Compulsive Masturbation

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Oh, yes, we are going there! A listener left a voicemail about masturbating so frequently that it began to disrupt her academics, her social life, and her relationships. In this episode, Nzinga dives into the stigma and shame around masturbation, what drives sexual compulsions, and how to best support those who find themselves in a similar situation. 

Please note, In Recovery contains mature themes and may not be appropriate for all listeners. This episode also contains details of sexual assault and rape. 

Show Notes 

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[00:02] Dr. Nzinga Harrison: Hey, everybody, this is Dr. Nzinga Harrison. And you are listening to In Recovery, an advice show about all things addiction. So we got a voicemail a while ago with a question about masturbation. And honestly, this is not a topic that anybody is talking about, like, will not touch it with a ten-foot pole. So what are we going to do? We’re going to talk about it. We are going to touch on the topics of sexual assault and rape, and so if those are not safe topics for you to be listening to, either by yourself or at all, I want you to know that up front. So rolling into this week’s topic, which Claire will tell you, we actually got this e-mail a while ago, and since we’ve gotten it, I’ve been badgering her to make sure we get this topic on air. 


[00:57] Claire Jones: It was like every single time we were talking about episode topics, what we want to do next, our next recording session, Nzinga would always slip in masturbation. Anytime we were redoing, you know, the teaser or ads and talking about all the different topics we’re gonna talk about, Nzinga was always like, yes, alcohol and drugs and also sex, masturbation, sex, masturbation. So she’s really psyched for this one. I’m excited for it, too.


[01:24] Dr. Nzinga Harrison: Did I mentioned sex and masturbation? And one of the reasons I’m like really pushing this is because what I want this show to do is take all of those things that we push in the dark because of stigma and shine a light on it. And so for sure, one of the things we push in the dark is sex. And even more than we push in the dark sex, we push masturbation in the dark. So one of the things that I hope to do on In Recovery, like I said, is to really talk about those things that we’ve built up a lot of shame around. Because when there’s a lot of shame, it basically keeps people from getting help. And so one of the biggest ways we accidentally shame people is with the words that we use. And the other way we shame, sometimes without even knowing about it, is by refusing to talk about things. And so I’m going to do my best here. And what I’m hoping from you, Claire, and what I’m hoping from our listeners for sure is that as we shine a light on these things that we’ve been too ashamed or too worried to look at, if I fall into some language — like this is your experience and I fall into some language that’s hurtful to you or shaming to you, call me out on it. Because we need to be putting that on air. I will talk about masturbation the same way I talk about the other addictions we’re going to address, which is biologically, psychologically, socially, what we’ve been doing wrong, what we can do right, how we can do better. And it all starts with compassion and connection. So with that kind of as a foundation, should we listen to Elisa’s voicemail? 


[03:14] eee: My sophomore year of college, my best friend was raped. And triggered in me severe dissociation and also coital cessation. This led to compulsions to mutilate my genitals. And that’s completely irrational, and I could recognize that. But I couldn’t get rid of the feelings, the urges. So I diverted this compulsion into masturbation instead. Eventually, this masturbation became so frequent and so erratic that it was debilitating, and I started to fail to meet all sorts of life responsibilities, from my commitments with my friends and my partners, to my academics and my extracurriculars. And it completely disrupted those things to the point that I was failing classes. And I think it eventually contributed to my break-up. With these struggles, I was identified as having ADHD, and this explains so much, especially when I researched it and I learned that ADHD has strong comorbidity with addiction. This means they come together. 

[04:23] Claire Jones: OK, so Nzinga, I am curious here, what’s your initial reaction to Elisa’s story? 


[04:29] Dr. Nzinga Harrison: I have said before that addiction can be any behavior that starts out bringing benefits, but then starts to bring negative consequences. And even though the negative consequences start to outweigh the benefits of that behavior, the compulsion to continue that behavior is what defines addiction. So just very simply, continued use, if it’s a substance, or continuing to do that behavior despite negative consequences is the broad definition that we’re using for addiction. And like so many other addictions, Elisa’s case, even though her behavior that came out was masturbation, it was based on trauma and a void of some sort that was being filled by this behavior. And even once you get to the point where you’re like, I really need some help for masturbation, who do you ask? So like the very, very early sneak-peek into In Recovery as a show was like your kid gets sick, you go to the pediatrician. You break a bone, you go to the E.R. You have an emergency, you call 9-1-1. Like we know what to do in those instances. And it’s like I’m having trouble with masturbation, who do I call? And so I think her story, even though it’s around masturbation, shares so much with all of the other addictions, substances and not substance, that we’re going to talk about. Really glad she sent it in. And I’m really glad that we’re here to talk about it.


