Treating Compulsive Sexual Behavior

Can sex become compulsive? Can it be an addiction? Like most behaviors, sex can be taken to its obsessive (thoughts) and compulsive (behaviors) extremes. Sexual obsessions and compulsions are recurrent, distressing and interfere with daily functioning. Many people suffer with these problems. It has been historically more difficult for those suffering from Compulsive Sexual Behavior (CSB) to get the appropriate help they need. For those who want to know more about this problem, it is helpful to know about the types of CSB, the various theoretical viewpoints and treatment approaches. While there are many types of compulsive sexual behavior, they can be divided into two main types: paraphilic and non-paraphilic CSB. Psychologists and sexual scientists have used various terms to describe this phenomenon: hypersexuality, erotomania, nymphomania, satyriasis, and most recently sexual addiction and compulsive sexual behavior. The terminology has often implied different values, attitudes, and theoretical orientations.

Paraphilic CSB: Paraphilic behaviors are unconventional sexual behaviors which are obsessive and compulsive. They interfere with love relationships and intimacy. While John Money1 has defined nearly 50 paraphilias, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association has currently classified the following paraphilias that are generally considered the most common:

In the official diagnostic manual, the paraphilias are defined as "recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving 1) nonhuman objects, 2) the suffering or humiliation of oneself or one's partner, or 3) children or other non-consenting persons: The behavior, sexual urges, or fantasies cause clinically significant distress in social, occupational, or other important areas of functioning." Some behaviors, such as sado-masochism when they are consensual and do not impair life functioning are not considered a paraphilia because they do not meet all the diagnostic criteria.

Nonparaphilic CSB: Nonparaphilic CSB involves conventional sexual behaviors that, when taken to an extreme, are recurrent, distressing and interfere in daily functioning. One example is given in the diagnostic manual under the category of Sexual Disorders Not Otherwise Specified. The authors of the DSM-IV describe an example of "distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used". Other forms of Nonparaphilic CSB include: compulsive searching for multiple partners, compulsive fixation on an unattainable partner, compulsive masturbation, compulsive love relationships, and compulsive sexuality in a relationship.

The Danger of Overpathologizing this Disorder: The possibility of overpathologizing this disorder is the main criticism given by those who do not believe in the idea of compulsive sexual behavior as a disorder. The pathologizing of sexual behavior may be driven by anti-sexual attitudes and a failure to recognize the wide-range of normal human sexual expression. This caution is important when assessing whether a person is engaging in compulsive sexual behavior. It is important for a therapist to be knowledgeable and comfortable with a wide range of people's normal sexual behavior; both in types of behaviors and frequency. Sometimes individuals with their own restrictive personal values will "diagnose" themselves with this disorder, or may be "diagnosed" by a friend or partner, creating additional distress. Therefore it is very important to distinguish between individuals who have a values conflict with their sexual behavior versus those who truly engage in obsessive and compulsive sexual behaviors.

A Possible Conflict Over Values: There is an inherent danger in diagnosing CSB or sexual addiction simply because someone's behavior does not fit the values of the individual, partner, group or society. There has been a long and sad tradition of pathologizing behavior which is not mainstream and which some might find distasteful. For example, masturbation, oral sex, homosexual behavior, reading or viewing erotic media, or even a love affair could be viewed as compulsive behaviors because someone might disapprove of these behaviors. However, there is no scientific merit to viewing these behaviors as categorically disordered, compulsive or "deviant." When someone is distressed about these behaviors, they are most likely in conflict with their own or someone else's value system rather than this being a function of a psychological compulsion.

Problemating or Compulsive Sexual Behavior? Behaviors that are in conflict with someone's value system may be problematic but not obsessive-compulsive or an addiction. Having sexual problems is common. Problems are often caused by a number of non-pathological factors. People can make mistakes. They can at times act impulsively. Their behavior can cause problems in a relationship. Some people will use sex as a coping mechanism similar to the use of alcohol, drugs, or eating. This pattern of sexual behavior can be problematic. Problematic sexual behavior is often remedied by time, experience, education or counseling. Obsessive and compulsive behavior, by its nature, is much more resistant to change.

