My interest in this field was awakened in 1984 when I read the book Sexual Addiction (since renamed Out of the Shadows: Understanding Sexual Addiction) by Patrick Carnes, Ph.D. However, I didn't act on anything I read until I was challenged by the patient I met in 1990. Involved in a fatal attraction romance, he was in his second such affair. His wife was willing to stick with him if they left Phoenix to get away from his obsessive sexual partner. He took his family to Norfolk, Virginia, thinking, "She will never find me there." However, on the day he told me about his problem, guess who moved in across the street! Obviously, his was quite a powerful addiction, and I was not prepared to treat it; furthermore, there was not anyone else nearby who was qualified. Before he came to see me, I had already noticed an advertisement for a conference on sexual addiction at the University of Minnesota, conducted by Dr. Carnes and his colleagues.

After attending the conference, I started a men's sex addicts support group for patients who came to weekly meetings. They saw me individually once per month and attended SAA (Sex Addicts Anonymous) meetings. Later, we added a counseling session for couples and encouraged the partners to attend COSA (Co-dependents of Sex Addicts), a Twelve-Step recovery program for the partners of sex addicts. Many patients gained freedom from sexual obsession, just as similar treatment helps alcoholics gain freedom from the craving to drink.

Becoming more and more involved in sexual addiction therapy, I sought to attend as many courses and conferences as I could on sexual addiction therapy, leading to my becoming a member of the National Council on Sexual Addiction and Compulsivity (NCSAC). This organization is pre-eminent in teaching counselors about sexual addiction recovery through its journal, Sexual Addiction and Compulsivity, the Journal of Treatment and Prevention and its National Conference.

The next conference, which is the 9th Annual NCSAC conference is entitled "Turning Sexual Tragedy into Triumph," in Atlanta, Georgia on May 4–6, 2000. Of special interest to counselors is the intensive training institute, which begins the conference, and the Cybersex Symposium, which runs throughout the day May 5th. Twenty-seven additional concurrent workshops on May 5 and 6 will present extensive information on this newly emerging field.

The NCSAC also has published a number of position papers, one of which is the paper on "Sexual Addiction," defining sexual addiction as "a persistent and escalating pattern or patterns of sexual behaviors acted out despite increasingly negative consequences to self or others." The paper also lists some compulsive behaviors indicating sexual addiction that may become repetitive: "masturbation, simultaneous or repeated sequential affairs, pornography, phone and cybersex, multiple anonymous partners, unsafe sexual activity, partner sexualization and objectification, strip clubs and adult bookstores, prostitution, sexual aversion." The position paper on sexual addiction also notes that sexual addiction resembles other addictions in these ways:

• Family background of addiction.
• Lack of nurturing and other forms of emotional, physical or sexual trauma in childhood.
• Multiple addictions co-exist; the consequences are progressive and predictable.
• Addicts tend to minimize the consequences and tend to blame others for these consequences.

The evaluation and treatment of sexual addiction mirrors that of chemical dependency. Both addictions are associated with compulsive behaviors, which do not stop even when the behavior creates loss after loss. These losses can affect many compartments of one's life and in respect to sexual addiction, losses in the interpersonal area create isolation and emotional distance from loved ones, which then results in loss of friendship and family relationships. There are also emotional losses, such as boredom, pronounced fatigue and despair, which build as the addiction progresses. There can be a number of physical losses, such as genital injury, sexually transmitted diseases, and even some sexual activities that can result in serious physical wounding or even death. Many sex addicts incur legal losses, especially those that are into exhibitionism, voyeurism, prostitution, child pornography and sexual harassment. Indebtedness can be enormous with the cost of cybersex, phone sex and multiple affairs.

