1. Internet sex addiction Clinical experience Walid Sarhan F.R.C.Psych
2. Google search Sex: 3,810,000,000 Free sex:1,200,000,00 Group sex:761,000,000 Child sex:402,000,000 Anal sex:281,000,000 Oral sex:140,000,000 Arab sex:98,500,000
3. Internet Sex 70% of porn traffic between 9am-5pm US porno revenue exceeds 6 billion currently (3rd) 12-17 year olds largest consumers of internet porn Average first time contact is 11 years of age Gender: – 60-70% males
4. What is Going onwith These People?
5. Etiology of Sexual Addiction Anyone, BUT:More from families multiple addictions rigid, disengaged familiesPsychological trauma commonPropensity for high-risk behaviorOnset due triggered around high stresseventsTrouble with accountability, authority
6. Prevalence Epidemiological estimates vary Inconsistent criteria for defining sexual compulsive behaviors – Lack of funding – Lack of committed researchers Most information comes from clinical treatment programs specialized in sexual addictions Best estimates are approximately 5% of general population Fong TW. (2006). Understanding and managing compulsive sexual behaviors. Psychiatry, November, 51-58.
7. Demographics 3: 1 ratio of men to women Younger and older persons in cybersex 65% of sex addicts run the risk of contracting STDs 79% have lost work productivity 70% severe marital or relationship due to behavior 65% report sleep disorder due to shame, fear, despair
8. Pornographic internet content Everything is possible „soft pornography“ „hard pornography“ – „sexually explicit in the extreme, and devoid of any other apparent content or purpose“ – including violence, sado- maso, electroshocks, urine, feces, very fat women, pregnant women etc., „gang-bang“, animals; even „snuff-videos“ – killing victims in front of the camera. pedophile content (often with sadistic torture) Chat with explicit sex talk – often leading to real-life encounters. Live-Video Mobile telephones: growing industry of short films, pictures, explicit sounds.
9. Some statistics Sex Industry Statistics (2003) – $57.0 billion revenue world-wide – $12.0 billion of this is US revenue, more than all combined revenues of all professional football, baseball and basketball franchises or the combined revenues of ABC, CBS, and NBC (6.2 billion). $2.5 of the $12 billion is related to internet porn. Porn on the Web – 25% of total search engine requests are porn-related. – 8% of total emails are porn-related. Average daily pornographic emails are 4.5 per internet user – 12% of total websites are pornographic Affecting Children – 100,000 websites offer illegal child pornography. – Child pornography generates $3 billion annually. – 90% of 8-16 year olds have viewed porn online (most while doing homework). – Average age of first internet exposure to pornography is 11 years old. – Largest consumer of internet pornography 12-17 age group.
10. Statistics II Affecting Adults – 20% of men admit accessing pornography at work – 13% of women admit accessing pornography at work – 53% of Promise Keeper men viewed pornography the previous week in one study – 10% of adults admit having internet sexual addiction. Business Productivity – 70 percent of all internet porn traffic occurs during the 9-to-5 workday.2 – Nearly one out of three companies has terminated an employee for inappropriate web use.2 (Some of this could be for liability reasons discussed below.) – According to Internet Data Center research 30 to 40 percent of employee internet activity is non business-related, costing millions of dollars in productivity.2 This does not mean all the activity is porn related. For example, the cost to businesses in lost employee productivity from the internet broadcasts of the Starr report and the Clinton grand-jury video was in excess of $450 million, according to a study reported by ZDNet.2
11. Statistics Tracking data from 2010 by Nielsen Online, showed that more than 25% of those with Internet access at work viewed pornography during working hours. This is an increase from 2007 figures
12. As of May, 2010, Alexa research, which tracks Internet usage, includes two porn sites in the top 503 for worldwide traffic. This may not seem that impressive until you realize that almost all of the top 50 sites are social networking sites and that CNN.com ranks 57th
13. 25 million Americans visit cyber-sex sites between 1-10 hours per week. Another 4.7 million in excess of 11 hours per week. (MSNBC/Stanford/Duquesne Study, Washington Times, 1/26/2000
14. everysecond $3,075.64 is being spent on pornography. Every second 28,258 internet users are viewing pornography. In that same second 372 internet users are typing adult search terms into search engines. Every 39 minutes a new pornographic video is being created in the U.S.
