Sex Addiction Assessment

Marie Wilson, MA and

Patrick J. Carnes, Ph.D., CAS

The following are some of the extreme examples we see today that exemplify the insanity of sexual addiction:

• A woman uses a vibrator so intensely she burns herself and has to go to the emergency room.
• A priest has a thousand-dollar-a-week prostitution habit. His only way to support the habit is to steal from the parish he serves.
• Their children and friends knew, but his wife was in the dark until she discovered three volumes carefully annotating his sexual encounters with fifteen hundred women.
• A sixty-six year old man is arrested for the third time for stealing lingerie.
• A thirty-one year old man, married and the father of three small children, has been having sex with men in "hot johns" since he was seventeen. He got married to stop. He went through treatment for alcoholism to stop. Now he has AIDS. So does his wife. They are both dying.

The signs of addiction. Some would say these cases are matters of sexual excess, bad judgment, or accidents. Others would dismiss them as bizarre or perverted. In reality, they represent a much more serious problem: a life-threatening obsession with sex. Such people are sex addicts. The patterns of their lives signify the presence of an illness we are now beginning to understand.

These cases of sexual addiction all present situations of an obvious loss of control. But many times therapists experience situations that are less clear. For example, the therapist may have little data. Or the addiction may be obscured by convoluted marriages or job situations. Or the addict may simply have dodged successfully all the consequences so far. Also, clients may deliberately deceive the therapist. Sometimes spouses will collude in that deception, although they may still want help desperately.

Sexual Addiction Defined

We are surrounded by the signs of sex addiction yet still resist its reality.
We can accept that people can be sick with alcoholism or can destroy themselves with gambling or food, but not sex. A comparison with other forms of addiction offers a fundamental foundation for understanding the key concepts of this compulsive sexual disorder. An alcoholic or chemically addicted person is said to have a pathological relationship with a mood-altering substance.

The addicted individual’s relationship with the substance becomes primary and, with continued use, impacts the person’s psychological adjustment, economic functioning, and social and family relationships. This relationship between person and substance progresses to the point where alcohol is necessary to feel normal. This progression leads to isolation since the primary relationship is with a substance, not with other people. Distortions in thinking, especially denial become part of how the addict keeps painful feelings and associations related to substance abuse at a distance.
Sexual addiction is similar. Sex addicts use sex in the same way an alcoholic uses alcohol. In other words, sex is used to numb feelings and escape from the painful parts of their lives. The sex addict substitutes a sick relationship for a healthy relationship with others. The sexual experience becomes mood altering and in time becomes central to the sex addict’s life. Leading a fantasy double life is a distortion of reality and separates the individual from those who love and care about them. The fact that the addict has no control over their behavior is a difficult concept for non-addicts to grasp. This is particularly so with regards to sex addiction and in view of the many damaged relationships, ruined marriages, parentless children, and even worse, victims of sexual misconduct or crimes. There is little neutral response to sexual improprieties.
One assumption often made incorrectly, is that addiction to drugs or alcohol decreases inhibition and therefore causes or is substituted for sex addiction. The truth is that alcoholism is a concurrent illness and not the cause of sex addiction. Treatment centers that miss the diagnosis of sex addiction may unintentionally contribute to relapse and to the recidivism factor of alcoholism and drug addiction.

The Making of a Sex Addict

In a study of more than a thousand recovering sex addicts and their partners, research determined that sex addicts tend to come from families where there were addictions of all kinds. For example, mothers (25%), fathers (38%), and siblings (46%) had significant alcohol problems. Mothers (18%), fathers (38%) and siblings (50%) had problems with sexual acting out. Parallel patterns existed with eating disorders, compulsive financial disorders, pathological gambling, and compulsive work. Only 13% of sex addicts reported coming from families with no other addictions.

Family type was also a factor. Sex addicts in this study experienced their families as rigid (77 %), defined as autocratic, dogmatic, and inflexible. Clinically, therefore, sex addicts will have difficulty with limit setting and accountability due to this experience, since accountability means loss of self. For them to comply with such rigidity meant they could not be different in any way. Many sex addicts experienced their families to be disengaged (87%), defined as detached, uninvolved, and emotionally absent. Failure to bond was a norm in these families. So, in part, their addiction stemmed from their search for nurturing without the risk of intimacy or trust. More than 68% of these families of origin were both rigid and disengaged. Therefore, the high probability in treatment is their difficulty with both accountability and trust.

Another major area of impact was the role of child abuse. Addicts reported physical abuse (72%), sexual abuse (81%). and emotional abuse (97%). In addition, the more sexually and physically abused the respondents were as children, the more types of addictions they had as adults. Emotional abuse was a significant factor in addicts who abused children themselves. It is clear that for sex addicts trauma and addiction are inextricably connected.

