There are several types of addictions that can affect a person in their lifetime. These addictions can range in type, form, and level of impact on the individual’s daily functioning, from process addictions to behavioral addictions. Sexual Addiction, also known as hyper-sexuality or sexual compulsive behavior, is a relatively unknown addiction. Sexual addiction is a behavioral addiction^[1] that is defined by Barrilleaux^[2], as a “persistent and escalating pattern of problematic sexual behavior, repeated over and again, despite negative consequences to self and others”.

  Approximately 17 to 37 million Americans struggle with sexual addiction^[2]. The combined number of gambling addicts and those who have eating disorders are fewer than those who have a sexual addiction in the United States^[2]. The large number of individuals dealing with sexual addiction reveals the relevancy for additional empirical research, diagnosis understanding, and educational training for clinicians^[1].

  Hughes (2012) explains that some of the main characteristics of the sexual addiction are “intense sexual urges, recurring fantasies and out of control sexual behavior”. Sexual addiction has become a major concern in the therapeutic realm because of the increased education of the addiction and the rise of sexual addiction cases in clinical settings. This review discusses several topics present in the conversation about sexual addiction as reviewed in the literature, including sexual addiction and its relationship with: trauma, attachment, mental health, pornography, relationships, and recovery/treatment.

Previous Experiences
  Previous trauma, life experience, and poor attachment styles have been shown to be precursors for this sexually addictive behavior. Out of Control Sexual Behavior (OCSB) has been studied as a defense mechanism against conflict and anxiety that individuals may exhibit when they are unable to form secure attachments with others^[3]. Further, Crocker (2015) also reported that these out of control sexual behaviors may be an attempt at affect regulation, possibly resulting from insecure or avoidant attachment with a caretaker or parent in childhood. These actions that occur in childhood greatly impact the rest of the individual’s life. Relational and sexual schemas develop in children around the age of puberty which, lasts throughout their lifespan as they meet and start new relationships^[4].

  Other childhood experiences have also had implications on the future sexual behaviors of individuals such as childhood sexual trauma. In regards to sexual offenders, incidents of Adverse Childhood Experiences (ACE) are found in this population at higher rates than the average male population^[5]. Sexual behaviors increase with life stressors, depression, and anxiety, and may be the result of childhood trauma^[6]. Delboy (2015) also noted that loneliness may be a trigger for this abnormal sexual behavior.

  “Molestation in childhood can make a unique contribution to sexually abusive behavior through a number of avenues: compensation for feelings of powerlessness, social learning by which individuals model their own abuser’s behavior and distorted thinking, or through the association of sexual arousal with adult-child sexual situations,”^[5].

  Wilson and Widom (2008) explored the reactions to childhood sexual abuse; this list includes “sexual inhibition, sexual avoidance or aversion, low desire, and vaginal or pelvic pain, sexual dis-inhibition, compulsive or impulsive sex, risk-taking sexual behaviors, and numerous sequential or simultaneous sexual partners.”

Linkage to Mental Health
  The review of the professional literature supports that sexual addiction is, majority of the time, combined with another mental health diagnosis^[7-9]. According to Rosenberg, Carnes, & O’Connor (2014), disorders related to sexual addiction could be, “affect dysregulation, depression and anxiety, impulsivity, loneliness, low self-worth and insecure attachment styles, personal distress, risk-taking behaviors such as substance abuse, and self-hatred and shame”.

  Because of the linkages to other mental health diagnoses, it can be difficult for a clinician to correctly diagnose and treat sexual addiction.

Addicts’ Use of Pornography
   In a specific study by Young^[10] (2008), one participant reported “Every time I felt stressed with another deadline at work or assigned a new case, I relaxed by looking at porn sites”. Access to the internet may contribute to sex addictions as it may be easier, more convenient, and, perhaps, more private than without internet. Pornography allows the addict to indulge in their fantasies without having to interact with others. This behavior becomes particularly concerning when the addict secludes him or herself and becomes consumed in their addiction. A study conducted by Short, Wetterneck, Bistricky, Shutter, & Chase^[11], (2016) suggested that youth and adult clients reported using pornography as their most frequent presenting problem. Cavaglion^[12] (2008) examined participants (N = 302) who sent over 2,000 messages to each other in this anonymous self-help online forum for individuals with cyberporn dependency. The group motivated each other and the group itself became a replacement addiction for some. One of the foci of this group is that those with the cyberporn dependency need to see that those individuals in the media portrayed may be suffering too, in hopes of creating more positive attitudes in the participant’s overall mental and emotional states^[13].

Sexual Addiction’s Impact on Couples
  Sexual addiction can affect couple relationships by violating boundaries, creating trust problems, and causing intimacy issues^[13-15]. They also found that the intimate relationship is not only the most vulnerable to addiction, but it can also be a place of security and strength, conducive to recovery. Interventions that include both partners tend to be more successful, especially when the underlying cause of the addictive behavior is being treated^[15].