15. It‟s big business. The pornography industry has larger revenues than Microsoft, Google, Amazon, eBay, Yahoo, Apple and Netflix combined. 2006 Worldwide Pornography Revenues ballooned to $97.06 billion. 2006 & 2005 U.S. Pornography Industry Revenue Statistics, 2006 Top Adult Search
16. 2006 Worldwide Pornography Revenues
17. Pornography in the Workplace More than 75% of people at work have accidentally visited a pornographic website, and 15% have visited such sites more than 10 times Fifty Percent of Workers Spend Nine days a Year on Personal Surfing at Work.
18. 63 percent of employees are concerned about the ease of access to objectionable content at work Fifty Percent of Workers Spend Nine days a Year on Personal Surfing at Work. Cerberian Inc. and SonicWALL, 20 July 2004.
19. Twenty percent of men and 13% of women admitted to accessing pornography at work Internet Pornography Statistics. Internet Filter Review, 2004
20. USA Out of all countries, the United States is the top producer of both pornographic websites and pornographic videos. In fact, the United States has produced 89% (244,661,900) of the pornographic web pages in the entire world. The average age of first exposure to Internet pornography is 11
21. Impact on the Marriage 47% of families said pornography is a problem in their home 42% of surveyed adults indicated that their partners use of pornography made them feel insecure 41% of surveyed adults admitted they felt less attractive due to their partners pornography use 30% of surveyed adults said their partners use of pornography made them feel more like a sexual object
22. Divorce 350 members of the American Academy of Matrimonial Lawyers, the nation‟s top 1,600 divorce attorneys, met in 2002 for an annual conference. Almost two thirds of these lawyers said that the Internet had played a significant role in divorces they had handled during the last year. The problems most cited by the attorneys were:
23. 1) Met new love interest over the Internet - 68 percent 2) Obsessive interest in pornographic sites - 56 percent 3) Excessive time on computer - 47 percent 4) Excessive time communicating in chat rooms - 33 percent
24. School children In 2008, a Catholic high school in the Midwest –USA. surveyed the pornography use of 175 of their 350 senior boys, who were taking a class on relationships. The results of the survey indicated that 48% were viewing pornography one or more times each week. Out of the boys who had viewed pornography, 36% had feelings of addiction to pornography, and 68% said
25. The high school also surveyed their entire freshman class, and 29% of the freshman boys were viewing pornography one or more times each week. Out of the freshman boys who had viewed pornography, 12% had feelings of addiction, and 74% said that their parents were unaware of their pornography use
26. Almost 90% of these students were from Catholic families, and the school has conducted other surveys on pornography over the last three years, and found results that were quite similar. Of the boys that were viewing pornography, between 80-85% indicated that they were accessing pornography through the Internet.
27. Impact on Society Approximately 40 million people in the United States are sexually involved with the Internet 25% of all search engine requests are pornography related Sex is the number 1 topic searched on the Internet
28. 15% of online porn habitués develop sexual behavior that disrupts their lives 4 38% of adults believe it is morally acceptable to look at pictures of nudity or explicit sexual behavior
29. American Society of Addiction Medicine On August , 2011 the statement defining all addiction (including sex addiction) in terms of brain changes. "Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry
30. Internet Addiction Disorder (IAD) - Diagnostic Criteria A maladaptive pattern of Internet use, leading to clinically significant impairment or distress as manifested by three (or more) of the following, occurring at any time in the same 12- month period: (I) tolerance, as defined by either of the following: – (A) A need for markedly increased amounts of time on Internet to achieve satisfaction Author: Ivan Goldberg, M.D. – (B) markedly diminished effect with continued use of the same amount of time on Internet.
