs than nonsexual offender groups.
Sexual Behavior of Sexual Addicts
It is possible that sexual addicts, described as unwilling or unable to control their sexual behavior, engage in a higher frequency and diversity of sexual behaviors than nonaddicts. Yet, no significant difference between sexual addicts and nonaddicts in the age of onset of sexual activity or in the frequency or diversity of sexual behaviors
was found (see Sidebar 19.3). Although sexual addicts report an inability to control their sexual desires, their overt sexual behavior does not significantly differ from that of nonaddicts, suggesting that although sexual addicts may be bothered by fantasies and urges, this strong sexual desire does not necessarily translate into overt sexual acts. Among sexually addicted sexual offenders, these unresolved fantasies and urges have led to attempts to meet sexual needs in inappropriate ways. This interpretation is supported by significant differences in self-reported sexual urges between sexual offending sexual addicts and sexual offending nonaddicts. Although sexual offending sexual addicts were more likely to report unconventional sexual thoughts, fantasies, and urges, they were no more likely to report engaging in these behaviors. In fact, sexual offending sexual addicts were less likely to engage in conventional sex with a partner, but more likely to masturbate to fantasies of unconventional sex than sexual offending nonaddicts. Thus, the problem for those sexual addicts who become sexual offenders is their withdrawal from appropriate sexual relationships and their retreat into deviant sexual fantasies which, ultimately, is expressed in an inappropriate way. Research on sexual offenders has shown an increase in deviant fantasizing when they are suffering from distress arising from various sources (Looman, 1995; McKibben, Proulx, & Lusignan, 1994; Proulx, McKibben, & Lusignan, 1996). It may be that a number of sexual offenders fantasize about previous sexual behaviors when under duress and, as a result, become so sexually preoccupied as to reach the threshold for sexual addiction.
Sexual Addiction as Coping
No significant differences between sexual addicts and nonaddicts were found in the age of onset of sexual activity, or in the frequency or diversity of sexual behaviors. Sexual addicts may be bothered by fantasies and urges, but this increased sexual desire does not necessarily translate into increased overt sexual acts.
Sexual offending sexual addicts were more likely to self-report using sex as a coping strategy than were sexual offending nonaddicts, but no relationship between sexual addiction and psychopathology was apparent.
Sexual Addiction and Using Sexual Activity to Cope
Sexual activity frequently functions as a coping strategy for sexual offenders (Cortoni & Marshall, 2001), that is, sexual offenders will use sexual activity of various kinds (both appropriate and deviant) as a way to cope with stress (see Sidebar 19.3). This finding matches research (Looman, 1995; McKibben, Proulx, & Lusignan, 1994; Proulx, McKibben, & Lusignan, 1996) demonstrating that sexual offenders, when in a negative mood, are more likely to engage in deviant sexual fantasizing. In our research, sexual offending sexual addicts were more likely to report using sex as a coping strategy than were sexual offending nonaddicts.
Sexual Addiction and Psychopathy
The issue of comorbid psychopathy is relevant to sexual offenders and thus has been widely examined. Based on Hare’s (1991) Psychopathy Checklist-Revised (PCL-R), 7.8% of incarcerated sexual offenders meet criteria for psychopathy (Serin, personal communication, September 2006). Thus, given the high rates of sexual addiction in sexual offenders, we might expect correlations between scores on the PCL-R and measures of sexual addiction. Specifically, a number of aspects of psychopathy may be related to sexual addiction: failure to accept responsibility for one’s own actions, impulsivity, and poor behavioral control. However, our research failed to find a relationship between sexual addiction and any of these variables (L. E. Marshall, Moulden, Serran, & Marshall, 2004). Higher levels of psychopathy were related to a higher number of orgasms per week, greater engagement in unconventional sex, and lower resistance toward engaging in inappropriate sex. However none of these features was specifically related to the measures of sexual addiction. Thus, from our limited research on incarcerated sexual offenders, no significant overlap occurs between sexual addiction and psychopathy.
The results of our research with sexual offenders suggest that sexual addiction is a significant problem for incarcerated sexual offenders: more than one-third of the sexual offenders in our studies could be classified as sexual addicts. Although a central feature of the use of the term sexual addiction is the expected presence of comorbid addictions, our research found no support for this hypothesis with respect to alcohol or drug addiction. Nor were sexual addicts found to have more overt sexual behavior problems than nonaddicts. However, they were bothered by a greater number of sexual thoughts, urges, and fantasies.