Treatment and Recovery
  Many case studies have been conducted to help therapists understand how to treat and help people recover from this addiction. Multiple studies show that individual and group therapy are successful in treating sexual addiction and are the most common^[12]. Though individual and group therapy are frequently utilized for treatment there are many more interventions that are used such as “cognitive behavioral therapy, dialectical behavioral techniques, psychoanalysis, family therapy, motivation training, 12-step and peer-support programs, self-help, diet and exercise enhancement, and psychopharmacology”^[15]. Other forms of treatment and recovery plans are the use of meditation, Eye Movement Desensitization and Reprocessing (EMDR), Acceptance and Commitment Therapy (ACT). Because of the similarities to other addictions, sexual addiction has become easier to treat.

  Much unknown about sexual addiction and this creates uncertainties when conducting research. Another interesting factor noted is that a practitioner may not seek out the symptoms or diagnosis for an individual due to their lack of knowledge and awareness about sex addiction^[12]. Sex addiction is becoming more prevalent in today’s society; therefore, it is imperative for social workers to be educated and readily able to recognize the symptoms of this epidemic.

  The authors have completed a SLR using keywords [social work + sexual addiction + intervention]. Ten articles were found and used from the SLR and were chosen by: publication years 2006 - 2016, peer-reviewed, English, adult population, specific databases chosen, and face validity. As this is an exploratory study, this review has no hypothesis. The purpose of our SLR was to make it known to the social work profession, and other related professions, that sexual addiction is a rising concern. Those who have a sexual addiction are not being recognized because there has not been enough research to properly diagnose or treat. There have been many methods of treatment tested and found to be beneficial to those with a sexual addiction, however the research is still lacking in the social work profession. Social workers must become more familiar with this addiction, so that they are able to practice within their scope as this population continues to rise.

Methods

  For our research, the authors used the Cochrane systematic review model. The Cochrane model, which is considered to be the highest standard of review, is an internationally recognized model of systematic reviews of primary research within the human healthcare and health policy fields. A Systematic Literature Review (SLR) is a way for reviewing all the data and results from research about a particular question in a standardized and systematic way in order to minimize bias. Only literature that meets the criteria set by the researchers is included in the systematic review^[16].

  In order for a literature review to be considered as ‘systematic,’ it must meet specific criteria; that the review is based on clearly formulated questions, identifies relevant studies and appraises their quality, and summarizes the evidence by use of explicit and systematic approaches that differs from traditional reviews and commentaries. As shown in Tables 1, 2, 3, and 4, the authors were able to show the methods used in finding the research articles their systematic literature review incorporates as well as, which articles were selected for this study, which articles were excluded from this study, and the reasons why these articles were included or excluded^[16].

Table 1: Literature Review Matrix for References.

Table 2: Synthesis of Keywords for Systematic Literature Review (SLR).

Engine Searches: PsycInfo, Education Research Complete, Soc Index, Social Work Abstract, psyc ARTICLES

Table 3: Exclusion Table.

Table 4: Synthesis of Key Articles for the Systematic Literature Review.

Framing questions for review
  This Systematic Literature Review (SLR) uses the Cochrane Systematic Review model to carefully analyze and evaluate literature surrounding social work interventions on sexual addiction. A SLR uses methods to collect and critically analyze literature that has been previously researched on the topic or research question. The research question for this SLR was “How many articles are there in the professional literature [PsycInfo, SocIndex, Education Research Complete] regarding key words [sexual addiction + social work + intervention] in the last ten years [2006 - 2016] using a systematic literature review?” Three key words were used to conduct the literature review, Social Work + Interventions + Sexual Addiction (see Table. 2). The search was conducted using five different databases: Psych Info, Education Research Complete, Psyc ARTICLES, Social Work Abstract, and Soc Index with full text.

Identifying relevant work
  The literature found that was relevant to the research question using the three key words and five search engines were compiled into a research matrix (Table 1). Articles (N = 192) to (n = 10) were deducted by using face validity, only including germane research conducted from 2006 - 2016 and applying limiters to the search (Table 2). When identifying work that fit the criteria, the relevant research themes identified were: sexual addiction DSM-V terminology and definitions, previous history of the individual, linkage to mental health diagnosis, use of Internet Pornography (IP), sexual addiction’s impact on couple relationships, and sexual addiction treatment.

Assessing the quality of studies
  The authors reviewed the remaining articles after applying the limiters outlined in Table 2. The remaining articles were thoroughly assessed using face validity, or how well these articles related to the research topic. Any article that did not have the key term “sexual addiction” in the title, or relevant to research themes that could have potential benefit to our topic were excluded (as seen on Table 3). The studies quality was determined by the conditions set in the Cochrane method. The data set was limited to scholarly peer-reviewed articles published between 2006 and 2017 that related to sexual addiction with specific regards to social work interventions (as seen in Table 1).

