Just as some people become obsessed and compulsive
about other behaviors, sexual behavior can become
the focus of a compulsive drive. 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, hyperaesthesia, erotomania, perversion,
nymphomania, satyriasis, promiscuity, Don Juanism,
Don Juanita-ism, Casanova type, and, more recently,
sexual addiction and compulsivity.
Such 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 self-perpetuating cycle. The
sexual activity provides temporary relief, but it is
followed by further distress. An individual engaging
in CSB puts him/herself and others at risk for STDs,
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 HIV epidemic.
I prefer the term compulsive sexual behavior over
other terms and especially over the term sexual
addiction. 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 DSM as an example of a "psychosexual
disorder not otherwise specified". The term has also
been widely used in a number of publications.
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 CSB
Paraphilic behaviors are unconventional sexual
behaviors that are compulsive and, consequently
devoid of love and intimacy. John Money has defined
nearly 50 paraphilias. Eight of the most common
paraphilias are currently defined in the DSM III-R
(pedophilia, exhibitionism, voyeurism, sexual
masochism, sexual sadism, transvestic fetishism and
frotteurism).
Nonparaphilic CSB
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.
Incidence of CSB
There are no good national statistics to
estimate how many people suffer from CSB. Estimates
are complicated by simultaneous under-and
overreporting. My own estimate is that the problem
occurs in approximately 5% of the population.
CSB may currently be overreported due to the
social climate with its more restrictive attitudes
toward sexuality. It is also in vogue to be
concerned about behavioral excesses, compulsions, or
addictions. We 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 of
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
nonparaphilic 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. There is a high
comorbidity of CSB with anxiety disorders,
depression, and alcohol and drug dependence. People
with CSB may experience motor tension (trembling,
shakiness, headaches, muscle aches, restlessness,
inability to relax, fatigue), autonomic
hyperactivity (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, 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. Specific questions need to be asked in
addition to a standard sexual history.
These questions are as follows:
- Do you or others who you know find that you
are overly preoccupied or obsessed with sexual
activity?
- Do you ever find yourself compelled to
engage in sexual activity in response to stress,
anxiety, depression?
- Have you had serious problems develop as a
result of your sexual behavior (eg. loss of a
job or relationship, sexually transmitted
diseases, injuries, or illnesses, sexual
offenses?)
- Do you feel guilty and shameful about some
of your sexual behaviors?
- Do you fantasize or engage in any unusual or
what some would consider "deviant" sexual
behavior?
- Do you find yourself constantly searching or
"scanning" the environment for a potential
sexual partner?
- Do you ever find yourself sexually obsessed
with someone who is not interested in you or
doesn't even know you?
- Do you think your pattern of masturbation is
excessive, driven, or dangerous?
- Have you had numerous love relationships
that are short-lived, intense, and unfulfilling?
- Do you feel a constant need for sex or
expressions of love in your sexual relationship?
Distinguishing Normal Sexual Variation from
CSB
It is important to recognize the wide range of
normal variations of sexual behavior-both in types
of behavior and frequency. A physician may have
sexual values that restrict successful communication
with a patient. Sometimes it is the patients 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, "I have discovered that my
husband masturbates. What should I 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.
Case 2. A 45 year old married man felt the 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.
In 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
recognize 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 eroto-sexual pathways in their
brain and the repetitious nature of the self
defeating 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 short-lived
anxiolytic (similar to other obsessive and
compulsive behaviors). In its obsessive and
compulsive form, the sexual behavior is senseless,
dysphoric, habitual, 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. It is speculated that these traumatic
experiences create or amplify an underlying or
evolving anxiety disorder. Dysthymia is often
experienced secondary to this primary anxiety
disorder. New developments in the understanding of
OCD have suggested that most paraphilia and
nonparaphilic CSB may be understood as a variant of
OCD. 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 neuropsychiatric problems.