31. Criteria – IAD II (II) withdrawal, as manifested by either of the following: – (A) the characteristic withdrawal syndrome (1) Cessation of (or reduction) in Internet use that has been heavy and prolonged. (2) Two (or more) of the following, developing within several days to a month after Criterion 1: (a) psychomotor agitation - (b) anxiety - (c) obsessive thinking about what is happening on Internet - (d) fantasies or dreams about Internet - (e) voluntary or involuntary typing movements of the fingers. (3) The symptoms in Criterion B cause distress or impairment in social, occupational or other important other area of functioning – (B) Use of Internet or a similar on-line service is engaged in to relieve or avoid withdrawal symptoms (III) Internet is often accessed more often or for longer periods of time than
32. (IV) There is a persistent desire or unsuccessful efforts to cut down or control Internet use. (V) A great deal of time is spent in activities related to Internet use (e.g. organizing files of downloaded materials; researching Internet vendors, trying new browsers.) (VI) Important social, occupational, or recreational activities are given up or reduced because of Internet use.
33. Destructive consequences (VII) Internet use is continued despite knowledge of having a persistent or recurrent physical, social, occupational, or psychological problem that is likely to been caused or exacerbated by Internet use – sleep deprivation, marital difficulties, lateness for early morning appointments, neglect of occupational duties, or feelings of abandonment in significant others. – Isolation
34. Disease or behavioral problem? Diagnostic Category following ICD-10 / DSM-IV unclear – Disorders of sexual preference (Paraphilia)? – OCD? – Disorders of Impulse control? – Non-substance Addiction? Internet addiction disorder – IAD (Ivan Goldberg 1995) Pathological Internet Use − PIU (Kimberly S. Young)
35. DSM The DSM-IV-TR still includes a miscellaneous diagnosis called Sexual Disorders Not Otherwise Specified
36. (ICD) which is not limited to mental disorders. The most recent version of that document, ICD-10, includes "Excessive sexual drive" as a diagnosis (code F52.7), subdividing it into satyriasis (for males) and nymphomania (for females)
37. 10 Criteria for Addiction
38. 1-Loss of ControlClear behavior in which you domore than you intend or want.
39. 2-Compulsive Behavior A pattern of out of control behavior over time.
40. 3-Efforts to StopRepeated specific attempts tostop the behavior which fail.
41. 4-Loss of Time Significant amounts of timelost doing and/or recovering from the behavior.
42. 5-PreoccupationObsessing about or because of the behavior.
43. 6-Inability to Fulfill ObligationsThe behavior interferes with work, school, family, and friends.
44. 7-Continuation Despite Consequences Failure to stop the behavior eventhough you have problems because of it (social, legal, financial, physical).
45. 8-Escalation Need to make behavior moreintense, more frequent, or more risky.
46. 9-Losses Losing, limiting, or sacrificing valued parts of life such ashobbies, family, relationships, an d work.
50. Differential Impulse control disorders Bipolar mood disorder PTSD Substance induced disorders Dissociative disorders OCD Gender identity disorder Dementia or other cognitive disorders
51. Role of the Primary Care Physician Most trusted relationship in healthcare – If relationship warm and supportive, Pt will often disclose Provide complete physical Assess, treat comorbidities – Major depressive episode – Sleep disorder – Irritability – Difficulty concentrating
52. The Ten Typesof Sex Addiction Patrick Carnes
53. 1-Fantasy SexSexually charged fantasies, relationships,and situations.Arousal depends on sexual possibility.
54. 2-Seductive Role SexSeduction of partners.Arousal is based on conquest anddiminishes rapidly after initial contact.
55. 3-Voyeuristic SexVisual arousal.The use of visual stimulation to escapeinto obsessive trance.
56. 4-Exhibitionistic SexAttracting attention to body or sexualparts of the body.Sexual arousal stems from reaction ofviewer whether shock or interest.
57. 5-Paying for SexPurchasing of sexual services.Arousal is connected to payment for sex,and with time the arousal actuallybecomes connected to the money itself.
