Lauren came to see me last year, describing sexually compulsive behaviour that had begun seven years previously, when she was 17 and became aware she was attractive to men. She had a long-term boyfriend, but she was not faithful. Her drinking and drug-taking were excessive. Three to four times a week, she picked up young men in pubs and clubs and had sex with them, in alleyways, cars, toilets, and in her bedroom at home. There was nothing in the experience of sex itself that was pleasurable for her; there was simply a powerful compulsion to get a man into bed. She would awake hungover the next day, filled with feelings of repulsion and contamination, and distressed that she had done it again. She could make no sense of these behaviours; she desperately wanted to stop, but could not.

Lauren is a composite portrait, typical of many of the clients I have seen with similar problems.

Controversy surrounds the idea of sex ‘addiction’. The influential American Association of Sex Educators, Counsellors and Therapists (AASECT) does not recognise sex addiction or porn addiction as a disorder. It states that ‘linking problems related to sexual urges, thoughts or behaviors to a porn/sexual addiction process cannot be advanced… as a standard of practice for sexuality education delivery, counseling or therapy.’1 I have taken to using the words ‘addiction’ and ‘compulsion’ interchangeably, although I favour the latter term. There is no doubt for me that some men and women struggle with compulsive sexual behaviours. These behaviours are, in my view, distinct from consensual, informed, consciously undertaken sexual activities, or infidelity, or having a high sex drive. The sexually compulsive person feels driven to have sex, or look at porn, or seduce someone (anyone), usually in response to difficult feeling states. They are preoccupied with sex, or seduction, and can experience states of intense sexual arousal in anticipation. The sex itself, however, does not make them feel good about themselves. It does not meet their needs in the way their anticipation and fantasies suggest it might. Over time, these behaviours can become hugely destructive to emotional wellbeing and, in the case of the women I have worked with, physically dangerous too. Contrary to what people may believe, sex addiction really is not that sexy.

While there is plenty of literature addressing the presentation in men (see, for example, Patrick Carnes and Rob Weiss in the US; and Thaddeus Birchard and Paula Hall in the UK), there is far less focus on sexually compulsive women. In the US, Alex Katehakis and Marnee Ferree have written specifically about women. Here in the UK, Paula Hall has called for more home-grown exploration of sexual compulsivity and addiction. I have found that the research of Manpreet Dhuffar2 and Fiona McKinney3 offers a sensitive and cogent insight into women struggling with these behaviours, and the issues that can arise in the work with them.

Women and sexual compulsivity

Women’s stories of problematic sexual behaviours are hidden, obscured by dominant narratives about female sexuality that conceptualise them in derogative ways: a mess, ‘fucked up’, damaged and dangerous. When a woman appears out of control in a social situation, uses alcohol and drugs, and/or disappears to have unsafe sex with strangers, the idea that there is a sexually compulsive behaviour going on is probably not considered.

I feel a fierce resonance with women who struggle with compulsive, out-of-control sexual behaviours, in part because I recognise something of myself in them, but also because I believe their conflicts reflect the profound difficulties women can face in trying to ‘realise’ themselves in a complex, contradictory, patriarchal social system. Dominance and submission play out in sexuality in myriad ways, both positively and negatively, and are often a theme in the sexual encounters craved by the women I see. As Michael Bader writes:4 ‘The answer to the question of how patriarchal gender roles create adults who derive intense sexual gratification from acting out [dominance and submission] in bed lies in the complicated ways our minds internalise social expectations and make them our own.’

Compulsive behaviour is the consequence of impulsive attempts to deal with uncomfortable and painful feelings. If a ‘sex addict’ is feeling sad, or lonely, or bored, or in emotional pain and despair, planning – often in a very ritualised way – and then carrying out the preferred sexual behaviour will temporarily alleviate it. The planning is often the most pleasurable part of the process. The sex itself is often mechanical, functional and disappointing; if euphoria is present, it is short-lived. Self-loathing and shame resurface as the arousal chemicals subside in the brain. Mark Lewis, a cognitive neuroscientist in recovery from substance addiction, argues that this is because dopamine, thought to be a major protagonist in the drama of addiction, is the neurochemical of desire, not pleasure. It creates the feeling of wanting; the thought of not therefore having is unbearable.5 This drives us to seek an intense experience, but it does not deliver the euphoria of a job well done. Over time this process cements itself into the neural pathways of the dorsal striatum, which is responsible for compulsive activities – activities requiring no thought or reflection, just compulsion. It is powerful, and it is not pleasurable. ‘Addicts’ are enslaved by this neurological process. There is a ‘deadness’ to compulsion, a lack of vitality.

