Sexual Behavior as an Addictive or Compulsive Phenomenon

Introduction

Due to the magnitude of the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) epidemic, and its profound impact on public health and social structures, an emphasis on the behavioral, social, and cultural factors associated with sexual risk and its relation to HIV transmission has been essential. However, an unanticipated artifact of disease-focused research is that much of the contemporary knowledge related to sexual behavior has been constructed in the context of HIV and other sexually transmitted infections. Recent sexual health research has made meaningful contributions to scientific understandings; however, scientists still know relatively little about sexuality in the general population in comparison with other aspects of health and human behavior.

The void in scientific understanding has allowed sexual behaviors that are incongruent with dominant social norms to be constructed as pathologies despite a lack of empirical evidence to support proposed links between behavioral variations and negative outcomes. A vivid example of this phenomenon can be seen in the social construction of sexual addiction, which proposes a threshold where sexual behavior becomes a clinical disorder. Although there has been substantial debate and controversy surrounding conceptualization of sexual behavior as an addictive phenomenon, the concept has been widely studied and measured in sexological, psychological, and public health research. Numerous sexual scientists, clinicians, and support groups have increased awareness of, and treatments for, sexually compulsive behavior. However, studies of sexual compulsivity and its associations with sexual risk behavior have primarily assessed individuals who are already considered high risk for adverse sexual health outcomes due to other characteristics (e.g., substance use, higher number of sexual partners). Furthermore, systematic documentation of adverse outcomes associated with sexual compulsivity is lacking.

Recently, there has been a conceptual shift away from addiction models, and hypersexuality is now the dominant focus of the clinical and research literature. Variations in the definition of hypersexuality exist; however, the common theme is that sexual behavior, including thoughts or fantasies, is excessive. The most recent iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) did not include hypersexuality as a diagnostic category despite some evidence to support the reliability and validity of proposed diagnostic criteria. Currently, critical questions remain unanswered and controversy persists. Ongoing conceptual and methodological challenges make systematic research difficult. The scientific and clinical communities will need to address gaps in the literature through well-designed studies that test conceptual frameworks with rigorous methods and sound measures.

History of Sexual Addiction and Sexually Compulsive Behavior

The earliest descriptions of sexually compulsive behavior can be traced to Greek myths describing satyrs and the god Dionysius. The term “nymphomania,” historically used to describe female sexual excess, is also derived from Greek. The 19th century term “Don Juanism” was used in reference to male sexual excess. In the late 19th century, Krafft-Ebing presented one of the first clinical case studies describing hypersexuality and its effects on life functioning.

Sexual behavior viewed as an addictive or compulsive phenomenon is relatively recent. During the mid-to-late 20th century, published case reports described similar clinical presentations of individuals reporting out-of-control sexual behaviors. However, there was inconsistency in the terms applied as well as conceptualizations of etiology. ^a

a References 5, 23, 28, 30, 43, 61, 67, 79.

Labels ranged from historical terms (e.g., nymphomania and Don Juanism) to moral reflections (e.g., perversions), to clinical terminology (e.g., paraphilias, compulsive sexual behavior, impulse control disorders, sexual addiction, and sexual compulsivity).

Currently, there is no universal agreement on terminology or a single accepted definition. The term hypersexuality dominates the contemporary literature but words such as sexual compulsivity, sexual impulsivity, and sexual addiction are still commonly used to reference sexual behavior that is beyond an individual’s control, leading to impairment in life functioning and negative outcomes. ^b

b References 11, 16, 17, 24, 33, 39, 49, 58, 72.

No single treatment strategy is widely accepted; rather, approaches range from individual cognitive and behavioral therapies, to the use of psychotropic medications, to group counseling..

Sex Outside the Norm

The idea that sexual behavior can exceed a threshold to become a clinical disorder has appeared in the scientific literature with increased frequency over the past 30 years. Prior to the emergence of HIV/AIDs in the late 1970s and early 1980s, interest in the phenomenon of out-of-control sexual behavior was limited primarily to researchers and clinicians from psychiatry, psychology, and medicine. In the early 1980s, the terms “sex addict” and “sexually compulsive” appeared in popular culture and were used to reference individuals whose sexual behaviors rested outside of accepted sociocultural norms. The emergence of HIV brought attention to sexual behaviors that increased the likelihood for transmission and sexual behavior perceived to be beyond an individual’s control was identified as a risk factor.

In the decades following the initial HIV crisis, there has been a rapid proliferation of research examining the etiology, consequences, and approaches to treating out-of-control sexual behavior. Much of the literature has resulted from research focused on sexual risk-taking behaviors among gay men, pedophilic clinical samples, and self-identified sex addicts. Fewer studies have examined subclinical levels of out-of-control sexual behavior and nonclinical populations. Research has largely ignored women and populations at lower risk for HIV/sexually transmitted infection (STI). As a result, disease-focused models emphasizing the link between sexual behavior at the higher end of the behavioral continuum and adverse sexual health outcomes (e.g., HIV/STI) dominate the research literature. One consequence has been that variation in sexual behavior remains seated within a disease paradigm without sufficient acknowledgment of the methodological limitations and conceptual biases on which findings have been based.

