From Actions to Feelings: On “Sex Addiction” and “Out of Control Sexual Behavior”

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Words by: Madame Miel
Artworks by Lina A
This article is a supplement within the “The Wawa Complex” issue

Tarek snuck to the bathroom after he and his partner went to bed. Though they were in a long term and loving relationship, he’d masturbate every night to cuckolding videos. He was secretly aroused by the idea of being submissive, but feared he would be perceived as unmasculine or deviant. One night, he came home to see his partner holding the iPad with tears streaming down their face – “you’re a sex addict.” His secret discovered, shame overwhelmed him.

The majority of us are taught that sex “should” be heterosexual, involve penetration, and happen within a monogamous relationship (or one going in that direction). What sexual behavior doesn’t fit these scripts is often carelessly labeled as “immoral” or “abnormal,” or a product of “addiction.” This is particularly true in cases where sex is a source of cultural conflict or taboo, and where healthy sexual behavior is not taught.

But the label of “sex addict” is problematic. Being labeled this way distracts from bigger issues in the relationship, in this case, Tarek’s kink and fear of sharing it. This secret and accompanying shame makes it easier to accept this label. From another side, people who have specific kinks or fetishes may also self-diagnose themselves as “sex addicts” out of shame, even if they have their behavior under control. 

Once this label is adopted as an identity, it puts people in a place where they have to fight their sexuality for the rest of their life. This article explores the harmful side of the “sex addict” label and why many clinicians have adopted “out of control sexual behavior,” instead. Because around 88% of the people who seek treatment for sex addiction are men, it will be focusing on male-bodied people.  

“Sex Addiction”

The term “sex addict” lumps up a group of people under the same umbrella even though their behaviors, impulses, orientations, motivations, and desires are different. Introduced in the later 70s/early 80s, early supporters used it to treat so-called “pathologies” like homosexuality, non-monogamous, and other non-heteronormative behaviors¹, and to sentence sex offenders to therapy as part of their court requirement. The term was also taken up to describe compulsive and uncontrollable exploits like watching porn or compulsive masturbation.

Factors like religiousness and non-heterosexual sexuality may correlate to one’s negative perception of porn, masturbation, desire, or sex, these may be a predictor of how people perceive their own sexuality and what drives them to report feeling dysregulated or uncontrollable.

Because sexuality is so complex and diverse, clinical and diagnostic approaches must also be complex. The DSM (Diagnosis and Statistical Manual of Mental Disorders) doesn’t presently have an official diagnosis for “sex addiction,” clinicians claim there isn’t sufficient research to label this a “disease,” and attitudes around terms and theories of sexuality have changed drastically due to shifting social attitudes.  For example, in the first DSM, even masturbation was diagnosed as a mental illness.

Today, therapists question whether this is a useful clinical diagnosis, at all. Are “sex addicts” showing compulsive behavior, or might they be sex-positive individuals with higher libidos and less shame than the average person? 

Because the traditional model is pathologically oriented and focuses on issues including lust, impulse control, guilt, and shame, it ends up pathologizing a lot of non-problematic behavior. Patrick Carnes, who coined the term “sex addicts,” had no training in sexuality and had a narrow view of what constitutes healthy sexual behavior, and treated it as an addiction. Thus, many clinicians – divorced from understandings of time, context, or cultural difference – would end up bringing in their own biases and conceptions of “health” and “dysfunction” during diagnosis and treatment, especially those who don’t have a background in sexuality.

The treatment model for “sex addiction” focuses on a 12-step program, like those for alcohol and drug abuse, and employs a religious rather than clinical framework. Fewer than 10% of people referred benefit from these programs, and there are potential harms that can emerge from it². Additionally, it’s so focused on “curing” people of their compulsion that it doesn’t understand that problematic sexual behaviors may be symptomatic of or a coping mechanism for other issues. For example, sex and pornography is often a way for males to cope with negative emotions³, or the majority of self-identified sex addicts had diagnosable disorders like anxiety and depression⁴.