[06:09] Claire Jones: Yeah, definitely. I mean, I think that was my first question, was like, who do you talk to? Do you go to a normal doctor? Do you go to a sex therapist? Like, if I have a problem with this. Where do I go? 


[06:22] Dr. Nzinga Harrison: And I wish it was a question with an easy answer. So I’m a psychiatrist and addiction expert. Masturbation was not part of my training. And so even if we look in the DSM-5, which is kind of like the diagnostic Bible, if you call it that, we used to make psychiatric diagnosis. There’s no masturbation diagnosis in there. And so this latest version of the DSM-5 actually considered a disorder called hyper-sexual disorder that masturbation would fall under, but that diagnosis didn’t even actually get put in the DSM. And so it’s like unless you can find a psychiatrist that specifically says I focus on sex disorders, that would be a place you could go. A sex therapist — and those can be difficult to find because the term is like so all-encompassing, like sex therapist can literally be a person that just designated themselves an expert. And so I would say you want to look for folks that have credentials either as a professional counselor or as a PhD-level psychologist or as a marriage-family therapist or as a clinical social worker. 


[07:40] Dr. Nzinga Harrison: And because just like as a psychiatrist, masturbation and sex-addiction-type disorders were not necessarily part of my training, you want to find a person who has, on top of that therapist credential, made it their business to become an expert in these sex-related disorders. And so searching for sex therapist, sex-relationship expert, yes. But also just make sure those additional credentials are there. Because what we know is that Elisa’s story, which is specifically about masturbation, but talking about sex addiction as a larger topic, shares so much with substance use disorders. And so I’ll try to introduce when I’m saying something, that’s my opinion as opposed to fact, because — Joel is my husband, he says I state my opinions as if they’re a fact. Sometimes it’s hard to tell the difference. So this is my opinion. 

[12:31] Dr. Nzinga Harrison: The neurobiology for sex addiction is shared with the neurobiology of substance addiction. So when we talk about the pathways in the brain that get disordered in heroin addiction and alcohol addiction, nicotine, cigarettes, tobacco, it’s the exact same system that’s disordered in sex addiction. And so why, as an addiction-trained psychiatrist, would that not be part of my training? Here’s my opinion: stigma, right? Because we don’t need to talk about sex the way we need to talk about substances. And substances are already stigmatized in medicine, so this is like the next-level. I saw Claire’s mouth open on Zoom, she had a question. 


[13:21] Claire Jones: I was just going to say that I think we’re telepathic because right before you said why this wasn’t in your training, I wrote down, “do you think that the reason this isn’t in your training is because of stigma?”


[13:34] Dr. Nzinga Harrison: So you know what, guys? I’m elevating my opinion to fact. It’s official. And so what’s also official about it is the same way — so for a long time, we couldn’t talk about substances. The ability to talk about substance is so open and freely, which we still have a lot of work to do, is very new. Like a Last Day podcast, having so many listeners is very new. Only the last couple of years. So easily the first 15 years of my career taking care of people with substance use disorder and other addictions — which, by the way, was very controversial in the places that I worked. It was like, no, we don’t take care of that, we only take care of cocaine or alcohol. And it was like these folks are walking in the door, which is very common, addictions run with addictions because the neurobiology is the neurobiology. And so the literature shows that probably about 20 percent of people — so that’s one in five — coming into a residential treatment for substance use disorder also have some sex addiction, some portion of which would be masturbation. And so when we’re looking at the ability to talk about those things in the open, it’s relatively new. And that contributes to Elisa’s story, which is just like a lot of people progressed to severe substance use disorder because they couldn’t ask for help, because either stigma or because they didn’t know where to go, the same is true for masturbation. The same is true for any other sex addiction. It’s like we’re letting these folks languish in silence because they don’t know where to go, or because when they ask for help, they get denigrated and discriminated against and treated badly. And so we have let these illnesses progress to severe when we could have intervened a lot earlier. And that gets back to your question. I know listeners are like, oh, my God. Claire asks a question and then Nzinga talks for 30 minutes before she gets to the answer. 


