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to provide counselors with a nonjudgmental approach to understanding this phenomenon as well as a useful paradigm for treatment. It also must be noted that the terms compulsion and addiction are currently being used interchangeably by some writers and are being more broadly defined than before.

John Bradshaw (1988) defined compulsive/addictive behavior as "a pathological relationship to any mood-altering experience that has life-damaging consequences" (p. 5). Ann Wilson Schaef, in her best-selling book When Society Becomes an Addict (1987), defined addiction as "any process over which we are powerless... It takes control of us, causing us to do and think things that are inconsistent with our personal values and leading us to become progressively more compulsive and obsessive" (p. 18). Schaeffer (1987) described many dependent love relationships in terms of addictive behavior. For the gay man who is plagued by a seemingly uncontrollable need for continuous sexual activity at the expense of other activities and values, his thought processes are obsessive, his behavior compulsive, and the need exhibits many of the features of a true chemical addiction.

Anxiety Reduction and Sexualization

Quadland and Shattls (1988) stated that, as with the classical addictions, changing the sexual behavior of the gay men in their study proved to be extremely difficult. These men, they believed, fell into a category of "those who have learned to use sex habitually to reduce anxiety..." (p. 288). This anxiety was not created by purely sexual motivation but "often had to do with low self-esteem, loneliness, and isolation" (p. 288). The pain of loneliness, accompanied by hiding one's sexual identity, exacerbates the isolation and exaggerates the sexual expression to reduce the pressure. Intimacy is difficult at best in this setting. They likened the pattern of lack of sexual control to be similar to the dynamics of overeating. Both food and sex are important aspects of most people's lives, but when either is used to sublimate other needs (such as intimacy), the perception of the need becomes distorted and the patterns of gratification become fixed, reinforced, and compulsive. When sex is sublimated in this way, the result is dysfunctional behavior, which was identified and termed sexualization more than two decades ago by Putney and Putney (1964). They defined sexualization as "the tendency to regard as sexual desire needs which are actually nonsexual in nature. . . " (p. 85). They continued by stating that the ensuing behavior is not likely to fulfill the other needs motivating the individual, and, in fact, it is those very needs from which a person is deprived that are likely to become sexualized.

Bradshaw (1988) stated that the issue of sexual compulsion is not about being "horny" but about "mood alteration" (p. 97). He believed that sex, in this case, distracts or alters feelings so that a person does not have to feel loneliness or the emptiness of abandonment. For gay people, the fear is often all too real because coming out of the closet might very well mean the real abandonment by family, friends, and employers. With this overlay of fear, the sexualization of the anxiety and the flight from intimacy, the sexual pattern produces at least partial relief. This anxietyreducing mechanism, be it by chemical or sexual means, is a main component of the addictive process. This process consists of the fix, seeking excitement, increase in tolerance, feelings of withdrawal, and loss of control coupled with denial.

The Fix

As the sexualization of anxiety progresses, intimacy and relationships become subservient to the very physical act of sexual expression. Schaef (1987), in identifying this as an addictive process, stated that "more and more people seem to be using sex not as a means of relating but as a way of getting a fix" (p. 23). The fix for the sexually compulsive is the calming effect of the anxiety reduction component. This can be likened to the sedative effect of traditional addictive substances. As with any "fix," however, the effects are transient. In the case of sexual addiction, the anxiety reduction component is temporary at best but just satisfying enough to allow a pattern to become embedded. The pattern of the sexually compulsive gay man, who after the bar closes goes to an adult bookstore, a park, and then cruises around in his car, is not at all an uncommon one. I, as a clinician, have observed this pattern and its many variations.

The sexual situations and even the orgasmic release produce just enough reinforcement to keep the system churning. It has not been uncommon for a gay man to report in counseling that he was still feeling "horny" even after leaving a bathhouse where he had experienced several orgasms. It seems almost superfluous to say that, in helping the gay man, as with overeating and gambling, the main therapeutic issues for the counselor becomes those of overindulgence and control.

The behavior just described is behavior that is now out of control. The sexually compulsive gay man, tired from the chase, repulsed by the treadmill on which he finds himself, afraid that he is risking losing his job, friends, and lover, makes all kinds of promises to himself and others, only to break them on subsequent nights. The risks of this sexual compulsivity are great. The possible loss of health, the threat of arrest, and the lowering of self-esteem are all prices the sexually compulsive individual must pay.

The Excitement

This price of compulsive sex may not always be perceived as steep by the client. Some researchers believe that it is the challenge of eluding arrest and the fear and the risks involved in the sexual exploits that energize, excite, and reinforce the behavior itself (Hoffman, 1968). Excitement is another important element in the addiction equation. The excitement of the chase produces a high that allows the sexually compulsive gay man to lose himself in the event of cruising, with the resultant release of inhibitions that is not unlike the process that also occurs with other traditional addictive substances. The chase, not the prey, is what is appealing. Cruising alone often reinforces itself. Many of these men report a rush, a quickening heartbeat, a nervousness, and an exhilaration when in the midst of the sexual chase. Nakken (1988) noted this same effect in compulsive gamblers:

Addictive gamblers are not chasing the win. If the win was [sic] important, gamblers would stop when they won. They are chasing the action, the excitement, the moment, and eventually they chase the losing, for this allows them a reason to chase again. (p. 15)

Nakken believes that "Emotionally, addicts get intensity and intimacy mixed up" (p. 15). For the sexually compulsive gay man, the excitement of the chase becomes the additional primary reinforcer. It is this excitement that provides the "losing of self" and the escape from feelings that seems to be at

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the base of this addictive behavior. For many, this overindulgence and lack of control eventually become troublesome, disruptive, and dysfunctional.

