Abstract
‘Sexual addiction’ is a clinically useful concept which, although not sanctioned by DSM-IV, enables a treating clinician to recognise patients who are tormented by their preoccupation with a variety of sexual behaviours (both paraphilic and normal) at great social, personal and economic costs to themselves and their families. As the case histories in this book so eloquently demonstrate, ‘Don Juanism’ and ‘nymphomania’ are just two expressions of a wide variety of problems which range from compulsive masturbation and financially ruinous addiction to telephone sex services, to the more sinister problems of exhibitionism and repetitive stalking accompanied by rape fantasies. The manifestations of sexual addiction follow a similar pattern to those seen in substance abuse, pathological gambling, over-eating and other addictive behaviours: the sufferer fails to control their behaviour, cannot respond to ever-increasing negative consequences and experiences all the emotional and behavioural concomitants of phenomena such as craving, tolerance, withdrawal and neglect of other important aspects of their life.
Dr Goodman's book provides some fascinating case material, a detailed consideration of some aetiological (particular psychodynamic) theories and a thoughtful discussion of the definitional problems inherent in the term ‘sexual addiction’ (including arguments for and against the use of the term itself). However, it does not live up to its claim of being a ‘serious and comprehensive text on the subject of sexual addiction’. There are a number of surprising and regrettable deficits, the most obvious being an extremely poor coverage of assessment issues: it devotes virtually no attention to matters such as special areas of the clinical interview (e.g. the psychosexual history) and the psychological testing and physiological and medical investigations.
Commendably enough, the book has a major focus on psychodynamic aetiology and treatment approaches, in an effort to integrate these with the cognitive-behavioural and pharmacological treatment modalities which have so dominated the area for the last 20 years. One justification for this is that psychodynamic theories are richer and more complex and, perhaps, give a better understanding of the character pathology that seems to underlie many sexual addictions. This, however, is not an excuse for neglecting other important theoretical considerations; for example, the technique of relapse prevention, enthusiastically espoused by the book, is itself based on a large body of theory which provides important and useful explanations of the relapse process and the connection between sexual fantasies and their acting out. This theory is not explained in the book. It is also disappointing to see that there is no mention anywhere of the legal and ethical issues which must inevitably be a part of working with patients with these sorts of problems.
Finally, there remains a lack of clarity as to what a sexual addiction actually is and, particularly, the thorny question of the relationship between sexual addictions and paraphilias. The author attempts to make a case for sexual addiction as a syndrome, rather than a symptom, by ascribing specific psycho-pathology to the sufferer, who seeks external (and ultimately unsatisfactory) resolutions for many complex intrapsychic dilemmas. The addictive process is primary, the choice of the behaviour or substance to which one is to become addicted is governed by situational and often arbitrary factors and, indeed, the comorbidity of the various addictions is high. In support of this thesis, the book relies heavily on the extensive psychoanalytic literature on perversions (roughly synonymous with paraphilias). Yet, as the author so rightly points out, perversions and sexually addictive behaviours are not the same; the DSM-IV definition of paraphilias focuses on the ‘what’ of deviant behaviours (e.g. sexual involvement with children or inanimate objects) whereas the concept of sexual addiction emphasises the ‘how’ (behaviour which is out of control, which persists despite negative consequences and which may involve preoccupations with ‘normal’ behaviours such as masturbation or consensual adult sexual activity).
This is an important point: in this reviewer's experience, many child molesters (for example) have excellent control over their behaviours, offend only when they are sure that they can avoid negative consequences and, in fact, do so for decades. But are these particular child molesters different (psycho-dynamically or otherwise) from those who might claim to be ‘addicted’ to their deviance? If so, how do we operationalise our definitions of behaviours which are perverse but not addictive? (Are ‘addicted’ child molesters simply those who are unlucky enough to get caught?) Are there treatment or prognostic implications in making this sort of distinction? The author seems to think that there are, but the exact nature of these implications is unclear. These sorts of questions should be at the heart of any attempt to define a ‘new’ psychiatric disorder such as sexual addiction, but unfortunately, receive only cursory attention.
This book is probably worthy of a space on a library shelf for its coverage of psychodynamic theories of perversion and some interesting clinical vignettes. However, if the reader is seeking a text which offers a truly integrated approach to sexual problems (perversions rather than addictions) and which goes further than the currently dominant cognitive-behavioural and organic paradigms, then a useful start might be Travin and Potter's Sexual Perversion: Integrative Treatment Approaches for the Clinician [1], itself recommended in Dr Goodman's book. Alternatively, for a general introduction to the whole area of sexual dysfunctions and their management in psychiatry, one still cannot go past the comprehensive and thoughtful coverage by Australia's own Professor McConaghy in his Sexual Behaviour: Problems and Management [2].