Compulsive sexual behavior (CSB) is characterized by inappropriate or excessive sexual thoughts or behaviors that lead to stress, are overly time consuming, or lead to interpersonal, family, marital, financial, or legal problems. It appears to be widespread, to preferentially affect men, and to have an onset early in life. Psychiatric comorbidity is common, and while its cause remains unclear, CSB probably results from multiple factors. There is little consensus on treatment, but individual psychotherapy, cognitive-behavioral therapy, and 12-step programs may be helpful. Selective serotonin reuptake inhibitors (SSRIs) may help patients regulate their sexual impulses, while testosterone-reducing agents may help control sexual aggressiveness. Additional studies are needed of subjects with CSB using standardized and reliable instruments as are careful treatment studies involving blinded assessments and placebo controls.
Characteristics of Compulsive Sexual Behavior
Compulsive sexual behavior is not listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), although many of its manifestations would fit criteria for various paraphilias such as pedophilia, voyeurism, exhibitionism, or transvestic fetishism. German psychiatrist Krafft-Ebbing described “pathological sexuality” over 100 years ago and wrote of a condition not unlike today’s CSB, in which a person’s sexual drive is abnormally increased. Various terms have been used to describe this condition, most pejorative, such as nymphomania and satyriasis in women and men, respectively, while men with this condition are frequently referred to as a “Don Juan” or “Casanova.” More neutral terms include compulsive sexual behavior, sexual addiction, or hypersexual disorder. It is unresolved whether this condition falls within an obsessive-compulsive spectrum of disorders, is related to addictive disorders, or represents an impulse control disorder.
The prevalence of CSB in adults is estimated to range from 3% to 6% and is thought to predominately affect men. Onset appears to be in the late teens or early 20s. Gender differences include its symptom presentation: Among men, the disorder predominately involves promiscuous sexual behavior, compulsive masturbation, or a paraphilia. Among women, the disorder is thought to involve cognitive or emotional states resulting in dangerous sexual encounters or multiple unsuccessful love relationships. CSB has been described as involving nonparaphilic behaviors (i.e., conventional sexual behaviors carried to an extreme) or paraphilias (i.e., abnormal or dangerous patterns of sexual arousal or behavior); some persons with CSB have both types of behaviors.
Psychiatric comorbidity is frequent, particularly of mood and anxiety disorders, substance misuse, and the impulse control disorders, including compulsive buying, kleptomania, and pathological gambling. Axis II (personality) disorders are also frequent, and in at least one study, 83% of persons with CSB met criteria for one DSM-IV personality disorder. No particular personality type predominated, though it has been observed that persons with CSB often exhibit narcissistic, borderline, dependent, or antisocial traits.
The natural history of CSB has not been well characterized, but it is likely chronic or recurrent. It has been described as beginning in adolescence with sexual preoccupations. The next stage, often referred to as ritualization, occurs when the person develops an idiosyncratic routine that prompts the sexual behavior. The third stage consists of the uncontrollable sexual behavior itself. The fourth stage is characterized by feelings of despair and hopelessness.
Persons with CSB are secretive about their disorder, which can lead to social isolation. In addition to social and interpersonal problems that develop as a result of CSB, the disorder can lead to marriage and family-related problems, work impairment, or financial and legal consequences. In some cases, CSB can lead to genital injury, sexually transmitted diseases, and unwanted pregnancies, or even the complications of abortion.
Cause of Compulsive Sexual Behavior
The cause of CSB is unknown, although developmental, behavioral, neurobiologic, and sociocultural mechanisms have been proposed. Early theorists focused on intrapsychic conflicts and environmental traumas. For example, Fenichel wrote that hypersexuality was prompted by unconscious incestuous wishes that lead to a futile search for the ideal sex partner. Contemporary theories continue to be driven by psychoanalytic views regarding the effect of abusive childhood experiences that lead to low self-esteem, anxiety, and feelings of shame. In this schema, CSB develops as a means of coping with uncomfortable affects. Learning theory has been invoked by behaviorists who argue that behavioral completion mechanisms create the drive for what becomes habitual behavior.
