Compulsive-Abusive Sexual-Relational Disorders: A New Diagnostic and Clinical Formulation for Sex Addiction and Compulsivity

By Dr. Omar Minwalla, Licensed Psychologist, Clinical Sexologist 

The Institute for Sexual Health (ISH), June, 2015

The Sex Addiction-Induced Trauma Model proposes compulsive-abusive sexual-relational disorders as a new diagnostic and clinical formulation© for traditional concepts of sex addiction (SA) or compulsive sexual behavior (CSB).   The model emphasizes not only sexual and relational acting out patterns (behaviors alone), but also the associated dynamics of perpetration, violation and abuse of others (SAIP = sex addiction-induced perpetrations), and also those impacted and harmed by these dynamics and the consequent trauma and wounding (SAIT = sex addiction-induced trauma). This is foundational and important to any diagnosis and treatment model.  To ignore the ways one is abusive to human beings, and the ways one violates integrity and the human rights of others, as “non clinical”, is inadequate, if not unethical. Once recognized as clinical, then there needs to be a diagnostic and treatment methodology and clinical model that accounts for all of these complex dynamics, the problem sexual or relational behaviors, the abusive patterns of harm to others, and the trauma symptoms that result.

Modern Clinical Sexology offers the SAI Trauma Model as one such clinical management paradigm that provides both a diagnostic and treatment method for sexual-relational behavioral disorders (sexual compulsivity and sexual acting out patterns) as well as the associated dynamics of violation and abuse of human beings, stemming from factors such as developmental, personality and gender pathologies. Thus, it conceptualizes these problems on a spectrum of both compulsive and abusive conduct.   Thus, rather than traditional terms and concepts of sex addiction or compulsive sexual behavior, which omit and avoid abuse as pathology, the umbrella term of compulsive-abusive sexual-relational disorders is proposed.

The current DSM-5 (Diagnostic and Statistical Manual, Fifth Edition) does not include a diagnosis of sex addiction or compulsive sexual behavior, thus options are limited.  However, based on current DSM-5 options, the model proposes diagnostic consideration of a Specified Disruptive, Impulse-Control, and Conduct Disorder (code 312.89), which is described in the DSM-5. This is actually the most accurate and useful diagnostic conceptualization for what is traditionally argued as sex addiction or simply compulsive sexual behavior, neither concept recognizing conduct disorder (SAIP) as pathology.  This DSM-5 diagnostic code is a broad umbrella category, and describes a spectrum of disorders that potentially include three aspects of pathology; disruptive behaviors, impulse control, and conduct disorders.  This conforms and is congruent in many ways to the clinical understanding of compulsive-abusive sexual-relational disorders, as existing on a spectrum of problems related to a lack of control and/or abusive sexual and relational conduct, often resulting in significant harm to others.  The idea of a spectrum, and the significant overlap of both compulsive and conduct disorder, begins to approach a proper diagnostic concept of these complex problems, that must be considered in any eventual inclusion of an established diagnostic classification in the Diagnostic and Statistical Manual.

When it comes to actual diagnostic and clinical conceptualization of problematic sexual-relational patterns, a reliance alone on “the lack of control” is grossly inadequate and lacks accounting for pathology that causes abusive patterns that also require treatment. Harm to relationships; harm to self and others; and impact on global life functioning, all require diagnostic consideration and treatment, which means they are indicated criteria for inclusion in diagnosis and conceptualization of these problems. Patterns of overt and covert abuse that cause such potentially serious clinical trauma and long-term impacts on human beings and that violate human rights are pathology, and not health. This is established in the field, and thus it follows that pathology requires diagnosis and treatment methodology per clinical protocol.

Thus, the criteria of whether sexual-relational behavioral patterns are compulsive or not, while important, is not all that is important. That these behaviors and associated patterns are abusive and causing serious harm and violating human beings is also important and thus, needs clinical accountability, and a clinical method and process to address whatever is causing this harm. Thus, whether it is anti-social rage, masculine sexual entitlement and male peer collusion, or a compulsivity disorder, all require treatment, based on the fact that all involve patterns of abuse and harm to human beings, and based on this abusive conduct, and systems of perpetration, criteria for a compulsive-abusive sexual-relational disorder would be diagnosed as indicated.

