How Does One Know if They
Need Help Regarding CSB?
If one can answer yes to some any of the following questions,
it would be advisable to consult a professional who has the
particular expertise in assessing and treating CSB.
1. Do you, or others who know you, find that you are overly
preoccupied or obsessed with sexual activity?
2. Do you ever find yourself compelled to engage in sexual
activity in response to stress, anxiety, or depression?
3. Have serious problems developed as a result of your
sexual behavior (e.g., loss of a job or relationship, sexually
transmitted diseases, injuries or illnesses, or sexual
offenses)?
4. Do you feel guilty and shameful about some of your sexual
behaviors?
5. Do you fantasize or engage in any unusual or what some
would consider “deviant” sexual behavior?
6. Do you find yourself constantly searching or “scanning”
the environment for a potential sexual partner?
7. Do you ever find yourself sexually obsessed with someone
who is not interested in you or does not even know you?
8. Do you think your pattern of masturbation is excessive,
driven, or dangerous?
9. Do you find yourself compulsively searching for erotica for
sexual stimulation?
10. Do you find yourself spending excessive amounts of time
on the Internet engaging in various sexual pursuits?
11. Have you had numerous love relationships that are short-
lived, intense, and unfulfilling?
12. Do you feel a constant need for sex or expressions of love
in your sexual relationship?
How Does Someone Find a Professional With
Expertise in CSB Assessment and Treatment?
There are several ways to find qualified professionals in
your area:
• Call your state licensing boards for psychologists,
psychiatrists, social workers, or marriage and family
therapists who have a specialized competence in treating
compulsive sexual behavior.
• Inquire through college or university psychology,
psychiatric or counseling departments.
• Contact your primary care physician or your health
insurance.
• Ask professionals for the credentials in treating compulsive
sexual behavior (e.g., AASECT certified sex therapist).
Summary Written by Eli Coleman, PhD, Academic Chair in Sexual
Health, Professor and Director of the Program in Human
Compulsive sexual behavior is a serious psychosexual disorder
that 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 who
believe they may be suffering from CSB should not hesitate to
seek professional guidance to properly assess their problem
and to find help through counseling and treatment.
References
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., text-rev.). Washington, DC:
Author.
Barth, R. J., & Kinder, B. N. (1987). The mislabeling of sexual impulsivity.
Journal of Sex and Marital Therapy, 13, 15-23.
Bradford, J. M. W. (2000). The treatment of sexual deviation using a
pharmacological approach. The Journal of Sex Research, 37,
248-257.
Carnes, P. (1983). Out of the shadows: Understanding sexual addiction.
Minneapolis, MN: CompCare.
Coleman, E. (1991). Compulsive sexual behavior: New concepts and
treatments. Journal of Psychology and Human Sexuality, 4, 37-
52.
Coleman, E. (1992). Is your patient suffering from compulsive sexual
behavior? Psychiatric Annals, 22, 320-325.
Coleman, E., Raymond, N., & McBean, A. (2003). Assessment and
treatment of compulsive sexual behavior. Minnesota Medicine,
86, 42-47.
Kafka, M. (2000). Psychopharmacologic treatments for nonparaphilic
compulsive sexual behaviors. CNS Spectrums, 5, 49-59.
Money, J. (1986). Lovemaps: Clinical concepts of sexual/erotic health
and pathology, paraphilia, and gender transposition of childhood,
adolescence, and maturity. New York: Irvington.
Raymond, N. C., Coleman, E., Benefield, C., & Miner, M. H. (2008).
Psychiatric comorbidity and compulsive/impulsive traits in
compulsive sexual behavior. Comprehensive Psychiatry, 44, 370-
380.
Raymond, N. C., Grant, J. E., Kim, S. W., & Coleman, E. (2002).
Treatment of compulsive sexual
behaviour with naltrexone and serotonin reuptake inhibitors: Two case
studies, International Clinical Psychopharmacology, 17, 201-205.
Stoller, R. J. (1975). Perversion. The erotic form of hatred. New York:
Dell.
Sexuality, Department of Family Practice and Community what sexual scientists know about...
