Welcome to Ask a Cleveland Sex Therapist. Want to ask Matt a question that could be tackled in a future column? Click here. Now, onto this week’s topic.
As an AASECT Certified Sex Therapist, I am trained to help my clients navigate the nuances of human sexuality. To help them break through the shame that sex negativity has fostered in themselves and their relationships. A piece of human sexuality that often gets mislabeled is what happens when it becomes “out-of-control” for an individual. Clients come into my office all the time telling me they’re a “sex addict” or a “porn addict.” They say it like a confession, as if they’ve done something dark and irredeemable. To some, maybe they have. But to most, that isn’t the case. Here’s the thing: “sex addiction” isn’t a real diagnosis. It’s not recognized by the DSM or the ICD, the two manuals that define and classify mental health disorders across the world. What that means is that no governing body in psychology, psychiatry, or medicine has found enough evidence or consensus to support sex addiction as a legitimate mental health condition. It’s a proposed idea, most of the time with good intent, that’s often based more in morality and shame than in neuroscience or psychology.
I want to get one this squared away: people can absolutely struggle with sexual behavior. They can harm themselves and their relationships in deep, penetrating ways that can lead them to questioning their entire sexual reality. They can use sex in ways that feel compulsive or misaligned with their values. I see it every day in therapy. But that doesn’t make them “addicted” to sex. It makes them out-of-control with their sexuality. Certified Sex Addiction Therapists (CSATs), on the other hand, do use that terminology, and how they approach working with people may not work for everyone. While I may disagree with the approach that CSATs take to treatment, it is important to note that both them and I want to help those clients who come to us figure out how to get their sexuality back in their control. With this article, I hope to show why I think the approach most Certified Sex Therapists take may be a little bit more healing and create more sustainability.
When we think about the term “sex addiction” today, this in large part comes from Patrick Carnes’s 1983 book Out of the Shadows, where he introduced the SAFE model. According to Carnes, sexual behavior is “addictive” if it is Secret, Abusive, used to avoid painful Feelings, or Empty (meaning outside of a loving, committed relationship). When you look at it, this probably makes sense, but when you unpack it, these are moral statements, not clinical ones. For example, labeling “Empty” sex as a symptom of addiction assumes that casual sex or sex outside of a romantic relationship is inherently unhealthy. It’s not. Plenty of people have fulfilling, consensual, and emotionally safe sex that doesn’t fit traditional scripts of monogamy or love. Carnes’s definition tells us more about his personal values than it does about human sexuality, and it’s worth noting that his framework was heavily influenced by Christian sexual ethics, not empirical research.
Another issue with this model is that it doesn’t understand the concept of privacy. Most people have sexual thoughts, desires, or fantasies they keep to themselves. That doesn’t mean they’re “keeping secrets” in a dysfunctional way. It means they have boundaries. Remember, no one gets access to you until you let them. Privacy in one’s erotic life is not only normal, but healthy. For marginalized groups like queer and kinky folks, privacy has historically been essential for safety and survival. But under the “sex addiction” framework, that same privacy can be interpreted as harmful and secretive. This is a perfect example of how sex negativity shapes what we call “normal” or “healthy.”
The “addiction” framing also falls apart scientifically. True addictions, like to alcohol, nicotine, or opioids, involve tolerance and withdrawal. Your body physically adapts to the substance. Over time, you need more to achieve the same effect (tolerance), and when you stop, your body reacts violently (withdrawal). None of that applies to sex. There’s no biochemical mechanism that mirrors substance addiction. When people say they need “more extreme porn” to get off, that’s not tolerance, that’s habituation. The same way horror fans get desensitized to jump scares and need something gorier to feel the same thrill. It’s not pathology; it’s the brain’s normal way of adjusting to repeated stimuli.
When it comes to withdraw, sure, people can get cranky or restless when they go without sex or orgasm, but that’s not a sign of disease. Humans are wired for pleasure and connection. We evolved to seek out touch, intimacy, and sexual release. To feel “off” without those things isn’t a disorder; it’s being human. So, when someone says they feel anxious or “off” after abstaining from porn or sex, that doesn’t mean they’re addicted, it often means they’re feeling shame for having normal sexual urges in the first place. The point I am trying to make here when it comes to tolerance and withdrawal is that we need to create a bigger space for people to not feel shame for engaging in intimacy, whether vanilla or kinky.
