Page 1 of 9 : The Premier Journal for Undergraduate Publications in the Neurosciences Submitted for Publication January, 2018 The Addictive Potential of Sexual Behavior

Heather Bool D’Youville College, Buffalo, New York

This paper examines the addictive potential of sexual behavior through behavioral and neurophysiological mechanisms analogous to other formalized . Sexual behavior refers to any action or thought preformed with the intention of sexual gratification, such as the consumption of explicit material, , fantasizing of sexual scenarios, and . is defined by the presence of tolerance, preoccupation, withdrawal, dependence, and the continuation of behavior despite risk and/or harm. demonstrates high potential due to the frequency of reward-associated cues encountered in daily life, and the low effort and risk required for sexual pleasure. Currently, sexual addiction lacks a formal diagnosis despite behavioral, psychological, and physiological evidence. An official diagnosis recognized by a governing authority, such as the American Psychological Association, would offer greater access to treatment, funding for research, and exposure and education for the general public about this disorder.

Abbreviations: None

Keywords: Sexual Behavior; Addiction; Sexual Addiction; Neurophysiology; Behavioral Neuroscience

Introduction

“Sexual addiction” is an umbrella term Confusion remains regarding the for sexual impulsivity, sexual compulsivity, out- etiology and nosology of sexual addiction, of-control sexual behavior, hypersexual which has led to the lack of a universally behavior or disorder, sexually excessive accepted criterion and, more importantly, the behavior or disorder, Don Jaunism, satyriasis, absence of a formal diagnosis. A lack of and obsessive-compulsive sexual behavior operationalization of the disorder has severe (Beech et al., 2009; Karila et al., 2014; effects on research; due to the use of Rosenberg et al., 2014). For the purposes of this inconsistent parameters and criteria, results can paper, sexual addiction is defined by the be difficult, if not impossible, to compare. This continuation of a sexual behavior despite risk or results in ambiguous prevalence rates and harm, preoccupation, tolerance, withdrawal, recovery outlooks. Standardization of diagnostic dependence, and relapse even after prolonged criteria and conceptualization of this disorder is (Goodman, 1993, 2008; Robbins and crucial, as has been done with various other Everitt, 2002; Hyman, 2005; Kafka, 2010; Luo substance use and behavioral disorders et al., 2013), and must not fall solely under the (Association, 2013). criteria of a (Stein et al., 2000). A The Diagnostic and Statistical Manual paraphilia is defined as atypical sexual interests of Mental Disorders (DSM-5) recognizes or behaviors that cause distress to the individual, substance use disorders relating to , though not simply as a result of societal , cannabis, hallucinogens, inhalants, standings, or that involves another party who , sedatives, hypnotics, anxiolytics, suffers harm or distress as a result of the (-type substances, paraphilic behavior (Association, 2013). , and other stimulants), tobacco, and other (or unknown) substances, and lists Page 2 of 9 The Addictive Potential of Sexual Behavior Submitted for Publication January, 2018 gambling disorder as the sole (Association, 2013). Though proposed Prevalence and Comorbidity by Martin Kafka in 2010 for admission into the DSM-5 (Kafka, 2010) as “hypersexual Without universal criteria, determining disorder”, sexual addiction was rejected on the prevalence and comorbidity rates is difficult. grounds of “insufficient peer-reviewed evidence The diagnosis is up to the discretion of the to establish the diagnostic criteria and course clinician or researcher, which results in various descriptions needed to identify these behaviors definitions of the disorder and clinical as disorders” (Association, 2013). representation. Estimates range from 1-6% of This position is also held by American the population, as compared to 1-4% with a Association of Sexuality Educators, Counselors, pathological gambling disorder, and 8.6% with a & Therapists (AASECT) due to a lack of disorder (Sussman et al., 2011; empirical evidence to support the disorder’s Villella et al., 2011; Inaba and Cohen, 2014). clarification and inadequate training, treatment, With a population of over 326 million people in and education pedagogies relating to sexual the United States, a 6% prevalence rate equates addiction (American Association of Sexuality, to almost 19.7 million sexual addicts. 