Using Twelve-Step Treatment for Sex Addiction and Compulsive Sexual Behaviour (Disorder): A Systematic Review of the Literature

Figures & data

Figure 1. Flow chart of literature search.

Table 1. Study quality assessment according to the mixed methods appraisal tool, MMAT.

Author(s) (Year)	Methodological quality criteria assessment according to MMAT
Quantitative Non-Randomized
	Clear RQ?	Collected data address RQ?	Participants represent target population?	Relevant intervention (exposure) & outcome measurements?	Complete data outcome?	Confounders accounted for?	Intervention/exposure occurred as planned?	Overall study quality
Efrati & Gola (2018)	Yes	Yes	Not clear	Yes	Yes	Yes	Yes	High quality
Mergati Khoei et al. (2021)	Yes	Yes	Not clear	Yes	Yes	No	Yes	Medium quality
Wnuk & Charzynska (2022)	Yes	Yes	Not clear	Yes	Yes	Yes	Yes	High quality
Wright (2010)	Yes	Yes	Yes	Yes	Yes	No	Yes	Medium quality
Quantitative Descriptive
	Clear RQ?	Collected data address RQ?	Relevant sampling strategy?	Sample represent target population?	Measurements appropriate?	Low risk nonresponse bias?	Statistical analysis appropriate?
Schneider & Schneider (1996)	Not clear	Not clear	Not clear	Not clear	Not clear	No	Not clear	Low quality
Qualitative Methods
	Clear RQ?	Collected data address RQ?	Appropriate qualitative approach?	Adequate qualitative data collection methods?	Findings adequately derived from the data?	Interpretation of results sufficiently substantiated by data?	Coherence between qualitative data sources, collection, analysis and interpretation?
Fernandez, Kuss & Griffiths (2021)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	High quality
Saulnier (1996)	Not clear	Not clear	Not clear	Not clear	Not clear	Not clear	Not clear	Low quality
Yamamoto (2020)	Yes	No	No	No	No	No	No	Low quality

Table 2. Detailed description of studies included in the systematic review of twelve-step treatments for people who identify as, or are identified as, having a sex addiction.

