Sanctuary for the Abused

Wednesday, January 27, 2010

Sex Addiction

What Sexual Scientists Know About...
Compulsive Sexual Behavior

Compulsive Sexual Behavior
Can sex become compulsive? Like most behaviors, sex can be taken to its obsessive & compulsive extremes. Sexual obsessions & compulsions are recurrent, distressing & interfere with daily functioning. Many people suffer with these problems but finding consensus about them among sexual scientists or treatment professionals is not easy. This makes it more difficult for those suffering from compulsive sexual behavior (CSB) to get the appropriate help they need. For those who want to know more about this problem, it is helpful to know about the types of CSB, the various theoretical viewpoints & treatment approaches. While there are many types of compulsive sexual behavior, they can be divided into two main types: paraphilic & non-paraphilic CSB. Sexual scientists have used various terms to describe this phenomenon: hypersexuality, erotomania, nymphomania, satyriasis & most recently sexual addiction & compulsive sexual behavior. The terminology has often implied different values, attitudes & theoretical orientations.

Paraphilic CSB
Paraphilic behaviors are unconventional sexual behaviors which are obsessive & compulsive. They interfere with love relationships & intimacy. While John Money(1) has defined nearly 50 paraphilias, the Diagnostic & Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association has currently classifed eight paraphilias & these are generally considered the most common:

pedophilia (sexual attraction to pre-pubescent children)
exhibitionism (sexual excitement associated with exposing one's genitals in public)
voyeurism (sexual excitement by watching an unsuspecting person)
sexual masochism (sexual excitement from being the recipient of the threat or administration of pain)
sexual sadism (sexual excitement from threatening or administration of pain)
transvestic fetishism (sexual excitement from wearing the clothing of the opposite sex)
frotteurism (sexual excitement from touching or fondling an unsuspecting person) (2)

In the recent DSM-IV, the paraphilias are defined as "recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving 1) nonhuman objects, 2) the suffering or humiliation of oneself or one's partner, or 3) children or other nonconsenting persons... The behavior, sexual urges, or fantasies cause clinically significant distress in social, occupational, or other important areas of functioning (p. 522-523)." Some behaviors, such as sado-masochism when they are consensual & do not impair life functioning are not considered a paraphilia because they do not meet all the diagnostic criteria.

Nonparaphilic CSB
Nonparaphilic CSB involves conventional sexual behaviors which when taken to an extreme are recurrent, distressing & interfere in daily functioning. One example is given in the DSM under the category of Sexual Disorders Not Otherwise Specified. The authors of the DSM describe an example of "distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used" (p.538). Other forms of nonparaphilic CSB include: compulsive fixation on an unattainable partner, compulsive masturbation, compulsive love relationships & compulsive sexuality in a relationship.(3)

The Danger of Overpathologizing this Disorder
The possibility of overpathologizing this disorder is the main criticism given by those who do not believe in the idea of compulsive sexual behavior as a disorder. The pathologizing of sexual behavior may be driven by anti-sexual attitudes & a failure to recognize the wide-range of normal human sexual expression. This caution is important when assessing whether a person is engaging in compulsive sexual behavior. It is important for professionals to be comfortable with a wide range of normal sexual behavior - both in types of behaviors & frequency. Sometimes individuals with their own restrictive values will diagnose themselves with this disorder, creating their own distress. Therefore it is very important to distinguish between individuals who have a values conflict with their sexual behavior & those who engage in obsessive sexual behaviors.

A Conflict Over Values
There is an inherent danger in diagnosing CSB simply because someone's behavior does not fit the values of the individual, group or society. There has been a long tradition of pathologizing behavior which is not mainstream & which some might find distasteful. For example, masturbation, oral sex, homosexual behavior, sado-masochistic behavior (S-M) or a love affair could be viewed as compulsive because someone might disapprove of these behaviors. However, there is no scientific merit to viewing these behaviors as disorders, compulsive or "deviant." When someone is distressed about these behaviors, they are most likely in conflict with their own or someone else's value system rather than this being a function of compulsion.