The Ten Types of Sexual Addiction

In the original research we did for Don’t Call It Love we started with a database of 114 behaviors in which we did a factor analysis. A series of “types” or “constellations” of sexually compulsive behavior emerged in the sex addicts surveyed. Over the years, we have elaborated the ten types as an empirically based model of compulsive sexual behavior. What follows is a review of the ten types.

Fantasy Sex – Notice attractive traits in others and will feel attracted, but they do not move beyond it. There is a safety in staying in the fantasy world as opposed to acting on the fantasy. Romance and sex can flourish when there is no reality testing. The person often becomes lost in sexual obsession and intrigue, including behaviors that support preoccupation.

Masturbation to fantasies is how we learn about our own desire. When masturbation becomes compulsive, we make it a way to escape our loneliness. It is about fear of rejection, fear of reality, and reduction of anxiety. It can also be self indulgent in the sense of seeking comfort as opposed to risking relationship. Many sex addicts find refuge in fantasy sex because other forms of acting out are simply too complicated, too risky, or too much effort. Fantasy sex is a way to disassociate from reality including relationships.

Voyeurism – Voyeurs are also non-participants in the sex game. They move beyond fantasy to searching out sexual objects in the real world. It is normal to enjoy looking at others sexually. When that means looking at people who do not know they are being viewed it becomes problematic. When it is about compulsive pornography use it becomes isolating. Voyeurs also venture into flirtation. Sitting in a strip bar and having someone do a table dance for you focusing on another’s sexual demonstration behavior without the voyeur doing anything. To put it in childhood terms, you show me yours and I’ll watch. Usually voyeurism means objectifying the other person so it is not a personal relationship.

Exhibitionism – Exhibitionism is the “I will show you mine” part. It is pleasurable and normal to have others notice you sexually. With a partner it is a significant part of sex play. Some addicts fixate on just being noticed and have difficulty moving beyond that. Eroticism for them is being looked at. For some it is the power of realizing they have captured the other’s attention. For some it is forcing their sexuality on the other, which is angry and aggressive.

From a relationship perspective it is introducing oneself in an inappropriate way. Or seeking attention from others with no intent of going further, which is to tease. Sometimes it is about the pleasure of breaking the rules. When it is obsessional and compulsive, it is a significant distortion of normal courtship.

Seductive Role Sex – Here relationships are about power and conquest. Flirtation, performance, and romance are the erotic keys for sex addicts in this category. They are hooked on falling in love and winning the attention of the other. Often once they have established that, the sexual interest subsides. While they can quickly gain the confidence of others, and can be intimate in the early discovery, romantic stage, establishing a deeper relationship eludes them. They are on the hunt for another.

Another common scenario is to feel trapped like they cannot be themselves. So they have multiple relationships in which they can be different with different people. They have a hard time being themselves or individuating. Often there is a fear of abandonment so having more than one relationship is a way to prevent the hurt they are sure they will receive. They are crippled in their ability to form lasting bonds and enduring relationships.

Trading Sex – Some sex workers actually do form some attachment for their clients but typically bartering sex for money is devoid of relationship. The goal is to simulate flirtation, demonstration, and romance. What actually happens in most cases is about replication of childhood sexual abuse in which the child gained power in a risky game of being sexual with the caregiver. If a prostitute is a sex addict, meaning that they found sex more pleasurable with clients than in personal relationships and are “hooked on the life,” it represents a significant distortion of normal courtship. Often the money is a sign of having been successful at the sexual “game” and the client can be disregarded except as a repeat customer. Forging significant, enduring bonds or being true to yourself as in individuation is not part of the game.

Intrusive Sex – People who do intrusive sex such as touching people in crowds or making obscene calls are really perverting the touching and foreplay dimensions of courtship. In most cases they are using others for sexual arousal with little chance of being caught. Their behavior represents both intimacy failure and individuation difficulties. In their behavior they do not see themselves as predatory although they are. An implicit anger exists and they “steal” sex because they believe no one would respond as they wish. So the goal is to take it without the other’s knowledge. They become quite expert in their subterfuge.

For example professionals such as physicians, clergy, or attorney’s will look quite compassionate when in fact they use their clients’ vulnerability for their own arousal. Stolen intrusion becomes the obsession. On-going relationship life suffers because of the secret shame.