Author(s), year, Country & publication type	Participants	Study design	Aim	Sampling strategy and outcome measures	Main results	Additional comments
Efrati & Gola 2018 Israel Scientific paper	97 participants: - 98% men - 18-55 years old, mean age 30.19 years old (SD 7.3) - 32% single, 66% married and 2.1% divorced - 79.4% were native Israelis, 5.2% born in Europe, 3.1% in the Commonwealth of Independent States – the former Soviet Union, and 12.4% from English- and Spanish-speaking countries - Mean number of years of schooling 13.57 (SD = 2.98)	Quantitative: Cross-sectional- analytical study	To examine the relationships between advancement in the recovery process in SA groups and severity of CSB, sexual-related sense of helplessness, treatment-seeking behavior, self-control, social support, sexual suppression, mental health (well-being and distress), and sociodemographic measures.	Availability sampling. Paper questionnaire examining: - Help-seeking styles (28 items) - Individual-based CSB (24-item) - Helplessness related to CSB (12 item) - Social support (Multidimensional Scale of Perceived Social Support, 12 items) - Self-control (Brief Self-Control Scale, 13 items) -Mental health (Mental Health Index, a subscale of the RAND SF-36 Quality of Life Scale, 5 items)	- Advancement in the SA program, measured as a current step of the program, is significantly related to lower levels of sexual-related overall sense of helplessness, avoidant help-seeking, self-control, overall CSB, sexual suppression and higher well-being.	–
Fernandez, Kuss & Griffiths 2021 UK/international Scientific paper	14 participants: - 13 men and 1 woman - Mean age: 43.86 years (SD 11.23) - 8 nationalities Dutch (n 3), British (n 3), American (n 2), Malaysian (n 2), French (n 1), Irish (n 1), Mexican (n 1), and Syrian (n 1). - Some were living abroad and attending the twelve-step meeting in the country of residence	Qualitative: Interview study	To conduct an inductive thematic analysis of phenomenological experiences of recovery from CSB among members of ‘S’ groups.	Purposeful snowball sampling. - Semi-structured interviews carried out via Zoom video call (except for one participant who preferred Zoom audio call). - Interviews covered the following topics: participants’ CSB history, motivations for initiating recovery, goals in recovery, challenges in recovery, strategies used in recovery, and how life in recovery was different compared to the past. Thematic analysis.	The analysis yielded 5 themes: -unmanageability of life as impetus for change, -addiction as a symptom of a deeper problem, - recovery is more than just abstinence, - maintaining a new lifestyle and ongoing work on the self, - the gifts of recovery.	–
Mergati Khoei et al. 2021 Iran Scientific paper	163 participants - All lived in Iran - 125 men and 38 women - Average age around 35 years - 85 were married	Quantitative: Cross-sectional- analytical study	To examine if community support, i.e. regular attendance in SA meetings, regular phone calls to other members, supporting other members as a sponsor or receiving support as a sponsored may be associated with coping styles (emotion-oriented, task-oriented, and avoidance styles).	Availability sampling. A survey (delivered in -person) measuring copying styles using a 48-item questionnaire to determine three coping styles: emotion-oriented, task-oriented, and avoidance styles.	Results show a significant association between coping styles and elements of community support of program for SA: - Participants who received community support including regular phone calls to other members and attending meetings regularly utilized task-oriented and avoidance-oriented coping styles more than emotion-oriented styles. - Sponsors utilized task-oriented coping styles more than emotion-oriented or avoidance-oriented coping styles.	Psychotherapy on the basis of stress coping style is suggested, unclear basis for this. Authors make an unsubstianted claim that Iranians have a collective spirit.
Saulnier 1996 USA Scientific paper	14 participants: - all women - 26 to 53 years, mean age 38 - all self-identified as black or African American - 4 lesbians, 9 heterosexuals - 12 had at least a high-school diploma	Qualitative: Multi-methods design	To explore how twelve-step programs are perceived by African-American women members, and the consequences of participation in such programs.	Non-probability sampling via word-of-mouth referrals and flyers. Group discussions, interviews and one case study. Unspecified analythic method.	- Participants were sometimes critical of twelve-step programs. - Participants experienced programs as white, in terms of both membership and culture. - Participants reported feeling a lack of understanding in twelve-step meetings. - Despite this, on many occasions, particpants were supportive of the twelve-step model, and felt it offered them something useful.	Research question is not consistent but presented in different ways throughout the article. Very limited material provided regarding SLAA as only one participant had this experience.
Schneider & Schneider 1996 USA Scientific paper	142 married sex addicts and coaddicts representing 88 marriages - 67 males and 75 females - Ages 24 to 71	Quantitative: Survey study	To obtain additional information by means of an anonymous survey.	During one year, married couples attending twelve-step groups for sexual addicts and coaddicts throughout the United States were offered to participate. 400 surveys distributed, 142 (35.5%) returned. 14-page on-line anonymous survey (open-ended questions and forced choices on a Likert scale) regarding: types of problems experience during recovery, effects of the addiction and/or coaddiction on the relationship and how difficulties were addressed.	Of those who had a high level of trust, most described a real commitment to recovery by their spouse and a long-term commitment to a 12-step program. -When describing trust building activities in the reelationshi, respondents reported talking with each other about their feelings, being honest with each other, going regularly to 12-step meetings, going to marriage and individual counseling, and to sex therapy, spending more quality time together, doing fun things, and improving their communication.	Study lacks a clearly formulated research question. Authors have been involved in facilitating twelve-step retreats during several years, and it is not clear whether the survey participants might have participated in the authors’ retreats, and how they obtained contact information to the participants. These ethical aspects are not discussed in the article.
Wnuk & Charzynska 2022 Poland Scientific paper	80 persons attending SA meetings: - 72 men (90%) and 8 women (10%) - average age 38.96 years (SD 5 10.56) - 78.8% had graduated from university - 52.5% in a formal or informal relationship - average duration of attending SA 47.48 months (SD 5 32.86) - average duration of abstinence from acting out 20.95 months (SD 5 28.64) - average number of twelve-steps completed 6.99 (SD 5 4.17)	Quantitative: Cross-sectional- analytical study	The study expected a direct positive relationship between SA involvement and life satisfaction of SA members. Besides testing the direct relationship, the aim was to seek the indirect relationships that underlie the relationship between SA involvement and life satisfaction. Two psychological constructs strictly related to the philosophy of twelve-step programs were considered: meaning in life and hope.	Self-selected on-line sample. Online questionnaire with the following measurments: -SA involvement (6 item scale) -Severity of CSBD (6 item scale) -Meaning in life (10 item scale) -Hope (12 item scale) -Satisfaction with life (5 item scale) -Subjective religiosity (single item)	-Path analysis showed a direct positive relationship between SA involvement and life satisfaction. The relationship between these variables was mediated by the presence of meaning in life and hope. -More severe symptoms of CSBD were related to lower levels of the presence of meaning in life and higher levels of the search for meaning in life, which, in turn, predicted lower levels of life satisfaction.	–
Wright 2010 USA & Canada Scientific paper	- 97 self-identified sexually compulsive heterosexual men - all were or had been in romantic relationships with female partners who knew about their sexual compulsivity - ages from 25 to 71 (M 50.96, SD 11.91)	Quantitative: Cross-sectional- analytical study	To examine associations between self-identified sexual compulsives’ attendance at 12-step meetings, involvement with 12-step sponsors, and levels of sexual compulsivity.	Participants sought via 12-step groups for sexually compulsive persons throughout the United States and Canadathrough and through therapists: self selected sample. On-line survey measuring: Sexual compulsivity (3 items) Meeting attendance (1 item) Sponsor work (I item)	Higher levels of meeting attendance and sponsor work at an earlier period in participants’ lives were associated with lower levels of sexual compulsivity at a later period in their lives. However, time-one meeting attendance and sponsor work did not explain interindividual change in sexual compulsivity from time-one to time-two.	Author do address several limitations, but do not discuss potential cofounders and their potential effect on the result.
Yamamoto 2020 UK Scientific paper	4 self-identified heterosexual men: >3 year concurrent engagement in treatment including individual psychotherapy and twelve-step program involvement > 2 years of continuous abstinence from problematic sexual behavior	Qualitative: Interview study	To examine the effectiveness of the combined intervention by exploring the quality of support which people draw from attending the two together, and how they manage this combination.	UK branches of SLAA, SAA and SA contacted and advertisement on-line resulted in a self-selected sample. Semi-structured interviews. Interpretative phenomenological analysis.	Analysis claims the strength of 12-step meeting attendance and active involvement with a sponsor and the complementary benefit of individual psychotherapy.	Study claims to examine the effectiveness of the combined intervention but the small sample and the chosen method does not allow for drawing conclusions regarding effectiveness.