Psychoanalytic theory can illuminate the self-harm apparent in acting-out behaviours. Marcus West describes a primitive ‘collapse and submit response’, in which the individual ‘becomes in thrall to the experience of death, which they cannot bear, yet from which they find it extremely difficult to escape’.6 In submitting, a woman hands herself over to the other ‘as a capitulation, as a surrender to their fate’, no longer able to struggle against the other’s overwhelming power. West suggests this pattern can become incorporated into the personality as ‘submission in the hope for protection and care’, which leads to a disavowal of ego-functioning, reinforcing the exposure or vulnerability, and leaving the woman powerless and trapped. This torment is nonetheless preferable to the dangers of abandonment.

Betty Joseph describes such ‘patients’ as having suffered early relational trauma – a lack of ‘warm contact and real understanding’, or a violent parent, emotionally or physically.7 ‘In the transference one gets the feeling of being driven up to the edge of things… potentially depressive experiences have been felt by them in infancy as terrible pain that goes over into torment [and] they have tried to obviate this by taking over the torment, the inflicting of mental pain onto themselves, and building it into a world of perverse excitement, and this necessarily militates against any real progress towards the depressive position… It is very hard for our patients to find it possible to abandon such terrible delights for the uncertain pleasures of real relationships.’

Lauren’s story

The women I have worked with have all had an immense impact on me. They stay with me outside of sessions. They make me feel about them. They are powerful and vivid, but also intensely vulnerable. Each has described a need to ‘push’ something when they have engaged in risky sexual encounters, and this often takes the form of violent, submissive sex with strangers or with partners they know are harmful to their wellbeing. This is not the negotiated, consensual power exchange of BDSM,* but exposing themselves to coercion and danger. It is as if they can only ‘find’ themselves through turbulent states of mind. Often there is identifiable trauma – childhood chaos and relational trauma, unnamed abuse or sexual assault – and significant problems with emotional regulation. Powerful feelings escalate fast and the only option appears to be an equally intense acting-out behaviour. I perceive in this a need to be embraced, to come alive, to find their shape. As Jessica Benjamin writes:8 ‘The desire to inflict or receive pain, even as it seeks to break through boundaries, is also an effort to find them.’

Lauren’s family history was chaotic and fractured by addiction and multiple, open parental infidelities. Her relationship with her mother was fraught, volatile, sometimes violent, and enmeshed. Her father watched pornography with her and brought women home for sex on a regular basis, with no discretion or sensitivity to how Lauren might feel. Her parents separated when she was nine. Lauren reported feeling unbearable emotional pain throughout this period, but, on the instruction of her mother, she told no one what was going on. This created a sense of deep shame about ‘having feelings’.

At the age of 14, at a party, she felt unable to say no when a man of 25 demanded oral sex. Afterwards, he offered her money, which she refused. She felt ‘indescribable’ revulsion and showered obsessively for days. At the age of 19, she charged a man for sex for the first time. She felt she had sunk to a new low and tried to get her act together. She found herself a job in an office, but would show up late, wretched and hungover, or drink too much and behave badly at work social events. Her boss, a man 20 years older than her, appeared to be taking her under his wing, but was in effect grooming her. She developed a powerful infatuation with him, during which she experienced episodes of arousal so strong it felt unbearable. She began an abusive relationship with him. He was overbearing and controlling, and would hurt her when they had sex. Lauren experienced this as annihilating to her spirit and soul, but it also felt in some way ‘right’. She told me she knew he would ‘destroy’ her, but that there was an inexorable sense of destiny to this relationship.

McKinney argues that sexual compulsivity in women shares ‘features of addiction, deliberate self-harm, borderline personality disorder and trauma’.3 It is a potent combination and, clinically speaking, working with these clients is not for the faint of heart. I found it very hard indeed to listen to Lauren’s story.

She described being triggered into overpowering arousal by obsessive attachments to dysfunctional men, and experienced violent sexual nightmares if she could not act on her sexual compulsions. She was bright, funny, attractive and had so much going for her. However, she could not hold onto any sense of self-worth. She was lost and vulnerable. She made bold statements that she only had sex with men she hated. Sex was about hatred – of herself, of the men she could seduce so easily, of the sexual double standards to which women are subject. Being sexually predatory and objectifying men made her feel powerful, for a time. This complex combination of feelings perhaps reflects the complexity of factors influencing this particular form of self-destructive behaviour: the cultural construction of ‘male’ and ‘female’ sexuality and gender power relations (the sociopolitical context); relational trauma in her family, and the impact of that on her ability to regulate her feelings and connect with others, and the shame produced by both.

Working relationally

My core training is in integrative psychotherapy. I tend to work ‘relationally’: that is, I subscribe to ideas around the co-regulation inherent in the therapeutic relationship – that we are mutually influencing and co-create the relational space, and that my material interacts with the client’s. I tend to be very attuned and empathic. I have undertaken training and personal work that enables me to connect therapeutically with others.

