Introduction
Sexual addiction disorder is characterized by repetitive intrusive sexual fantasies and thoughts, excessive sexual behaviors, and inability to control one’s own sexuality, resulting in distress and impairment of relational and social life. Although sexual addiction disorder or hypersexuality was proposed as a distinct disorder in the latest Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, it was subsequently not included (Table 1). Conversely, World Health Organization has planned to include excessive sexual behaviors within the latest version of the International Classification of Diseases (ICD-11) as a disorder of sexual compulsive behavior (Table 2). Important attributes that distinguish sexual addiction disorder from other patterns of sexual behavior are (a) failure to control sexual behavior and (b) the sexual behavior has significant harmful consequences and (c) continues despite these consequences. Sexual addiction disorder is a serious clinical problem with damaging consequences if left untreated, and can negatively impact social, occupational, and mental well-being.
Clinical Characteristics
Prevalence
Currently, there is a paucity of literature examining sexual addiction disorder in nonclinical samples. Due to a lack of both a generally accepted diagnostic definition, and valid and reliable methods of measurement, estimates of incidence and prevalence of sexual addiction disorder vary considerably. Nevertheless, a few studies on “hypersexuality” have estimated its prevalence to be 2% to 6% of the general population. However, recent epidemiological studies in the United States estimate higher overall prevalence of “compulsive sexual behavior” at 8.6%.
Gender Differences
Although research studies examining gender differences in sexual addiction disorder are lacking, in general, majority of the patients seeking treatment for sexual addiction disorder are men. For instance, a research study by Black et al on persons with self-identified compulsive sexual behavior, recruited through newspaper advertisements, found that 78% of respondents were men and only 22% were women. When the researchers analyzed gender differences on illness and sociodemographic characteristics, they found that the only significant gender difference was in the number of sexual partners in the past 5 years. Men had a significantly greater number of sexual partners (59) compared to women (8).
Risk Factors
Higher incidence of sexual addiction disorder has been observed among individuals with substance use disorders. Sexual addiction disorder has also been linked to adverse childhood events which include sexual, physical, and emotional abuse. However, systematic data regarding the risk factors associated with the disorder, weather genetic, personality, early life experience, and so on, as well as associated sociocultural and sociodemographic factors are lacking.
Comorbidity
Sexual addiction disorder usually presents with comorbid anxiety disorder, depression, substance use disorders, attention-deficit/hyperactivity disorder (ADHD), and other psychiatric and physical conditions. A study of comorbidity among individuals with compulsive sexual behaviors found that 88% of the participants had a comorbid axis I disorder, and all of them met the diagnostic criteria for an axis I disorder at some time in their lives. Personality disorders such as borderline, paranoid, histrionic, and passive-aggressive personality disorders have been reported to be the most common comorbid condition in this population.,
Onset and Clinical Course
When DSM-5 field trial for hypersexual disorder explored the onset and clinical course of the disorder, it was found that 54% of the participants reported experiencing some difficulties in regulating their sexual behavior during their adolescent years, and 30% reported experiencing these difficulties during late adolescence and early adulthood years. Regarding the course of illness, 83% reported a gradual onset lasting several months or years, and 17% indicating a rapid-acute onset in less than 90 days.
Etiological Models
The sexual addiction diagnosis integrates biopsychosocial aspects drawn from various etiological theories.
Psychodynamic Model
Psychodynamic theory postulates that excessive sexual behaviors is an attempt to recover from adverse early childhood experiences. Unhealthy attachment patterns and deficits in affect regulation have also been identified as risk factors predisposing the individual for dysregulated sexual behaviors. Maladaptive attachment is hypothesized to lead to a conflicting sexual interest (ie, desire for intimacy, but intense fear of it). A preoccupied attachment may result in an emotionally needy individual with uncontrolled sexual behaviors as they crave for validation from multiple partners. Some researchers in this field have also discussed life instinct and death instinct in relation to sexual addiction, suggesting that sexual addiction is perhaps an attempt to replace death anxiety through sexual activities, although in a dysregulated way. Hence, within the psychodynamic perspective, sexual addictions are considered as a defense mechanism against death anxiety.