58. 6-Trading SexSelling or bartering sex for power.Arousal is based on gaining control ofothers by using sex as leverage.
59. 7-Intrusive SexBoundary violation without discovery.Sexual arousal occurs by violatingboundaries with no repercussions.
60. 8-Anonymous SexHigh-risk sex with unknownpersons.Arousal involves no seduction orcost and is immediate.
61. 9-Pain Exchange SexBeing humiliated or hurt as part of sexualarousal; or sadistic hurting or degradinganother sexually, or both.
62. 10-Exploitive SexExploitation of the vulnerable.Arousal patterns are based on target“types” of vulnerability.
63. Signs and Symptoms: Physical Carpal Tunnel Syndrome Dry Eyes Migraine Headaches Back Aches Eating irregularities (skipping meals) Sleep disturbances Failure to attend to personal hygiene
64. Signs and Symptoms: Psychological Inability to stop the activity Craving more and more time at the computer Neglect of family and friends Feeling empty, depressed, irritable when not at the computer Lying to employers and family about activities
65. Signs and Symptoms: Psychological con’t. Problems with school or job Having a sense of well-being or euphoria while at the computer But above all: – A loss of control over use!!!!!
66. Why so Compelling? In an on-line world… you can 1. be anyone you want to be. 2. be part of a group and play a role not possible in “real life.” 3. have social connections with other gamers/chatters is highly reinforcing 4. maintain a relationship not possible in “real world” (romantic/sexual)
67. Associated Difficulties Social Anxiety Disorder – Fear of social or performance situations that evoke anxiety Avoidant Personality Disorder – Avoidance/reluctance in interpersonal relationships Depression – Loss of interest in external world, feelings of sadness, lethargy, appetite changes, sleep disturbance.
68. Complications - Comorbidity Alcoholism: Alcohol is being used to get calmer but also to enhance the sexual excitement. Substance abuse (from Cocain to Viagra) Depressive Episodes: caused by negative psychosocial consequences of the cyber-addiction or the break-up of relationships. Suicidal thoughts: out of despair and hopelessness. Obsessive-Compulsive Behavior: Online addicts develop complex rituals to conceal their dependency and to make sure their family, colleagues or company cannot access their “hidden area”. Paranoid Thinking: Fear of being discovered and being ashamed lets them associate even marginal observations with personal threats. (Examples: If a police car passes: “I hope they do not come to confiscate my computer!” – If the boss asks for a meeting: “Does he want to confront me with my Internet activities during last week?”)
69. Differences between men and women MEN – „Kick“ through visual material – Sexual excitement with masturbation. – collecting mania. – tendency towards violent and abasing content. WOMEN: – „Kick“ through communication (Chat). – Romantic stories and images
70. Brain functions in sexual addiction 4 5 3 frontal brain 2 1 Limbic System1. Visual Stimulus2. Sexual Excitement3. Dopamin – „Happiness“4. Adaptation – Desire for more andstronger stimuli5. Loss of control Genital Stimulation 2
71. Biopsychosocial Model Why (bio), what (psycho), where (social) Interactionism and cycle of pain: pain and suffering loss pain, stress and drinking more pain Family as a system, roles Why need to know about addiction? 80% behind bars, child welfare, alcoholics at work. Headlines: -“Hooked on the net” -“Girl died at poker Binge” Relevant movies: 28 days, Traffic
72. Prevalence, Severity, and Correlates of Problematic Sexual Internet Use in Swedish Men and Women Archives of Sexual Behavior The Official Publication of theInternational Academy of Sex ResearchMichael W. Ross , Sven-Axel Månsson and Kristian DanebackTable Percent endorsing items on Internet sexualproblems scale (n = 1,913)
73. None Few Some BigHas sexually-related Internet use caused problems for you?Male 79.1 15.8 3.7 1.4Female 86.7 9.2 3.4 0.7Do you have difficulties controlling your sexually-related Internet use?Male 49.1 31.5 13.0 6.5Female 74.8 17.5 5.8 1.9I feel bad about my sexually-related Internet use?Male 51.9 34.9 8.5 4.7Female 60.4 28.7 7.9 3.0I feel that I have become addicted to the Internet for love- and sexualpurposes?Male 44.0 34.9 15.6 5.5Female 68.2 21.8 6.4 3.6
74. Mr. M.H. is 28 years old Jordanian Muslimsingle man; he is graduate of computerscience.He presented in October 2007 with s ofAnxiety Depression with panic attacks, andobsessional treats of personality was treatedsuccessfully until Feb. 2009.