Clinicians must recognize that some seek treatment for their “addiction” because their behaviors might be in conflict with a partner or environment, rather than unhealthy ones. One may not be able to explore certain practices with their partner, like Tarek and cuckolding, or they may believe their desire to engage in BDSM is dysfunctional because there are no spaces to explore it. Lack of openness, spaces, or communication, can lead one to feel shame. The tendency to approach this through as a perpetrator/victim binary when working with a couple is not only not empathetic, but it puts the therapist in the position of marshaling an already “fixed” dynamic in a relationship. These dynamics should never be dismissed or overlooked, because like everything else, there are underlying causes or tensions: stress, distaste for sexual preferences, working past a moment of infidelity, etc. Rather than endorsing this binary thinking, therapy should allow for shared responsibility and further communication. 

“Out of Control Sexual Behavior”

Many clinicians are now opting to use the term “Out of Control Sexual Behavior” (OCSB), suggested by Braun-Harvey and Vigorito⁵. The way we describe things determines treatment and client response. While “sex addiction” implies negativity and shame, and removes attention to underlying issues, the descriptive approach of OCSB places attention on the feeling of being out of control. While it’s unlikely that any label will be adequate or effective enough in describing a wide range of behaviors and motivations, this approach allows sexual health clinicians to approach their client in an individualized matter that identifies and addresses underlying mental health issues, moral and relational conflicts, and other factors that contribute to the issue with sexual behavior that they are facing. 

Moving past the arbitrary “quantified” nature of the addiction label, OCSB focuses on the feeling of being out of control. Many self-identified sex addicts do not appear to engage in more frequent sexual behaviors than others, but men who view their sexual behavior and desires as incongruent with their morals are more likely to report OCSB⁶. Because factors like religiousness and non-heterosexual sexuality may correlate to one’s negative perception of porn, masturbation, desire, or sex⁷, these may be a predictor of how people perceive their own sexuality and what drives them to report feeling dysregulated or uncontrollable. 

Artwork by Lina A

What causes the distress over their desires and behaviors, or the inability to control them? Depression, bipolar disorder, an inability to self-soothe, an unwillingness to acknowledge orientation, a fear of intimacy, a desperate attempt to stay in a relationship where the sex is unsatisfactory, etc. When therapists explore these factors during treatment, as well as the “background” moral attitudes they hold, they come to recognize that each individual holds their own definition of “healthy behavior.” They must work with the patient rather than taking their self-diagnosis as fact. Like Braun-Harvey and Vigorito remind us, it would be odd if when a patient says “I have cancer,” the doctor simply replies “well at least we don’t have to run all these tests, let’s just start treatment” (2015).

Rather than focusing on suppressing unwanted behavior, which can cause social and personal harm, the OCSB model takes a holistic approach to developing and enhancing coping skills and problem-solving strategies. It takes sex and sexuality as positive, healthy, and beneficial rather than something shameful, and introduces “six principles of sexual health” to discuss a healthy foundation for sexual interaction: honesty, shared values, mutual pleasure, consensual, non-exploitative, and free from STIs or unwanted pregnancy⁸. This framework allows people to build their own vision of an ideal sexual relationship, one rooted in safety and pleasure, and guides them to make informed choices and take responsibility. 

OCSB clinicians also incorporate a variety of treatments to help treat underlying or co-existing issues. This might include SSRI for anxiety or depression; CBT for internet addiction, phobias, or traumas; healthy communication and honesty-focused exercises for those who seek couples therapy with a primary partner. But, most of the work requires sexual re-education and unlearning harmful things they’ve been told about sex. “Healthy relationships” are not simply monogamous or long term; they can take a variety of forms, including being short term, poly, queer, or non-penetrative. 

Conclusions

Clinicians who are well versed in OCSB take a more holistic approach, shifting the focus from an action to the feeling of being out of control; feeling out of control isn’t the same as being out of control. Through thorough evaluations and explorations of mental health, sexual satisfaction, medical history, and the social context of reported sexual problems, they can better understand the distress of OCSB and how it affects work/relationships.

Destigmatizing sexual behavior — seeing it as connected to these other factors — also helps patients move from shame to understanding other life factors: whether they use masturbation to self soothe, or their orientation is more aligned with polyamory, or if their desires don’t align with their partner’s. Invoking sexual help principles and sex education, rather than controlling or judging along a classical mode of “sex addiction”, allows them to make amends and move toward a place where they feel less out of control. 

Moving away from these moralistic notions of (un)conventional sexual behavior and rigid expressions of sexuality also allows partners to feel safer, allowing for greater pleasure, and allows a more inclusive understanding of sexuality that honors and elevates pleasure and communication of all partners.