[15:40] Dr. Nzinga Harrison: So here’s the answer you’ve been waiting for from that very first question, which was like, how do you even know it’s a problem? And getting back to that very early definition of addiction that I gave, which we’re applying to masturbation today, which is the earliest inclination you get, is when you raise that question in your head, like, is this causing me trouble? It’s the exact same progression. So you have your first drink, and most people, the very first time they have a drink of alcohol, it’s not going to be like this is a problem. Even a person with a severe family history of alcoholism where they know it’s a risk and they’ve told themselves, I’m never going to drink because of, you know, the hurt and pain that my dad’s alcoholism brought. Or the hurt and pain that my mom’s alcoholism brought. I’m never going to drink. That first drink is not typically kicking you over the ledge. But once that first drink turns into two drinks every night, and once that turns into I can’t wait to get off work to have a drink, and once that turns into, I’m going to have a drink at work. You feel yourself walking up the curve, but we’ve put so much negativity on the idea of having this illness that we either close our eyes to the fact that we’re walking up the curve or it’s too scary to tell somebody else, “I think I may be walking up the curve.” 


[17:07] Dr. Nzinga Harrison: And so the same is true for masturbation. Masturbation honestly never starts out as a problem. Like toddlers start masturbating. Infants start masturbating before the age of 1. Like masturbation feels good, masturbation develops a dopamine signal in the brain, just like drugs do, which tells your brain this is good for you. Do it again. Masturbation never starts out as a problem. But when you start thinking to yourself, should I be doing something else and I’m masturbating instead? Could I feel comfortable telling myself, like, even just thinking about it with myself, the amount that I’m masturbating or the type of masturbating that I’m doing. And it’s so wrapped up in all of our whatever cultural beliefs and religious beliefs, there’s like so much that we heap on sex. But once you start asking that question is when you should be reaching out to one of those professionals we mentioned earlier for help. Don’t wait until you have a heart attack to start changing your eating and exercise habits. Right? It’s the exact same concept. And you can’t — people think it’s so easy, like, oh, I’ll just start exercising. Oh, I’ll just change my eating habits. We all know how hard that is. And those are attached to a smaller dopamine signal than masturbation. And so the soonest you think to yourself — like the first step is the first step for a reason. The first step is I recognized maybe I had a problem. I’m even trying to go earlier than the first step. I’m trying to go to the zero-th step, right? I recognize maybe I have a problem. We have to create the space for people to be able to reach out at that point because the biology builds on itself. It builds on itself. It builds on itself. And then suddenly there’s really a problem that is severe and difficult to address. 


[19:10] Claire Jones: How do you exactly parse that out from guilt and shame with masturbation? Because like I live in Salt Lake City, which is very religious, Mormonism is huge in Utah. And I wasn’t raised there, I’m not Mormon. But you can kind of feel that in Salt Lake City for sure. And I’m just thinking about people that start to masturbate, and because it is so shameful and we’re constantly told it’s a bad thing, if I’m a person who’s been told that my whole life, and then I start to masturbate, I’m going to feel guilty about it. I’m going to feel shame about it. And that’s not going to feel like masturbation is necessarily a good thing and it could make it feel like it is a problem. So how do I parse out my own shame and beliefs about what masturbation is and whether or not it’s good or bad, and like this is an addiction?


[20:02] Dr. Nzinga Harrison: That’s a perfect question, Claire. And so this is exactly why I’m asking people to get help sooner, because a therapist can help you untie that. I always say every single illness is biological, psychological, social and cultural. Right. Bio, psycho, social, cultural. Every single illness. Those are inputting into the illness. Those are also determining how successful we can be at treating an illness. So also determining how much a behavior develops negative consequences. 