75. CASE M.H. Mr. M.H. is 28 years old Jordanian Muslim single man; he is a computer engineer. He presented in October 2007 with symptoms of Anxiety Depression with panic attacks, and obsessional personality,was treated successfully with SSRIs and cognitive therapyuntil Feb. 2009.
76. On Jun 2011 he presented again withrelapse and revealed that he is spendingfew hours at work watchingpornographic websites, andmasturbating , with religious guiltfeelings, as he prays regularly and wasvery ashamed of the whole matter, wasonce seen by his father and stoppedusing the internet at home
77. As he started that since the age of 18 he used the internet for sex sites but it was only after he graduated and started working when the use became too much, even before his first visit in 2007 he was overusing it, but he thought he could handle it, which didn’t happen he got worse especially in the last 3 years, following his first consultation.
78. Mr. M. never had relationship with girls as he has been shy and religious. He feels that not having sexual outlet and good knowledge of using the internet without paying money were pushing him towards the overuse, he was expecting the problem to be solved after marriage,
79. but when some of this friends couldn’t stop even after marriage, he got scared and realized that the problem is serious. Mr. M. prefers the category of lesbians although he has been looking at all other categories. He is preoccupied with the matter, on the weekends he doesn’t use the internet but he cannot stop thinking about it.
80. Over the last period he has been improving in all aspects but he was slipping into the use every few days at the beginning and then every few moments. He feels that he missed a lot of chances to develop himself and his career.
81. Mr. B. M. 23 years old who has been addicted to internet pornography sine the puberty at age 13 with excessive masturbation, he is an Arab American Muslim, who is not having any relationship with girls he developed severe generalized anxiety and OCD, in a background of obsessional personality disorder. His obsessions are mainly violent sexual thoughts and images that he picked up from the sex websites,
82. Mr. B. M. he is a graduate of biochemistry planning to join the medical school , he has been advised to get married, and not to join the medical school, he is not using the computer or internet now except occasionally he has been improving, able to control his addictive be behavior,
83. Mr. B. M. but he is preoccupied with sex and masturbates daily although paroxetine is a effecting his desire and delayed the ejaculation he is in a crisis at home, as the father can‟t see where is the problem, and the mother is reading Quran for him his mobile phone. He has been.
84. Assalamualaikum He wrote: I have been experiencing anxiety, panic attacks, depression, and irrational/delusional thoughts. Ever since I was thirteen years old, I was exposed to Internet pornography. I became addicted to it on and off for almost a decade. One day in college, I woke up and started getting racing thoughts, my heart beat so fast, and I felt like I could not make it to the
85. Assalamualaikum, I tried listening to Quran, being around people, but the cerebral electricity would not stop. It went on for many months during the last semester of my premedical course work in college. All of my thoughts are extreme, like for example, I can get AIDS from something that is not considered a risk factor. The "What if" questions never stop.
86. Its like my brain is always on emergency mode, where I have to use all my coping mechanisms to keep an outside appearance of calm. These mechanisms break down, and I feel physically tired. Its like a hamster on a wheel. I work as a research assistant at a company . I got accepted to medical school, but I cannot continue so long as I am experiencing these symptoms..
87. My compulsions are Prayer and Du3aa.he says that I am extremely intelligent, and that backfires chemically in the form of excess dopamine and low serotonin
88. My psychiatrist diagnosed me with Obsessive Personality Disorder has been treating me since December 2009, when all of this started. I have fasciculation all throughout my body, and they become more frequent when I try to achieve a mental state where I am at peace of mind.