McKinney comes from a background in addiction treatment and found in her research that ‘treatment’ in the addiction field was often ‘limited to formulaic, task-focused cognitive and behavioural interventions, a top-down, directive approach’.3 The relational aspect of the work is less elaborated in the more behavioural models. I feel I can see why. There is an intensity to relational work that demands an ability to stay with the strong affect and sometimes disturbing and distressing material – a sense of volatility and unpredictability. ‘These are not difficult clients, but difficult treatment dyads,’ McKinney writes.3 Working from a more relational, integrative or humanistic stance, it can feel very hard to contain the volatile and potent affect triggered by close interpersonal contact. I also noticed that attempts to ground the affect by working with the body can also be derailed by what feels like the client’s hypervigilant sensitivity to having her body ‘controlled’ by an empathic other (as opposed to an abusive other).

Lauren could feel invaded by these interventions and become shy and reticent, or uncomfortable and snappy. She feared her body would betray her, and she would become overwhelmingly aroused. It was difficult for her to bear intimacy. She was accustomed to intensity, which is, as we know, not the same thing.

We may be eroticised or sexualised by the client, or find ourselves becoming aroused. Almost all my clients have described being seductive without realising it. It’s a procedural memory, suggesting sexualisation of the attachment system. I try, with varying degrees of success, to stay vigilant to enactments and collusions. The erotic transference that may enliven therapeutic alliances with clients who are not sexually compulsive becomes complicated in the relationship with a sexually compulsive woman – and, in my experience, more so than with a sexually compulsive man.

Conscious collaboration

I found with Lauren that it was empowering to work collaboratively to help her ‘think’ more about what was going on internally when she was triggered. At the clinic where I work, we use a containing framework for understanding behaviours and establishing bottom lines early in the therapy process, such as Hall’s ‘Cycle of Addiction’.9 Hall’s work is clear and instructive, and is enormously useful in terms of psychoeducation. I think working this way mediates the affect so it is more tolerable. When I have asked my female clients what they found most useful in helping them to stop on previous occasions, the answer has been ‘strict boundaries’. They do not want tenderness and empathy; they want something ‘strict’, something to ‘come up against’. This, in a way, echoes the ‘pushing’ of compulsive sex – Benjamin’s ‘effort to find their boundaries’,8 but it also, perhaps, expresses a disavowed longing to be held emotionally. They perhaps also feel their ‘locus of accountability and responsibility’ must be outside themselves, at least to start with. There is a need for the therapist to function almost as an auxiliary ego for a while, and fulfil a robust containing function. Arguably, the task of therapy is to help the client internalise this locus, so they can look after and regulate themselves, for themselves.

Early recovery is often fragile. With Lauren, over time, we began noticing that the energy and charge of her sexual activities was lessening. The behaviour patterns became ego-dystonic, and her increasing awareness of her emotional process made ‘acting out’ a far less attractive option. She began to empathise with others’ experiences of her when she was at her most florid, and to deal more directly with her shame. She began to grieve the loss of the bright hyper-reality of compulsive sexuality, but also to grieve more deeply for the confused and lonely child and adolescent she had been. Her relationship with herself began to change.

Escape from the ordinary

She also began to see how much she ran away from ‘ordinariness’ and the ‘everyday’. She was having to tolerate some boredom, without trying to ‘enliven’ herself with destructive or dramatic behaviours. Slowly, as the behaviours lost their grip, more of life became available to her – a moment of noticing sunlight sparkling on water, a feeling of hopefulness as she walked down the street, the pleasure of hanging out with new female friends. According to Lewis,5 new neural pathways associated with reward are building, while the pathways associated with compulsive sex are beginning to lose their power.10 In relational terms, she also learned that she defensively objectified herself and men when her pain got too great, and that she could call on the help of a growing circle of friends, or find other ways to soothe herself. Sometimes this worked and sometimes not, but we were moving in the right direction.

Esther Perel writes that ‘loving another without losing ourselves is the central dilemma of intimacy’.11 To truly engage sexually, we need to have a stable sense of self, so that we can let go of it for a while, and have enough trust in the relationship to be able to tolerate our partner letting go of us – so we do not need to ‘mask our ravenous appetites and conceal our fleeting need to objectify the one we love’.

I think the activity of therapy can be akin to the activity of having sex. We pay attention to all those signals that our clients hide or that escape their awareness, note what we feel in our bodies or observe in theirs, and sense whether they will allow us in or surrender to intimacy, or if they surrender too easily, or resist, or try to penetrate us instead. We notice the rhythms of interaction, where there is tension and where there is flow. Therapy, like sex, is profoundly exposing and profoundly intimate, and sometimes a bit messy (if you’re doing it right). Where there is mutual trust and respect, and the capacity for recognition, both activities can be vital and restorative. The bedrock of a positive, rewarding sexuality is a good-enough relationship with a partner but, more cogently, also with one’s self, and I believe there is much we can do to help ourselves, and our clients, achieve this.

*The term BDSM includes bondage and discipline, dominance and submission, and sadism and masochism.

Sophie Livingstone is a psychotherapist and supervisor in private practice, and a psychosexual and relationship therapist at Innisfree Therapy, a sex-addiction treatment centre in central London.


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