Summarizing the evidence
  As shown in Table 2, there is limited research available on the topic of sexual addiction and social work focused interventions. After conducting a test for face validity, only ten articles were found to be relevant to the study. These 10 articles are summarized in Table 4 to provide an overview of the key findings. Although the research available is limited, common themes were illustrated throughout the articles.

Interpreting the findings
  The findings of these articles provide evidence for, and demonstrate common themes, that sexual addiction is influenced by past childhood trauma, sexual abuse, substance usage, and the use of pornography and the internet. The authors documented these themes and key points in the literature review sheets. These articles were organized in Table 4, and used to derive the findings for this study.

  The articles chosen came primarily from journals focused on social work and sexual addiction. In order to reduce bias, the authors used a variety of databases and journals, whose focuses included psychology, community health, substance usage, offender counseling, human behavior, childhood sexual abuse, trauma, and therapeutic approaches for marital, couples, and sex. Articles were limited on language (English), but not limited to those only in the United States as to provide a larger dataset. With the language limiter set on English, the total number of articles did not change. However, the small amount of available data suggests a lack of research in this area.

Results

  As seen in Table 2, the initial database search results yielded (N = 192) articles, using only the keywords social work, sexual addiction, and intervention. Using a systematic approach to assess the quality of the articles, we reduced the number of articles to those that met our specific criteria of sexual addiction. After limiting the articles that were scholarly peer-reviewed, the number of articles decreased to (n = 161). The articles were reduced further, (n = 110) after limiting publication date [EU1] [C2] to only include articles published on or after 2006, and that were published in English. The articles were further reduced when we put ‘social work’ as a search term in quotations, (n = 83) and when duplicate articles were eliminated (n = 61).

  Using face validity, we eliminated an additional 51 articles, which were excluded because they did not fit the criteria set, the key terms, or were relevant to our research themes, resulting in 10 articles that met the criteria. The criteria were established by the four MSW student researchers were that the title of the journal article or the abstract needed to include the term sexual addiction. There may be evidence to support the themes mentioned earlier in the paper, that sexual addiction is influenced by past trauma, poor attachment styles, is impacted by using pornography and the internet, affects the sexual addict’s quality of future relationships. Treatment methods often differ, but individual and group therapies are the most common and successful. These themes were used to formulate the results and direction of this research.

  Table 1 included information from the articles found in our preliminary literature review of sexual addiction, social work, and intervention. One hundred ninety-two articles were found when searching these key terms in the databases mentioned above. This table outlines the number of participants, activities used in the study, its research design, measures used, statistical analysis package used, and the outcome of the study. Table 2 includes each step of the keyword search process, with the limiters used and number of articles found for each search, beginning with N = 192 with no limiters, and articles found dating back to 1982, to six limiters used, and n = 10. The keywords remained the same throughout the literature review. Table 3 reflects the 51 articles that were excluded from our SLR and the reasons for each one as to why it was excluded. The criteria set for exclusion was that each article must include sexual addiction in the title or abstract. A theme found among those articles excluded was that they had a substance abuse component that was not included in the methodology of this SLR. Table 4 outlines the 10 articles chosen for this SLR, their purpose, the type of study they were, general comments by the MSW student researchers, and the strengths and limitations of each study.

Discussion

  Our research on sexual addiction started with a broad review of the literature and its connectedness with social work interventions. With the use of the SLR, our research revealed 10 articles relating to sexual addiction that fit our parameters. Using these ten articles we found themes, limitations, and reasons for social workers to become involved in this research while conducting the SLR.

Summary of Findings
  The purpose of this study was to evaluate the literature on social work and interventions as it relates to sexual addiction. The researchers summarized the findings after they categorized the articles into six themes: sexual addiction DSM-5 terminology and definitions, previous history of the individual, linkage to mental health diagnosis, use of internet pornography (IP), sexual addiction’s impact on couple relationships, and sexual addiction treatment. The themes are illustrated in Table 1.

Interpretation of Findings
  Looking mostly at psychology articles, the authors found that sexual addiction has been positively impacted by treatment linked to other addictions. Social work had very few articles on the topic of sexual addiction; however these articles, when found, were favored. The authors made an effort to look at many different themes while researching sexual addiction after completing literature reviews on relevant articles. This review confirmed the prevalence of sexual addiction in clinical settings and supported the need for additional literature and clinical education on sexual addiction. Additional research on sexual addiction is necessary for social workers to work in their scope of practice and to use evidence based research that will help clients create sustainable change. The articles chosen by the authors came primarily from journals focused on social work and addiction. Additional articles came from journals focusing in psychology, community health, substance usage, offender counseling, human behavior, childhood sexual abuse, trauma, and therapeutic approaches for marital, couples, and sex.

