Just as some people become obsessed and compulsive about other behaviors, sexual behavior can become the focus of a compulsive drive.1 When such behavior results in social and legal sanctions, exposure to HiV infection and other sexually transmitted diseases, and extreme guilt and shame, compulsive sexual behavior can be diagnosed and controlled through counseling and medication.
Compulsive sexual behavior (CSB) has been called hypersexuality, hyperphilia, hypereroticism, hyperlibido, hyperaesthcsia, erotomania, perversion, nymphomania, satyriasis, promiscuity, Don Jmv nism, Don Juanita-ism, Casanova type, and, more recently, sexual addiction and compulsivity.2'1Such labels suggest that CSB is an exotic or rare phenomenon, but, in fact, many men and women experience periods of intense involvement in sexual activity. Some of these may be short-lived, or may reflect normal developmental processes, but sexual obsessions and compulsions may also interfere with daily functioning or be accompanied by a variety of medical problems. When such difficulties bring a patient to your office, it is important to be able to assess for CSB, and to refer or treat appropriately.
Compulsive sexual behavior is defined as behavior driven by anxiety-reduction mechanisms rather than by sexual desire. The obsessive thoughts and compulsive behaviors reduce anxiety and distress, but they create a se Ifperpetuating cycle. The sexual ac? i vi Iy provi d es I em pora r y rei i ef, but it is followed by further distress.13,14 An individual engaging in CSB puts him /herself and others at risk for sexually transmitted diseases, illnesses and injuries, often experiences moral, social, and legal sanctions, and endures great emotional suffering. The concern about CSB as a problem to be identified and treated has been heightened by the current HlV epidemic.
I prefer the term compulsive scxtinl beiiavior over other terms and especially over the term sexual addici ion. The latter term has received enormous recent attention from the lay public as there is a tendency in the media to label all uncontrolled behavior as addictions. Not only has this term become popularized in the media, but is used in the current Diagnostic and Statistical Manual of the American Psychiatric Association as an example of a "psychosexual disorder not elsewhere classified ."1^ The term has also been widely used in a number of publications. ln'!q
The term addiction is an unfortunate misnomer. People do not become addicted to sex in the same way they become addicted to alcohol or other drugs. You cannot be addicted to sex. Sexual addiction has become a popular metaphor similar to "workaholism" - but the term sexual addiction obviates the complex interplay of biological, social, and psychological factors that cause the behavior. I have urged that the use of this term be changed in future revisions of the DSM.
TYPES OF CSB
There are many manifestations of CSB, which can be subsumed under two basic types: paraphilic and nonparaphilic CSB.
Paraphilic behaviors are unconventional sexual behaviors that are compulsive and, consequently, devoid of love and intimacy. John Money has defined nearly 50 paraphilias.20 Eight of the most common paraphilias are currently defined in the DSM-ÏII-R (pedophilia, exhibitionism, voyeurism, sexual masochism, sexual sadism, transvestic fetishism, fetishism and frotteurism). See Table 1 for definitions of these paraphilias.
Nonparaphilic CSB involves conventional and normative sexual behavior taken to a compulsive extreme. Little attempt has been made to define the various types of nonparaphilic CSB, but I have attempted to delineate five subtypes and their characteristics: compulsive cruising and multiple partners, compulsive fixation on an unattainable partner, compulsive autoeroticism, compulsive multiple love relationships, and compulsive sexuality in a relationship (Table 2).
Eight Paraphilias Defined in DSM-III-R
INCIDENCE OF CSB
There are no good national statistics to estimate how many people suffer from CSB. Estimates are complicated by simultaneous under- and o verre por ting. My own estimate is that the problem occurs in approximately 5'/r of the population.
CSB may currently be overreported due to the social climate with its more restrictive attitudes regarding sexuality. It is also in vogue to be concerned about behavioral excesses, compulsions, or addictions. Wc must be concerned with overdiagnosis of CSB as a result of a more restrictive social climate or popularization of the concept.
CSB may be underreported because embarrassment, secrecy, shame, and depression prevent individuals from contacting professionals. The paucity of trained professionals and lack of awareness that CSB is treatable may also discourage people from coming forward.
CSB IN MEN AND WOMEN
More men than women have identified themselves with CSB but this may be due to our restrictive definition of sexuality or to the fact that we tend to define sexuality from a masculine perspective. Since males are socialized to be more sexually aggressive, visually focused, and experimental, it is not surprising that more males are identified with this problem.
Women are socialized to define their sexuality in terms of relationships and romance. It is not surprising, then, that women are more susceptible to certain types of CSB, such as compulsive multiple sexual relationships or compulsive sexuality in a relationship rather than compulsive cruising and multiple partners. This is not to say that women do not develop paraphilias or the other types of nonparaphiiic CSB.
