Thursday, 12 December 2019
Are you worried about your sexual behaviours? Do you think you might be watching too much pornography? Do you keep being unfaithful even though you love your partner? Do you promise yourself not to repeat an unwanted sexual behaviour, and find yourself doing it again?
If so, you might be worried that you’re a ‘sex addict’. It is easy to worry about it. There are so many books and online forums that discuss people suffering from the ‘illness’ known as ‘sex addiction’. Those forums might make you feel even more shame about your unwanted sexual behaviours and increase your fear that you’re ‘one of them’. At that point, it is common for people to leap onto an online test to check if they are indeed a ‘sex addict’. There are various online tests you can take, an American one and a British one.
If you scored high enough to be in the category of ‘sex addiction’, don’t panic. Don’t call a ‘sex addiction’ therapist straight away. Keep reading this blog.
The diagnosis of ‘sex addiction’
Firstly, let me reassure you: ‘sex addiction’ is not a recognised mental health diagnosis. The correct term currently is Compulsive Sexual Behaviour Disorder (CSBD). The CSBD diagnosis is under the Impulse Control category, not addiction. If an online test uses the term ‘sex addiction’ it will not be testing with the clinically endorsed diagnostic framework. Similarly, if a therapist uses the term ‘sex addiction’, they may not be up to date with the latest diagnostic criteria.
To be diagnosed with CSBD, you have to meet a set of criteria which most people don’t meet. Many people have sexual behaviour problems with a range of sexual compulsivity elements that can be examined in therapy, but to have the actual disorder is pretty difficult. Yet, those tests diagnose many people with ‘sex addiction’ every day.
Those online tests are designed to score you as a ‘sex addict’ because they are made by clinicians who offer expensive ‘sex addiction’ treatments. They have a financial interest in making you fear you’re a ‘sex addict’. Some of my sexologist colleagues and I took the American test several times and we all scored as ‘sex addicts’ every time, although none of us have sexual behaviour problems. So what do those tests really assess? I believe they test for a breach in heteronormative monogamy. In other words, ‘sex addiction’ is another term for sexual oppression. It seems that all you need to qualify as ‘sex addict’ is to enjoy masturbation more than the creators of the tests, or you might have a high sex drive; or perhaps you might be sexually adventurous or maybe you are polyamorous. None of these things are a disease or wrong, but they might not fit in your current monogamous arrangement.
How are those tests design to diagnose so many people as a ‘sex addict’?
Any good psychometrics need to have a time period in which to report a behavioural problem. The diagnostic criteria of CSBD has a time period of six months. The American test doesn’t mention any time period, so the way that the questions are phrased are confusing as they are formulated as an absolute. For example, if you cheated on your partner when you were a teenager (not all that uncommon behaviour) but haven’t done so in years, the phrasing of the question enquiring about infidelity will encourage you to tick ‘yes’ even though it is actually irrelevant to your sexual problems today.
The British test is milder. When I took the British test titled: ‘Am I a Sex Addict?’ I didn’t score as a ‘sex addict’. At least, it does have a time window of ‘more than two years’ to report sexual behaviour problems rather than the absolute reporting of the American test, which means that your normal frequent masturbation as a teenager won’t be taken into consideration.
However, the phrasing of the British test is questionable too. The second question on the test is: ‘Do you regularly view pornography for more than 11 hours a week?’. The threshold of eleven hours is arbitrary as there are no solid studies, clinical evidence nor any diagnostics that support that more than eleven-hour use is a problem. Some people masturbate to pornography for over one hour a day without any negative consequences to their lives at all. This eleven-hour threshold seems to be more of a moral bias of the clinicians who constructed the test rather than any clinically sound studies.
Both the American and British tests fail to ask important questions in order to assess someone’s sexual behaviours: there are no questions about sexual pleasure, which is an important component of the diagnostic for sexual compulsivity. They don’t ask the questions about why you think your behaviours are unwanted. Is it because of feeling sexual shame that watching pornography ‘should’ be wrong? Is it because of a partner’s disapproval? Is it because of a particular society or faith prohibiting a sexual behaviour that one is turned on by? These are crucial questions because people can’t actually be assessed without those answers, according to the ICD-11 diagnostic.
The phrasing of the questions in the American and British tests covertly imply that the best way to be sexual and relational is in heteronormative monogamy. Having multiple partners is wrong. Watching pornography is wrong. Choosing to be a sex worker is wrong. Buying the services of a sex worker is wrong. All of those reflect a lack of knowledge in sexology and a lack of understanding of sexuality and relationship diversity.
After the tests, meet the ‘sex addiction’ therapists.
The clinicians creating those tests believe in the unrecognised addiction model. It means that they are likely to offer an addiction treatment, which is not clinically endorsed. The World Health Organisation recently released their clear statement:
“… although the term ‘sex addiction’ has been taken up by the popular media, the Working Group concluded that available evidence did not support this conceptualization… materials related to the ICD-11 make very clear that CSBD is not intended to be interchangeable with sex addiction, but rather is a substancially different diagnostic framework.”
In summary, I suggest you stay away from online ‘sex addiction’ tests as they are not clinically sound. You are more likely to be assessed by someone’s moral bias rather than someone informed by the science of sexology.
The treatment for sexual compulsivity is not focused on stopping the behaviours, which are only symptoms of an underlying disturbance, but to treat those disturbances underneath with psychosexual therapy, integrative and humanistic psychotherapy and CBT.
It is totally ok to ask a therapist before you meet them how they think and work with sexual compulsivity and if they offer an addiction treatment or not. Beware of the ‘one-size fits all’ type of treatment programmes.
A proper assessment is enquiring about what works in your sexual behaviours, what you find pleasurable, what turns you on, what your relationship(s) are like, what are the functions of the unwanted sexual behaviours, why you don’t want those sexual behaviours, and so on. The therapist’s questioning should be open and curious about your entire life rather than only enquiring about the problems in leading questions that imply ‘wrongness’.
It is currently challenging to find a therapist who is practicing a sex positive approach to their treatment of sexual compulsivity (many therapists will say that they’re sex-positive, but rarely practice it). If you’re in doubt, feel free to send me an e-mail and I will be happy to refer you to a trusted colleague who works beyond the addiction model.