[20:36] Dr. Nzinga Harrison: And so when we think about negative consequences, we always think about the external negative consequences. So it’s affecting my job. It’s affecting my relationships, affecting my productivity, somehow affecting my ability to fulfill my major life roles, which is actually from the DSM-5 when diagnosing an addiction. We less think about the internal consequences. And so to your question about shame and guilt, a lot of those internal consequences start to build way before external consequences become apparent. And a lot of those internal consequences are based on what we believe we should do, based on how we’ve been raised, what we’ve been told, what our religious beliefs are, what our spiritual beliefs are, what our social, cultural, societal acceptances are. 


[21:29] Dr. Nzinga Harrison: And so very early on, if you’re noticing like you’re masturbating, and instead of just getting the pleasure out of masturbation, your masturbation is mixed in with feelings of shame and guilt, those are early negative consequences that need to be teased out. And so at the earliest you get that signal, connect yourself to someone who can help you develop the insight. So to help you with some insight-oriented work that says, where is the shame coming from? Where’s this guilt coming from? Because it could be for one person that shame and guilt is coming from a religious construct that they don’t subscribe to anymore, but that has still laid itself down in their brain. So for that person, the work might be just decoupling the shame and guilt that is coming from, you know, masturbation that’s not harmful. For the other person, it may be exactly the same frequency of masturbation, exactly the same type of masturbation. Like everything could be exactly the same about it, but they still have religious beliefs that they want and that are important for them to ascribe to. And so it may be that the exact same masturbation pattern in two different people represents a problem for one person, doesn’t represent a problem for another person because of internal beliefs. And so getting to a therapist helps tease that apart, because we don’t want to under-appreciate the importance of the religious beliefs of this person and say you’re masturbation is not a problem, when the shame and the guilt that it is causing them is a problem.


[23:13] Claire Jones: So if you’re having negative feelings about it, regardless of whether it’s internal or external, you should start to talk to somebody. Because you can start to parse out the internal. And then if it’s still affecting the external, then you can continue to talk to somebody about it and see what you can do. 


[23:29] Dr. Nzinga Harrison: And that, my friends, is how Claire sums up my 30-minute speech into a two-minute bullet point.


[23:36] Claire Jones: The TLDR, is a term I only recently learned. Let’s say I go through all of these steps and I’m talking to a doctor. I’m also talking to a therapist. And I’m diagnosed. Is there a treatment for this? How do I address this?


[23:56] Dr. Nzinga Harrison: Yeah. So one thing that’s really important when we move into the idea of treatment is that masturbation — so, we can call it — because like I said earlier, there’s no current diagnosis that we can officially call it. But if you’ll let me wrap this into the concept of sex addiction, hypersexuality that is causing a person some kind of negative consequences, whether those are internal or external negative consequences. What’s really important is that those almost never exist in a vacuum. Almost never. Same thing, like all addictions almost never exist in a vacuum. And so you’ll hear me with this concept over and over, like the antidote to addiction is connection and compassion. And figuring out like what is the empty space that is being filled by this compulsive behavior? Whether it’s substance or whether it’s sex. And so I do want you, when you get diagnosed, that diagnosis should absolutely include a hunt for depression. It should include a hunt for anxiety. It should include a hunt for bipolar disorder. It should include a hunt for ADHD. And it should include a hunt for trauma. Those are going to be the biggest things. So if you talk to a professional about some sex-related symptom that you’re having that’s bringing you some kind of heartache and pain, if your evaluation hasn’t included an evaluation for depression, anxiety, bipolar disorder, ADHD and trauma, you’ve not had an adequate evaluation. And so to get to your question about treatment, number one treatment is figuring out if and how any of those other things are contributing, and trying to get to the root cause. Because most often masturbation or other sex addiction symptoms are symptoms like the tip of the iceberg? There’s a lot more under the surface. 


[26:09] Dr. Nzinga Harrison: And so when we get at the specific treatments, the same way I always talk about illness: bio, psycho, social, cultural. We always have to talk about treatment: bio, psycho, social, cultural. So biologically I already said there’s a tight link between sex addiction symptoms and substance use disorders symptoms. So if there’s also a substance use disorder, your biological interventions are going to be getting control of that substance use disorder. Because all substances increase impulsivity, and part of masturbation that is out of control is the compulsive, impulsive nature of it. 


