More and more women are getting involved with porn, cybersex, hook-up apps and sexting. Given the technological advances, it’s not surprising that these behavioral addictions have blown up.
Dr. Stefanie Carnes, Ph.D., CSAT-S is the President of the International Institute for Trauma and Addiction Professionals (IITAP) and a senior fellow for Meadows Behavioral Healthcare, where she works with people struggling with sex, love, and intimacy disorders and their families. As the daughter of Dr. Patrick Carnes, the nationally recognized expert credited with popularizing the term “sex addiction” in the early 90s, she grew up in the midst of the theoretical underpinnings of modern behavioral disorders like sex addiction, porn addiction, and love addiction.
The Fix is honored to have the opportunity to speak with Dr. Stefanie Carnes about the rise of sex and porn addiction and how it’s tied to the increased availability of online pornography and hook-up apps, the necessity for a different paradigm in treating family members, and how stigma is causing harm to a growing and largely unrecognized population of sex addicts: women.
The Fix: Can you explain why compulsive sexuality is similar to substance use disorders?
Dr. Carnes: Although the treatment can be very different, the latest neuroscience research reveals very similar patterns in the reward center of the brain. In the latest edition of the journal World Psychiatry, the WHO recently released an article that said they are moving the behavioral addictions into a new category under the umbrella of addictive disorders. Thus, gaming, gambling, and substance use disorders are all going to be included in a single category. My hope is that they will move compulsive sexual behavior from the impulse control disorder category to this much broader addictive disorders category. It’s the same path that gambling took, and I hope we will follow that classification path as well. Although the WHO remains somewhat conservative by keeping compulsive sexual behavior as an impulse control disorder, it is possible that it will be moved over once more research is examined and evidence accumulated.
The definition by the WHO in the World Psychiatry article is as follows:
Compulsive sexual behaviour disorder is characterized by a persistent pattern of failure to control intense repetitive sexual impulses or urges, resulting in repetitive sexual behaviour over an extended period (e.g., six months or more) that causes marked distress or impairment in personal, family, social, educational, occupational or other important areas of functioning.
The focus is on behaviors that are out of control, thus there are a lot of similarities with gambling and substance use disorder.
Dr. Patrick Carnes believes that at least 40 percent of female Internet users engage in problematic cybersex. Do you agree with this statistic? If so, what percentage of those women are potentially sex addicts? What steps could be taken to help this massive population gain awareness and receive potential help?
I’m not sure what specific study was being cited in that article, but I can tell you that we are seeing huge increases for women in terms of such behaviors online. It’s very underestimated how both sex addiction and porn addiction are impacting women. A big part of that gap is that the stigma is greater for women. It’s harder for them to come forward and ask for help. If you look at a recent study done by Dickenson and colleagues, the results proved surprising:
In a nationally representative sample that asked how many people in the United States were struggling with some form of out of control sexual behavior, the percentage of the overall female population came back at about seven percent. It was much higher than what people in the field had anticipated. There are over 150 million adult women living in the United States, and 7% means that over 11 million women are struggling with this issue to one degree or another. Even if we cut that number in half, it’s still an enormous number of people.
We are seeing that a lot with women struggling with pornography, for example. For example, Porn Hub designated 2017 as the “year of porn for women” because rates of women using porn almost doubled during that period according to their statistics. We are seeing more and more women getting involved with porn, cybersex, hook-up apps and sexting. We see really high rates in the college student population where porn is normalized. In that group, the use of porn has become normative behavior. Any time you have greater availability and accessibility of an addictive substance or behavior, you are going to have higher rates of addiction. There is a reason why there are more gambling addicts in Las Vegas than in any other part of the country.
The higher rates for women mean the battle against destigmatization has become even more important. The stigma prevents women from accessing help and professional support. In terms of porn addiction for men, you have a lot of well-known men ranging from political leaders and athletes to movie stars and other public figures that have come out and said they were struggling with this problem and were getting help with it. In contrast, there still have been very few women that have done the same. Like with alcoholism, we need the Betty Ford moment where women stand up and say that we, too, are struggling with this. Such a moment had a tremendous impact on the process of the destigmatization of alcoholism and substance use disorder. We have seen a lot of men coming forward, but we haven’t seen that as much with women. This is a women’s problem too, and we need to open and expand that national discussion.