Limitations
  The American Medical Association defined substance addiction over 50 years ago and later defined non-substance addiction but failed to include sexual addiction^[2]. One limitation to studying this topic is that not every researcher agrees with one specific definition of sexual addiction, nor the criteria for this diagnosis. Sexual addiction was not added to the DSM-5 until a DSM task force advocated for its inclusion in the manual as a non-substance addiction. While there is generational research on sex and sexual behaviors, there is not much generational research on sexual addiction because of its general lack of understanding as an addiction and because of its unclear use of different terms or definitions in research. Another limitation may be the self-reporting data that is typically used in this type of research. A third limitation for this research on sexual addiction is also sample size of those the research was gathered from; many of the individuals studied in the literature review were case studies. These limitations were unavoidable in our sexual addiction research. Holosko (2006) specifically discusses how limitations impact research by not only their significance, but also why future research needed.

Application to Social Work Policy and Practice
  This information gathered on sexual addiction is pertinent to social work policy and practice because of the growing number of those with this specific addiction. The emphasis for social workers who may read this SLR is that this growing population will need guidance and treatment regarding their addiction, meaning social workers need to be able to not only see and evaluate symptoms of sexual addiction, but also provide effective treatment plans. Of the10 articles resulting from the SLR, only three were published in social work journals and only three articles spoke about policy. The lack of published research confirms that social workers need to complete more research on sexual addiction to implement policies and improve practice when working with clients with sexual addiction.

Social Work Policy
  Because there is so little research in the social work field on sexual addiction, there is a lack of policy pertaining to it. With more research, social workers could help solve the problem of sexual addiction before it even begins. Social workers should be advocating for sexual addiction and how they can use their skills to be a solution to the rising problem. If social workers were to take an interest in researching sexual addiction, there could be funding to start programs to help those who have a sexual addiction, or to educate youth aged children on how to avoid it. To, Ngai, and Iu Kan (2012) suggest, “policymakers need updated information about young people’s sexual attitudes, knowledge, and behavior to design quality and tailor-made sex education programs”. Social workers could help formulate a sexual education programs to teach adolescents in hope of preventing sexual addiction. Riemersma & Sytsma (2013) state, “Despite the many studies that have explored excessive sexual behaviors, little is known about socio-demographic, psychiatric, and psychosocial background of treatment-seeking self-identified sexually addicted individuals”. These are topics social workers cover in assessments every day, and could be used to find treatment options for those with sexual addition. Van Gordon, Shonin & Griffiths (2016) expressed the need for individualized treatment for specific symptoms or expressions of an individual’s sexual addiction. Without research on sexual addiction, there cannot be policy to aid in the preventative education needed in our country.

Social Work Practice
  Majority of the articles found during the SLR were published in psychology journals, not social work. Sexual addiction has been mostly overlooked in the social work field until the past few years. Many things are now sexualized in today’s society; movies, television shows, video games, commercials and advertisements, books, and music. Sexual acts have become normalized and accepted in America’s culture, which makes sexual addiction the least of anyone’s worries. Though sexual content is normative in our society, it is also a very sensitive topic. Many people do not freely share their sexual habits, making this addiction easily hidden and overlooked. Social workers are trained to identify a person’s natural defense mechanisms, and how to connect with a person to make them feel comfortable enough to let their guard down. Because sexual addiction is such a personal topic, social workers could use interpersonal skills to understand when the client is comfortable enough to proceed in treatment. Other professionals do not build the same rapport as social workers, therefore may miss the root of the problem of sexual addiction. It seems there is little research because it has not yet become a well-known issue to many professionals or the general public. Because society has become so sexualized, it becomes more difficult to see when there is an addiction. With proper training and education of the public and professionals, sexual addiction could be easier to identify. With easier identification comes help and treatment for those who need it.

  Sexual addiction impacts more people and gambling and eating disorders combined (Barrilleaux, 2016). This addiction can ruin families, employment, and every day functioning, just like any other addiction, so why depend on social workers for effective treatment? Social workers have successfully treated many other types of addiction; therefore, they could successfully treat sexual addiction as well. While psychologists and other helping disciplines limit addiction intervention to the client whereas social workers intervene with the client and their environment. This means social workers evaluate clients and how they relate with family, their community, their employment, and agencies policies. Many of the treatment methods described by the SLR articles focus on treatment methods used to correct other addictive behaviors such as alcoholism, gambling, and drug addiction. These treatment methods can include meditation, Cognitive Behavioral Therapy (CBT), and group therapy. Sexual addiction is impacting a substantial percentage of the population, and the rates are not slowing down. Social workers have a responsibility to their clients to recognize sexual addiction and be skilled in intervention. Social workers must be a part of the research, treatment, and policy implementation.

References