[26:45] Dr. Nzinga Harrison: So treating any co-occurring substance use disorders is going to be very important. Treating any anxiety or depression or ADHD or trauma is going to be very important because those are driving — so think of it, the dopamine system. I know you guys are gonna be like, oh, my God, if I hear her say dopamine one more time. But guess what, guys? Dopamine. OK? So the dopamine system tells you what you need to survive. And it also feeds information to your emotional system, which is your limbic system, your thinking system, which is your prefrontal cortex right underneath your forehead in the front, about how to avoid danger. And so that part of your brain that’s responsible for telling you, one, how to avoid danger, and two, what behaviors keep you alive, it’s the exact same system that underlies sex, drugs, food, nurturing. It’s all dopamine, right? Other neurotransmitters, for sure. But dopamine. And so think to yourself, what scary experience, what scary emotion is my brain trying to protect me from using the good neurobiological chemicals that come from masturbation as the fix. And so you have to be looking psychologically. In terms of medication, there is no medication that is FDA approved for sex addiction or for masturbation. But there are for depression, anxiety, ADHD, bipolar disorder, PTSD. So if any of those syndromes are there, we want to be thinking about medication. From a psychotherapy perspective, CBT, cognitive behavioral therapy, which helps you draw the connections between your thoughts, your emotions and your behaviors. Those can get into a snowball loop. And so the purpose of CBT is to kind of catch that snowball and try to help that be more intentional than just running on its own. And then, like I said, insight-oriented therapy. So looking at what are those past experiences, and what are those ingrained beliefs and attitudes that we’re not even necessarily consciously aware of, that are heaping shame and guilt on this.


[30:42] Dr. Nzinga Harrison: And so it’s a 360-degree approach, as has to be any approach to any illness if we’re really going to make a difference. And that approach, no one has to start with compassion. Because the very first thing is like this is distressing. This is distressing. And part of the reason a person is masturbating to the point that they’re losing relationships and losing grades at work is because something else distressing is going on that masturbation is trying to fix. But masturbation has become distressing in itself. So those two distressing things are layered. And so when you are in distress, the very first thing you need is a warm set of arms to wrap around you. Everything else can flow from that. All of those, you know, like evidence-based medical things that I said can make a difference, but really only in the context of a person that is not judging.


[31:43] Claire Jones: I think that is the coolest part about Elisa’s story, is that she does talk about all of these things that you talked about, like mental health and ADHD, anxiety and depression. And I think that just makes me wonder, like, if I address all of those things, if I get on top of all of that and I’m talking to a therapist and I’m also seeing a doctor, does I guarantee that this will be fixed? Is “fixed” the right word?


[32:04] Dr. Nzinga Harrison: “Fixed” is fine. As long as we also say fix your diabetes, fix your blood pressure. So equitable fixing is fine. I wish I could guarantee that anything could be fixed, and I think that’s part of the problem. So when we talk about what we’ve been doing that works and what we’ve been doing that doesn’t work, what doesn’t work is this idea that mental health disorders, substance use disorders included, sex addiction included, has to be fixed with a guarantee. Because it’s just not how health works. It’s not how health works. So could I guarantee and fix it maybe for today? Maybe. But can I predict what’s going to be happening in your life next week, the month after that, that’s going to trigger that survival pathway in your brain and urge you to go back to a behavior that, at least in this moment, feels like it’s getting me out of danger? I cannot guarantee that any more that I can guarantee your blood sugar will stay controlled if you go on a donut binge. 


[33:18] Claire Jones: Right. That’s what I was just going to say is like it is even the same thing with anxiety and depression, which are both things that I have and have had my whole life. And it’s like, yes, sometimes there are periods of time where I’m like, man, I’m killing it. I am not anxious. I haven’t been depressed. Things are going super well. And then it’s like out of nowhere for absolutely no reason, I’m like, my anxiety is so high that I don’t know if I can function well today. You know, it’s like none of this — if I think about it just in the context of my own experience in mental health, none of it is fixed. If I think about it with my mom who has pre-diabetes, same thing, it’s like, yeah, she can watch her diet, she can do the best she can, but like, it’s not so cut and dry. 