Compulsivity Model
Compulsivity model of sexual addiction has often been compared with the phenomenology of obsessive-compulsive disorder, characterized by egosyntonic repetitive intrusive thoughts and uncontrolled sexual acts. Here, repetitive sexual thoughts and images constitute the obsession, and sexual behaviors constitute the compulsion. According to this model, intrusive, repetitive sexual thoughts, images, and fantasies produce anxiety, and the individual uses sexual acting out to reduce this tension, but it produces more distress due to negative self-evaluation.
Addiction Model
Sexual addiction disorder has been postulated as a behavioral addiction by many researchers. The symptomatology involves the cravings and preoccupation with sexual activity, and abstinence-withdrawal symptoms of depression, anxiety, and blame. Parallel to other substance abuse, sexual behaviors initially induce pleasure, euphoria, and stress relief; however, it leads to dependence, craving, and frequent relapse. Sexual behaviors are thought to serve as a coping mechanism to deal with painful affects; however, it is a maladaptive coping style, which results in loss of control despite negative consequences. As in other forms of addiction, individuals with sexual addiction spend increased amount of time looking for novel sexual partners, and compromise their social and relational life, without considering potential negative consequences.
Impulsivity Model
Sexual addiction disorder has parallelism with impulse control disorder. The core characteristic of impulse-control disorders is an inability to resist an impulse to perform an act that is harmful to self or others. There is an increased tension or affective arousal prior to the act, followed by relief after the act. Similarly, individuals with sexual addiction disorder engage in sexual behaviors repetitively, although it could be damaging to self or others. They tend to experience tension before engaging in sexual behavior, followed by pleasure and relief during the act, and later experience regret and guilt.
Cognitive-Behavioral Model
According to cognitive-behavioral model, sexual addiction may be attributed to an unrealistic expectation of life, and an irrational belief system that consists of a deteriorated self-image. Coleman attributed it to maladaptive use of sexual behaviors as a means to cope with emotional pain. According to Carnes,, sexual addiction consists of 3 specific beliefs: (a) “I am a bad person and unworthy of love,” (b) “nobody can love me as I am,” and (c) “my needs will never be satisfied if I have to depend on others.” These ideas generate a false belief system that prompts a faulty thought which results in the expression of an addictive behavior.
Childhood Adversities and Trauma Model
Few researchers have hypothesized that individuals with sexual addiction are more likely to have traumatic family experiences such as sexual abuse during childhood. Researchers have also suggested that individuals with sexual addiction disorder are more likely to have experienced or exposed to violent behaviors in adulthood than healthy volunteers. These studies suggest that childhood adversity is an important risk factor for sexual addiction disorder.
Neurobiological Model
Neurobiological models postulate that neurobiological risk factors such as endocrine abnormality, brain pathology, substance abuse, and imbalance between the sexual activation system and the sexual inhibition system, cause sexual addiction disorder. Sexual addiction is also conceptualized as a sequela of medical conditions such as brain injury, degenerative disorders, or temporal lobe deficits. Researchers have demonstrated a greater activation of the dorsal anterior cingulate, ventral striatum, and amygdala among the patients when they were exposed to sexually explicit stimuli. Activation of this neural network has been linked to higher subjective sexual desire among the patient group when compared to the control group. “Monoamine hypothesis” is thought of as another possible neurobiological cause of dysregulated sexual desire. According to this model, enhanced dopaminergic neurotransmission is thought to be associated with sexual excitation, and enhanced serotonergic neurotransmission is thought to be associated with sexual inhibition.
