This article has been cited by other articles in PMC. Abstract Compulsive sexual behavior, otherwise known as sexual addiction, is an emerging psychiatric disorder that has significant medical and psychiatric consequences. Until recently, very little empirical data existed to explain the biological, psychological, and social risk factors that contribute to this condition. In addition, clinical issues, such as the natural course and best practices on treating sexual addictions, have not been formalized.
Despite this absence, the number of patients and communities requesting assistance with this problem remains significant. This article will review the clinical features of compulsive sexual behavior and will summarize the current evidence for psychological and pharmacological treatment. Compulsive sexual behaviors, sexual addiction Introduction Sexuality in the United States has never been more socially acceptable.
Sex has become part of mainstream culture as reflected through the explicit coverage of sexual behaviors in the media, movies, newspapers, and magazines.
In many ways, sexual expression has become a form of accepted entertainment similar to gambling, attending sporting events, or watching movies. Internet pornography has become a billion-dollar industry, stretching the limits of the imagination. Digital media offers portability, access, and visually explicit depictions of sexual acts in high-definition that leave nothing to the imagination.
Sales and rental of adult movies through DVDs and pay-per-view services allow access to sex anywhere and at any time. Strip clubs have evolved from backroom cabarets into large multimillion dollar nightclubs and are present in virtually every state in the US. Inside them, the degree of physical contact has also increased, as compared to a generation ago, to the point where the boundaries of what constitutes sexual intercourse are blurred.
Escort services, massage parlors, and street prostitution continue to be available in every major city in the US. Strengthening their presence and availability is the internet, which has created an information portal for these services through online dating services, classified ads, and discussion boards for those in pursuit of sexual gratification.
Together, these cultural changes have increased the acceptability and availability of sexual rewards. For some, though, this increase in availability has uncovered an inability to control sexual impulses resulting in continued engagement in these behaviors despite the creation of negative consequences—otherwise known as sexual addiction. This term has been used synonymously with others, such as compulsive sexual behaviors, hypersexuality, and excessive sexual desire disorder.
Furthermore, debate is ongoing about where this behavioral pattern fits into the American Psychiatric Association's Diagnostic and Statistical Manual DSM-IV , and how it should be classified and conceptualized. Does it merit enough empirical evidence to stand alone as a separate disorder? Finally, what are the boundaries and limits that distinguish disease patterns, at-risk behaviors, and socially appropriate expression?
Compulsive sexual behavior has not yet received extensive attention from researchers and clinicians. To date, there have been very few formalized studies of compulsive sexual behaviors. Funding agencies, such as the National Institutes of Health NIH , and pharmaceutical companies have not supported research into the etiology and mechanisms of compulsive sexual behavior and, as a result, evidenced-based treatments are limited.
Despite the paucity of research, a significant number of patients with sexual addictions do present for treatment. This is evidenced by the number of treatment centers dedicated to the treatment of sexual addictions in both residential and intensive outpatient settings. Mental health professionals in any setting are likely to encounter patients with this hidden addiction and require better tools to diagnose and manage them.
This article will review the terminology, the epidemiology, and the existing treatments that are currently available for compulsive sexual behaviors. There are 12 listed sexual disorders and they are divided into disorders of sexual dysfunction, paraphilias, and gender identity disorder. In fact, the only place where compulsive sexual behaviors might be included is within the context of sexual disorder, not otherwise specified NOS or as part of a manic episode.
In other words, hypersexuality, sexual addiction, or compulsive sexual behaviors are terms that are not found within the DSM-IV. Some of the reasons for why there is a lack of formalized criteria include the lack of research as well as an agreed-upon terminology.
This is due, in part, to the heterogeneous presentation of compulsive sexual behaviors. Others will demonstrate elements of an impulse control disorder, namely reporting irresistible urges and impulses, both physically and mentally, to act out sexually without regard to the consequences. Finally, there are patients who demonstrate sexual obsessions and compulsions to act out sexually in a way that resembles obsessive compulsive disorders. They do so to quell anxiety and to minimize fears of harm.
For these patients, the thoughts and urges to act out sexually are ego-dystonic, whereas other types of patients describe ego-syntonic feelings about their sexual behaviors. One important feature to note is that hypersexuality is not necessarily symbolic or diagnostic of compulsive sexual behaviors.
Libido and sexual drive can be seen as similar to other biological drives, such as sleep and appetite. States of hypersexuality induced by substances of abuse, mania, medications e. Clinical Features Compulsive sexual behaviors can present in a variety of forms and degrees of severity, much like that of substance use disorders, mood disorders, or impulse-control disorders.
Often, it may not be the primary reason for seeking treatment and the symptoms are not revealed unless inquired about. Despite the lack of formalized criteria, there are common clinical features that are typically seen in compulsive sexual behaviors. One of the fundamental hallmarks of compulsive sexual behavior is continued engagement in sexual activities despite the negative consequences created by these activities. This is the same phenomenon seen in substance use and impulse control disorders.
Psychologically, sexual behaviors serve to escape emotional or physical pain or are a way of dealing with life stressors. Compulsive sexual behavior can be divided into paraphilic and non-paraphilic subtypes.
Paraphilic behaviors refer to behaviors that are considered to be outside of the conventional range of sexual behaviors. Exhibitionism, voyeurism, pedophilia, sexual masochism, sexual sadism, transvestic fetishism, fetishism, and frotterurism. A key clinical feature in diagnosing a paraphilic sexual behavior is that it must be distressing and cause significant impairment in one's life, with the exception of pedophilia and fetishism. In other words, with the noted exceptions, engagement in these behaviors leads to sexual gratification but does not cause distress or impairment and do not represent clinical disorders.