Problematic Vs. Compulsive Sexual Behavior
Behaviors which are in conflict with someone's value system may be problematic but not obsessive-compulsive. Having sexual problems is common. Problems are often caused by a number of non-pathological factors. People can make mistakes. They can at times act impulsively. Their behavior can cause problems in a relationship. Some people will use sex as a coping mechanism similar to the use of alcohol, drugs, or eating. This pattern of sexual behavior can be problematic. Problematic sexual behavior is often remedies by time, experience, education or brief counseling. Obsessive & compulsive behavior, by its nature, is much more resistant to change.

Developmental Process vs. Compulsive Sexual Behavior
Some sexual behaviors might be viewed as obsessive or compulsive if they are not viewed within their developmental context. Adolescents, for example, can become "obsessed" with sex for long periods of time. In adulthood, it is common for individuals to go through periods when sexual behavior may take on obsessive & compulsive characteristics. In early stages of romance, there is a natural development period where an individual might be obsessed with their partner & compelled to seek out their company & express affection. These are normal & healthy developmental processes of sexual development & must be distinguished from CSB.

What Causes CSB?
Disagreement exists as to whether CSB is an addiction, a psychosexual development disorder, an impulse control disorder, a mood disorder, or an obsessive-compulsive disorder. Patrick Carnes (4) popularized the concept of CSB as & addiction. He believes that people become addicted to sex in the same way they become addicted to substances or behaviors. However, many dispute the idea that you can become addicted to sex in the same way that someone becomes addicted to alcohol or sex. Despite this criticism, sexual addiction has become a poplar metaphor similar to "workaholism." Twelve-step programs of spiritual recovery (similar to Alcoholics Anonymous) have become popular solutions to those who view CSB as an addiction. However, the "abstinence model" useful for alcoholics, cannot be applied to sexuality since sexual expression is a basic need of life. Critics view the abstinence solution as an oversimplification of CSB & potentially dangerous when proper medical & psychological treatment is not provided. Different explanations have been given as causes of CSB. Robert Stoller (5) was a strong advocate of psychodynamic factors. His theories have been helpful to our understanding of inner conflicts which fuel obsessive & compulsive drives.

Others have suggested factors of anxiety, mood & personality disorders. In some cases, CSB can result from a bipolar mood disorder. In other cases, CSB can be caused by a neurological disorder such as epilepsy or Alzheimer's. John Money has assisted us to understand the complex interplay of biological, psychological & environmental factors in CSB. CSB in some cases may be caused by irregular chemical functions in the brain which produce repetitious nature of the self-defeating behavior. In this model, CSB is driven by anxiety where certain sexual behaviors provide temporary relief of the anxiety but is followed by further anxiety & distress - creating a self-perpetuating cycle.(6)

Since CSB is such a complex disorder involving biological, psychological & social factors, a careful assessment by a well trained professional is necessary. Because of disagreements in theoretical approaches, the lay person should ask the professional about his/her own theories on CSB & consider other professional opinions.

Treatment of CSB
While disagreement exists about the nature of CSB, treatment professionals have generally found a combination of psychotherapy & prescription drugs to be effective in treating CSB. While medications which suppress the production of male hormones (anti-androgens) are used to treat a variety of paraphilic disorders, newer anti-depressants such as Prozac (®), Zoloft(®) or Paxil(®) which selectively act on serotonin levels in the brain are also effective in reducing sexual obsessions & compulsions & their associated levels of anxiety & depression. These newer medications interrupt the obsessive-compulsive cycle of CSB & help patients use therapy more effectively. The advantages of these anti-depressants over older anti-depressants or anti-androgens are their broad efficacy & relatively few known side effects.

How Does One Know if He/She Needs Help Regarding CSB?
The following questions are examples of those used in assessing & treating CSB:

Do you, or others who know you, find that you are overly preoccupied or obsessed with sexual activity?

Do you find yourself compelled to engage in sexual activity in response to stress, anxiety, or depression?

Have serious problems developed as a result of your sexual behavior (e.g., loss of a job or relationship, sexually transmitted diseases, injuries or illnesses, or sexual offenses)?

How Does Someone Find a Professional Who Has the Expertise in Assessment & Treatment of CSB?
There are several ways to find qualified professionals.

