Joshua* was addicted to the hunt. Addicted to prowling for his next hit, cruising for the next woman he'd go home with.
The fair-haired and brawny mining engineer in his early thirties was not certain how many times he has cheated on his wife. He plucks a number from the air. Fifteen women?
"I'd get a rush and a thrill, and then I'd go back home. Knowing what I'd done, the secret was like another hit of that euphoria," he says.
It was easy. He'd head to a bar, or feverishly swipe through hook-up apps on his phone.
"But it got to a point where I would cheat and that intoxicating feeling, and then I'd crash and burn and wallow in self pity. The come down was terrible, like a drug addict, until I could source the next hit," he says.
Joshua says his wife is beautiful, intelligent, an incredible mother, but he was numb to the sexual desire he once felt for her and only satiated by sex with strangers.
"Any bloke who saw her on the street would be head over heels, but I couldn't get there. That wasn't enough for me. It wasn't enough to satisfy my urges. I was going to dark places.
"The addiction was everything. I stopped doing all the things that used to give me a sense of contentment. I would go out in my boat, or go fishing and I felt like a piece of driftwood."
The only thing that came close to the rush of sex was gambling. For Joshua, the two addictions were inseparable.
"Even the most amazing things didn't make me happy," he says.
The day his son was born, Joshua was watching the clock, waiting for the moment he could slink away into one of the hospital's bathroom cubicles to place his bets.
"Nothing registered. Nothing made me happy, or made me feel anything but empty. Not being a father, or a husband. Nothing." Joshua says.
"Except sex."
The diagnosis that doesn't exist
"Sex addiction" is a fraught phrase. Its very existence is at the crux of long-running debates between proponents and critics among psychiatrists, psychologists, therapists, counsellors and others in the medical and addiction fields.
The tensions traverse a litany of clinical and cultural landmines, from adequate evidence-based diagnostic criteria to vested interests and social taboos and moralism.
But the core contention is whether "sex addiction" strays dangerously close to medicalising normal sexual behaviour.
Could people with hearty sexual appetites be slapped with a psychiatric diagnosis? Or has it become a convenient excuse for unfaithful partners that attracts pity instead of divorce proceedings, promoted by high-profile celebrities publicly detailing their own sex addiction demons?
Is one person's sexual addiction another's weekend of endless orgasms?
Proponents argue it's a fitting diagnosis for patients experiencing a preoccupation with sex to the point of obsession.
Sex addicts have lost control over their sexual urges, fantasies and behaviours, causing severe damage to their wellbeing. It ruins relationships, careers, finances, and mental health. It often piggybacks substance addictions, or other behavioural addictions like drugs and alcohol. The shame of the addiction alone can be devastating, according to the US-based International Institute of Trauma and Addiction Professionals, which runs a certified sex addiction therapist program.
Sexual disorders are not recognised as addictions in the two medical tomes used to categorise mental illness. "Sex Addiction" and "Hypersexual disorder'' were rejected for inclusion in the current psychiatrist's bible, the Diagnostic Statistical Manual published in 2013. The DSM-5 does include an intriguing list of eight paraphilic disorders – or sexual disorders – exhibitionism, fetishism, frotteurism (rubbing one's genitals against an unsuspecting stranger, usually in a public place), paedophilia (attraction to prepubescent children), voyeurism, transvestic fetishism (sexually arousing cross-dressing), sadism and masochism.
Sexual disorders had a fraught history of medicalising sexual appetites. Photo: SMH
The manual also includes the catch-all "paraphilic disorder not otherwise specified" (PDNOS), a diagnostic home for the dozen or more paraphilias identified including necrophilia (attraction to corpses), zoophilia (sexual fixation on animals) and podophilia (foot fetishism).
Sex addiction is also absent from the World Health Organisation's ICD-10 (International Statistical Classification of Disease). However, the diagnosis "excessive sexual drive" is included as a compulsive behavioural disorder.
But some psychiatry academics have suggested doctors use loopholes to diagnose their sex addict patients (especially in the US, where insurance is predicated on an official diagnosis) most commonly the DSM-5 categories "other specified sexual dysfunction" and "unspecified sexual dysfunction".
"It's highly contentious," former Royal Australian and New Zealand College of Psychiatry president Dr Mal Hopwood says.