Tolerance, Withdrawal,

and Lack of Control

The nature of the uncontrollable behavior and its effects have striking similarities to chemical addiction. When an individual is addicted to a chemical substance, a vicious cycle begins. The addict needs increasing amounts of the substance just to maintain equilibrium. Withdrawal produces painful effects and presses the addict to continue taking the substance. Values and life-styles change to allow adaptation for the drug's grip. For the sexually compulsive gay man, the same process seems to occur. More and more of the addictive agent (in this case, sexual exploits) is needed just to maintain equilibrium and function. The world becomes focused and centered on obtaining the addictive agent and maintaining a steady supply. Sexual activities become the primary focus of life. Other interests, ambitions, goals, and aspirations all take on secondary importance to the addiction. Values, ethics, and standards all become channeled through the clouded thinking of a pressing drive. For these men, the primary counseling objective centers on putting the client back in control of his life.

Putting the client back in control of his life becomes all the more difficult because of a seemingly unbreakable cycle that emerges. Not being in control but under the influence of this (or any other) addictive entity is ego-deflating. This assault on self-esteem leads to a vicious cycle, in which the lowered self-esteem produces anxiety. This anxiety then becomes sexualized, leading to a partial reduction in the anxiety by further compulsive sexual acts. This produces deflation of selfesteem, and so on, ad infinitum.

Denial and the

Loss of Control

As with chemical addiction, the denial of the problem must first be addressed. Denial is the first and perhaps most difficult barrier to recovery (Nakken, 1988). All the traditional defenses of repression, rationalizing, minimizing, and intellectualizing are used by the compulsive individual to avoid admitting that there is a problem and that his life is out of control. In a clinical setting with a sexually compulsive gay man, this denial is filled with both excuses and promises. One often hears such things as the following: He only got arrested because he was careless; he wouldn't have to seek out sex in bookstores if the bars were better or if the town had a better choice of men; if his lover "understood" him better, he wouldn't be feeling so needy. "Next" time he will learn how to avoid arrest. . . . The excuses and explanations are all very similar to the self-delusion seen by clinicians in dealing with chemical dependency. All are designed to rationalize the behavior and keep the magnitude of the problem repressed by the client.

As with chemical dependency, the problem becomes obvious to other people before it is readily admitted by the sufferer. As with chemical addiction, recognition usually comes when the individual has "reached his bottom." In the case of sexual compulsions, this may take the form of an arrest (or close call), an illness, the loss of a job, or the loss of a lover or friends. Whatever the catalyst, recognition does not come easily nor without pain. There is a strong need to shield from conscious awareness the unacceptable truths that make up the distorted

Sexual Compulsivity in Gay Men

reality. The harmful consequences, the extent of the problem, the inappropriateness of behavior-all are hidden from ready view by the mechanism of denial.

Addictive Treatment Models

In dealing with the sexually compulsive gay male client, clinicians are treating some of the same phenomenon that surface when treating chemical dependency and addiction. There is disappointingly little in the literature to guide the counselor in this area.

What counselors working with chemical addictions have discovered is that traditional therapeutic approaches alone have not been very effective. Working just with the deep-seated frustrations, anxieties, and unfinished childhood issues will be in vain unless the behavior becomes the primary focus in therapy. Quadland (1983, 1987), who took a therapeutic group approach to compulsive sex, and Carnes (1983), who advocated the addictive model of the Twelve Step self-help groups, both concentrate primarily on a behaviorally oriented group approach to the problem.

Therapeutic groups. Quadland and Shattls (1987) advocated treatment in a group setting. The groups were specifically designed to allow the gay male client to gain control over his sexual behavior and ... not to conform to any arbitrarily imposed standard of frequency" (p. 289). The definition as to what behavior and how often were left to the client to decide. It was the client's perception of lack of control that set the individual goal for each client. This perception, stated as a behavioral goal, became the therapeutic contract.

Mere recognition of a problem, Quadland and Shattls (1987) stated, did not automatically lead to change even when the client viewed the changes as desirable and necessary. Because they believed the gay man's compulsive sexual behavior had been learned and reinforced, they argued that the conduct, and habits associated with it, needed to be unlearned. They saw this behavior as directly connected to "the avoidance of anxiety associated with feelings of loneliness, low self-esteem, problems with intimacy and closeness, and internalized homophobia" (p. 283), and it was these feelings that these groups worked to ultimately undo.

Quadland and Shattls (1987) reported that the groups took a twofold approach. First, the group explored the feelings, fantasies, and internal motivations that are related to the sexual behavior. Issues such as competence, attractiveness, and selfimage were also examined and challenged both by the therapist as well as by other group members. The goal here was to increase understanding of the behavior and promote a decisionmaking process regarding sexuality that was more rational.

Second, and perhaps more important, there was a primary focus on the sexual behavior itself. A group norm pressing for behavioral change emerged almost at once. Decisions for a change in sexual behavior were encouraged whether or not the client understood the reasons for his own behavior. Specific questions relating to each client's sexual activity, its frequency, the objective, the rewards, and the sexual cues were all common items discussed freely in the groups. Goals were set and therapeutic contracts were made by individuals with the group, which involved reducing, eliminating, or changing old sexual behaviors. New positive behavior was encouraged, attempted, and supported. It was from these behavioral changes that feelings and self-image changes occurred. It seems that it was the existence of group norms and the peer support that encouraged and reinforced the positive behavioral changes. In-

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