Call your state licensing boards for psychologists, psychiatrists, social workers, or marriage & family therapists who have a specialized competence in treating compulsive sexual behavior.

Inquire through college or university psychology, psychiatric or counseling departments.

Ask professionals for their credentials in treating compulsive sexual behavior (e.g., certified sex therapist).

Compulsive sexual behavior is a serious psychosexual disorder which can be identified & treated successfully. CSB does not always involve strange & unusual sexual practices. Many conventional behaviors can become the focus of an individual's obsessions & compulsions. The exact mechanism of CSB is still under debate & various treatment approaches have been developed. Research is needed to further clarify the nature of the disorder, the mechanisms involved & to test the most effective treatment approach. In the meantime, individuals suffering from CSB should not hesitate to seek professional guidance to properly assess their problem & to find help through counseling & treatment.

Money, J. (1996). Lovemaps: Clinical Concepts of Sexual/Erotic Health & Pathology, Paraphilia & Gender Transpositions in Childhood, Adolescence & Maturity. New York, NY: Irvington Publishers.
American Psychiatric Association. (1994). Diagnostic & Statistical Manual of Mental Disorders. 4th ed. Washington, D.C.: American Psychiatric Association.
Coleman, E. (1992). Is your patient suffering from compulsive sexual behavior? Psychiatric Annals, 22(6), 320-425.
Carnes, P. (1983). Out of the Shadows: Understanding Sexual Addiction. Minneapolis, MN: CompCare Publishers.
Stoller, R. (1975). Perversion: The Erotic Form of Hatred. New York: Pantheon.
Coleman, E. (1991). Compulsive sexual behavior: New concepts & treatments. Journal of Psychology & Human Sexuality. 4(2), 37-52.

Written by Eli Coleman, Ph.D. Professor & Director of the Program in Human Sexuality, Department of Family Practice & Community Health, University of Minnesota Medical School, University of Minnesota.

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Wednesday, January 20, 2010

Internet and Cybersex Addiction: Signs, Symptoms, Effects and Treatment

The term “addiction” used to be exclusive to chemicals such as alcohol, drugs, or nicotine. With recent research on the brain and its processes, we now understand that many behaviors can become as chemically addictive as a substance. Extreme overuse of the Internet is such an addiction.

Internet Addiction Disorder
Like all other addictions, Internet Addiction Disorder is a psychophysiological disorder involving:

tolerance (the same amount of usage elicits less response; increased amounts become necessary to evoke the same amount of pleasure)

withdrawal symptoms (especially, tremors, anxiety, and moodiness)

affective disturbances (depression, irritability)

interruption of social relationships (a decline or loss, either in quality or quantity).

What are the signs, symptoms and patterns of Internet addiction?
At this time, there is no official diagnosis of Internet Addiction Disorder by the American Psychiatric Association, which defines mental health disorders and establishes criteria to be used by mental health professionals. However, since the patterns so closely match those of Pathological Gambling (which was included in the most recent update of the diagnostic manual), many in the addiction field expect Internet Addiction to be added to the next edition. If it is included, it is likely to require that a person meet three or more of criteria such as these during a twelve month period:

The need for increasing amounts of time on the Internet to achieve satisfaction and/or significantly diminished effect with continued use of the same amount of time on the Internet.

Use of the Internet as a way of escaping problems or relieving feelings of helplessness, guilt, anxiety or depression.

Feelings of restlessness or irritability when attempting to cut down or stop Internet use.

Lying to family members or friends to conceal the extent of involvement with the Internet.

Giving up or reducing important social, occupational, or recreational activities because of Internet use.

Risking the loss of a significant relationship, job, educational or career opportunity because of excessive use of the Internet.

Two or more withdrawal symptoms developing within days to one month after
reduction or cessation of Internet use (i.e., quitting cold turkey), which cause distress or impair social, personal or occupational functioning, including: tremors, anxiety, and voluntary or involuntary typing movements of the fingers.

Use of the Internet to relieve or avoid withdrawal symptoms.

What causes or precipitates Internet addiction?
While it may appear that addictions are pleasure-seeking behaviors, the roots of any addiction can usually be traced to a wish to suppress or avoid some kind of emotional pain. Addiction is a way to escape from reality, from something that is either too full of sadness (such as an abusive relationship) or too devoid of joy (an emotionally empty life). Emotional trauma in early life may be at the source of many addictions.