Health, University of Minnesota Medical School, University of
Minnesota, Minneapolis, MN 55454; President of the Society
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Can sex ever become compulsive? Like most behaviors,
sex can be taken to its obsessive and compulsive extremes.
Compulsive sexual behavior (CSB) has been defined as a
clinical syndrome characterized by the experience of sexual
urges, sexually arousing fantasies, and sexual behaviors that
are recurrent, intense, and a distressful interference in one’s
daily functioning. CSB has also been referred to in the literature
as sexual addiction, sexual compulsivity, sexual impulsivity, or
paraphilia-related disorder. Individuals with CSB often perceive
their sexual behavior to be excessive but are unable to control
it; they act out impulsively and/or are plagued by intrusive,
obsessive thoughts and driven behaviors. Some have more
problems with impulsivity and, for others, it is more of a problem
of a compulsive drive. CSB can cause emotional suffering
and potentially lead to social, ethical, and legal sanctions and
increased health risks, such as HIV infection.
Many people suffer with these problems, and finding consensus
among sexual scientists or treatment professionals about
terminology, etiology, or treatment has not been resolved.
This makes it more difficult for those suffering from CSB to
get the help they need. For those who want to know more
about this problem, it is helpful to know more about the types
of CSB, the various theoretical viewpoints, and treatment
approaches. Although there are many types of CSB, they can
be divided into two main types: paraphilic and nonparaphilic
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 sexual behaviors are unconventional sexual
behaviors that are obsessive and compulsive. They interfere
with love relationships and intimacy. Although John Money
(1986) described nearly 50 paraphilias, the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV-TR; American
Psychiatric Association, 2000) has currently classified eight
paraphilias, and these are generally considered the most
common: pedophilia (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), and frotteurism (sexual excitement from touching or
fondling an unsuspecting person. In the DSM-IV-TR, the
paraphilias are defined as “recurrent, intense sexually arousing
fantasies, sexual urges, or behaviors involving 1) nonhuman
objects, 2) the suffering or humiliation of oneself or one’s
partner, or 3) children or other nonconsenting persons. . . .The
behavior, sexual urges, or fantasies cause clinically significant
distress in social, occupational, or other important areas of
functioning” (p. 566). Some behaviors, such as S-M, which
may involve consensual suffering or humiliation and does not
impair life functioning, may not necessarily be considered a
paraphilia because it does not meet all the diagnostic criteria.
There is intense debate going on whether some of these
“disorders” should be declassified as mental illnesses in the
next revision of DSM (DSM-V, anticipated publication date May
2012; American Psychiatric Association).
Nonparaphilic CSB
Nonparaphilic CSB involves conventional and normative
sexual behavior, which when taken to an extreme end of the
spectrum of expression, are recurrent, intense, distressing, and
interfere in daily functioning. One example is given in the DSM-
IV-TR under the category of Sexual Disorders Not Otherwise
Specified. The authors of the DSM-IV-TR 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” (2000, p. 582). Other
forms of nonparaphilic CSB include compulsive cruising and
multiple partners, compulsive fixation on an unattainable
partner, compulsive masturbation, compulsive use of erotica,
compulsive use of the Internet for sexual purposes, compulsive
love relationships, and compulsive sexuality in a relationship
(Coleman, 1992). Recently compulsive use of the Internet for
sexual purposes has become a growing problem.
The Danger of Overpathologizing This Disorder
The possibility of overpathologizing this disorder is the main
criticism given by those who do not believe in the idea of
compulsive sexual behavior as a disorder. The pathologizing
of sexual behavior may be driven by antisexual attitudes and
a failure to recognize 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 an individual who has a values conflict with their
sexual behavior and those who engage in sexual behaviors
that are driven by impulsive, obsessive, and/or compulsive
mechanisms.
A Conflict Over Values
There is an inherent danger in diagnosing CSB simply
because someone’s behavior does not fit the values of the
individual, group, or society. There has been a long tradition
of pathologizing behavior that is not mainstream and that
someone might find distasteful. For example, masturbation,
oral sex, homosexual behavior, sado-masochistic behavior, or
a love affair could be viewed as compulsive behaviors because
someone might disapprove of these behaviors. However, there
is no scientific merit to viewing these behaviors as disordered,
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 a function of
compulsive sexual behavior.