Types of Nonparaphiiic CSB
Associated Symptoms or Disease States of CSB
RECOGNIZING CSB IN YOUR PATIENTS
Most patients will not identify CSB as a presenting problem. CSB may be identified by looking for associated symptoms and illnesses (Table 3). There is a high comorbidity of CSB with anxiety disorders, depression, and alcohol and drug dependence. People with CSB may experience motor tension (trembling, shnkiness, headaches, muscle aches, restlessness, inability to relax, fatigue), autonomie hyperact i vi t y (shortness of breath, tachycardia, sweating, dry mouth, dizziness, nausea, diarrhea, frequent urination, trouble swallowing) or hypervigilance ("on edge," easily startled, difficulty concentrating, insomnia, irritability).
Anxiety is exhausting and demoralizing. Chronic low grade depression often develops along with symptoms of dysthymia, including poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration, and feelings of hopelessness.
Many patients with CSB experience acute and chronic anxiety or depression in response to their compulsive sexual behavior. They may describe a sexual act as a "fix" to their anxiety or depression. This relief is short-lived, however, and they experience further anxiety. Some become depressed and even suicidal. They attempt to resist further obsessive thoughts or compulsive behaviors, but these efforts are frustrating and the individual usually ends up engaging in the behavior. When associated symptoms or disease states are diagnosed, a few additional questions will help in recognizing this problem (Table 3). Specific questions need to be asked in addition to a standard sex history. These questions are listed in Table 4.
Distinguishing Normal Sexual Variation from CSB
It is important to recognize the wide range of normal variations of sexual behavior - both in types of behaviors and frequency. A physician may have sexual values that restrict successful communication with a patient. Sometimes it is the patient's own restrictive values that create his/her sexual discomfort.
It is dangerous to define compulsive sexual behavior simply as behavior that does not fit normative standards. Unfortunately, we have many examples of this type of thinking. A woman once innocently asked me, "1 have discovered that my husband is masturbating. What should T do about his compulsive sexual behavior?" Some churches have argued that homosexuals should not be ordained, because homosexuality is an "addiction." The following cases illustrate how behaviors can be viewed as compulsive when they are better understood as behaviors in conflict with value systems.
Case 1. A 21-year-old single man from a rigid religious background came to me for help with his "sexual addiction." When I asked him to tell me what behaviors he thought were compulsive, he told me that he was masturbating several times a week, was unable to stop masturbating/ and felt no control over these urges.
Questions to Identify Patients with CSB
Case 2. A 45-year-old married man felt he was addicted to sex because he was constantly bothered by homosexual fantasies. On occasion, he would seek out a male partner for sex. He had never told anyone about these fantasies or behaviors. He was determined to commit suicide if he could not rid himself of these "deviant" thoughts.
Tn both of these cases, it was important to help these individuals recognize the normal range of human sexual behavior and to understand that their distress was due to a conflict between their sexual values and their behavior.
Identifying Problematic or Compulsive Sexual Behavior
Individuals have varying degrees of problems related to CSB. It is difficult to draw a clear distinction between someone who has some problems that can be corrected easily through education or brief counseling, and someone who needs intensive treatment. It is common to experience periods in which sexuality is expressed in obsessive and compulsive ways. This may be part of a normal developmental process. In other cases, it may be problematic. During adolescence it is normal to become "obsessed" with sex for long periods of time. However, some adolescents begin to use sexual expression to deal with the stress of adolescence, loneliness, or feelings of inadequacy. Compulsive sexuality can be a coping mechanism similar to alcohol and drug abuse. This pattern of sexual behavior can be problematic.
During adulthood it is not uncommon for individuals to go through periods when sexual behavior may take on obsessive and compulsive characteristics. Relationships outside committed relationships or frantic searches to fill the void of loneliness following dissolution of a relationship are common. For some, these common behaviors become problematic. When individuals recogni/e that their behavior is not solving problems but creating them, they can often alter their pattern of behavior on their own or after brief counseling.
Some individuals, however, lack the ability to alter problematic sexual behavior. Their behavior is "hard- wired" in the erotosexual pathways in their brain and the repetitious nature of the selfdefeating behavior can be explained by neurotransmitter dysfunction. Compulsive sexual behavior is, at this point, pathological because brain pathology is causing anxiety and the pattern of sexual behavior is acting as a shortlived anxiolytic (similar to other obsessive and compulsive behaviors). In its obsessive and compulsive form, the sexual behavior is senseless, dysphoric, and harmful. The CSB often has damaging consequences, including arrest, injury, loss of jobs or relationships.
Unlike problematic sexual behavior, compulsive sexual behavior is resistant to simple therapies. For many of the people I have treated, resolutions to change are fruitless. Like other forms of obsessive-compulsive behavior, the obsession is too strong for even the most determined to resist.