The Dual Control Model and Affect Regulation Model
According to dual control model of sexual arousal, neurobiological predispositions moderate individual propensities to engage in sexual behaviors to regulate negative mood states. Equilibrium between the sexual activation/excitation system and the sexual inhibition system, each of which has a neurobiological substrate, determine the sexual arousal and response in an individual. There are individual differences in people’s proclivity for both sexual excitation and sexual inhibition, and for most people, these predilections are nonproblematic. However, individuals with an unusually high propensities for excitation and/or low propensities for inhibition are more likely to engage in problematic sexual behavior. Whereas, individuals with a low inclination for sexual excitation and/or high inclination for sexual inhibition are more likely to experience problems with sexual response.
An Integrated Approach to Etiology of Sexual Addiction
Contrary to unidimensional theoretical approach to the classification of sexual addiction (whether compulsive, impulsive, or addictive), integrated models postulate that it may be more useful to explore several phenomenological and psychobiological mechanisms that underpin sexual addiction disorder. Stein proposed an A-B-C model of the disorder with 3 key components: (a) affective dysregulation, (b) behavioral addiction, and (c) cognitive dyscontrol. Similarly, Goodman attempted to integrate several models and proposed that behavioral disinhibition affects dysregulation and an aberrant motivational-reward system is the cause of sexual addiction. This model hypothesizes that individuals with poorly modulated sexual behavior are prone to chronic negative mood states and affective instability, and these individuals may easily give in to urges for short-term reinforcement, overriding long-term consequences.
Assessment
Individuals who seek treatment for sexual addiction disorder are a heterogeneous group. It is therefore essential to conduct a thorough assessment so as to ascertain the psychopathology that needs to be addressed. The most important part of assessment is a comprehensive clinical interview which should include history of the presenting problems, psychosocial history, sexual history, psychiatric and mental health history, substance use history, and medical history. Sexual addiction could also be a symptom of an underlying condition, such as bipolar disorder or dementia, and organic- and substance related. The possibility that the patient may have contracted a sexually transmitted disease should not be overlooked. Questionnaires and rating scales may also be used to acquire supplemental information (Table 3). In addition to interviewing the patient, supplemental information may also be obtained from a spouse/partner or family members, who can provide objective description of the patient’s observed behaviors.
In general, the detail work up by the clinicians may explore the following components before making a diagnostic formulation and treatment plan:
Excessiveness, Frequency, and Duration
The clinicians need to assess how much time is spent engaging in sexual urges, fantasies, and behaviors. Generally, frequency and duration of sexual urges, fantasies, and behaviors can vary among the patients, and may influence the severity of the disorder, which can help determine whether a behavior is excessive and problematic.
Level of Impairment, Diminished Control, and Consequences
In patients with sexual addiction disorder, diminished control may contribute to repetitive sexual behaviors, creating negative consequences which impair the patient’s ability to function. Consequences may be marital conflicts, divorce, job loss, and so on. Therefore, clinicians need to explore the extent to which sexual addiction is causing significant impairment in the patient’s social, occupational, and other important areas of functioning, as well as adverse life events and distress as a consequence of the disorder.
Comorbidity
It is important to ascertain comorbid conditions such as anxiety, depression, substance abuse, suicidality, and personality traits which need to be treated. Individuals with comorbidity require special consideration as their complexity can influence the seriousness, pain, and suffering, leading to a greater level of distress.
Level of Risk Taking
One of the symptom of sexual addition disorder is risk-taking behavior, which is defined as repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others. Severity of risk-taking behavior has significantly higher potential for greater damage such as sexually transmitted diseases, unintended pregnancies, physical harm to self or others, legal problems, involvement in illegal acts in order to engage in sexual activities, and so on. Overall, the amount of risk a patient is willing to take in order to pursue sexual urges, fantasies, and behaviors should be evaluated during clinical interview.
Onset and Clinical Course
The assessment should also explore the onset (adolescence, early adulthood, stressors, etc) and clinical course (gradual onset, rapid-acute onset, continuous, episodic, etc) of sexual addiction among the patients. The onset and clinical course of sexual addiction symptoms may have implications on treatment adherence, relapse, and overall prognosis for the patients.