In a factor analysis of the sexual addiction measure (SAST), items loading most heavily on the underlying single factor were those related to sexual thoughts, in particular to feelings of shame and guilt about sexual behavior. This finding suggests that incarcerated sexual offending sexual addicts may have difficulties regarding the interpretation of their sexual desires: the more they try not to think about sex, the more intrusive such thoughts become (W. L. Marshall & Langton, 2004); and if they act on these thoughts when in a vulnerable state (see W. L. Marshall & Marshall, 2000, for a description of vulnerability in sexual offenders) they interpret their behavior as being out of their control both to rationalize and to explain it.
Online Sexual Behavior Problems
Easily available pornography on the Internet appears to have brought problems for some people. A number of our sexual offender clients have been incarcerated because they accessed illegal material online. Others have problems functioning due to their excessive use of the Internet for sexual purposes. Such clients may chat or engage in sexual activities online with others while essentially ignoring people in their immediate environment or neglecting their responsibilities, thereby disrupting key supportive relationships. The most common time for accessing the Internet for sexual purposes is between 9 a.m. and 5 p.m., or work time (Carnes, 2001; Cooper, Griffin-Shelley, Delmonico, & Mathy, 2001). Such behaviors may cause problems at work for these individuals, including the possibility of losing their jobs.
Sex has been one of the biggest factors in the development of, interest in, and activity on the Internet (Cooper, 1997; Cooper, Boies, Maheu, & Greenfield, 1999), to the extent that an estimated 20% of Internet users engage in some form of online sexual activity (Cooper, Delmonico, & Burg, 2000). According to Carr (2000), this number is rapidly increasing, not surprisingly, given that sexuality has been a significant financial engine driving the growth of the Internet since its inception (Hapgood, 1996; Stefanac, 1993). In fact, Sprenger (1999) suggests that 70% of money spent online is related to sexual pursuits. Sex, combined with the anonymity, peed, and capabilities of the Internet, has produced an effect so dramatic that some researchers claim it is heralding the next “sexual revolution” (Cooper, Boies, et al., 1999). Figures taken from www.sexual-addict.com estimate some 4.2 million pornographic web sites (about 12% of the total number) and 68 million daily pornographic search engine requests (about 25% of the total). As such, the Internet presents an unprecedented opportunity for individuals to have anonymous, cost-effective, and unfettered access to an essentially unlimited range of sexual stimuli. And many are taking advantage of this opportunity.
Cooper and his colleagues (Cooper, Boies, et al., 1999; Cooper, Scherer, Boies, & Gordon, 1999) suggest that despite the large number of people engaging in online sexual activity, the majority who visit sexual sites on the Internet do so in moderation and do not suffer any negative consequences. In fact, research by Cooper et al. (2000) found that nearly 83% of all users of sexual sites on the Internet reported no difficulties in their life related to their online activities.
The National Council on Sexual Addiction and Compulsivity (NCSAC, 2000) claims two million Internet users are sexually addicted, presumably a relatively small percentage of those who use the Internet for sexual purposes yet still a large number of people overall. Still, the overall impact of such usage is unclear. Based on he first large-scale study of online sexual activity, only 8.3% of those who used the Internet for sexual purposes 11 hours or more per week experienced difficulties in other areas of their lives (Cooper, Scherer, et al., 1999). Cooper et al. (2000), using an online survey with a measure of compulsivity to better understand those who had used the Internet for sexual purposes, report that 13% of the 9,265 respondents showed signs of moderate to severe problems of distress and compulsivity (see Sidebar 19.4). Carnes (2001) found that about 6% of Internet users have concerns about their use of the Internet for sex. All in all, then it appears that the perceived impact of Internet use for sexual purposes is limited if, at least, one accepts the validity of such self-report measures from self-selected samples of users.
Sexual Addiction and Online Access to Sexual Stimuli
In three separate large-scale studies of online sexual activity, concerns about the impingement of this activity on day-to-day living were expressed by 6% to 13% of respondents.