Sexual addiction represents the acting out of sexual fantasies, showing that the condition exists primarily in the mind as obsessive sexual thought. Dr. Carnes describes a cascade following the obsession as ritual, sex act and despair, which can be overwhelming, but in the early stages is not recognized as being directly related to the sexual addiction. The patients are often unable to relate the despair they experience to sexual addiction, in part because they live in a society that tends to normalize such behavior. The therapist must show them the course and point out that the despair is a manifestation of withdrawal. All addictions have two effects: the primary effect, which is sought, usually stimulation in sexual addiction, followed by the secondary effect, the opposite of what is sought, withdrawal, played out in this case as despair. The despair can last for weeks or months, even when acting out has stopped. The addict, of course, attempts to rid himself of the despair by further acting-out.

Although the sex addict will use the language of love to describe his or her activity, that person is actually deprived of knowing the meaning of love. Addicts are more lust than love oriented, and as a result they are not able to recognize the essence or true being of their sexual partners. Sexual addiction therapy involves not only helping the patients to recognize the disease and get help for it, but also to provide education in learning what intimacy is all about. In fact, bridging the gap from sexual acting out behavior to a life of intimacy often means a period of sexual abstinence. Although the idea of abstinence is fearful to the sex addict, as he or she gains in recovery, the wisdom of shifting the focus from outside self to within becomes clear; the addict is gradually getting to know himself or herself better. Abstinence helps addicts see how they used sex to medicate and avoid genuine feelings.

Sex Addicts Anonymous, Sex and Love Addict Anonymous, Sexaholics Anonymous and Sexual Compulsive Anonymous are some Twelve-Step sexual addiction self help groups, each with a slightly different approach. Sex and Love Addicts Anonymous for instance, addresses "love addiction" as well. A useful complement for the Twelve-Step recovery programs is Recovering Couples Anonymous, in which both relationship partners work on a Twelve-Step recovery program with other couples. There are two support groups for family members of sex addicts, Co-Dependents of Sex Addicts and S-ANON.

NCSAC membership brings not only the journal but also the opportunity to be listed on the web and receive information about the National Conference. Regional NCSAC groups are starting in various parts of the country. If you equip yourself with information from the available resources, you will be getting off to a good start in this much needed and very rewarding area of addiction medicine.t

Dr. Michael E. Bohan is certified by the American Society of Addiction Medicine and the American Board of Internal Medicine. He presently serves on the medical staffs at several Virginia hospitals, having practiced in the Navy until 1982. He is Associate Professor of Internal Medicine at Eastern VA Medical School, serves on the Board of Directors of NCSAC and APTNA. His publications include Propoxyphene Withdrawal With Clonidine in the American Journal of Psychiatry, 1983. You may contact Dr. Bohan at Meridian Psychotherapy, 4616 Westgrove Court,Virginia Beach, VA 23455 or phone 757/464-9520.

Resources
For further information contact NCSAC — The National Office, 1090 Northchase Parkway, Suite 200 South, Marietta, GA 30067 or by calling 770/989-9754. Information about the Twelve-Step based programs and other resources can be obtained through the NCSAC website at www.ncsac.org.

Patrick Carnes, Ph.D. (1-800/621-4062) and The Meadows bookstore in Wickenburg, AZ (1-800/632-3697), offer a number of educational programs for therapists, including the "Sexual Dependency Inventory" prepared by Patrick Carnes, Ph.D. and David Delmonico, Ph.D. This inventory provides history of the types of sexual compulsivity and the losses created by these types of behavior. It can be ordered from The Meadows bookstore. Dr. Carnes has a number of books and videotapes on sexual addiction recovery, available through the Gentle Path Press at 1-800/955-9853. Of special interest to the partners of sex addicts is the book Back from Betrayal: Recovering from his Affairs by Jennifer Schneider, a Ballentine book. Two useful resources for women and sexual addiction are the book by Charlotte Kasl, Women, Sex and Addiction and the Women's Sexual Screening Addiction Test by Patrick Carnes, Ph.D. and Sharon O'Hara available at www.sexualrecovery.com. This website also contains a screening test regarding sexual addiction for gay males.