Level of Motivation
Individuals with sexual addiction may present with limited motivation for treatment, because sexual experiences are pleasurable. Patients maybe ambivalent about addressing these behaviors, despite harmful effects. Quite often, it may be a family member’s pressure or a recent negative experience that is pushing the patient to seek help. Therefore, it is important to determine the level of motivation in the patient, as this will help develop a treatment plan.
Management
Sexual addiction disorder is a complex disorder, and needs a multifaceted treatment approach that includes various modalities such as cognitive-behavioral therapy, relapse-prevention therapy, psychodynamic psychotherapy, and psychopharmacological treatment. Various therapy techniques are employed to help individuals with sexual addiction disorder in individual, group, and/or couples module, with the goal to help them find the sources of their behaviors, to aid them in developing adaptive approaches for dealing with triggers, and to strengthen their sense of self-worth. The high degree of comorbidity in this population demands that associated conditions such as mood disorders, substance use disorders, and other psychiatric disorders be treated concomitantly along with the treatment of sexual addiction.
Cognitive Behavior Therapy
The principles and techniques of CBT are designed to help the individual to identify unhealthy, negative beliefs, and behaviors; replace them with more adaptive ways of coping, and learn more healthy patterns of thoughts and actions. Treatment plan in CBT includes learning new strategies for coping with urges, secrecy, shame, and guilt, as well as replacing old behaviors, adopting values-based activities, practicing new behaviors, and managing relapses. CBT also focuses on relapse prevention strategies, managing thoughts, feelings and behaviors, and lifestyle improvements. Principles of CBT developed for relapse prevention in substance abuse have been adapted for the treatment of sexual addiction disorder. Relapse-prevention uses strategies such as skills training, cognitive restructuring, and lifestyle modifications. These strategies help individuals anticipate and identify high-risk situations, identify and replace cognitive distortions with more rational thoughts, and cope with stressful situations that may trigger a relapse. CBT has been found to be effective in treatment of sexual addiction disorder.
Psychodynamic Psychotherapy
Psychodynamic psychotherapy is used in the treatment of sexual addiction to explore unconscious content of psyche, past trauma, and underlying causal factors in order to facilitate the individual’s awareness of unconscious thoughts and behaviors, and help them develop new insights into their motivations, and resolve conflicts. The primary objective of psychodynamic therapy in treatment of sexual addiction disorder is to improve the individual’s emotional self-regulation, and to promote their ability to establish meaningful interpersonal relationships. The basic processes of psychodynamic psychotherapy are (a) intellectual understanding which allows patients to become aware of the mental processes and psychological basis of their subjective experiences and their behavior, (b) integration of feelings, needs, fears, and basic defenses, hidden from conscious mind with the healthy part of the system and adaptive personality, and (c) internalization of self-regulatory process that were not properly internalized during childhood.
Twelve-Step or Addiction Treatment
Twelve-step model of Alcoholics Anonymous, originally developed for the treatment of alcohol use disorder, has now been adapted for sexual addiction disorder as a means to recovery. These support groups play an important role in recovery by helping individuals to be honest with themselves and peers, by holding them accountable to their behaviors in a supportive atmosphere. Support recovery groups offer group support, sponsorship, and structured programs, which are not available in clinical setups. Treatment focuses on helping the individual control his or her problematic sexual behaviors, as well as to learn new coping strategies. Some of the self-help programs for sexual addiction disorder are Sex and Love Addicts Anonymous, Sex Addicts Anonymous, Sexaholics Anonymous, and Sexual Compulsives Anonymous.