At least some men who access child pornography sites on the Internet are led there by previous access to other adult-oriented web sites.
Categorization of Online Sexual Behavior Problems
Three subtypes of online sexual compulsivity have been identified through research by Cooper, Griffin-Shelly, et al. (2001). The Depressive type uses Internet sex as an escape from depression; the Stress-Reactive type uses Internet sex as a way of relieving high levels of stress; the Fiction and Fantasy type uses Internet sex as an escape from the daily routine of life in order to fulfill sexual desires.
The behaviors of all three subtypes can rapidly accelerate. Schneider (2000) found that users initially accessed certain types of pornography out of curiosity, sites which quickly became the focus of interest. Clients frequently reported new sexual behaviors or obsessions that became part of their sexual repertoire as a result of accessing online sexual material. Some frequent users of the Internet, becoming desensitized to the material initially accessed, move on to progressively more eccentric, and finally to deviant sexual materials, with some few ultimately seeking out child pornography (Cooper, Golden, & Marshall, 2006). Of course, some Internet users who access child pornography go directly to those sites because they already have such sexual proclivities. In a large sample of men convicted for accessing child pornography on the Internet, all of whom denied throughout the criminal investigation and prosecution process that they had ever sexually touched a child, as many as 70% admitted after almost 2 years in treatment that they had indeed sexually abused children.
Etiology of Online Sexual Behavior Problems
Griffiths (2000), in a study of five cases of excessive sexual computer usage, concluded that use was symptomatic of other problems, and he highlighted the way subjects used the Internet to counteract other deficiencies. For example, those with psychological problems used the Internet to hide behind rather than face their sexual or social conflicts and fears. Higher rates of Internet sexual usage reflect increased levels of depression (Walther, Anderson, & Park, 1994; Young & Rogers, 1998), and Reed (1994) suggests one possible consequence of depression is that certain users become vulnerable to the sexually addictive use of the Internet.
Consequences of Online Sexual Compulsivity
Not only might depression increase vulnerability to sexually addictive use, Schneider (2000) reports that the adverse consequences of online sexual compulsivity include social isolation and depression, decreased job performance or job loss, and abandonment of other social activities. One key consequence reported in Schneider’s study was a loss of interest in “ordinary” sex with their usual partner. Similarly, sexual offending sexual addicts in our research reported masturbating more frequently to unconventional fantasies, as well as engaging less frequently in conventional sex with a partner, than did sexual offenders who were deemed to be nonsexual addicts. One commonly expressed concern is that, as online sexual activity becomes more widespread, even more people will develop unrealistic expectations of their sexual relationships, thereby threatening them. Several authors (Greenfield, 1999; Kraut et al., 1998) have expressed the fear that long-term exposure to sexually explicit material may decrease attraction to one’s primary partner or increase the desire for emotionally uncommitted sexual involvement. The research reviewed by Cooper et al. (2006) supports this possible consequence. In a major study of nearly 1,000 people who engaged compulsively in online sexual activity, Carnes (1999) found that “by far the biggest losses recorded were in the workplace” (p. 87), with work time as the main loss: 86% reported acting out sexually in some way in the workplace and 80% reporting a loss of productivity. In a survey of almost 40,000 adults, 20% reported going online for sexual activities at work (Cooper, Scherer, & Mathy, 2001). Compulsive users with access at work may spend over 2.5 hours per day in online sexual activity during work hours (Cooper, Scherer, et al., 2001), a finding made plausible by Carnes’ (2001) report that 70% of all adult content Internet traffic occurs during the workday.
Relationship to Offending
The need for sexual satiation can, for at least some, become an obsession that may escalate into a criminal act (see Sidebar 19.4). At least some men who access child pornography sites on the Internet are led there by previous access to other adult-oriented web sites (Cooper et al., 2000; Cooper et al., 2006; Cooper, Putnam, Plan-Chon, & Boies, 1999; Greenfield, 1999; Schneider, 2000). Moreover, Zwicke (2000) reports that the distribution of online “child pornography” is rapidly increasing: specifically, Wyre (2003) reported that a half-year period in 2001 saw a 345% increase in sites containing child abusive images on the Internet.
