When she hung out her shingle as a sex addiction therapist in 1997, Alexandra Katehakis had only a handful of colleagues.
"There were five people in this field and we all knew each other," she said.
These days, Katehakis, a licensed marriage and family therapist, has hundreds of competitors and has grown her Los Angeles solo practice into the Center for Healthy Sex, "a full-blown organization" with a team of counselors, an intensive outpatient program, a range of therapy groups, an expansive website and training for other therapists.
Celebrities have been the greatest evangelists for treatment. "My practice wouldn't exist without them," Katehakis said.
The for-profit field is booming, thanks largely to Tiger Woods and other celebrities whose public visits to rehab have moved sex addiction, a controversial diagnosis not recognized by the medical establishment, into the mainstream and led a growing number of Americans to conclude that they — or in many cases, their spouses — needed treatment.
A testament to the increasing demand for services and the potential money to be made providing them is the entrance into the sex addiction market this week of the private-equity-backed corporation that owns Promises, the high-end Malibu drug rehabilitation center known for its Hollywood clientele. The Cerritos company, Elements Behavioral Health, is buying a Westside treatment center, the Sexual Recovery Institute, as part of an expansion that will eventually include luxe in-patient facilities like Promises for wealthy sex addicts and a national network of two-week outpatient programs for those of lesser means.
The company has not disclosed the purchase price, but Chief Executive David Sack said Elements was making a significant investment on the belief that the Internet, with its easy access to pornography and casual liaisons, had created an epidemic of untreated sex addiction in America and that the rehab stays of Woods, actors Russell Brand and David Duchovny and others had informed a previously ignorant public about the existence of treatment programs.
"You have a backlog of people who need this treatment, and all of a sudden through a celebrity they have become aware that something can be done," said Sack, a psychiatrist.
Just how many people are seeking treatment is unclear. The rapid expansion of sex addiction programs, frequently described as "exponential" by those in the field, is occurring without the government regulation that exists in drug and alcohol treatment.
Public health agencies, insurance companies and others who compile data for other types of treatment do not monitor sex addiction because it is not listed in the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Assn.'s compendium of ailments.
Dr. Martin Kafka, a Boston-area psychiatrist and leader in the research of compulsive sexual behavior, said there was serious disagreement in the scientific community over whether humans could be addicted to sex in the same way they could be to alcohol or drugs. He said there was a lack of data demonstrating that sex addicts build up a tolerance over time or go through withdrawal if deprived of sex — two characteristics of substance addiction.
"That's not to say that in the next decade that there won't be … an empirical scientific backing for withdrawal and tolerance, but it's just not there now," Kafka said.
That's left it to the industry to define sex addiction, and it does so broadly. Sex addiction is "any sexually related, compulsive behavior which interferes with normal living and causes severe stress on family, friends, loved ones and one's work environment," according to a group that certifies sex therapists, the International Institute for Trauma and Addiction Professionals, or IITAP.
Some in the field estimate that 3% to 5% of Americans are sex addicts, while others say the proportion is probably greater.
The made-for-tabloid scandals around Woods and reality-TV star Jesse James, with their beautiful wronged wives and choruses of mistresses, prompted some pundits to dismiss sex addiction as a convenient recasting of run-of-the-mill infidelity. Therapists acknowledge that the threatened loss of a marriage, job or health is normally what prompts treatment, but they say someone who has had an affair or two would never be diagnosed as a sex addict.
"By the time they get here, they usually have hundreds of [sexual] contacts and years and years of a double life," said Rob Weiss, the founding director of the Sexual Recovery Institute, an outpatient center near Beverly Hills.
However sex addiction is defined, there is ample anecdotal evidence that more people think they have it. The number of sex therapists certified by the international institute has doubled — to about 900 — since 2007, and counselors say demand increases monthly.
Weiss said business at the Sexual Recovery Institute was up 50% from a year ago.
"I think the Tiger story sort of blew [the issue of sex addiction] out of the water because he went to a treatment center specifically for sexual addiction," Weiss said, referring to reports that the golfer was treated at Gentle Path, an in-patient program in Hattiesburg, Miss.
A Saturday morning information session for the public that the Sexual Recovery Institute began offering the month after Woods went to rehab draws 35 to 50 people each week.
That sex addiction is not considered a legitimate psychiatric diagnosis appears irrelevant to clients. They are finding rehab centers and outpatient programs through Google searches rather than referrals from their family doctors, Weiss said.
"It is absolutely consumer-driven. People are saying, 'I don't care what the clinical community says. My husband is out three nights a week, and he just gave me herpes,' " he said.
On the day in 2008 that Duchovny publicly announced he was checking into rehab for sex addiction, the website sexhelp.com, which features a quiz titled "Am I a Sex Addict?," got 50,000 visitors before its server crashed, according to Tami VerHelst, the vice president of IITAP, which runs the site. Capacity was expanded, and VerHelst said an average of 16,000 users took the quiz every month, answering questions such as "Has sex become the most important thing in your life?" and "Have you felt degraded by your sexual behavior?"
Sex addiction treatment is expanding despite costs that can quickly rise into the tens of thousands of dollars. The tony Sierra Tucson, an Arizona center for sex, drug and other addictions and the place where James sought treatment after his split with actress Sandra Bullock, costs $40,000 a month. The Sexual Recovery Institute charges $7,500 for a two-week outpatient program.
There is already an array of treatment options, including six-week in-patient facilities, three-day out-patient programs and couples counseling. Treatment varies, but most centers follow the therapy plan laid out by Patrick Carnes, the dean of sex addiction treatment and the executive director of Gentle Path.
Therapy often includes full disclosure of sexual encounters to spouses, including names, dates and locations, and a search for an underlying problem, such as childhood trauma or depression. There are no independent studies on recidivism in sex addicts, but practitioners describe it as extremely high. For an alcoholic, sobriety is abstinence, but the goal for a sex addict is more amorphous: a healthy sex life. Part of therapy is reaching a personal definition of sobriety, and it is often a trial-and-error process.
"It's really difficult in terms of people being able to get traction for recovery. Relapse is the norm," said Brigitte Lank, a Marin County psychologist who treats sex addicts.
On the Web — the main driver of business for treatment centers — therapists tout programs as "cost-effective" and "affordable." Their sites are polished and feature videos, blogs, reading lists and descriptions of the problems they treat — from voyeurism to porn addiction.
Although the overwhelming majority of those treated for sex addiction are men, the sites often seem geared toward their wives, with photos of couples engaged in deep conversation and women with pained expressions.
According to treatment centers, women frequently place the initial calls seeking information, and most therapists and in-patient programs have special programs for spouses. One Houston counselor, Milton Magness, promises follow-up polygraph tests so wives will know whether their husbands have changed.
Magness also runs a separate website, celebritysexaddict.com, that advertises total discretion for those in the entertainment field during three-day intensive outpatient programs. "If you prefer, we will work directly with your agent in making all arrangements," it says.
This aggressive marketing is a concern to some practitioners of sex addiction treatment.
"Unfortunately, there are some less-than-reputable providers and websites where they are trying to capitalize on what they see as the en vogue disorder," Magness said.
Without oversight by government agencies or accrediting groups, some worry that patients will suffer.
"It sets up the potential for treatment to be delivered from a business milieu rather than what is in the best interest of the client," Lank said. She said that, in her experience, recovery took two or three years and that many people needed several types of treatment as well as regular attendance at 12-step meetings.
"We should be making it very clear upfront that a two-week program is not even scratching the surface," she said.