Although documentation linking out-of-control sexual behavior to adverse psychological and sexual health outcomes exists, the construct remains controversial within the scientific community. Scholars have argued that conceptualizations of normative sexual behavior are influenced by cultural and historical understandings that reflect sociocultural mores governing behavior. Social and psychological theories are a reflection of existing norms that are unique to time and place, and much of the debate surrounding sexual compulsivity centers on the ambiguities in the definition of “out-of-control.” Historically, the universal standard for identification was behavioral frequency. In 2004, Bancroft and Vukadinovic wrote a critical review calling for scientific evidence that out of control sexual behavior is qualitatively different from normative sexual behavior that occurs at the high end of the continuum. In their critique, Bancroft and Vukadinovic maintained that it is negligent to assume that engaging in frequent sexual activity is inherently risky or problematic without documenting the occurrence of negative consequences.

Other scientists have argued that perceptions of control over sexual behavior are social constructions, and that the importance and meaning of out-of-control models might reflect broader values related to self-control and self-consciousness that are unique to the American culture. It has been suggested that diagnosis, and subsequent labeling, reflect attempts to pathologize and medicalize variations in sexual behavior. Arguments in favor of this perspective often cite the fact that homosexuality was listed as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association until the late 1970s. This point is central to understanding the lack of consensus in the scientific community given the rapidly emerging possibilities for the expression of sexuality and the diverse range of sexualities that exist in contemporary society. There remains a need for research that takes into account that sexual behaviors and norms vary among individuals and cultural groups. Indeed, what may be viewed as problematic for one individual, or within one culture, may be normative for another. The wide variation in contemporary sexual behavior, including behavioral frequency, makes it critical to systematically link behavior to adverse outcomes. Understanding the influence of sociocultural factors will allow scientists and clinicians to avoid errors in the diagnosis and treatment of problematic sexual behaviors.

Clinical Criteria

Despite some research linking out-of-control sexual behavior to adverse psychological and sexual health outcomes, the DSM-5 contains no specific diagnostic criteria or category for classification. A categorization and diagnostic criteria for Hypersexual Disorder were proposed by Kafka in 2010. Kafka characterized hypersexuality as a behavioral pattern involving repetitive and intense preoccupation with sexual fantasies, urges, and behaviors, leading to adverse consequences and clinically significant distress or impairment in social, occupational, or other important areas of functioning. Kafka also hypothesized that hypersexual individuals usually experience multiple unsuccessful attempts to control or reduce the amount of time spent engaging in sexual fantasies, urges, and behaviors in response to dysphoric mood states or stressful life events. Consistent with DSM criteria for other disorders, it was proposed that symptoms must be present for at least 6 months and occur independent of substance use, mania, or a medical condition in order for a diagnosis to be established. Kafka recommended that an operational definition should be derived from large, nonclinical community samples where a range of normative sexual behaviors can be examined. He emphasized the need to consider demographic characteristics (e.g., age, gender, education, culture) when contextualizing sexual behaviors.

The results of a field trial designed to assess the reliability and validity of the diagnostic criteria proposed by Kafka reported high interrater reliability and stability of the criterion over time. Sensitivity and specificity indices showed that criteria accurately reflected presenting problems and the diagnostic criteria demonstrated acceptable validity. Based on these findings, the Sexual and Gender Identity Disorders Working Group recommended the inclusion of hypersexual disorder as a diagnostic category; however, it was ultimately excluded from the final publication of the DSM-5. Critics of the proposed category argued that the concept of hypersexuality resulted from moral norms and psychosocial values that should have no place diagnostic decision-making.

Currently, diagnostic categorization lies in the hands of the practitioner. Options fall within one of three major categories: paraphilia, either one or more specifically identified or paraphilia not elsewhere classified; impulse control disorder not elsewhere classified; sexual disorder not elsewhere classified.

Despite the lack of specificity in diagnostic categorization, there is consensus among researchers regarding the relationship between hypersexuality and psychiatric comorbidity The literature reports consistent associations between out-of-control sexual behavior and psychological impairment and substance use disorders. ^a

a References 26, 46, 50, 69, 70, 86, 88.

Scientists have begun to document comorbidities in nonclinical populations, community samples, and among groups at lower risk for HIV.