Sexual preoccupation in general has been linked to reoffending (Hanson & Harris, 2000; Hanson & Morton-Bourgon, 2004); in fact, it was not only one of the strongest predictors of sexual offending, but also strongly related to violent reoffending, sexual and nonsexual. These authors suggested that for such offenders, sexual preoccupation may be accompanied by specific problems controlling sexual impulses, a general lack of self control (more common among young people and criminals), and a tendency to overemphasize sex in the pursuit of happiness. For some, sexual activity on the Internet will not constitute illegal behavior but will seriously interfere with pursuing a satisfying lifestyle, and quite possibly relate to future acts of criminality.
Involvement by Women and Children
Some recent findings suggest that women may be well represented among those with online sexual compulsivity (Cooper et al., 2000). According to Nielsen NetRatings, the number of women in Britain downloading Internet pornography has soared 30% to 1.4 million (Downloads of net porn, 2006). Research regarding young people and sexual activity on the Internet is also emerging. As for children, some evidence suggests that 90% of the 8- to 16- year age group have viewed pornography online (Ropelato, 2007), and according to Nielsen NetRatings more than half of all children admit to having viewed adult images “while looking for something else.” The Internet Filter Review authored by Ropelato (2007) also reports that 11 years is the average age of first exposure to Internet pornographic images among users in the United States.
Longo, Brown, and Orcutt (2002) express concern about children’s exposure to large amounts of inappropriate sexual material on the Internet, given that the American Psychological Association has determined that exposure to excessive amounts of television violence has a negative impact on children’s aggressive behaviors. Boies (2002) reports that 3.5% of a sample of college students viewed sexually explicit material online and masturbated to it at least once a day. This finding suggests a potential for compulsivity in this subgroup, although whether this behavior actually leads to sexual offending is unknown.
Treatment of Sexual Addiction
A number of different approaches, both pharmacological and psychological, have been used in attempting to treat those with sexual addiction. For further information on the pharmacological treatment of hypersexuality, see Kafka (1997). To date, the most predominant psychological strategy for treating sexual addictions has been a 12-step approach, which emphasizes the need for the addict to admit to powerlessness over his or her behavior. Further information on this approach may be found in Carnes (1989).
In contrast with the 12-step approach, our cognitive-behavioral treatment requires sexual offender clients to accept at least some degree of responsibility for their behavior. The observed sexual recidivism rate in the 534 sexual offenders we have treated, released for a mean of 5.4 years, is just 3.2%, markedly lower than the rate reported in other studies, 16.8% (see W. L. Marshall, Marshall, Serran, & Fernandez, 2006 for a review of our treatment approach and outcome data). Although not an indicator of a change in clients’ sexual addictive behaviors, but to the extent that these populations show some overlap, the fact that the program has so markedly reduced sexual offending suggests that it may contribute to the amelioration of sexual addiction as well.
Certain aspects of our treatment program may be effective in the treatment of sexual addiction. For example, therapists help clients learn to cope more competently with their problems without resorting only to the use of sex. For the many clients who have attempted to meet their sexual needs in inappropriate ways, therapists in our program help clients explore more suitable means. Focusing on understanding and achieving real intimacy may help those who have withdrawn from appropriate sexual relationships in the past. Therapists lead group discussions and exercises on sex, and on the role of sex in relationships, thus helping those who may have overemphasized sex in the pursuit of happiness. To this end, therapists also present the Good Lives model (Ward, 2002), asking clients to select purposeful and personal goals to help them maintain a satisfying and balanced lifestyle. Given the link between feelings of shame and guilt on the one hand, and sexual behavior and sex-related problems on the other, therapists lead discussions and exercises on normative sexual behaviors and on the restrictions to the enjoyment of these acts such unhelpful feelings can produce. Therapists also help clients deal with feelings of loneliness and low self-esteem in order to help them learn how to alleviate both social and emotional isolation.
This field is clearly young. The growth of the Internet over the past 15 years has required researchers and clinicians to examine new paradigms, but as Cooper (1998) correctly asserts, health professions have been relatively slow to respond to these new developments. Continued research is needed to fully understand, evaluate, and treat those with online sexual behavior problems. Once these problems are better understood, future research should focus on developing reliable and valid protocols for accurate evaluation and effective treatment. Such research is imperative, given that online access to sexually explicit materials in the future will only continue to expand.
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