Internet addiction offers a fantasy world in which there are endless people who appear to be interesting to—and interested in—the person. Young, sexually inexperienced people, especially males, may find it easier to engage in Internet “relationships” than risk the face-to-face rejection of a real person. As the addict becomes more immersed in this shadow world, denial takes hold and he or she comes to view these these “friends” and “partners” as more real than the actual spouse or family.

What is cybersex addiction?
Until recently, men dominated the overall use of the Net but women are now online more than men. Both men and women use the Internet for "cybering" (cybersex). Cybersex is defined as the consensual sexual discussion online for the purpose of achieving arousal or an orgasm.

In addition to viewing and/or downloading pornography along with masturbation, Dr. Jennifer Schneider says that cybersex activities also include:

reading and writing sexually explicit letters and stories

visiting sexually oriented chat rooms

placing ads to meet sexual partners

e-mailing to set up personal meetings with someone

engaging in interactive online affairs sometimes using electronic cameras for real-time viewing of each other

While some people will eventually move away from the Internet back to the real world, others will escalate their involvement, arranging meetings with online contacts for in-person sex. For some, this increased danger in real life grows out of viewing dangerous content online, what Dr. Michael Conner calls “danger downloading.” Often, their cyber screen names reflect this view toward risky behavior.

What are the effects of Internet addiction?
Like most addictions, Internet addiction disrupts relationships with family and friends and tends to replace education and other positive activities. A spouse or partner who discovers this behavior usually feels “cheated on,” as real a betrayal as any infidelity, and one that can lead to a break-up. In addition, Internet addiction creates risks and losses in the workplace. For example:

Nearly 55% of workers exchange potentially offensive messages at least once a month (PC Week).

Personal e-mails – 47% of employees send up to 5 per day, 32% send up to 10 daily, and 28% receive up to 20 per day (

Almost one in five people go to cybersex sites while at work (MSNBC poll, June '98). 68% of companies characterize messaging misdemeanors as widespread, with losses estimated at $3.7 million per company a year (Datamation).

Recently a major US computer manufacturer installed monitoring software and discovered that a number of employees had visited more then 1,000 sexually oriented sites in less than a month. Twenty people were fired for misusing company resources (USA Today).

Can you break addiction to the Internet?
Treatment for people who have been diagnosed with Internet addiction is very hard to find:

Not all psychologists or physicians acknowledge that the disorder is real.

Many psychologists do not know how to diagnose, treat, and follow-up for these patients.

Spouses or other family members who become aware of the addiction may try to intervene.

Just as an alcoholic’s spouse or child may pour contents of bottles down the drain, the Internet addict’s family may try to monitor computer use, put blocks on chat rooms, or make frequent calls to the person to interrupt computer activity. While these interventions may have brief effect, the only lasting change will occur when the addict fully realizes the costs being paid for his or her behavior: loss of family, job, money, etc.

Treatment alternatives include:
quitting “cold turkey” – can work for some, but is particularly difficult for people who work in a job where computer use is a requirement

12-step group programs developed from the Eating Disorder model to help participants gradually reduce the addictive behavior

other methods analogous to the treatment of alcohol or drug addictions

Psychotherapy with an addiction specialist
professional counselors offering chat and telephone counseling at reasonable rates to provide immediate assistance for individuals, partners, and parents in crisis

Clinics specializing in treatment of computer/Internet addiction, such as those at Proctor Hospital in Peoria, IL and at Harvard Medical School’s McLean Hospital in Belmont, MA.

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Sunday, January 17, 2010

A Marriage of Pain

The Tragedy of Spousal Abuse

By M.K.

The night that should have ended my marriage, but didn’t, was a mid-winter night about six months after my wedding, during my senior year in college. I don't remember why my husband and I started arguing, or when the fight escalated. I do remember getting thrown against the wall repeatedly, punched in the arms and torso, then slapped to the floor, my glasses shattering. This continued for a while until my husband went to bed.