An important and critical criterion of compulsive-abusive sexual or relational disorders is a deceptive, compartmentalized sexual-relational system in the context of intimate relationship. This indicates a significant abuse dynamic, that then requires proper clinical assessment and appropriate treatment for this form of abuse, which goes way beyond sexual sobriety alone, or simply stopping sexual behaviors.  To be able to deceptively violate a partner, children, and family system with a chronic and covert compartmentalization system that involves a secret sexual and or relational life, is a pathology that is more complex than “a lack of control of sexual behaviors”.  This criterion, a deceptive, compartmentalized sexual-relational system in the context of intimate relationship, indicates serious pathology, and treatment requires an understanding of developmental trauma (PTSD and CPTSD), attachment templates and patterns, and core gender wounds, that often contribute to adult personality disorders and/or adult gender pathology.

Personality disorders can and do often underlie sexual acting out and are often relevant to systems of deceptive and covert abuse and violation of an intimate partner and family system. This can include anti-social personality, narcissistic personality, schizoid personality disorders, dependent personality disorders and many other various personality features, traits or disorders, which often appear in the psychological tests of sex addicts seeking treatment. This is not always the case, however, and hence psychological testing is often indicated at the onset of treatment. It is not always narcissistic or anti-social templates that are underneath these problems, even though sexual acting out systems often include patterns that are behaviorally narcissistic and anti-social in description. But diagnostically in terms of personality pathology, there are many different types of variations and configurations that underlie sex addiction and compulsivity disorders or compulsive-abusive, sexual-relational spectrum disorders. Traditional models often may ignore evaluation and integration of personality pathology and reduce sexual acting out problems to simply an addiction, versus a symptom of possible personality pathology, thus becoming more complex than simply a brain disorder.

What is even less often described, but also highly relevant and an underlying contributor to sex addiction-compulsivity patterns is gender pathology, and for many men, masculinity pathology, (female sexual acting out related to “femininity pathology”).  For boys and men, this involves core wounds to male gender identity caused by developmental gender trauma (both personal and societal) that then contributes to the underdevelopment and maladjustment of gender formation, resulting in problematic adult patterns of masculine ego regulation, rage towards women and those vulnerable, poor ability for healthy emotional regulation, and the integration of core gender schemas and beliefs about sexuality, gender, masculinity, relationships, intimacy, family, and power, that is essentially abusive. Male abuse of others is related to socio-cultural contexts of power and gender, a psychology where masculinity is defined by externally based power and domination, thus sexual acting out and sexual entitlement over human rights being a symptom and expression of this underlying abusive gender pathology.

Healthy mature masculinity is not abusive to others. Healthy mature masculinity is not based in being one-up over girls and women, and masculinity does not need to be based in the domination or control of female flesh, our environment, or our humanity. What most people do not recognize clearly is that male violence against women is not the inevitable result of male biology or sexuality, but much more a matter of how society views masculinity and what boys and men internalize psychologically. Healthy mature masculinity is creative and generative, not abusive, by definition. It is not simply in masculine nature to be abusive, particularly as an adult.  Integrity disorders among men often have to do with the lack of healthy mature masculine development, based in the progressive and generational erosion of the mature masculine influence on male psycho-sexual development, which is necessary for healthy masculine psychological maturation.  Sexual acting out systems that involve deceptive compartmentalization in context of relationships are forms of an integrity disorder, not just brain disease, due in part to male socialization and the consequent profound normative psychological underdevelopment and maladjustment of masculine psychology.  Masculinity is past the crisis point now, in terms of yearning for the healthy mature masculine, and suffering the consequences of this serious erosion of the father archetype, leaving abusive boy psychology, to progressively become our normal concept and definition of masculinity and male sexuality.

Traditional conceptualizations of sex addiction as simply a brain disease like other addictions that do not acknowledge gender pathology as a significant reason as to why men (and women) may sexually act out, are missing a significant contributor to understanding sexual acting out concerns.   Gender pathology as an adult is related to gender-based trauma and core schema and scripts and ways of regulating gender-based ego, shaped by underdevelopment and core wounding to gender development. Men often act out sexually because of issues related to masculinity, inadequacy, gender drives and needs that are unmet and rendered unconscious, core gender wounds, and unconscious scripts based on immature and underdeveloped psychic scaffolding of masculinity, void of healthy masculine modeling, mentoring or healthy psychological development.  Sexual acting out is often a way of regulating masculine ego and gender-esteem, compensatory processing of aggression and anger, and the pathological acquisition of masculine ego states that often include dynamics related to power, control, safety, gender-based adequacy and worth, as well as attempts to contact and metabolize deep core gender-based wounds and trauma, etc.