Problematic vs. Compulsive Sexual Behavior
Behaviors that are in conflict with someone’s value system may
be problematic but not impulsive, obsessive, or compulsive.
Having sexual problems is common. Problems are often
caused by a number of nonpathological factors. People may
make mistakes; they may be ignorant. They may, at times,
act impulsively. Their behavior may cause problems in a
relationship. Some people use sex as a coping mechanism
similar to the use of alcohol, drugs, or eating. This pattern of
sexual behavior may become problematic. Problematic sexual
behavior is often remedied, however, by time, experience,
education, or brief counseling. Impulsive, obsessive, and
compulsive behavior, by its nature, is much more resistant to
change.
Developmental Process vs.
Compulsive Sexual Behavior
Some sexual behaviors might be viewed as impulsive,
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. They
can act impulsively. In adulthood, it is common for individuals
to go through periods when sexual behavior may take on
impulsive, obsessive, and compulsive characteristics. In early
stages of romance, there is a natural developmental period in
which individuals might be obsessed with their partners and
compelled to seek out their company and to 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 developmental disorder, an impulse control
disorder, a mood disorder, or an obsessive-compulsive
disorder. Patrick Carnes (1993) popularized the concept of
CSB as an addiction. He believes that people become addicted
to sex in the same way they become addicted to substances
or other 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) and 30-day inpatient
treatment centers have become popular solutions to those who
view CSB as an addiction. Although there is general recognition
that the “abstinence model” is useful for alcoholics, many
believe this approach cannot be applied to sexuality because
sexual expression is a basic appetitive drive. Again, critics
view the addiction model as an oversimplification of CSB and
potentially dangerous when proper medical and psychological
treatment is called for.
Robert Stoller (1975) was a strong advocate of psychodynamic
mechanisms involved in CSB. His theories have been helpful
to some in resolving inner conflicts fueling obsessive and
compulsive drives. Others have suggested that CSB is basically
an impulse control disorder (Barth & Kinder, 1987). Others
have suggested complex mechanisms of anxiety, mood, and
personality disorders with some individuals possessing more
impulse control problem and others more of an obsessive-
compulsive type problem (Coleman, Raymond & McBean,
2003; Raymond, Coleman, Benefield, & Miner, 2008). In some
cases, CSB can be a manifestation of a bipolar mood disorder.
In other cases, CSB can be caused by a neurological disorder,
such as epilepsy or Alzheimer’s. John Money (1986) assisted
in the understanding of the complex interplay of biological,
psychological, and environmental factors in CSB. With new
understandings of obsessive-compulsive disorder, some
have suggested that CSB is caused by irregular chemical
functions in the brain and cause the repetitious nature of the
self-defeating behavior (Coleman, 1991). In this model, CSB
is driven by anxiety, in which certain sexual behaviors provide
temporary relief of the anxiety but is followed by further anxiety
and distress—creating a self-perpetuating cycle. Others feel
that there is a dysregulation of neurotransmitters related to
areas of the brain that are involved in mood states, impulse
control, and pleasure (see Coleman, 1991). Because 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 layperson should ask the
professional about his/her own theories on CSB and consider
other professional opinions.
Treatment of CSB
Although 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. Whereas medications that suppress the production
of male hormones (anti-androgens) have been successfully
used to treat a variety of paraphilic disorders, antidepressants
that selectively act on serotonin levels in the brain have
been effective in reducing sexual impulses, obsessions/
compulsions, and their associated levels of anxiety and
depression. Other medications, such as mood stabilizers and
other types of antidepressants, have been found to be useful
alone or in combination with other medications. Naltrexone,
an opioid antagonist, has also shown some promising effects
(Raymond, Grant, Kim, & Coleman, 2002). These newer
medications interrupt the obsessive-compulsive cycle of CSB
and improve impulse control and help patients use therapy
more effectively. The advantages of these antidepressants
over older antidepressants or anti-androgens are their broad
efficacy and relatively few known side effects (Kafka, 2000).
However, in more severe cases of CSB, anti-androgens can be
quite helpful (Bradford, 2000).