How has the rise of the internet and online dating affected sex addiction?
Availability and accessibility almost always is a key part of the development of any form of addiction. Given the technological advances, it’s not surprising that these behavioral addictions have blown up. Today, we have hook-up apps with location features on every smartphone and any kind of porn at the tip of your fingertips at any point in time. Thus, we are having much higher rates and much higher instances of sex and love addiction than we’ve ever had in the past.
Can you help illuminate the relationship between sex addiction and porn addiction, particularly online porn addiction? Is there a widespread direct relationship or is it contextualized case by case?
There is a widespread relationship. One study done recently showed that about 80% of people that identify as sex addicts also said that they had some form of problematic pornography use. Having made that point, there’s a difference in terms of treatment for people that just have porn addiction versus people that have both sex and porn addiction. The people who only identify as porn addicts, and it’s a large group, their behavior has not transitioned to being problematic in real life and offline. Although porn addiction affects their life, it tends to be very isolating and lacks interaction with other people. Thus, treatment looks very different for them. As a population in general, they look very different from sex addicts and have very different needs in terms of a recovery program.
For example, a recent paper made a very interesting distinction between contemporary porn addicts and classic sex addicts. Most of the classic sex addicts have multiple addictions, high rates of trauma, attachment problems, and mood disorders. They are using sex and porn to self-medicate, and that’s the typical classic presentation. In contrast, the contemporary presentation of porn addicts tends to be young people that got exposed to pornography online at a very young age. They tend to have less trauma, fewer attachment problems, and fewer co-occurring disorders. Instead, they simply got hooked on internet porn at a very young age and it deeply affected their sexual interactions as they grew older. With someone like that, it’s a very different treatment process than with somebody that has the attachment wounding, the trauma history, and serious co-occurring substance use disorder.
With porn addicts, we focus on healthy device management, content filters, social support, and managing triggers and cues. Those kind of treatment methods are very important when it comes to treating porn addiction. The goal is to foster a healthy way of living moving forward.
On November 14, 2017, IITAP released a position statement about Harvey Weinstein and the sexual assault and abuse scandals that led to the #MeToo movement, which reads in part: “It is critical to understand that sex addiction and sex offending behavior are not the same things. A sex offense occurs when there is a non-consensual sexual behavior that has a victim…. most studies show that only about 10%-30% of sex addicts have behaviors that constitute sexual offenses. The majority of sex addicts struggle with issues like pornography addiction, prostitution, anonymous sexual behaviors, and sexual promiscuity and boundary failure.”
How severe is the damage done by these misconceptions to the sex addiction treatment industry? How can the industry rehabilitate itself, shifting public opinion?
The media and the public have a hard time making the distinction between a sex addict and a sex offender. Since they classify sex offenders like the Craigslist Killer as sex addicts, suddenly everyone with a problem with compulsive sexual behaviors becomes a sex offender. This is not right, and it prevents many people from admitting their problem and reaching out for treatment.
For example, let’s take Bill Cosby and his crimes. Bill Cosby is a sex offender who was committing crimes, yet the media would refer to him as only a sex addict. His actions were coercive, exploitative, and criminal. The Craigslist Killer had anti-social personality disorder so it doesn’t make sense to define him as a sex addict. He was sociopathic and psychopathic. By defining him as a sex addict, you are making the implication that sex addicts are sociopathic and psychopathic, and this implication is grossly unfair. From a clinical standpoint, we understand the distinctions. However, the media conveys a wrong message to the general public by looking at extreme sex offenders and saying, “Oh, this person is just a sex addict.”
We have to be better about teaching people the appropriate language. We have to help them understand the distinctions. Indeed, we need to educate them so they understand that sexual harassment, rape, and other criminal behavior are sex offenses. Sex offenses and sex addiction are two very different things, and people need to understand the difference.
In the position statement, you also write, “There are many misconceptions about sex addiction treatment. The first is that it is a retreat or a way to escape problematic behavior. Nothing could be further from the truth.” Can you describe how sex addiction treatment works at your facilities?
A lot of people have the mistaken perception that sex addiction is an excuse for bad behavior. They believe that sex addicts go to treatment only to escape the consequences of their actions. In my firsthand experience treating clients, such a perspective is just not the reality of what treatment is like. By the time you are going into inpatient treatment for sex addiction, you have done damage to yourself, and you truly need help. Many have destroyed their lives. Thus, there is no escape without doing the work.
