Dr. J. Reid Finlayson

Examples of sexual excess or just bad sexual decisions are splashed throughout the media these days with almost daily frequency.

Pro golfer Tiger Woods … would-be president John Edwards … former Tennessee Titan Pacman Jones … and, of course, former members of the U.S. Congress — the toe-tapping Larry Craig and picture happy Anthony Weiner. The point is made without even venturing into the world of rock stars and Hollywood.

Yet, how is the distinction made between willful misbehaving and sexual excess as a result of a mental-health disorder? The answer isn’t an easy one, and that’s evidenced by the fact that even the American Psychiatric Association (APA) can’t settle on a definitive diagnosis. The APA’s Diagnostic and Statistical Manual of Mental Disorders used to include a diagnosis of problematic hypersexuality. Yet the DSM-IV edition, currently in effect, eliminated the diagnosis.

That was a mistake, according to A. J. Reid Finlayson, MD, assistant professor of Psychiatry and Addiction Medicine at Vanderbilt University. “It’s unfortunate because it means that we haven’t been really paying attention to hypersexuality,” he said. He explained that while patients who are uninterested in sex or can’t become aroused are evaluated, diagnosed and treated, options are extremely limited for people for whom sex becomes a harmful compulsion. In fact, Finlayson and two other researchers authored a paper a decade ago supporting “the inclusion of specific diagnostic criteria for problematic hypersexual behavior into the mainstream of clinical psychiatric practice.”

Finlayson went further to categorize sexual compulsive behavior as an addiction, one that can be devastating to the individuals and those who love them. On Aug. 15, the American Society of Addiction Medicine (ASAM) released a new definition of addiction, highlighting that it is “a chronic brain disorder and not simply a behavioral problem involving too much alcohol, drugs, gambling or sex.” It was the first time ASAM took the position that underlying the harmful outward behaviors is the disease of addiction.

“I think that psychiatry is finally catching up. The people who founded Alcoholics Anonymous said it was a chronic, progressive and fatal disease in the ’30s when the program developed. Yet it was 1955 before the AMA recognized it as a disease,” Finlayson said. And he likened sexual addiction to any other addiction, complete with the need to keep the behavior under wraps. Just like other addicts, sex addicts develop a tolerance for certain behaviors and require more and more excitement for the same thrill. They also suffer withdrawal. “It may not be as severe as someone going through DTs, but it’s definitely a withdrawal phenomenon,” Finlayson said.

Nashville psychiatrist Thomas W. Campbell, MD, treats sex addicts in his private practice. “Sexual addiction is really not about sex, in my opinion,” Campbell said. “It’s an attempt to ward off some kind of underlying emotion like anxiety, emptiness or traumatic experiences. It’s not about sex as an expression of love or a desire to be physically close to someone you care about. It’s in service of other things.” That’s what separates a sexual addict from someone who enjoys occasional “kinky fun” with an equally willing partner, he explained.

Sexual addiction may manifest itself in sadistic and masochistic behaviors. “You’ll see someone with a very rigid script that requires another person to be involved,” Campbell said. “But to make it exciting, the script has to be followed in a particular way and have a particular outcome for it to be gratifying.” A telltale sign of sexual addiction is that it “interferes with someone’s ability to have a reciprocal relationship that involves the other person,” he said.

The sex addict’s partner may eventually suffer as well, Finlayson noted. He or she may feel “devalued,” lose self-esteem and develop compulsive sexual habits of his or her own. The damage also extends to the addict’s family and friends. In fact, because of sexual addiction, families dissolve and careers crumble, he said.

Research has found that sex addicts often come from dysfunctional families and are more likely than non-sex addicts to have been abused. One study found that 82 percent of sex addicts reported being sexually abused as children.

Campbell said this correlates with his clinical experience and patients’ desires to “eroticize the trauma. … You try to convert passive into active. You’re not the one being abused; you’re the one who’s in control, making things happen. You’re the seducer. Underlying this is an attempt to master a very painful and traumatic experience by reconstructing the original situation and flipping it.”

Some treatments for sexual addiction mimic those for other addictions, such as 12-step programs. For some sexual addicts, anti-depressant medications offer relief. Other therapies work specifically to control the behavioral tendencies while not delving too deeply into what prompts them. Campbell said his bias leans toward long-term psychotherapy to understand the root of the problem. “What are they trying to fix or repair? What’s the underlying problem? Then we work to come to terms with it so it’s less destructive in their lives,” he explained, “or at least come to terms with it in such a way that their quality of life is improved.”

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