Book Review: Clinical Management of Sex Addiction

Richard B. Krueger, M.D., and Meg S. Kaplan, Ph.D.
edited by Patrick J. Carnes and Kenneth M. Adams

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Clinical Management of Sex Addiction is divided into four sections: one discussing the early stages of the “addiction” process, one discussing treatment and therapy, one discussing special populations, and the final section providing a listing of resources (mainly listing twelve-step organizations and their websites), and offering pointers on how to expand one’s practice into this area.

We found the first section to be the most useful. It offers, in addition to an assessment of other addictions such as alcohol and drugs, a discussion of how to assess how out-of-control an individual’s sexual behavior has become. The authors provide the Sexual Addiction Screening Test, which presents a useful way of estimating how serious the loss of control has become. One drawback of the book is that little discussion is included of etiology apart from speculation based on clinical information, addiction theory, and twelve-step ideology. However, there are many splendid anecdotes of how progressive the process has become and of practical interventions that can be accomplished by a clinician, borrowing from the classic literature of relapse prevention in the substance abuse area and from a rich body of clinical experience. The book also includes ways of encountering an individual and breaking through cognitive distortions that support such behaviors, plus a welcome discussion of work with family members.

The section on treatment offers several therapeutic strategies, again derived from addictions and involving twelve-step therapy. Specific ideas about how to treat this population are also presented. The authors present descriptions of working with couples in a twelve-step process for couple recovery and of how much and when to disclose. Another chapter discusses the integration of psychotherapy with twelve-step programs. The authors explore how often, sexual acting-out reflects problems of a nonsexual or sexual nature in the individual or the couple, such as cocaine addiction or a sexual disorder.

The section on special populations was informative, covering the occurrence of compulsive sexual behavior of a cybersexual nature in females, in impulsive and borderline women, in the clergy and medical professionals, in the homeless, in gay male sex addicts, and in adolescents.

The final section and chapter were limited to advice on how to build a practice treating patients with sex addiction and to a listing of twelve-step resources and web addresses.

The content of the book consists largely of clinical anecdotes and speculation derived from the private practices of therapists treating patients or family members with compulsive sexual behavior. There is a considerable overlap in the chapters and bias towards the use of twelve-step and addiction treatment models. The chapters are also uneven, with some offering a deeper citation of the literature and discussion and others being rather superficial. No mention is made of cognitive-behavioral therapy, which is the main modality for treating paraphilias and which has been widely used with this population. There is only one chapter on psychopharmacological treatment and almost no mention of biological underpinnings. No attempt is made to compare the etiology, evaluation, or treatment of these disorders with those of the paraphilias, which frequently coexist.

Although reference is made to working to include such disorders in DSM-V, there is a persistent bias in the book toward addictive nomenclature. In fact, the concept of sexual addiction was considered by the DSM-IV work group on sexual disorders. Although the group felt that there was considerable scientific evidence for the existence of what could be characterized as excessive sexual behavior, they determined that there was not enough evidence to consider it addictive in the medical sense of the term. (Schmidt, Schiavi, Schover, Seagraves, & Wise, 1998). The authors also omit alternatives descriptions of sex addiction, such as that by Stein, Black and Pienaar (2000).

The audience that we recommend for this book use practicing clinicians and sexologists who treat or would be interested in treating patients who are sexually compulsive or “hypersexual” or their family members. This book is useful for acquiring information and awareness of some treatment strategies for patients with these problems. Overall, this book will be a useful addition to the library of clinicians who wish to enhance their knowledge in this area and to the medical and psychological literature, which is beginning to include what will undoubtedly prove to be a more significant problem than has heretofore been recognized. The book’s unfortunate bias towards only addictive and twelve-step models should be noted, however.