"There is certainly not universal agreement about there it should be diagnosed at all.
"Australian psychiatrists in general view it as something to be considered with great caution," Hopwood says.
No large epidemiological studies have investigated the prevalence of sexual addiction. A systematic literature review estimated people with symptoms of compulsive sexual behaviour could be somewhere between 3 to 6 per cent, though critics argue this is excessive.
Despite the lack of an official diagnosis, private rehabilitation clinics have catered to a boom in behavioural addictions in recent years, including sex addiction.
The RANZCP has called for increasing regulation for private addiction treatment centres in Australia and overseas.
The rise of for-profit private operators providing services to vulnerable people for a contentious condition warranted scrutiny, Hopwood says.
But there was little doubt patients that are trying to wrest back control of their lives.
"All addiction problems [alcohol, drug, behavioural] share the fact that they can have a dreadful impact on people's lives and that of their partners and children,"Hopwood says.
Finding treatment for a taboo
Joshua's wife gave him an ultimatum: go to rehab or she would leave him. She took their children and moved interstate.
"She said she'd get a lawyer, divorce me and I'd only have visitations with my kids," Joshua says.
"I was so worn down. I had to sell my car, my boat. I had hit rock bottom and I was heading for suicide. I thought that was it, that I'd never see my kids again. So I gave in."
His wife did her research and footed the $14,000 bill for a 28-day program at The Cabin, Chiang Mai, Thailand, a rehabilitation centre for alcohol, drug and process, or behavioural addictions.
"All I had to do was book the flight and that alone was a really big deal. It meant admitting I had a problem, but I didn't know what it was " he says.
A lack of an official diagnosis leaves vulnerable patients caught in the middle of the sex addiction debate, says psychotherapist and sex addiction therapist at The Cabin, Brian Russman.
"People look at sex addiction as immoral or from a religious standpoint and say to someone with a possible sex addiction that they are weak-willed because we don't have a legitimate diagnosis and it makes it difficult to offer them treatment," Russman says.
The safeguard should be straightforward: to diagnose sex addiction – or any mental illness – the tipping point must be whether a person's symptoms are causing them harm.
"We don't make diagnoses on behaviours," Russman says.
"If someone has kinks, fetishes, or even has a lot of sex that wouldn't necessarily make them a sex addict.
"What defines a sex addict is the same addiction criteria we see in other process [behavioural] and chemical addictions. Preoccupation, withdrawal, negative consequences, internal conflict, shame, guilt, the inability to control, moderate or manage sexual activity."
Historically the "harm" failsafe has been monumentally flawed for conditions that flaunt cultural taboos.
When harm includes shame, isolation, depression and anxiety, the way a society moralises sex could be the difference between a mental illness diagnosis or a Casanova.
"We need to be very careful of how we make diagnoses subject to ambiguity of social and cultural views," Hopwood says.
"There are significant cultural variations in a lot of flux. What we might have thought was problematic 15 years ago, we clearly have different ideas now."
Madness From The Womb
The history of sexual disorders is paved with women whose sexuality has been poked, prodded and derided by the clinical fraternity.
Seventeenth century France, physician Lazare Riviere described a malady of epidemic proportions affecting French women. He declared unchaste women with insatiable sexual appetites and young girls pleasuring themselves were afflicted with "madness from the womb", in which noxious gases from their "seed" would infect their nervous systems and mental faculties.
Riviere's treatments for women so afflicted included leeches applied to the labia, baths filled cold lettuce heads, and shunning dances and romance stories.
"Even a normally pious and reserved woman could go insane with passion this way," New Zealand academic Jesse Bering wrote in Perv: The Sexual Deviant in All of Us.
In the Victorian era, women and teenage girls with particularly stubborn cases of persistent masturbation underwent surgical clitoridectomies (female circumcision) to quell their ability to feel sexual pleasure, in some cases without their consent.
The current ICD-10 still uses the gendered and archaic categories "satyriasis" for men and "nymphomania" for women.
"Whereas mere masturbation was often enough to get a woman diagnosed with nymphomania, a man had to exhibit an extraordinary degree of carnality to receive a diagnosis of satyriasis," Bering wrote.
Men were also much more likely to be punished as criminals than treated as patients.
Not so anymore. Men are diagnosed in far greater numbers than women, and make up the bulk of patients treated in rehab centres.