Couples Therapy
Sexual addiction can affect the partners adversely. The effects can be severe and may include betrayal, distrust, shame, guilt, self-blame, and low self-esteem. Spouses of individuals with sexual addiction often report feeling sad, betrayed, traumatized, angry, and confused about whether to continue in the relationship. Further, there may be issues related to deficits in sexual intimacy. Addressing infidelity and learning skills of intimacy are essential to recovery and to building a sense of trust. Williams identified 3 stages of healing in order for couples to recover from an affair: (a) normalizing feelings, (b) deciding whether to recommit or quit, and (c) rebuilding the relationship. Rebuilding relationship involves owning responsibility for one’s problematic behaviors, setting and respecting boundaries, dealing with issues of honesty, and developing reasonable expectations for the relationship.
Pharmacological Treatment
Use of psychopharmacological drugs to treat sexual addiction has been receiving attention in recent years. Hormones and neurotransmitters are the physiological precursors to sexual drive. Therefore, treatment of deviant sexual behaviors may include hormonal agents such as antiandrogens and psychotropics drugs which affect neurotransmitters. Given the similarities between paraphilias and sexual addiction disorder, psychopharmacological medications used for the treatment of paraphilias could also provide a basis for treatment of the sexual addiction, as both types of disorders involve sexual behavior that is out of control. Some reports indicate the utility of topiramate, naltrexone, serotonin reuptake inhibitors, citalopram, leuprolide acetate, nefazodone, clomipramine, and valproic acid. A review on the pharmacotherapy of sexually compulsive behavior highlights that the frequently used drugs are selective serotonin reuptake inhibitors, medroxyprogesterone acetate, cyproterone acetate, and luteinizing hormone-releasing hormone.
Critical Evaluation
Due to dearth of research and available literature, sexual addiction disorder has continued to remain a misunderstood and underdiagnosed condition. It is still uncertain if sexual addiction/hypersexuality is an addiction or an impulse control disorder or a compulsive disorder. Researchers have been using these terminologies interchangeably when describing the problem. Another problem faced by the researchers is to differentiate between strong sexual drive and sexual addiction. While, it is generally accepted that socio-occupational dysfunction and distress are important indicators of mental disorders, therapists need to be mindful of the religious, cultural, or moral values of the client, mismatch of sexual drive between the partners, and stigma or negative attitude toward sexual behaviors, as these may be the source of guilt, shame, and anxiety in the client. Because of lack of generally accepted diagnostic definition, it is easy for therapists to overlook nuances of the disorder. Despite recent efforts to understand the phenomenon, there is a huge research gap in the area of sexual addiction disorder. For instance, association between sexual addiction and endocrine dysfunction or other medical conditions is an unexplored area. For a comprehensive understanding of the disorder, there needs to be rigorous research addressing issues in the areas of nosology, epidemiology, genetics, and neurobiology. Therefore, it is important that budding researchers take a keen interest and generate knowledge, which is supported through empirical studies using strong research methods.
Conclusion
Sexual addiction disorder often commonly referred to as sexual addiction, hypersexuality, or compulsive sexual behavior, can have adverse consequences which include personal distress, guilt, and shame. Quite often, the patient may not seek help fearing stigma, or due to shame. However, recent research suggests that a large proportion of the population, majority of whom may be males, is suffering from it. Sexual addiction disorder often presents with comorbid disorders such as anxiety, mood disorders, substance use disorders, ADHD, and so on, further emphasizing the psychological distress an individual is likely to experience. Several etiological hypotheses have been postulated to conceptualize sexual addiction disorder based on the models of obsessive-compulsive disorder, impulse control disorder, and addictive disorder. However, a lack of empirical evidence has resulted in the disease’s absence from the fifth edition of Diagnostic and Statistical Manual of Mental Disorders, although it is now being included in the latest version of the ICD. Several pharmacological and nonpharmacological interventions have been discussed in treatment and management of sexual addiction disorder. However, more randomized controlled trials are warranted in order to establish clear guidelines for treatment. Further, the need of the hour is to raise awareness of the condition with an aim to remove stigma and shame associated with it, so that individuals who are suffering from it may seek timely help. Another need of the hour is to train mental health professionals in identifying, assessing, and managing these conditions successfully.
We appreciate all who helped us in this article.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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