There are no family studies of CSB, but at least one uncontrolled survey of “sex addicts” suggests that first-degree relatives often suffer from substance misuse, CSB, eating disorders, or compulsive gambling. In a small family history study of pedophilia, which may be relevant to CSB, it was reported that this disorder runs in families (19% of pedophiliacs had relatives with the same disorder vs. 3% of controls).
A monoamine theory of paraphilic disorders has been proposed invoking dysregulation of the neurotransmitters serotonin, dopamine, and norepinephrine. The theory is based on the fact that these monoamines play a modulatory role in regulating sexual motivation and behavior, and that drugs that enhance serotonin neurotransmission seem to reduce sexual arousal and increase behavioral control. Neuropeptides (e.g., gonadotropin-releasing hormone [GRH]), and the androgenic hormones have also been suggested as having a role in CSB, because they are involved in human sexual behavior and have been successfully used to treat paraphilias.
Cultural concepts are also relevant in that sexual behavior occurs in a societal context; one must keep in mind that our notion of appropriate sexual behavior is constantly evolving. For example, pornography is widely available throughout the United States, though in the past it was considered illegal and its purveyors criminal.
Compulsive Sexual Behavior Diagnosis
The assessment of CSB begins with its recognition, although many patients may not discuss the problem unless asked; others will seek help specifically for the disorder, or at the behest of a concerned spouse, friend, or an attorney or law enforcement officer. Persons who acknowledge being sexually preoccupied or overactive should be questioned about the extent of the preoccupation and behavioral excess. Distress or impairment related to the problem should be explored. The clinician needs to distinguish normal sexual behavior from CSB, although it may sometimes be difficult to draw a clear distinction. For example, a patient may masturbate 2 or more times daily, yet report no impairment from the behavior.
Clinicians should be aware of the wide variation in sexual drive and that no specific number of orgasms can be used to describe when the behavior is “excessive” or constitutes CSB. Clinicians should also be aware of the differences in frequency of orgasms reported by men and women and understand that frequency generally declines with advancing age. Careful judgment needs to be exercised in assessing CSB so as not to mislabel a person’s behavior as pathological because it may conflict with the clinician’s view of what constitutes normal behavior. In some persons, a physical examination and neurologic examination will need to be done to rule out medical causes. Rarely, hypothalamic disturbances, brain tumors, or temporal lobe epilepsy will be the cause of inappropriate sexual behavior. Drugs of abuse, such as psychostimulants (e.g., cocaine) can cause hypersexual behavior. The manic phase of bipolar disorder is well known to cause temporary hypersexuality, and some psychotic disorders and dementing illnesses can also cause inappropriate sexual behavior.
Treatment for Compulsive Sexual Behavior
There are no standard treatments for CSB. Individual psychotherapy is often recommended, its purpose being to provide accurate information about sexual behavior and help patients understand their disorder. The goal is to assist patients in learning more appropriate ways to express their sexuality and to meet their intimacy needs. Group therapy models have also been developed that may be beneficial in confronting the patient’s defensive lies as well as in sanctioning one another’s acceptance of more appropriate sexual behavior. A 12-step program, Sex Addicts Anonymous, similar to its sister programs Alcoholics Anonymous and Gamblers Anonymous, is helpful to some persons. Self-help books are also available. Because CSB can damage marital relationships and family ties, treatment may need to include the spouse or partner and sometimes the entire family. If substance misuse appears to be promoting or fostering CSB, then that should be a focus of treatment as well. Comorbid psychiatric disorders need to be addressed.
Medications have also been used to treat CSB, including SSRIs and antiandrogenic agents. The SSRIs are well tolerated and appear to reduce sexual preoccupations and impulsivity. Case reports and open label studies of SSRIs suggest that these agents are effective, but there have been no randomized, controlled trials. Other antidepressants have also been used in small open-label studies and may be effective. In one case study, a patient with CSB was treated successfully with naltrexone, an opiate antagonist. Testosterone-reducing agents, such as medroxyprogesterone, have been used mainly to control sexually aggressive forms of CSB, though there have been no controlled trials of these agents. A controlled trial of the GRH analog triptorelin in men with severe paraphilias suggests that it is effective.
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