Paying for Sex – Here sex addicts are willing participants in simulated intimacy. They are focused however on the touching, foreplay, and intercourse dimensions without the hassle of relationship. Frequently they tell themselves it is because of their partner’s inadequacies that they resort to prostitution. Compulsive prostitution is a larger problem but it does reflect relationship failure. Often times the failure is about the sex addict’s inability to communicate feelings to their partner or to be willing to work on their own attractiveness behaviors. For some sex is intimacy – or as close as they will allow themselves to be.

Frequently there is sexual anorexia in that it is difficult to be aroused in the presence of someone for whom you care. Commitment to and renewal of relationships are profoundly undermined by the secret life of this behavior.

Anonymous Sex – By definition, this sexual behavior is not about relationship. You do not have to attract, seduce, trick, or even pay for sex. It is compulsive sex, often in high-risk circumstances with people one does not know. Ironically the sexual anorexia counterpart is often also present with the associated loneliness and isolation. Frequently for sex addicts, part of the high is the risk of unknown persons and situations. In part, that stems from early sexual relationships that were fearful. Having to experience fear in order for arousal or sexual initiation to work fundamentally distorts the courtship process. The safety of enduring bond is never there to allow the deeper, profound risks of being known by another.

Pain Exchange Sex – People who are compulsively into painful, degrading, or dangerous sexual practices such as “blood sports” (creating wounds which bleed as part of sex) or asphyxiation, often have significant distortions of courtship. Specifically touching, foreplay, and intercourse become subordinated to some dramatic story line that usually is a reenactment of a childhood abuse experience. For a woman to be aroused only if a man is hurting her is a distortion of what goes into sexual and relationship health. Enduring relationships are difficult to build given the arousal scenarios embedded in high-risk sex.

Exploitive Sex – To exploit the vulnerable is clearly distorted courtship. With sex offenders who rape there exists deep issues around intimacy and anger. Less obvious are non-violent predators that use seduction, as with children or professional sexual misconduct with clients. In the workplace where there is a differential of power, employees can be exploited.

Assessing Sex Addiction

Criteria for assessing sex addiction closely parallels guidelines for assessing substance abuse, alcoholism, and compulsive gambling. On the basis of research and clinical experience, there are ten signs that indicate the presence of sexual addiction. A minimum of three criteria must be met; however, most addicts have five, and over half, have seven or more.

1. Recurrent failure to resist sexual impulses in order to engage in specific sexual behaviors. Addicts can even see that they are endangering their life and yet they persist in their sexual patterns. Many non-addicts are capable of abusing their sexuality at times, going through periods of sexual excess or making mistakes, but ultimately regaining control. Sex addicts are incapable of permanently making that adjustment by themselves. Addicts will often go to extremes to limit or resist their sexual activity. They make promises to stop and never can. They convince themselves that if they can change some of the external circumstances, this will, in turn, control their behavior. They are unaware that the only way to change their behavior is the desire to change from within, which requires intervention and treatment.
2. Frequently engaging in those behaviors to a greater extent, or over a longer period of time than intended. Frequently sex addicts lose track of time when they are engaged in their addiction. Hours may pass with little recognition of the outside world or other obligations in their lives.
3. Persistent desire or unsuccessful efforts to stop, reduce, or control those behaviors.
   Sex addicts entering treatment have all tried, unsuccessfully, to stop sexual behaviors with a "white knuckling" approach. Since underlying causes of the behaviors are not dealt with, the addict cannot sustain the control and fails, only reinforcing shameful feelings about self and hopelessness.
4. Inordinate amounts of time spent in obtaining sex, being sexual or recovering from sexual experiences. For sex addicts, sexual obsession becomes the organizing principle of daily life. Everything revolves around this. The basics of living such as clothes, food, sleep and work become a lower priority. Most of the addict’s time is devoted to initiating sex, being sexual or dealing with the aftermath. There is an extraordinary amount of time spent on the addiction.

In addition, another source of lost time is the time spent dealing with the consequences. Lies have to be covered. Upset and exploited lovers need to be calmed down. Money shortages have to be faced and diseases dealt with. Outraged spouses, disappointed bosses, neglected children and arresting officials all take time. Further subterfuges are required to prevent more discoveries. Addicts become even more depleted by these problems and then attempt to restore or reward themselves with sexual behavior.