Sexual entitlement over human rights as part of normative male socialization, is one significant example of gender pathology, that relates and contributes to deceptive, compartmentalized sexuality among men in intimate partnerships and family systems. In fact, a psychology where wives were property of men is deeply ingrained in our psyches and our sense of normal even today.  Thus, it follows that boys and men are socialized towards sexual entitlement over the human rights of the wife.  It was only in the 1980’s that laws changed in the United States that acknowledged that a wife could actually be raped. This idea confused us as a culture and people, and our traditional way of thinking.  So, men feeling entitled to deceptive, compartmentalized sexual and relational lives, is a patriarchal norm and tradition, and still very much part of male psychology and socialization and our collective psychology.  For this reason, we still have a difficult time acknowledging that a deceptive, compartmentalized sexual-relational reality in the context of intimate relationships and a family system is abusive versus normal biology or normal sexuality-based male behavior.  Sexual acting out problems are more than just a “brain disease”, sexual acting out problems are also a “gender dis-ease”.

Finally, sex addiction-compulsivity must be understood in a contemporary context of a global evolution in terms of the cyber-age. Cyber-technology are dynamics that are clinically relevant because they relate to deceptive, compartmentalized sexual-relational patterns and the profound shifts in human sexuality and human relating.  This human experience of change and shift and a deconstruction of traditional boundaries, socially, globally, inter-personally, and sexually – it has all changed and we are all metabolizing these dynamics.  This must be understood and taken into consideration as well in understanding modern day sexual acting out and relational problems.

Thus, a spectrum diagnostic concept of compulsive-abusive sexual-relational disorders, includes as a diagnostic criteria, dynamics of perpetration, violation and abuse associated with sexual-relational patterns, referred to as Sex Addiction-Induced Perpetration (SAIP) as well as the traumatic impacts and symptoms on victims, referred to as Sex Addiction-Induced Trauma (SAIT). Abuse equals trauma. One typically results from the other. A diagnosis and conceptual understanding of these dynamics of abuse and (covert) violence and victimization and complex trauma is not established as a norm in the clinical field, and thus requires specialized training and formulation. SAIP equals SAIT.   To acknowledge one, necessitates the acknowledgment of the other, because one results directly from the other by definition.

On this level it is important that the abuse (SAIP) is addressed, but also that the victims are recognized and provided clinical care and indicated treatment for sex addiction-induced trauma (SAIT) as part of clinical management. SAIT impacts not only the intimate partner, but also the acting out partner, the children and the family as well, etc.   The model is systemic and relational, and utilizes a “three plates spinning” metaphoric concept; the acting out partner, the partner/spouse, and the relationship as a separate, third entity.  The model asserts and emphasizes the importance of clinical coordination and congruence in models for clinical care between all three entities (or “plates”).  All three entities are impacted by SAIP and SAIT and will require immediate stabilization, etc.

There is a dire need for a more nuanced, differentiated, evolved and expanded clinical conceptualization of these problems. Modern Clinical Sexology proposes a Compulsive-Abusive Diagnostic Spectrum of Sexual and Relational Disorders as a way to assess, diagnose and then treat all these dynamics. This includes sexual-relational sobriety and behavioral containment, as well as the underlying contributors, often including personality pathology and gender pathology, in order to treat the violation and abuse of others. The forms of harm to others and patterns of abuse are recognized and understood as a clinical treatment priority and necessity from a sexual, psychological and relational health perspective.  It is important to be clear in both conceptualization and treatment, because these modern day problems constitute a form of domestic and interpersonal abuse, and a form of child, family, community and social harm.

Dr. Omar Minwalla, Licensed Psychologist, Clinical Sexologist, Founder of Modern Clinical Sexology and SAI Trauma Model

This information is the intellectual property of Dr. Omar Minwalla and The Institute for Sexual Health (ISH). June 2015. Compulsive-Abusive Sexual and Relational Disorders: DIAGNOSTIC and CLINICAL FORMULATION © JUNE, 2015