Sexual Compulsivity

Once a person has developed a taste for something the pre-encounter flush of dopamine is the most intense.  And this is what makes sexual compulsivity very different from ingesting a stimulant, gulping alcohol, devouring food or cutting one’s arm: it only takes a thought. No need to call a dealer, to spend money, to break a promise. – Greg Rowe

An old friend recently came to visit from out of the country. He’s someone I see rarely and with whom I know I can have long, curiosity-driven conversations about a variety of topics. I always enjoy his company.

We joined other friends and went to the beach – the sun was radiant, the waves brisk, the conversation playful. But there was something absent about him, he didn’t seem very interested in talking with me or getting to know my friends.

Suddenly he turned to me, flashed me his little mobile screen and said, “This is the guy I have a date with tonight”.

A beheaded, naked torso and crotch appeared before my eyes – and a little jolt went through me, a multi-determined jolt.

With hindsight- here’s what I think it was saying to me :

1 – Imposed upon – I don’t wanna see porn on the beach!

2 – Annoyed – You put online sex above me?, above our friendship?

3 – Titillated –  Ooooh that image was sexy.

4 – Relieved – Now I understand why you’re so “Not here”

My private practice is almost entirely made up of men –and some women — who have sexual compulsions -without any mention of it as a speciality on my Web site.

These folks experience porn, sexting, massage parlors and/or casual hook-ups as intrusive and destructive at times causing real life pain in one or all three of the beloved DSM IV realms: social, professional and family.

I have spent a lot of time reading and writing about this phenomenon. Clearly it is deeply painful. And at the same time I read powerful arguments written by esteemed colleagues who say it doesn’t exist. Others debate whether it is an addiction or not. The DSM V team chose to include online gambling but not online sexual compulsions.

I’d like to share some of my thinking.

According to a Stanford neuroscientist I interviewed the brain scans millions of data in the environment for “that which will give me pleasure in the next 10 minutes”. This is called the “pleasure seeking” part of our brain; the moth seeking a light bulb.  The simplified version is that there are two parts of our brain that can stop the powerful pleasure-seeking behavior. 

These are:

• the “punishment avoidant” part of our brain and
• the frontal cortex, the part that allows us to project into time, to imagine outcomes, to sense what other people might be feeling.

How does the brain work?

Ironically the “punishment avoidant” part of our brain is not super reliable. It  communicates incredibly rapidly with the “pleasure seeking” part of our brain and,  like it, developed quite early in our evolution – no doubt pre-mammalian. Hence its only criteria for whether or not an organism seeks out pleasure is “How much energy will that take up? Enough to put the organism in danger?”

 If the answer is “no” it gives the go-ahead for the pleasure seeking- behavior.

Only the frontal cortex, the part of our brain that separates us from all other animals has the capacity to wonder about things like values, mores, customs, law, long term priorities, past commitments.

The pre-frontal cortex over-rides the rapid pleasure-pain dialog by asking questions such as:

• Is this a violation of a promise I made to myself or someone else?
• Will this have long term deleterious effects?
• Didn’t I already determine that I don’t think this is a good idea and that I only feel like crap afterwards?
• Or even something as simple as….Do I really have time right now just to do this a little before I need to be at work? (part of the executive function process that can go offline when the reward area is activated).

Alas – and here is the rub — having developed much later in the evolution of our species – it is far slower than the more limbic pleasure-punishment parts of our brain.  As therapists – the frontal cortex is where we have “leverage”, it’s the “muscle” we can help people develop. On the condition that the client agrees to cut off the easy flow of dopamine.  We can’t keep our clients from opening their laptop and turning to hot ads on a Saturday night, but we can help them explore, wonder, develop (and of course get praised for not opening up that damned laptop!).

Dopamine – a natural euphoric which actually represents a very small part of the brain cells but gets lots of press – is a powerful modifier of the human body. According to Daniel Siegel it changes –among other things– our heart rate, our body temperature, our mood, our decision-making capacity and what he calls our “moral compass”. The more a person repeats a behavior the more dopamine gets delivered.

It is the natural stimulant that we animals release into our brains when we see food, something sexually attractive or the possibility of a victory (Picture a stadium full of sports fans). We give it to ourselves when we encounter these things but –more intensely– we give it to ourselves BEFORE we re-encounter one of these things.

Once a person has developed a taste for something the pre-encounter flush of dopamine is the most intense.

And this is what makes sexual compulsivity very different from ingesting a stimulant, gulping alcohol, devouring food or cutting one’s arm: it only takes a thought. No need to call a dealer, to spend money, to break a promise. I worked with one client who during a very difficult period of transition was often dissociating when I asked probing questions. When I said “Where did you just go?” the response I got was that basically I had just been sexualized. It’s that easy.

I also think it’s important to consider the supply side of the equation: i.e. what is “out there”.

We all know how the internet coupled with cellphones bearing the capacity of last decade’s desktop computers has transformed our banking, travel, shopping and entertainment habits. It would be naive to imagine that the same revolution is not happening with sex.

Take a twirl on Craigslist’s “Men Seeking Men” (after clicking past the warning link sending you to SF’s “Clap Clinic”). Once in a while you might come upon someone looking for a long term relationship but most of the time the photos – rivaling any porn mag from the 1990’s – are coupled with frank explicit sexual requests and plenty of consenting adults eager to meet those requests with a simple click.

Visit xtube.com where home-spun porn reigns for free. These are far from the Playboy magazines dad used to hide under his bed.

Read about “grindr”, the telephone app that allows you to see where someone sexually available is geographically located like an efficient GPS for hot times.

For someone sexually available in today’s IT world it’s hard to imagine how they might get any work done!

I find that – like with many substance addictions – there is clearly a pattern of comorbidity amongst folks who use sex compulsively. ADD, anxiety disorders, PTSD, and substance misuse in a family of origin – are those I see most frequently.

But without such a stark clinical picture there are many situations when using porn and prostitutes just makes a lot of sense:

• A 24 year old recent college grad who can’t find work, identifies as socially awkward, isn’t feeling terribly confident and finds dating daunting.
• A 35 year old corporate player who can’t seem to find a spark with his wife, spends lots of time in hotels and airports with a laptop, feels pressured to produce more and more in the downturn and though outwardly is champion of his team inwardly feels inadequate and judged.
•  A 40 year old whose parents divorced early and never got along. Who always felt like an outsider, can’t seem to meet that special someone and spends weekends prowling for one off casual sex.

Unlike the difficult ambiguous dark waters of navigating a career, a long term relationship with real intimacy or just the ups and downs of life, porn, prostitutes and casual sex mostly  deliver on their promise to be predictable, soothing and non-committal. They are as reliable vectors of a pleasant altered state as a good stiff whisky or a hit of marijuana.

So to get back to the moment on the beach: My friend was in an altered state. He was less available to me because he was under the influence of pre-encounter dopamine levels. Just a flash of his small screen gave me a small dose of pre-encounter dopamine – taking me out of my blissful, half asleep beach state. And the result was –in my opinion– that we missed the opportunity to  be in the moment together – to enjoy our friendship in a more connected way.

For more information: download my WhitePaper on Sexual Compulsivity free on my web site.