CAUSES OF CSB
CSB has been linked strongly to early childhood trauma or abuse, highly restricted environments regarding sexuality, dysfunctional attitudes about sex and intimacy, low self-esteem, anxiety and depression.-1 It is speculated that these traumatic experiences create or amplify an underlying or evolving anxiety disorder. Dy s. thy mia is often experienced secondary to this primary anxiety disorder. New devclopments in the understanding of obsessive-compulsive disorder (OCD) have suggested that most paraphilic and nonparaphilic CSB may be best understood as a variant of OCD.-2 In other cases, the behavior may be caused by other psychiatric or neurologic disorders that explain the compulsive nature of the sexual expression. Contrary to common beliefs, and in most cases, individuals with CSB are not oversexed (in the sense of having high sexual desire or hormonal imbalances). Their hypersexuality is in response to anxiety caused by neuropsychiatrie problems.
TREATMENT OF CSB
Problematic sexual behavior is often resolved by individuals on their own or through simple information, education, or brief counseling. Flaving been arrested for prostitution, for example, is often enough to deter a man from soliciting prostitutes.
Patients who suffer CSB are helped through a combination of psychotherapy and pharmacotherapy. If the patient is chemically dependent, this must be the first treatment intervention. CSB treatment often begins with the use of serotonergic medications to help immediately interrupt the obsessive thoughts or compulsive behaviors and to treat their anxiety and depression. This pharmacotherapy must be accompanied by psychotherapy.
The severity of the patient's obsessions and compulsions and comorbidity with other physical or psychiatric disorders needs to be taken into account before prescribing any medication. Serotonergic medications have been very effective in treating a variety of CSBs. -^-s In addition, antiancirogens have been used successfully in treating paraphilias.2'1 Unfortunately, most studies have relied upon case report methods and we are lacking more controlled experimental designs to demonstrate their efficacy. At this time, 1 prefer to use the serotonergic medications over the antiandrogens because of fewer potential side effects and the fact that the serotonergic antidepressants have antilibidinai anxiolytic and antidepressant effects. In our clinic, we have found that fluoxetine (Prozac) given 20 mg daily has been shown to be the most effective medication and dosage. Higher dosages of fluoxetine or other serotonergic medications can be effective also. In the most resistant cases, antiandrogens can be used.
Through psychotherapy a person am resolve the sources of psychiatric problems and psychosexual disorder, learn better ways of managing anxiety, and healthy ways of expressing sexuality and meeting intimacy needs. Since many individuals with CSB come from dysfunctional family environments and/or were abused, treatment focusing on family-of-origin issues is critical. Family therapy is often essential.
Intensive treatment is best accomplished in a group therapy format with adjunctive family or relationship therapy. The spouses or partners should also be involved in the treatment process given that they are often similarly afflicted or need assistance because of the damaging effects of the patient's CSB on the relationship.
Treatment of CSB does not involve eradicating all sexual behavior. Sexual expression is an important ingredient of sexual health. Patients need to set limits or boundaries around certain patterns of sexual expression. They set these boundaries by clearly identifying their obsessive and compulsive sexual behavior. For example, a man who has been involved in compulsive autoeroticism does not stop masturbating. He identifies the behaviors and patterns of obsessive and compulsive masturbation and eliminates these behaviors. At the same time, he needs to learn new ways and patterns of masturbation that are self-nurturing and pleasing. Although sexual behavior is being restricted, patients should be given permission to be sexual human beings.
Many patients with CSB feel enormous guilt around sexuality and will try to set overly restrictive boundaries, only to set themselves up for repeated failure and further feelings of guilt, shame, and low self-esteem. Professionals must be careful in guiding patients to set appropriate boundaries that recognize normal and healthy patterns of sexual expression.
When attempts at brief counseling and education have failed, it is important to find a competently trained sex therapist. The sex therapist must be knowledgeable in evaluating and treating general mental disorders (especially anxiety, mood, and substance abuse disorders). The primary care physician can often assist nonphysician sex therapists by prescribing and monitoring the pharmacotherapy.
Compulsive sexual behavior is a serious psychosexual disorder that must be identified and treated appropriately. CSB doesn't always involve strange and unusual sexual practices. Many conventional sexual behaviors become the focus of the individual's sexual obsessions and compulsions. New advances in the understanding and treatment of obsessive-compulsive disorder have given us a new direction and hope for better treatment of individuals with CSB. New pharmacotherapies combined with traditional psychotherapies have been shown to be effective in treating the various types of CSB.
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Eight Paraphilias Defined in DSM-III-R
Types of Nonparaphiiic CSB
Associated Symptoms or Disease States of CSB
Questions to Identify Patients with CSB