I didn't know how to respond to getting beaten up by my husband for the first time. I put on my coat and boots and trudged out into the snowstorm. I made my way to a phone booth and dialed information. When I asked for the number to a women's hotline, the operator asked if I had been raped. Lacking the vocabulary to even describe what had happened, I said “no.” The operator responded that the only number he had was a rape hotline and he hung up. I went home and crawled into bed.

I was shocked to realize that my husband's anger towards me knew no bounds.

The night that did end my marriage wasn't particularly violent by comparison. After more than two years of being beaten up semi-regularly, of covering bruises, lying to my co-workers, and being distanced from my family and friends, I came to my senses through three simple realizations in one night. First, I found myself lying to my husband to placate him, telling him that I was on the phone with his mother rather than my grandfather. How wrong, I realized, to have to lie about a simple phone call to my grandfather.

Later that evening, my husband slammed on the car brakes seconds before crashing through the garage door. Our infant daughter, strapped tightly into her car seat, was jolted and began crying. I was shocked to realize that my husband's anger towards me knew no bounds and that he might harm this innocent little baby he claimed to cherish. Lastly, as our heated argument continued up the stairs and down the hall of my parents' house, my mother asked us to lower our voices. I watched in horror as my husband tried to push my mother aside. For the first time, I turned on him. “How dare you,” I said, “slam a door on my mother in her own home?” Late that night I stared at him sleeping peacefully despite all that had happened and knew that I had to leave him.

I am often asked why I stayed in an abusive relationship for so long. The sad part is that statistically speaking, I left several years earlier and with fewer children than most Jewish women in the same situation. The misconception is that educated, intelligent women would never stay in such a relationship. But the truth is different. I am college educated, I come from a loving family, and I have and had a strong network of friends.

My husband and I were high school sweethearts, dating for five years before we married. Our friends, centered in our Jewish youth group, recognized us as a unit. It was hard to walk away from that, even though we should have separated after high school. In hindsight, there were signs of his violent behavior even then, but he always had a convincing excuse for losing his temper, and I idealistically believed his promises that he would change. I was also reluctant to let go of someone who claimed to love me.

I idealistically believed his promises that he would change.

The diary I kept back then reveals my attempts to rationalize his behavior. In many ways, it was easier to have an excuse to be in the relationship than to admit that I was being abused by my own husband. Typical entries include statements like these: "He may not be perfect, but who says anyone more perfect is out there?" "Isn't the point of marriage to bring two very different viewpoints together?" I also believed what he had told me over many years: that my parents were "messed up" and didn't know what I needed in life, and that he just needed an equal chance to succeed in life.

There was also tremendous pressure to make a marriage work. In my community, shalom bayit: making peace in the home, was of utmost importance. I can't imagine that anyone would have suggested that I remain in an abusive relationship, but, young and naïve as I was, I kept telling myself that if I were just more patient, more loving, more this or more that, then we could have the shalom bayit I so desperately wanted. As I lit candles every Friday night I would pray that I would be worthy of having a “faithful Jewish home.” Divorce seemed unthinkable, a rejection of the family values I lived by, as well as an admission of failure.

Fortunately I had friends who noticed, who pulled me aside and said, “I don't like the way he talks to you.” Colleagues who saw the bruises and didn't buy my excuses. I also had the good fortune to befriend someone who is a social worker. At the time she was working with victims of domestic violence. One night when our husbands were out, she slipped me the business card of a colleague. I denied needing it, but tucked the card away where my husband wouldn't find it. Six months later I called the number on the card.

My parents supported me, emotionally and financially, as I finally broke away from my “high school sweetheart” and came into my own as a single mother, working and going to school. Countless friends babysat, listened to my tears, and stood by me in every way.

Unfortunately, others believed my husband’s tales and shunned me as a crazy woman who broke up a happy home. Too many didn't want to believe it, insisting that “it must be a misunderstanding” or “he’s not that kind of guy” or even “he just needs more exercise to release his energy and frustrations.” For too long I had listened to those unhelpful remarks, but once I had faced the truth, I couldn't go back to that kind of wishful thinking. My husband was abusive, and there was nothing I did to cause it and nothing I could have done to prevent it. For my sake, for my daughter’s sake, I just needed to leave.