1. Preoccupation with sexual behavior or preparatory activities. Planning, thinking, searching, intriguing, and looking for opportunity becomes a way to get through each day. Sex addicts can easily escape into an altered state simply through obsession and fantasy. For days on end, sex addicts may spend most of their time in a sexual stupor. This becomes a primary tool to help them regulate their emotional life. Sex addicts become dependent upon it to the point that sex is no longer a choice or an option, but rather a coping mechanism that is connected with survival.
2. Frequently engaging in the behavior when expected to fulfill occupational, academic, domestic or social obligations. Family, friends, and work obligations are all subordinated to the pursuit of sex. Promises are made and broken again and again, damaging the trust that others have in the addicted person. Often relationships that have meaning are neglected in favor of less personal ones or relationships that have sexual potential. Pursuit of educational or career opportunities become sidetracked as volition decreases and is substituted for what seems effortless and easy. The addict wants no distractions from the energy required for sexual fantasies and sexual pursuits.
3. Continuation of the behavior despite knowledge of having a persistent or recurrent social, financial, psychological, or physical problem that is caused or exacerbated by the behavior. Despite the multitude of adverse consequences of their addiction, sex addicts simply cannot contain or control their behaviors, except for very brief periods of time. Sex addiction is a pervasive illness that touches every aspect of the addict’s life, creating chaos and causing damage to anything or anyone in its path. The losses associated with sex addiction are accumulative and just increase over time. Sex addicts lose family, friends, financial resources, health, self-esteem and a connection to a Higher Power. They experiences arrests, humiliation, risk discovery and sexually transmitted diseases, yet still persist.

In a survey we found a seemingly unending array of ways that sex addicts harm themselves and others: The majority of sex addicts say they routinely run the risk of venereal disease. Many have lost a partner or spouse and most have experienced severe marital or relationship problems. Some have lost the rights to their children. Women sex addicts report deep grief over abortions and unwanted pregnancies. Some reported losing the opportunity to work in the career of their choice. A majority have routinely pursued activities for which they could be arrested.

1. The need to increase the intensity, frequency, number, or risk level of behaviors in order to achieve the desired effect; or diminished effect with continued behaviors at the same level of intensity, frequency, number, or risk. Often sexual behaviors escalate over time because the sexual fix becomes more difficult to obtain without increasing effort. This is similar to the alcoholic who at one time felt intoxicated with four beers and whose tolerance has increased to needing at least six beers in order to experience the same effects. In sex addiction, an addict may go through periods of excessive control before eventually returning to or going beyond old levels.
2. Giving up or limiting social, occupational, or recreational activities because of the behavior. Any activity that interferes with the sex addict’s pursuit of their addiction is given up in favor of activities that feed the addiction. Remember that the planning, implementation and consequences of the addiction are all very time consuming, forcing the addict to give up other life activities. Even activities that were once a source of pleasure or relaxation such as spending time with friends, exercising, fishing, family functions, etc. are now looked upon as interference with the addiction.
3. Distress, anxiety, restlessness, or irritability if unable to engage in the behavior.
   Sex addicts experience withdrawal from compulsive sexual activities in a similar way that the alcoholic or drug addict experiences withdrawal from chemicals. All compulsive addictive behaviors are mood altering and when mood-altering activities are stopped, there is often an acute, related reaction. No longer able to decrease pain with sex, the addict plunges into despair. Sex addicts report symptoms that absolutely parallel the withdrawal experience of cocaine addiction. Sex addicts have reported these withdrawal symptoms: dizziness, body aches, headaches, sleeplessness, restlessness, anxiety, mood swings, irritability, depression.

Many addicts who have recovered from both a chemical addiction and sex addiction say that recovery from sex addiction was more difficult. They generally agree that while the initial physical symptoms are less severe, the withdrawal experience is more prolonged and more painful.

Collateral Indicators of Sexual Addiction

In addiction, there are 20 collateral indicators, which assist in the assessment of sexual addiction. A minimum of 10 criteria must be met:
1. Patient has severe consequences because of sexual behavior.
2. Patient meets the criteria for depression and it appears related to sexual acting out.
3. Patient meets the criteria for depression and it appears related to sexual aversion.
4. Patient reports history of sexual abuse.
5. Patient reports history of physical abuse.
6. Patient reports emotional abuse.
7. Patient describes sexual life in self-medicating terms (intoxicating, tension-relief, pain-reliever, sleep aid).
8. Patient reports persistent pursuit of high risk or self-destructive behavior.
9. Patient reports sexual arousal for high risk or self-destructive behavior is extremely high compared to safe sexual behavior.
10. Patient meets diagnostic criteria for other addictive disorders.
11. Patient simultaneously uses sexual behavior in concert with other addictions (gambling, eating disorders, substance abuse, alcoholism, compulsive spending) to the extent that desired effect is not achieved without sexual activity and other addiction present.
12. Patient has history of deception around sexual behavior.
13. Patient reports other members of the family are addicts.
14. Patient expresses extreme self-loathing because of sexual behavior.
15. Patient has few intimate relationships that are not sexual.
16. Patient is in crisis because of sexual matters.
17. Patient has history of crisis around sexual matters.
18. Patient experiences anhedonia in the form of diminished pleasure for same experiences.
19. Patient comes from a "rigid" family.
20. Patient comes from a "disengaged" family.