Russman says "sex addiction" is no crutch or excuse for an unfaithful spouse. He doesn't allow patients to abdicate responsibility, and neither should their families.
"Consequences are incredibly important for driving change and recognising the need to make changes in their life," Russman says.
"I believe addiction is an illness and disease, however I don't believe it is an excuse to accept unacceptable behaviour. Loved ones need to make a decision about what's safe and appropriate for them.
"[They may say] 'I love you to death, but I'm not going to stick around for your addiction'."
The Cabin
After Joshua touched down in Thailand, the first person he met was a recovering addict. All counsellors at the Cabin are recovering addicts.
Experience of addiction is a core part of the treatment process as staff can both embody hope of recovery and have a keen understanding of an addict's thought processes.
"An addict will die an addict," several counsellors and clients say, regardless the length of their sobriety. Addiction is a constant. The compulsion is ingrained, but can be managed.
In appearance, The Cabin in the foothills of north Thailand's mountains is less rehab centre and more luxury holiday resort, in keeping with the property's previous career.
The Cabin, Chiang Mai looks more luxury resort than rehab centre. Photo: Supplied
The steep cost is more affordable than many Australian rehab clinics.
There is little indication that guests are addiction patients. But there are a few incongruous inclusions.
On arrival, luggage is rigorously searched for contraband by staff familiar with ways to hide drugs or pornography. Male and female living quarters are separated, and internet access is strictly controlled.
All clients must commit to complete sobriety, regardless of their addiction. No drugs, alcohol, sexual activity including masturbation, pornography or gambling.
Sex and sobriety
The first step is getting a person sober. Sexually sober, Russman says.
"The foundation of sobriety is essential."
But sobriety for sex addicts is not as cut-and-dry as it is for alcohol or drug addictions.
"We treat it a lot like eating disorders. You can't give up food and thankfully for sex addicts it's not about giving up sex entirely forever," Russman says.
"It's about identifying behaviours that are addictive and unhealthy and will lead them back to full blown addiction, whether it be pornography, anonymous sex or sex work."
The Cabin's inpatient program involves talk therapies, including psychotherapy and cognitive behavioural therapy, the "12-Steps method", and a holistic approach to managing addiction including investigating core beliefs, mindfulness, meditation, and making lifestyle changes including nutrition, sleep hygiene, as well as psycho education.
"We teach these guys what's going on in their brains to help them understand why we do the things we do," Russman says.
"The evidence for sex addiction is much more concrete that it has previously been."
Sex addiction therapist Brian Russman during a psychoeducation session at The Cabin, Chiang Mai Photo: Supplied
But the research-base for treatment models is as contentious as the diagnosis itself.
"There is clear evidence about what works for traditional addictions like alcohol and opiates. There are well-established models for psychiatrist therapy, social rehabilitation and pharmacotherapy," Hopwood says.
"We don't have clear evidence about what effective treatment are for behavioural addictions."
Even with evidence-based treatment, Hopwood says the relapse rate for addiction in general is "very high".
The relapse rate is between 40 and 60 per cent, according to the US National Institute of Drug Abuse.
The Cabin records a high recovery rate among its patients, which measures how many complete its inpatient program, but does not keep records of long-term recovery rates.
For Joshua and other patients who spoke to Fairfax Media, The Cabin's most potent antidote for addiction was the connection they made with other addicts.
"Knowing that I wasn't alone. I can't tell you how important that was. I realised that I wasn't the only one with these problems and my problems weren't the worst in the world," Joshua says.
"You're not ostracised. You're sitting in a room all suffering from the same disease. I barely drink and barely used drugs, but you hear the story of an alcoholic and you put their blueprint over my own? It's exactly the same."
Joshua had been back in Australia and 84 days sober when he spoke to Fairfax Media.
"It's a battle, but I take recovery three minutes at a time," he says.
"My wife has moments where she gets triggered because of the things I've done. But she says that I'm such a different person now. She says 'I've never seen you so happy and content'."
He found ways to connect with her in unlikely forms.
"It was that Christmas movie, Elf. I haven't laughed that much in years.To be with her, laughing. Feeling her laugh. It felt amazing," he says.
*Names have been changed
Kate Aubusson travelled to Chiang Mai as a guest of The Cabin.
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