Developmental Process vs. Compulsive Sexual Behavior... Some sexual behaviors might be viewed as obsessive or compulsive if they are not viewed within their developmental context. Adolescents, for example, can react to their new sex drive by becoming "obsessed" with sex for long periods of time. In adulthood, it is common for individuals to go through periods when sexual behavior may appear to take on obsessive and compulsive characteristics. For example, in the early stages of romance, there is a natural developmental period where an individual might be obsessed with their partner and compelled to seek out their company and express affection. These are normal and healthy developmental processes of sexual development and must be clearly distinguished from CSB.

What causes CSB? Disagreement exists as to whether CSB is an addiction, a psychosexual developmental disorder, an impulse control disorder, a mood disorder, or an obsessive-compulsive disorder. Patrick Carnes popularized the concept of CSB as an addiction. He believes that people become addicted to sex in the same way they become addicted to substances or other behaviors. However, many scientists dispute the idea that you can become addicted to sex in the same way that someone becomes addicted to alcohol or sex. Despite this criticism, sexual addiction has become a popular metaphor similar to "workaholism." Twelve-step programs of spiritual recovery (similar to Alcoholics Anonymous) have become popular solutions to those who view CSB as an addiction. However, the "abstinence model," while sometimes useful for alcoholics, cannot be applied to sexuality since sexual feelings and expression are basic aspects of life. Critics view the abstinence solution as an oversimplification of CSB and even potentially dangerous when proper medical and psychological treatment is not provided. Robert Stoller was a strong advocate of psychodynamic factors as an explanation. His theories have been helpful to our understanding of inner conflicts which fuel obsessive and compulsive drives. Others have suggested factors of anxiety, mood and personality disorders. In some cases, CSB can result from a bipolar mood disorder. In other cases, CSB can be caused by a neurological disorder such as epilepsy or Alzheimer's. John Money1 has assisted us to understand the complex interplay of biological, psychological and environmental factors in CSB. CSB in some cases may be caused by irregular chemical functions in the brain which produce repetitious nature of the self-defeating behavior. In this model, CSB is driven by anxiety where certain sexual behaviors provide temporary relief of the anxiety but is followed by further anxiety and distress creating a self-perpetuating cycle.

Since CSB is such a complex disorder involving biological, psychological and social factors, a careful assessment by a well-trained professional is necessary. Because of disagreements in theoretical approaches, the lay person should ask the professional about his/her own theories on CSB and consider other professional opinions.

Treatment of CSB: While some disagreement exists about the nature of CSB, treatment professionals have generally found a combination of psychotherapy and prescription medications to be effective in treating CSB. While medications which suppress the production of male hormones (anti-androgens) have been used to treat a variety of paraphilic disorders, the newer anti-depressants such as Prozac, Zoloft, or Paxil and others that selectively act on serotonin levels in the brain are usually very effective in reducing sexual obsessions and compulsions and their associated levels of anxiety and depression. These newer medications interrupt the obsessive-compulsive cycle of CSB and help patients use therapy more effectively.

How Does One Know if He/She Needs Help With CSB?
The following questions are examples of those used in assessing and treating CSB:

Here is what our program looks like:

Comfortable, healthy and exciting sexual functioning does not easily happen for many people. Very few of us have been taught how to have a healthy relationship or how to evaluate our own sexual thoughts and feelings. Fortunately, this knowledge and these perspectives can be learned and sex therapy can be an effective way to learn them. These kinds of problems almost always get worse and rarely go away on their own. Perhaps now is the time to look into making some important changes in your life.

The major portions of this fact sheet were derived from a publication of The Society for the Scientific Study of Sexuality, written by world expert Eli Coleman, Ph.D., Professor and Director of the Program in Human Sexuality, University of Minnesota Medical School. Edited by Robert W. Hatfield, Ph.D. Provided as an educational service by Chestnut Hill Counseling Associates. Contact SSSS if you would like reprints of the SSSS fact sheet.

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