Today my daughter and I live in a different state from my ex-husband, happily settled into our life with my second husband and three more children. Thankfully, my daughter has no recollection of the horrors that her father committed, and is surrounded daily by healthy, loving, supportive For my sake, for my daughter’s sake, I just needed to leave relationships. However, she is gradually sensing her father’s uncontrollable rage and she too is learning to appease him or pay a price.

When I divorced more than ten years ago, the state where we lived would only take away a man's right to be with his child unsupervised if there was concrete evidence that he had abused the child as well as the mother. Since I had no formal evidence that he was a threat to her -- no medical records, no 911 calls, no photographs, no proof that he had ever abused her – I had no legal option but to let her spend long, unsupervised visits with her father.

My daughter asks difficult questions about why we divorced and if I hate her father. For now I lie, but it is only a matter of time until she learns the truth about our marriage. I only hope that through education and awareness activities, girls of her generation will know how to recognize the warning signs and behavior patterns involved, and be able to avoid the trap of abusive relationships that are so common today.

I pray my daughters will find men who respect them and their individual identities. Men who will live by the words they recite under the chupah, the marriage canopy, Harei at mekudeshet li, “Behold you are holy to me.” For that is what marriage is supposed to be about.

And that is what every woman deserves.


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Thursday, January 14, 2010

Invisible Scars

Verbal abuse triggers adult anxiety, depression

by Jill Elish

A new study by Florida State University researchers has found that people who were verbally abused as children grow up to be self-critical adults prone to depression and anxiety.

People who were verbally abused had 1.6 times as many symptoms of depression and anxiety as those who had not been verbally abused and were twice as likely to have suffered a mood or anxiety disorder over their lifetime, according to psychology Professor Natalie Sachs-Ericsson, the study's lead author.
"We must try to educate parents about the long-term effects of verbal abuse on their children," Sachs-Ericsson said. "The old saying about sticks and stones was wrong. Names will forever hurt you."
Sachs-Ericsson co-authored the study, published in the Journal of Affective Disorders, with FSU psychology Professor Thomas Joiner and researchers from the University of Illinois at Urbana-Champaign and the University of North Carolina at Chapel Hill. The researchers studied data from 5,614 people ages 15 to 54—a subset of the National Comorbidity Survey. The average age of the multiethnic sample was 33.

The findings are significant because of the clear implications for clinical treatment. Research has shown self-critical people can benefit from cognitive-behavioral therapy, an approach that helps people identify their irrational thought patterns and replace them with more rational thoughts, Sachs-Ericsson said. In addition, they are taught new behaviors to deal with uncomfortable situations.

The high percentage of study participants who reported that they were sometimes or often verbally abused by a parent—nearly 30 percent—surprised the researchers, Sachs-Ericsson said. Verbal abuse included insults, swearing, threats of physical abuse and spiteful comments or behavior.

Parents may have learned this style of parenting from their own parents, or they simply may be unaware of positive ways to motivate or discipline their children, Sachs-Ericsson said. They may also have a psychiatric or personality disorder that interferes with their parenting abilities.

Over time, children believe the negative things they hear, and they begin to use those negative statements as explanations for anything that goes wrong. For instance, a child who does not get invited to a party or does poorly on a test will think the reason is because he or she is no good if that is the message conveyed by a parent. This pattern of self-criticism continues into adulthood and has been shown to make an individual more prone to depression and anxiety.

To assess self-criticism, researchers asked participants to respond to statements such as, "I dwell on my mistakes more than I should," and "There is a considerable difference between how I am now and how I would like to be." Those who had been verbally abused were more likely to be self-critical than those who were not.

Those who suffered parental physical abuse (6.6 percent) or sexual abuse by a relative or stepparent (4.5 percent) also were more self-critical, but the researchers determined that self-criticism may not have been as important a factor in the development of depression and anxiety for physically and sexually abused participants as it was for those who experienced verbal abuse.
"Childhood abuse of any type has the potential to influence self-critical tendencies," she said. "Although sexual and physical abuse don't directly supply the critical words like 'You're worthless,' the overall message conveyed by these kinds of abuse clearly does."

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