Raymond and colleagues reported that mood and anxiety disorders were the most consistent diagnoses among their community sample of 23 men and 2 women who self-identified as hypersexual, with 80% meeting the diagnostic criteria for an Axis I disorder at the time of data collection and 100% meeting the criteria across their lifetime. Research has also established a link between hypersexuality and trait variables associated with psychological impairment. A study examining personality, psychological, and sexuality trait variables among 510 heterosexual, bisexual, and homosexual women and men who self-reported hypersexual behavior found that hypersexual behavior was related to depressed and anxious mood states and trait impulsivity. Furthermore, higher neuroticism and lower agreeableness significantly predicted hypersexual behavior. Research examining sexual compulsivity in a sample of 235 women found that hypersexual behavior was predicted by psychoticism. A similar study conducted among men ( N = 152) reported finding that psychoticism, neuroticism, and agreeableness were significant predictors of hypersexual behavior. Pachankas and colleagues (2014) established a relationship between maladaptive cognitions and hypersexuality among gay and bisexual men.

A strong and consistent association between substance use and hypersexuality has been established. Grov et al. (2010) found that higher sexual compulsivity scores were associated with the use of ketamine, MDMA (ecstasy), gamma hydroxybutyrate (GBH), cocaine, and methamphetamines among a community-based sample of 1214 gay and bisexual men. Kalichman and Cain found that higher levels of sexual compulsivity were linked to higher usage rates of alcohol, powder cocaine, crack cocaine, and inhalants. Sutton et al. (2015) conducted chart reviews of patients referred for hypersexuality and found that there were more substance abuse disorders among those who were paraphilic when compared to other subtypes.

The findings reported above are only a few examples of research documenting the association between psychiatric comorbidity and out-of-control sexual behavior. Numerous studies conducted over the past two decades have consistently found similar links. The observed associations between out-of-control sexual behavior and psychiatric comorbidity have caused some scientists to question whether associations provide evidence that out-of-control sexual behavior is a unique psychiatric disorder, or whether it should be conceptualized as a behavioral symptom of an underlying condition. Although it is possible that out-of-control sexual behavior does warrant its own classification, it is also possible that individuals with other disturbances use sex as a means of self-medication to alleviate or temporarily escape discomfort caused by underlying distress. Research has shown that nonclinical negative mood states influence sexual interest among some individuals. The Dual Control Model (DCM) proposes that sexual arousal is influenced by two distinct psychophysiological systems: sexual excitation and sexual inhibition. In this model, individuals with low inhibition and a high propensity for excitation may be more prone to problems of hypersexuality. Systematic investigation of the DCM as a possible explanation for hypersexuality in some individuals suggests that stress and dysphoric mood state may trigger hypersexual behavior. These findings lend support to the hypothesis that some hypersexual behavior may represent attempts to escape psychological discomfort through sexual behavior.

Recent scientific attention has focused on examining psychological traits that may predispose individuals to hypersexuality. As interest in documenting the phenomenon among nonpatient populations has increased, there has been a shift toward understanding how structural dimensions of personality may influence hypersexual behavior. Prior research on the relationship between personality and addictive behavior has demonstrated positive associations among certain characteristics. Studies examining hypersexuality and sexual risk-taking have also demonstrated significant associations between specific personality traits and out-of-control sexual behavior. The Big Five model of personality developed by McCrea & Costa (1987) proposes five distinct structural dimensions of personality: Neuroticism, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness. Although there have been inconsistencies in the strength of relationships between personality traits and hypersexuality, studies have repeatedly found that higher levels of neuroticism and extraversion and lower levels of conscientiousness and agreeableness predict hypersexual behavior.

When examining the evidence as a whole, there is support for the idea that there may be different types of sexual compulsivity that derive from different factors. Mood state might account for hypersexual behavior among some individuals, whereas others may be more prone to out-of-control behavior due to personality traits. A proportion of people may be using sexual behavior as a form of self-medication that allows them to alleviate negative emotions for some period of time. Observed comorbidities suggest that there may be some underlying mechanism causing dysregulation in both sexual behavior and mood. Additional research among diverse clinical and community samples will add specificity to our understandings of the mechanisms that cause and support hypersexual behavior. Debate about the construct is ongoing, with many scientists favoring the perspective that hypersexuality is a natural and harmless variation in sexual behavior, while others remain convinced that it is a psychiatric condition that warrants inclusion in the DSM.

Etiology

The ongoing debate regarding the construct of sexual compulsivity has resulted in varied perspectives on etiology. Many researchers have attempted to explain the development and maintenance of hypersexuality, which has resulted in several theoretical representations of causation. Early theoretical explanations include Carnes’ Addiction Model, Coleman’s Compulsive Sexual Behavior Model, and Kalichman’s Impulse Control Model. More recent additions to the literature include Bancroft’s Dual Control Model and Parson’s Syndemic Model. Parsons’ model, which aims to explain hypersexuality in gay and bisexual men, is still in the early stages of testing and will not be reviewed here. However, preliminary evidence suggests that a three-group categorization of sexual compulsivity may be one systemic factor that explains HIV risk among gay and bisexual men. Each perspective suggests etiological explanations; however, overwhelming empirical evidence favoring any of these is markedly absent.