Paraphilias begin in late adolescence and peak in the mids. The onset, clinical course, and male predominance are fairly similar to paraphilic disorders. This has the potential to confuse and cloud clinicians. In addition, a clinician that screens only for some but not all of the potentially problematic sexual behaviors is likely to miss important clinical information.
Thus, asking about both paraphilic and non-paraphilic behaviors is critical in screening. In addition, it is important to assess the consequences as well as the nature of the behavior.
Identifying a compulsive sexual disorder is a challenge because of its sensitive and personal nature. Unless patients present specifically for treatment of this disorder, they are not likely to discuss it. Even signs of excessive sexual behaviors such as physical injury to the genital area or the presence of sexually transmitted diseases does not necessarily indicate compulsive sexual activity. Their presence does signal the need to screen for those behaviors but one cannot assume a compulsive sexual disorder exists based on physical examination alone.
Consequences of compulsive sexual behaviors can vary with some being similar to that seen in other addictive disorders while others are unique. Medically, patients are at a higher risk for sexually transmitted diseases STDs and for physical injuries due to repetitive sexual practices. Human immunodeficiency virus HIV , Hepatitis B and C, syphilis, and gonorrhea are particularly concerning consequences.
Another significant consequence is the loss of time and productivity. It is not uncommon for patients to spend large amounts of time viewing pornography or cruising also called mongering for sexual gratification. Financial losses can mount quickly, and patients can accumulate several thousands of dollars of debt in a short amount of time.
In addition, there is a long list of legal consequences, including arrest for solicitation and engaging in paraphilic acts that are illegal. One look at recent news headlines will likely reveal several stories focusing on illegal sexual activities or behaviors that jeopardize someone's livelihood or wellbeing.
The psychological consequences are numerous. Effects on the family and interpersonal relationships can be profound. Compulsive sexual behaviors can establish unhealthy and unrealistic expectations of what a satisfying sexual relationship should be. At the same time, the deception, secrecy, and violations of trust that occur with compulsive sexual behaviors may shatter intimacy and personal connections.
The result is a warped view of intimacy that often leads to separation and divorce and, in turn, puts any future healthy relationship in doubt. Finally, the shame and guilt that those with compulsive sexual behaviors experience is different from those with other addictive disorders. There are no substances of abuse to explain seemingly irrational behaviors. The stigma of not being able to control sexual impulses carries with it a connotation of depravity and moral selfishness.
As a result, access to care and seeking care, even when one recognizes that sexual behaviors are out of control, is a decision faced with barriers and limitations. Epidemiology There have been no national studies documenting the past-year or lifetime prevalence of compulsive sexual behaviors in the general population.
Regional and local surveys suggest that approximately five percent of the general population may meet criteria for a compulsive sexual disorder using criteria that are similar to substance use disorders. One of the reasons why reliable epidemiological data are lacking is the inconsistency in defining criteria for compulsive sexual behaviors, lack of funding, and the lack of researchers committed to documenting the extent of this problem.
Most of what is known about the epidemiological nature of this disorder comes from clinical treatment programs that focus on sexual addictions. Men appear to outnumber women with compulsive sexual behaviors.
Etiology As with impulse control and substance use disorders, no single biological cause has yet been identified to explain the origins and maintenance of compulsive sexual behaviors. Neuroscience research, which would be an excellent approach to understand basic brain differences between those with and without compulsive sexual behaviors, has rarely been applied to this population. In particular, neuroimaging studies in patients with compulsive sexual behaviors would be interesting to compare with those involved in substance abuse and other behavioral addictions.
To date though, most of the neuroimaging work has been done with nonclinical populations and has examined the biology of sexual arousal in healthy subjects. Hypersexual behaviors have been reported in patients with frontal lobe lesion, tumors, and in those with neurological conditions that involve temporal lobes and midbrain areas such as seizure disorders, Huntington's disease, and dementia.
Neurotransmitter studies in compulsive sexual behaviors have focused on the monoamines, namely serotonin, dopamine, and norepinephrine. Normal sexual functioning involves all of these monoamines as evidenced by selective serotonin reuptake inhibitor SSRI -induced sexual dysfunction and the increased sexuality observed among those on stimulants. Cases of hypersexual behavior have also been shown to be induced by medications for Parkinson's disease, implicating dopamine systems in compulsive sexual behaviors.
In addition to neurotransmitters, the sex hormones are obviously a critical component to sexual functioning. Testosterone levels have been correlated to sexual functioning but curiously, levels do not necessarily correlate to libido and sexual desires.
It may be that regions of reward and pleasure are modulated by these hormones through facilitating or enhancing the response to sex and the desire for sex. Clinical Assessment Measures There are existing screening instruments, which are only as valid as the responder's honesty and integrity. Although this is true of all psychiatric screening instruments, revealing sexual practices is probably the most humbling because of its private nature.
Questions about time spent on sexual activities and impact of functioning are important clinically, but also rely on self-report. Patrick Carnes, one of the pioneers in the field of compulsive sexual behavior research, developed the Sexual Addiction Screening Test, which is a item, self-report symptom checklist that can be used to identify those at risk to develop compulsive sexual behaviors.