The […] simplified correlation of specific patterns of behaviour […] will, in the long run, impede scientific progress. Why then, do we persist in the attempt to devise characterologies? The answer is that such classifications […] can for a while be valuable guides in psychological territory in which we feel not yet at home.”(Kohut and Wolf, 1978:420)
“He is a sex addict, you know!” This comment by a colleague about a public figure, amidst continuing debates around the appropriacy of a term that has long been used as shorthand for a complicated behaviour, prompted me to think about the many faces of an issue that thrives in faceless secrecy and disowned shame – as well as the implications of how we refer to “it”, if it does not reach the level of Compulsive Sexual Behaviour Disorder that has been defined in the latest World Health Organisation diagnostic manual, ICD-11.
I am not a great fan of labels. I tend to use the usual terms: “sex addiction”; “compulsive sexual behaviour”; and “out-of-control sexual behaviour” interchangeably, depending on the aspect of the behaviour I wish to focus on at a particular time, and I always use quotation marks in my head when I tentatively utter the words.
The reality of it is that none of them is particularly apt for everyone, or even for most people. The fact that the issue is self-diagnosed also does not help because in its diluted, non-disorder level expression, it may hold an internal conflict that the client will, by the very nature of the presentation, be unable to accurately articulate. However, even beyond the internal conflict, none of the terms seem particularly appropriate; not least because there is such variety in the expression of a behaviour that can hold symbolic meaning.
Take Tom*, for example. He is the quieter type. He tends to lose himself for hours on end, in isolation – with just an internet-enabled device and a box of tissues. His main purpose appears to be to confirm his own invisibility. And then there is Tim*, who is leading a very busy social life with his second wife and their three kids. Tim is more interested in the manipulation of a situation involving other people in order to gain satisfaction, so he will meet sex workers or strangers while making up an elaborate lie about the time he was unaccounted for. Tim’s behaviour also serves a higher purpose, which seems to be confirmation of his existence and his value or power.
“Out-of-control”? Not so much. Of course there is a reason why the term caught on when it did. But, if anything, there can be an excessive amount of control involved in keeping a problematic behaviour hidden from anyone that matters, before the universe aligns to expose years’ worth of sexual practices. Not to speak of chemsex or BDSM**, which are all about control – or about allowing one to lose control (in a controlled fashion).
“Compulsive” is more like it, and the ICD-11 inclusion of the term makes it the obvious frontrunner – not usually to disorder level, but as psychotherapists we can work with greyer areas. I find this one fairly innocuous, but to me it has an inaccurate connotation of the behaviour taking place in isolation, as though it just happens completely out of context. It might also be playing down the depth of the issue by reducing it to simple lack of control over impulses – which is only partly accurate.
Both “compulsive sexual behaviour” and “out-of-control sexual behaviour” seem to depersonalise the presentation and put some distance between the person and the action by referring specifically to the behaviour; the obvious benefit being allowing some breathing space between the client and a behaviour that may be cause for (or represent) overwhelming distress. However, this could also have the unwanted effect of putting too much distance between those two – which brings me to the much more contentious term “sex addiction”.
Scientifically inaccurate as the term “addiction” may be in the context of sex, I am often reminded of a client who seemed to wear the label of “sex addict” with a sense of inclusion. When the behaviour expresses parts of the self that may have been disowned, split off, a label that can be turned into a (part-)identity could serve a purpose – namely, as a first step towards integration of the self. Even if, somewhat ironically, it has to start from a shared identity.
Speaking of shared identities, research from the early 2000s (Bergner and Bridges, 2002) suggests that “PSAs” (Partners of Sex Addicts***§) will often view their partners along a spectrum ranging from “sick” to “bad”. This points to some work around differentiation being required to allow the couple to eventually hop off the Drama Triangle merry-go-round. Indeed, couples work is especially fascinating when compulsion around sex comes into play – and it is hardly ever just about sex. The onset of the behaviour may pre-date the relationship, however, the deception does not, and so, while the issue may be linked to the compulsive partner’s upbringing, it may also hold some of the tensions within the relationship or be part of a larger power struggle in the couple. And what happens if one partner needs sex in order to regain their sense of safety in the relationship but the other cannot engage sexually until they do feel safe?
Returning to the original question: is the public figure that my colleague was referring to a sex addict? Or does he behave in a compulsive way when it comes to sex? In trying to answer that, we have to consider how boundary issues and acute compartmentalisation techniques from this particular client group might be seeping through into the profession and complicating the process of giving “it” a suitable label. There is something about not being able to sit with “it” long enough and with enough presence that mirrors a behaviour designed to mask what really matters. And what we call it does matter, not just to the person exhibiting the behaviour, but also to their partner(s), their wider social circle and even the general population. It also matters, by extension, to how we work with it, be it in an individual or a couple setting.
When considering different options for what (not) to call “it”, the vast differences between the potential expressions of it come to mind and these already compromise the accuracy of the label. However, the issue is compounded when focusing on the similarities, because what we are really talking about is repetition compulsion and/ or heightened anxiety around all things intimacy. Therefore, using terms that either highlight the behaviour or are associated with a behavioural treatment plan is misleading and off-topic at best, or harming at worst, when the more pertinent exploration would be around patterns of attachment or trauma.
So, would we be colluding with something if we just agreed that whatever we call it – a problematic behaviour or a sort of addictive process – will be shorthand for whatever a deeper exploration reveals? Perhaps owning some of the lack of consensus still surrounding the issue, while maintaining the boundaries that we do agree on, is a responsible and respectful start to framing such a personal and nuanced issue.
* Tom and Tim are fictitious characters.
** It is not my intention to pathologise non-conventional sexual practices; the topic is to consider the terminology when these are deemed problematic by those who engage in them themselves (but not problematic enough to achieve disorder status).
*** We have come a long way from “enabler”, “co-addict”, “codependent” and “wife”, but the issue of acknowledging the differentiating characteristics of this particular client group while maintaining its internal diversity has a familiar ring to it, especially given the context of this post. The irony is not lost on me, that we are reinforcing an undifferentiated identity every time we adjust the partner’s terminology according to their partners’ labels.
§ The publication refers to pornography use only, although arguably the range of responses would apply to a broader expression of the issue.
Bergner, R.M. and Bridges, A.J. (2002). ‘The Significance of Heavy Pornography Involvement for Romantic Partners: Research and Clinical Implications’. Journal of Sex & Marital Therapy, 28:193–206.
Kohut, H. and Wolf, E. S. (1978). ‘The disorders of the self and their treatment: An outline’. The International Journal of Psychoanalysis, 59(4):413-425.