At our treatment center, we have both a men’s unit and a women’s unit. Gentle Path is our men’s unit and Willow House is our women’s unit. When both men and women enter treatment, we have very high rates of suicidality. To ensure their safety, many clients are put on one-to-one suicide watch at the beginning of their stay until the threat passes. In terms of the work being done, the clients are in group sessions for almost forty hours a week. Then, they have individual therapy sessions on top of it. They also have homework to complete as well as 12-step meetings at night. If you want a vacation to avoid consequences, the Meadows is not the right choice to make. Our program is about attaining sobriety from addiction and working a program that leads to long-term recovery.
One of the aspects about my father’s treatment philosophy that I have always admired because it really works is the idea that you have to grab onto a client’s frontal lobes and hold on. What he means is that to enact positive change in a person’s core personality takes focus and determination. Thus, it’s a very intensive treatment program because the addictions we are treating are life-threatening. The stakes are high, and people come to us really needing to be helped and supported.
From morning meditations and journal entries to a whole protocol of exercises and nutritional support, everything is designed to foster this process. Then, it’s also extremely emotional on account of the trauma work which pulls up the root causes behind the behaviors and all of the original pain points. The very deep experiential work around the root trauma is not easy for anyone.
Beyond their own work, the process builds up to family week where they have to face the devastation caused by their addictions within their own families. Revealing the truth and facing your family for an entire week is heart-wrenching. As I mentioned, the men’s unit is called the Gentle Path, and that is also the name of the program. Our clients jokingly refer to it as the Brutal Path because the process is so difficult. They are grateful for the results of the work because they know by the end that they have done the work. It’s not easy by any stretch of the imagination. As you can see, there is a huge discrepancy between the public perception of sex addiction treatment and the reality of sex addiction treatment. The blatant falsehood of sex addiction treatment being an easy escape is an unfortunate perception because it puts treatment in a negative light. One of our goals is to change this perception.
In contrast to your father’s focus on treating sex addicts, you also have become laser-focused on supporting their partners and loved ones. How does your work help the loved ones of people with sex addiction?
Coming from a family with sex addiction and having been impacted by it as a family member, I feel it has often been overlooked. When I first entered the field, many therapists denied the existence of sex addiction. If you asked for help, you were sent along your merry way. Thus, many people looking for help were turned away, and many families were negatively impacted.
Back in the 1980s and 90s, since the only therapists treating sex addiction in the beginning were addiction therapists, the same treatment principles used for substance use disorder were applied to sex addiction. However, when it comes to families, there are some big differences between chemical dependency and sex addiction. When I entered the field, there was so much that was misunderstood, and there simply were not a lot of resources for partners and family members. It seemed that what happened after treatment in the context of the family was more of an afterthought. The treatment of the sex addict was put first during treatment and helping the family was nothing more than an adjunct to the addict’s treatment.
Another problem was that the codependency model was being applied to the majority of these families when most of them did not actually know that the addiction was going on. The families felt they were being pathologized by such an approach. I’ve tried to use a lot of my efforts in outreach and training to educate therapists about the traumatic nature of these kind of addictive behaviors for family members. Beyond being very difficult to even learn, it often becomes downright devastating for them. They really need a kind of help and support that is not the same as with families dealing with chemical dependency. For example, disclosure is a huge issue. How does a sex addict share information about the sexual betrayals with their partner without traumatizing the heck out of them?
Moreover, think about the challenge of the children. What are you going to tell the children about this? It becomes very complex and very age specific as well. In our Certified Sex Addiction Training for therapists, I teach our second module which is all about how to work with the couples, how to handle the betrayal trauma, and how to talk to the kids about what is happening. It’s an incredibly important aspect of treatment. If it’s not handled well, it can really derail the addict’s recovery. When it comes to compulsive sexual behavior, you have to look at the family from a relational paradigm. You have to examine and address the whole system or treatment doesn’t work.
Dr. Stefanie Carnes is the author of numerous publications including Mending a Shattered Heart: A Guide for Partners of Sex Addicts, Facing Heartbreak: Steps to Recovery for Partners of Sex Addicts, and Facing Addiction: Starting Recovery from Alcohol and Drugs.
