Compulsive sex and its treatment

Can sex become compulsive? Like most behaviors, sex can be taken to its obsessive and compulsive extremes.

Sexual obsessions and compulsions are recurrent, distressing and interfere with daily functioning. Many people suffer from these problems, but finding consensus about them among sexual scientists or treatment professionals, is not easy.

This makes it 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.

Types of compulsive sexual behaviour
While there are many types of compulsive sexual behavior, they can be divided into two main types: paraphilic and non-paraphilic CSB.

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 Money(1) has defined nearly 50 paraphilias, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association has currently classifed eight paraphilias and these are generally considered the most common:

• paedophilia (sexual attraction to prepubescent children)
• exhibitionism (sexual excitement associated with exposing one's genitals in public)
• voyeurism (sexual excitement by watching an unsuspecting person)
• sexual masochism (sexual excitement from being the recipient of the threat or administration of pain)
• sexual sadism (sexual excitement from threatening or administration of pain)
• transvestic fetishism (sexual excitement from wearing the clothing of the opposite sex)
• frotteurism (sexual excitement from touching or fondling an unsuspecting person) (2)

Definition of paraphilias
In the recent DSM-IV, the paraphilias are defined as "recurrent, intense sexually arousing fantasies, sexual urges, or behaviours involving:

• nonhuman objects
• the suffering or humiliation of oneself or one's partner
• children or other nonconsenting persons

The behaviour, sexual urges, or fantasies cause clinically significant distress in social, occupational, or other important areas of functioning (p. 522-523)."

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, which, when taken to an extreme are recurrent, distressing and interfere in daily functioning.

One example is given in the DSM under the category of Sexual Disorders Not Otherwise Specified. The authors of the DSM 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" (p.538).

Other forms of nonparaphilic CSB include: compulsive fixation on an unattainable partner, compulsive masturbation, compulsive love relationships, and compulsive sexuality in a relationship.(3)

The danger of overpathologising this disorder
The possibility of overpathologising this disorder is the main criticism given by those who do not believe in the idea of compulsive sexual behavior as a disorder.

The pathologising of sexual behavior may be driven by anti-sexual attitudes and a failure to recognise 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 professionals to be comfortable with a wide range of normal sexual behavior - both in types of behaviors and frequency.

Sometimes individuals with their own restrictive values will diagnose themselves with this disorder, creating their own distress. Therefore it is very important to distinguish between individuals who have a values conflict with their sexual behavior, and those who engage in obsessive sexual behaviors.

A conflict over values
There is an inherent danger in diagnosing CSB simply because someone's behaviour does not fit the values of the individual, group or society. There has been a long tradition of pathologising behavior which is not mainstream and which some might find distasteful.

For example, masturbation, oral sex, homosexual behavior, sado-masochistic behavior(S-M) or a love affair could be viewed as compulsive, because someone might disapprove of these behaviors. However, there is no scientific merit to viewing these behaviors as disorders, 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 compulsion.

Problematic vs. compulsive sexual behavior
Behaviors, which are in conflict with someone's value system, may be problematic, but not obsessive-compulsive. 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 remedies by time, experience, education or brief counseling. Obsessive and compulsive behavior, by its nature, is much more resistant to change.

Developmental process vs. compulsive sexual behaviour
Some sexual behaviors might be viewed as obsessive or compulsive if they are not viewed within their developmental context. Adolescents, for example, can become "obsessed" with sex for long periods of time.

In adulthood, it is common for individuals to go through periods when sexual behavior may take on obsessive and compulsive characteristics. In early stages of romance, there is a natural development 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 distinguished from CSB.

What causes CSB?
Disagreement exists as to whether CSB is an addiction, a psychosexual development disorder, an impulse control disorder, a mood disorder, or an obsessive-compulsive disorder.

Patrick Carnes (4) popularised the concept of CSB as and addiction. He believes that people become addicted to sex in the same way they become addicted to substances or behaviors. However, many 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" useful for alcoholics, cannot be applied to sexuality since sexual expression is a basic need of life. Critics view the abstinence solution as an oversimplification of CSB and potentially dangerous when proper medical and psychological treatment is not provided.

Different explanations have been given as causes of CSB. Robert Stoller(5) was a strong advocate of psychodynamic factors. His theories have been helpful in 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 Money 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.(6)

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 disagreement exists about the nature of CSB, treatment professionals have generally found a combination of psychotherapy and prescription drugs to be effective in treating CSB.

While medications, which suppress the production of male hormones (anti-androgens), are used to treat a variety of paraphilic disorders, newer anti-depressants such as Prozac (R), Zoloft(R) or Paxil(R), which selectively act on serotonin levels in the brain, are also 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. The advantages of these anti-depressants over older anti-depressants or anti-androgens are their broad efficacy and relatively few known side effects.

How would one know that help was needed regarding CSB?
The following questions are examples of those used in assessing and treating CSB.

• Do you, or others who know you, find that you are overly preoccupied or obsessed with sexual activity?
• Do you find yourself compelled to engage in sexual activity in response to stress, anxiety, or depression?
• Have serious problems developed as a result of your sexual behaviour(e.g., loss of a job or relationship, sexually transmitted diseases, injuries or illnesses, or sexual offenses)?

Finding a CSB health professional There are several ways to find qualified professionals.

• Call your state licensing boards for psychologists, psychiatrists, social workers, or marriage and family therapists who have a specialised competence in treating compulsive sexual behavior.
• Inquire through college or university psychology, psychiatric or counselling departments.
• Ask professionals for their credentials in treating compulsive sexual behavior (e.g., certified sex therapist).

Summary

• Compulsive sexual behavior is a serious psychosexual disorder, which can be identified and treated successfully.
• CSB does not always involve strange and unusual sexual practices. Many conventional behaviors can become the focus of an individual's obsessions and compulsions.
• The exact mechanism of CSB is still under debate and various treatment approaches have been developed. Research is needed to further clarify the nature of the disorder, the mechanisms involved, and to test the most effective treatment approach.
• In the meantime, individuals suffering from CSB should not hesitate to seek professional guidance to properly assess their problem and to find help through counseling and treatment.

References
Money, J. (1996). Lovemaps: Clinical Concepts of Sexual/Erotic Health and Pathology, Paraphilia, and Gender Transpositions in Childhood, Adolescence, and Maturity. New York, NY: Irvington Publishers.
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, D.C.: American Psychiatric Association.
Coleman, E. (1992). Is you patient suffering from compulsive sexual behavior? Psychiatric Annals, 22(6), 320-425.
Carnes, P. (1983). Out of the Shadows: Understanding Sexual Addiction. Minneapolis, MN: CompCare Publishers.
Stoller, R. (1975). Perversion: The Erotic Form of Hatred. New York: Pantheon.

(Written by Eli Coleman, Ph.D. Professor and Director of the Program in Human Sexuality, Department of Family Practice and Community Health, University of Minnesota Medical School, University of Minnesota.)