The Sexual Addiction Screening Test (SAST)

A wealth of literature exists on the usefulness of screening instruments to assist in diagnosing alcoholism. Historically, these instruments have proved valuable as adjuncts to the therapist’s assessment process. This kind of tool has been developed for sex addiction, called the Sexual Addiction Screening Test or SAST. Developed in conjunction with hospitals, treatment programs, private therapists, and community groups, the SAST provides a profile of responses which help to discriminate between addictive and non-addictive behavior. To complete the test, patients are asked to answer a total of 25 questions by placing a check in the appropriate yes or no column. The SASTs are available free on Dr. Carnes’ website located at www.sexhelp.com.

The Sexual Dependency Inventory (SDI)

A comprehensive online test is now available that measures all aspects of sexual addiction.  It gives a complete sexual history (without names of course), shows what kinds of things are arousing, what types of behavior are currently being manifested, what makes them appealing, what motivations there are for treatment, what other addictive behaviors are active or at risk, and it shows several measures of how honest the respondent is being with himself and in filling out the test. With a print-out of some 35 pages for the test-taker, it also gives homework assignments to transform the test into a learning experience. This test costs $100, and it can be done anytime by contacting your CSAT counselor, who will be happy to answer further questions about this instrument.

Resources and Guidelines

There are some important guidelines to remember in doing assessments. First, be aware that there are women sex addicts. A tendency exists to see this as only a male problem. For every three male sex addicts, there is one woman. This ratio of men to women is an exact parallel to the gender ratios found in compulsive gambling and alcoholism.
Second, sex addiction is seldom isolated. More that 83 percent of addicts report multiple addictions. The DSM-IV does not include sex addiction under substance-related disorders, but rather in a separate category called Sexual and Gender Identity Disorders. There is however, cause to examine sex addiction from an addiction perspective given that more than 83% of sex addicts report multiple addictions, including chemical dependency (42%), eating disorders (38%), compulsive working (28%), compulsive spending (26%), and compulsive gambling (5%). Studies of alcoholism treatment find sexual compulsion in patients, ranging from 42 to 73 percent.

Third, sex offenders can also be sex addicts. Our data show that serious sex offenses occur in only 13 percent of the cases of the general population of sex addicts. However, a number of studies used sexual addiction criteria to identify sex addicts in groups of sex offenders. The results ranged from 55 percent to 100 percent of the population studied. Often, the compulsive behavior of sex offenders includes non-offending behavior as well.
Fourth, about 72 percent of sex addicts also evidence symptoms of sexual aversion-desire disorder, or as it is sometimes called, “sexual anorexia.” Similar to those with eating disorders, patients will flip from being out of control into a super “in-control” period. Or there will be a binge/purge pattern. Also, it is not unusual to see simultaneous binge/purge, as in a patient who is out of control outside of the marriage and compulsively non-sexual with his or her spouse. There are different criteria for assessing sexual anorexia.
In a recent issue of Sexual Addiction & Compulsivity, David Wines (1997) contributed a study of 57 participants in a Sex Addicts Anonymous group who had been in recovery, on average, two and a half years. In part, stimulated by the Wines study, we started gathering data on patients admitted for inpatient treatment.

Within the first 48 hours of treatment, sex addicts do an assessment with nursing and psychiatry professionals. The attending nurse, the doctor, and the patient discuss each criterion and determine whether the patient’s experiences actually fit the criteria. We then compared our “initial assessment” with the Wines’ “long-term assessment” of individuals with two or more years of recovery. A discrepancy existed between the initial and long-term figures, with the long-term figure always being a larger percentage. The argument can be made that this reflects denial. Addicts in recovery for longer than 2 years will have much more clarity about their illness than those in the initial 48 hours of treatment. Even so, 80 % of those initial assessments yielded at least 3 of the criteria, which is the standard in the DSM-IV for gambling, alcoholism, and substance abuse. Wines found that 94% had at least 5 criteria, and over 50% had at least 7 criteria.

This points, however, to an area of research of strategic importance in the field of sex addiction. If we have accurate descriptors of the patient’s condition, it will help us legitimize the field and the work we do with our clients. Sex addiction has emerged as a clinical entity. With the hard work of many people, this information makes the shadow of sex addiction less elusive now than it was 20 years ago.