89. It always switches from thought to thought, where I get stuck, and can only get out of one horrible thought by thinking about something that is equally or even more
90. even though I know a little spit on to my face from somebodys conversation is not a risk factor. Ive spoken to infectious disease experts, and they tell me to deal with this as an emotional issue.
91. Right now, I am taking Paroxetine Hydrochloride at 40mg, so I do not feel anxiety attacks, and I do experience decreased libido and weight gain. I am trying to continue my studies in medical school, but I cannot get past these intrusive thoughts on my own.
92. My parents, especially my mother, are worried about me. I have put them through so much psychological trouble. At one time, Dr. N. suggested that I get married. But I dont know. Will that improve my situation, or will it make me worse? I beg you in earnest to help me as if I am your son. Also, when I decreased the Paxil, and stopped it for a few days, the pornographic
93. Addiction requires Detoxification The biological component of sexual addiction is not to be underestimated. It can be compared to substance abuse. „A Sex-Addict is like an alcoholic, but it is his own the brain which is his bar.“ This makes decisive withdrawal necessary. In contrast to substance abuse, here a return to „controlled sex“ would be the
94. Risk factors for compulsive sexualityLessons from Addiction Research: Personality: impulse control, self esteem, introversion, patterns of tension reduction, Disposition for addictive behavior upon stimuli (Award-Dependence). Inner emptiness, isolation, emotional burnout, neglect of rewarding interpersonal relationships. Presence of harmful material (just a click
95. Risk factors II Dealing with hidden emotional pain. History of childhood trauma / neglect Pathological search for new Stimulation. Lack of inner discipline / behavioral control Rationalising negative behavior: „This helps me to relax“ – „ I owe myself a treat“ – „It„s only pictures“ etc. Unrealistic expectations towards others, sexual partners, emotional immaturity.
96. Treatment Factors Addiction oriented primary therapist – 3-5 years involvement – 1st 2 years most intensive 12 Step sex addiction group to prevent relapse 12 Step for other co-morbid addictions Work the program, not just attend – Find sponsor, step work, service Early family involvement
97. What about medication? Serotonin: produced as a side effect of addiction process. Antidepressants are also elevating serotonin levels. – Could Serotonin reduce Craving? – possibly reduce feelings of emptiness and underlying depression. Dopamin (increases desire in addiction) – No proven strategies in this area without severe side effects (neuroleptics). Opiates: central in addiction, creating the feeling of being „high“. – Although there are opioid blockers there is no indication that they reduce non-substance addiction. Conclusion: – Medication (unfortunately) is not a solution; perhaps partially a support for behavior therapy, where a person is additionally suffering from depression.
98. Psychotropic Medication Treat for Mood, Anxiety Disorders “Start low, go slow” may NOT work in most cases Need to target as more treatment resistant: – Major depressive illness – Anxiety disorders
99. Learning from Addiction Therapy The diverse evaluation of sexual behavior in our society makes life hard for the addicted person. Cybersex Dependency requires consequent strategies of addiction therapy. Detoxification: complete withdrawal. Removal of access to addiction. Working at immature expectations and
100. Eight Tipps for addicts Admit the fact that you are addicted. Realize the fact that you support sexual abuse with your behavior. Use filter software (www.max.com). Be transparent towards your partner / counselor. Be accountable to a person you trust. Keep your computer in an open room. Choose to live without a computer or internet access for some time.
101. Psychotherapy FactorsMulti-disciplinary approach crucial!Inpatient vs. outpatient?Is 12 step sexual addiction group enough?Other modalities? Individual psychotherapy Family therapy Couples therapy
102. Goal of therapy: relationship orientation Not secular vs. Christian BUT: individually centered vs. stabilizing relationships. Short term satisfaction vs. long-term integrity. Individual lust vs. an ecology of relations. Double moral standards vs. dignity, respect and empathy.