*Efrati, Y., & Gola, M. (2018). Compulsive sexual behavior: A twelve-step therapeutic approach. Journal of Behavioral Addictions, 7(2), 445–453. doi:10.1556/2006.7.2018.26

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*Wright, P. (2010). Sexual compulsivity and 12-step peer and sponsor supportive communication: A cross-lagged panel analysis. Sexual Addiction & Compulsivity, 17(2), 154–169. doi:10.1080/10720161003796123

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*Schneider, J. P., & Schneider, B. H. (1996). Couple recovery from sexual addiction/coaddiction: Results of a Survey of 88 Marriages. Sexual Addiction & Compulsivity, 3 (2), 111–126. doi:10.1080/10720169608400106

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*Fernandez, D. P., Kuss, D. J., & Griffiths, M. D. (2021). Lived experiences of recovery from Compulsive Sexual Behavior among members of Sex and Love Addicts Anonymous: A qualitative thematic analysis. Sexual Health & Compulsivity, 28(1–2), 47–80. doi:10.1080/26929953.2021.1997842

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*Saulnier, C. F. (1996). Images of the twelve-step model, and sex and love addiction in an alcohol intervention group for black women. Journal of Drug Issues, 26(1), 95–123. doi:10.1177/002204269602600107

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*Yamamoto, M. (2020). Recovery from Hypersexual Disorder (HD): An examination of the effectiveness of combination treatment. Sexual Addiction & Compulsivity, 27(3–4), 211–235. doi:10.1080/10720162.2020.1815267

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