[33:58] Dr. Nzinga Harrison: It’s not so cut and dry. And so I think part of what we have to do, getting back to your use of the word “fix,” which we can commandeer, like fixing an illness, is knowing what triggers it, doing the best to avoid what triggers it, having a magic formula in place that can keep it stable under the best circumstances. But then also in those times, which is going to happen, that something does trigger it, like a trigger that we didn’t have on our radar. That one, we can recognize early that the symptoms are coming back so we can intervene early. Two, that we’ve created a space that people can actually ask for help early. For example, part of my psychiatry residency was getting a therapist so that we could learn what it feels like to be on the other side of the couch. And so I was broke, like I was a psychiatry resident, I didn’t make any money. So I was broke. I can’t afford therapy, so I’m going to use my health insurance. And the psychiatrist was like, I have to put a diagnosis for you to be able to use your health insurance. And I was like, OK, because I didn’t have a good concept of how that was going to affect my insurability later in life. 


[35:21] Dr. Nzinga Harrison: One, why should you have to give a diagnosis if a person’s coming in pre-diagnosis? Two, why should a diagnosis screw you later? Like that keeps people from getting help. That keeps people from getting help. So we have to create the space where you can ask for help early, you can get help without being discriminated against later, and we can all — if we just start from a position of not what did you do? Because that’s how we do people with substance use disorder, with sex addiction, with depression, anxiety. It’s like, well, what did you do? Is the reason why your symptoms are back? Instead of what happened in the world and what can we learn from this? Like open arms, warm hug, let’s figure this out. Let’s add it to our tool box of things that maybe we can prevent in the future. It’s a totally different stance and we haven’t gotten there yet. And that’s one of the reasons why people are suffering, because we haven’t gotten there yet. 


[36:22] Claire Jones: So how does sex addiction connect to masturbation? Are they connected? 


[36:29] Dr. Nzinga Harrison: So they can be connected. There’s not a one-to-one relationship by any stretch of the imagination. They are connected in that both of them are sexual behaviors. So that’s kind of like the biggest, broadest connection. And so when we look at a diagnostic manual, like a DSM-5 that we use for psychiatry, we collect things by these big themes. So mood disorders are going to be in one section. Anxiety disorders are going to be in another section. Sex-related disorders are going to be in another section. Eating and feeding-related disorders are going gonna be in another section. So masturbation and sex addiction, if they were in the DSM-5, would be the same section because they’re sharing that same behavior and the ideas that behaviors follow neurobiological pathways. So that’s kind of like why we try to categorize them like that. 


[37:22] Dr. Nzinga Harrison: I think the bigger connection that I’m trying to make is less between masturbation and sex addiction, and more to this concept of the basic brain we have. And that dopamine pathway, which is like, there are certain behaviors — food, sex, water, nurturing — that naturally determine that dopamine signal that our brain interprets as protecting us from something dangerous. And so if we want to get at the true treatment, we have to identify what is it that’s “dangerous” — that can be anxiety, that can be depression, that can be disconnected. So like, what is the dangerous thing? But then also, how do we get that dopamine signal in a way that isn’t dangerous in and of itself?


[38:11] Claire Jones: Yeah, that makes sense. I think that is probably it for my questions. Nzinga, do you have any other thoughts that you want to add?


[38:19] Dr. Nzinga Harrison: I think that was probably a lot, so probably enough. But I will say, I know I kind of ran down all of these different types of professionals that you can reach out to kind of comfortably knowing that they have the skill set, but also will approach you with compassion. So don’t worry about if you didn’t get all of those letters that I rattled off, we’ll be sure to drop it in the show notes along with a resource for you. 


[38:44] Claire Jones: Yep. I’ll put them there. I got you guys. 


[38:49] Dr. Nzinga Harrison: Thanks for listening. That’s it for this week’s episode. You are listening to In Recovery. In Recovery is a Lemonada Media original. The show is produced by Claire Jones and edited by Ivan Kuraev. Music is by Dan Molad. Jessica Cordova Kramer and Stephanie Wittels Wachs are our executive producers. Rate and review us and say nice things. And follow us @LemonadaMedia across all social platforms, or find me on Twitter @naharrisonmd. If you’ve learned from us, share the show with your others. Let’s help destigmatize addiction together. 


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