Speaking of shame, it tends to be at the core of “sex addiction.” Studies have shown that people’s beliefs about their sexual morality predict feelings of being “out of control” more than their actual sexual behavior does. In other words, it’s not how often you’re having sex or watching porn that creates distress, it’s how guilty you feel about it. One study even found that students at a religious university used porn less often than those at a secular university but were more likely to report feeling “addicted.” Why? Because they were taught that their desires were sinful. Sound familiar? When your values tell you your sexuality is dirty, every expression of it can feel like a relapse.
So, what does therapy look like when you treat this behavior as “out-of-control” instead of as an addiction? Well, we start by looking at the behavior as a symptom, not a stand-alone condition. Did you know that about 70% of people labeled “sex addicts” meet criteria for a mood disorder like depression? That around 40% also meet criteria for anxiety or substance use disorders. For some people, sexual behavior becomes the way they temporarily escape pain, numb anxiety, or seek affirmation. Think about it: if a depressed person spends all day watching porn, isolating, and skipping meals, the problem isn’t porn addiction, it’s depression. The porn is just one of several maladaptive coping tools and we have to focus on creating that insight
first before we can change the behavior. Treating it like an addiction misses the point entirely. In therapy, we treat the underlying emotional distress, not the sex itself, so that clients can create a healthier, more sustainable relationship with their sexual selves. If they can do that, the behavior will usually shift overtime.
I often think to myself, who am I to judge the terminology that someone else uses to describe themselves? When I sit with people who come into my office for the first time and call themselves “sex addicts,” I don’t look at them and yell, “Sex addiction is not real!” That would be wild. Could you imagine? Not really the best approach to shame someone when trying to help heal their sexual shame. I simply listen and use my expertise to help open their minds to a new way of thinking about their problems. When we understand sexual struggles as symptoms of deeper emotional pain, disconnection, or shame, rather than evidence of addiction, we open the door to compassion. We start asking better questions: What does this behavior do for you? What feelings are you trying to manage? Where did you learn that your desires are wrong? What are you seeking in those moments? Healing doesn’t come from control; it comes from curiosity.
The truth is, CSTs and CSATs are doing what we believe is the best approach in helping heal out-of-control, concerning sexuality. It may sound like I am bashing CSATs, but that is not my intent. I am trying to introduce more flexibility to an area that freaks out a lot of us. No one wants to feel out of control when it comes to sex unless they are consenting to it. My training tells me that someone can struggle with how they use sex, they can have compulsions, and they can even hurt themselves or others, but sex itself isn’t the problem. Shame is the problem. Moral judgment is the issue. The lack of education, erotophobia, and open conversation about sex is what needs to be addressed. If we could move beyond the idea that desire is dangerous, we might actually help people build healthier, more integrated relationships with themselves and their sexuality.
Matt Lachman is a Licensed Professional Clinical Counselor and Supervisor, AASECT Certified Sex Therapist, and owner of Cleveland Sex Therapy, located in the heart of Gordon Square. Since opening Cleveland Sex Therapy in 2019, Matt has been dedicated to promoting sex positivity and inclusivity in his work with individuals, couples, and polyamorous relationships. When he’s not helping clients navigate their sexual and relational journeys, you can find him enjoying a cold brew at Gypsy Beans, sipping a cocktail at Luxe, or relaxing on his couch watching reruns of Happy Endings. Ask a question of your own here.
Disclaimer: The advice provided in this column is intended for generalinformational purposes only and should not be considered a substitute for professional therapy or mental health treatment. Each individual’s situation is unique, and the insights offered here may not address the complexities of your specific circumstances. If you’re experiencing challenges related to your mental health, relationships, or sexuality, I strongly encourage you to reach out to a licensed therapist or mental health professional for personalized support. You’re not alone—help is available.
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