Treatment of CSB
Problematic sexual behavior is often resolved by
individuals on their own or through simple
information, education, or brief counseling. Having
been arrested for prostitution, for example, is
often enough to deter a man from soliciting
prostitutes.
Patients with 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 (prozac, zoloft, celexa, lexapro) to
help immediately interrupt the obsessive thoughts or
compulsive behaviors and to treat the anxiety and
depression. This pharmacotherapy must be accompanied
by psychotherapy.
Pharmacotherapy
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. In addition, antiandrogens have
been used fairly successfully in treating
paraphilias. Unfortunately, most studies have relied
upon case report methods and we are lacking more
controlled experimental designs to demonstrate their
efficacy. At this time, I prefer to use the
serotonergic medications over antiandrogens because
of fewer potential side effects and the fact that
the serotonoergic antidepressants have antilibidinal
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.
Psychotherapy
Through psychotherapy, a person can 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 behaviors (similar to the concept of sexual
abstinence often suggested in such groups as SAA,
SLAA, etc). 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 autoeroticsm 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 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.
Summary
CSB 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 individuals sexual obsessions and
compulsions. New advances in the understanding and
treatment of OCD spectrum disorders 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.
"There is no question that there is a heated
debate about the concepts of compulsive sexual
behavior and sexual addiction. While some do not
believe that any such condition could exist, there
is quite a bit of consensus and data building
supporting the fact that some type of hypersexual
syndrome exists. Any behavior can be taken to its
obsessive and compulsive extremes and people can
have a lack of control over their behavior. Sexual
behavior is not sacrosanct from this natural
phenomenon. When behavior is engaged in such excess,
compulsion, and lack of control it meets our
definitions of mental disorder. We do not have clear
clinical criteria and lack epidemiological data.
And, there are dangers of overpathologizing out of
moralism. However, there is a clear consensus that
this clinical syndrome affects a significant number
of people and that mental health systems need to
address this problem through appropriate recognition
and treatment. Unfortunately, there is neither
consensus on the type of treatment. However, by
doing nothing, individuals suffering from this
syndrome are at risk for many severe social, legal,
and interpersonal consequences. We are in urgent
need for further investigation into this problem.
But, in the meantime, we need to offer people the
kinds of treatments that have been developed and
have shown some promise."
Eli Coleman, PhD
Department of Family Practice and Community Health,
Minneapolis, USA
Professor Coleman is a graduate of Marquette
University and received his doctoral degree in
counseling psychology from the University of
Minnesota in 1978. Currently he is the director of
the Program in Human Sexuality, Department of Family
Practice and Community Health, University of
Minnesota Medical School in Minneapolis, Minnesota
(USA). He is the author of numerous articles and
books on the topics of sexual orientation,
compulsive sexual behavior, sexual offenders, gender
dysphoria, chemical dependency and family intimacy
and psychological and pharmacological treatment of a
variety of sexual dysfunctions and disorders. He is
particularly noted for his research on
pharmacotherapy in the treatment of compulsive
sexual behavior and paraphilias. Professor Coleman
is the founding and current editor of the Journal of
Psychology of Human Sexuality and the International
Journal of Transgenderism. Professor Coleman is one
of the past-presidents of the Society for the
Scientific Study of Sexuality, the past-president of
the World Association of Sexology, and the current
President of the Harry Benjamin International Gender
Dysphoria Association. He has been the recipient of
numerous awards including the Surgeon General's
Exemplary Service Award for outstanding support of
the United States Surgeon General as a contributing
Senior Scientist on "Surgeon General's Call to
Action to Promote Sexual Health and Responsible
Sexual Behavior", released June 28, 2001. He has
also received the Richard J. Cross Award for
Sexuality Education from the Robert Wood Johnson
Medical School. He was given the Distinguished
Scientific Achievement Award from the Society for
Scientific Study of Sexuality in 2001 and awarded
the Alfred E. Kinsey Award for outstanding
contributions to the field of sexology by the
Midcontinent Region of the Society for the
Scientific Study of Sexuality in June of 2002.