2016). Furthermore, comorbidity rates are estimated to The lack of empirical research regarding be almost 40% for substance use disorders sexual addiction is most likely due to negligence (Sussman et al., 2011) and is correlated with of its underlying neurophysiological and other psychiatric disorders such as and behavioral mechanisms. Patrick Carnes is one of mood disorders, personality disorders, impulse the first to introduce the concept of sexual control disorders, and (Goodman, addiction (Carnes, 1994, 2001) but as a 1993; Schneider and Schneider, 1996; Black et practitioner, most of his research is toward al., 1997; Kafka and Hennen, 1999; Raymond et classification and the clinical manifestation of al., 2003; Grant and Steinberg, 2005; the disorder. His prime audience, as with fellow Berberovic, 2013). author Gary Wilson (Wilson, 2014), is the general public, not academia. This is not to discredit their work, but instead to illustrate the Sexual Behavior and Natural need for further empirical research regarding Reward this disorder. The purpose of this paper is to explore For the purpose of this paper, sexual the addictive potential of sexual behavior behavior refers to any action or thought through comparison of neurophysiological and preformed with the intention of sexual behavioral mechanisms to other recognized gratification. This includes, but is not limited to: addictions. For the purpose of this paper, sexual consumption of explicit material, paying for sex, addiction will be defined by the continuation of autoerotic stimulation (masturbation), visiting the behavior despite risk or harm, locations where sexual services are offered, preoccupation, tolerance, withdrawal, soliciting prostitutes, engaging in sexually dependence, and high relapse potential. In doing driven activities, sexual intercourse, and so, this paper aims to support the argument that fantasizing of sexual scenarios. Problematic use sexual addiction should be considered for formal is defined as any instance of engaging in sexual diagnosis, which would aid in establishing a behavior when there are immediate or delayed universal criterion that would result in more negative consequences to oneself and/or others consistent and reliable research as well as (Goodman, 1993). provide greater access to treatment, prevention, As with all of abuse, sexual and provide exposure and education about this reward and behavior is processed through the disorder to the general public (Association, mesocorticolimbic system, circuitry 2013). that is widely associated with reward (Komisaruk et al., 2004; Robbins et al., 2008; Olsen, 2011). Key structures include the of 9 Impulse: The Premier Journal for Undergraduate Publications in the Neurosciences Submitted for Publication January, 2018 , (NAc), prefrontal A definitive characteristic of substance use cortex, anterior cingulate cortex, and disorders and sexual addiction is the orbitofrontal cortex which, in conjunction with continuation of sexual behavior despite a one another, have been shown to modulate persistent or recurrent social, financial, motivated behavior and executive function, psychological, or physical problem caused or regulate , process reward, and assign exacerbated by the behavior (Schneider, 1991; reward salience (Chao and Nestler, 2004; Goodman, 1993; Association, 2013). Examples Hyman, 2005; Olsen, 2011). of this may be the loss of a job due to Dopamine is a monoamine inappropriate sexual advances or displays, neurotransmitter known to be released from preoccupation with sexual behavior, or absences neurons during rewarding experiences, including caused by engaging in sexual behavior. the hedonic properties of sexual behavior, Additionally, sexual addiction has significant use, and other natural rewards (Hyman, 2005; adverse effects on relationships (Schneider, Olsen, 2011). Dopamine has been found to play 1991; Carnes, 1994; Schneider and Schneider, a role in sexual motivation, copulatory 1996; Schneider et al., 1998; Carnes, 2001; proficiency, motor activity, genital reflexes, and Wilson, 2014). consumption is copulatory patterns in male rates(rats) (Hull et linked with lower perceptions of attractiveness, al., 2004). Furthermore, dopamine has been warmth, and intelligence in partners, as well as found to modulate synaptic activity in the lower , , and satisfaction rates prefrontal cortex (Otani et al., 1998; Gurden et with their partner or spouse (Wilson, 2014). al., 1999; Gurden et al., 2000; Huang et al., Many experience or 2004), amygdala (Bissière et al., 2003), and rates after periods of (Huang and Kandel, 1995; prolonged, excessive pornographic use (Wilson, Otmakhova and Lisman, 1996), areas associated 2014). Financial strain may come from paying with motivation, executive functioning, and for sexual services such as pornography or reward processing (Olsen, 2011). Tolerance is prostitutes, either digital or in person, or loss of defined as the reduced effect of a reward after a job due to sexual preoccupation. This could repetitious use and is associated with a also include the cost of treatment and healthcare downregulation of dopamine receptors (Hyman fees, or legal costs that result from the et al., 2006). The maladaptive behavioral individual’s sexual behavior, such as sexual changes associated with addiction, such as assault, sexual advances and interactions with a impaired decision making and , are minor, and domestic violence (Horvath et al., believed to be a result of this neuronal plasticity 2018). (O'Brien et al., 1992; Majewska, 1996; Bechara, 2005). Preoccupation In substance abuse, preoccupation is best defined by drug taking and seeking Defining Addiction behavior, which is mirrored in sexual addiction. This manifests as spending a great deal of time Major components of addiction are the on activities necessary for sexual behavior, engaging in the sexual behavior, or recovering continuation of a behavior despite risk or from its effects (Goodman, 1993). harm, preoccupation, tolerance, withdrawal, Preoccupation may result in a neglect of dependence, and relapse even after occupational, academic, domestic, or social prolonged abstinence (Goodman, 1993; obligations. It can also be characterized by Robbins and Everitt, 2002; Hyman, 2005; fantasizing of sexual scenarios, and “seeking Goodman, 2008; Kafka, 2010; Luo et al., behavior”, or behavior driven by sexual 2013). cravings. Like substance abuse, this may take up a significant amount of the addict’s time, Continuation Despite Risk and Harm resulting in damage to romantic, professional, and platonic relationships. It is important to note Page 4 of 9 The Addictive Potential of Sexual Behavior Submitted for Publication January, 2018 that, though an individual may spend a extended periods of time (Wilson, 2014). significant period of time engaging in sexual ‘’, or masturbating just below the point behavior, so long that it doesn’t detract from any of orgasm, may last for several hours, elevating other aspect of their lives, it is not considered an dopamine levels for an unnaturally long period addiction. This is a critical distinction to make, of time. As a result, dopamine receptors are because sexuality rests on a broad spectrum and downregulated in areas such as the nucleus cannot be standardized. accumbens (NAc), which could result in desensitization (Wilson, 2014). Tolerance and projections of the NAc Tolerance is defined as the necessity to are hypothesized, often in collaboration with the increase drug dosages or behavior Ventral Tegmental Area (VTA), to play a large intensity/frequency in order to elicit the same role in the , craving, relapse, and effects (Chao and Nestler, 2004). Tolerance in self-administration of psychoactive substances substance abuse disorders is best explained (Goeders et al., 1984; Koob, 1992; Caine and through pharmacokinetic and Koob, 1994; Breiter et al., 1997; Childress et al., pharmacodynamics changes that occur with 1999; Bonson et al., 2002; Chao and Nestler, repeated and prolonged drug use (MacRae et al., 2004; Hyman et al., 2006; Robbins et al., 2008). 1987; Hammer et al., 1997; DuPen et al., 2007). , cocaine, heroin, , Sexual addiction can generate behavioral cannabis, and alcohol have all been shown to tolerance, as consistent, patterned consumption increase dopamine transmission in the NAc shell of pornography and other sexually explicit (Robbins and Everitt, 2002). Consequently, as material often leads to behavioral tolerance dopamine desensitizes, the erotic responses and (Goodman, 1993; Kafka, 2010; Wilson, 2014). hedonic effects decrease, and tolerance is , or the attenuation of a experienced (Carnes et al., 2005; Kühn and physiological or behavioral response to a Gallinat, 2014; Wilson, 2014). stimulus, occurs after repeated exposure to the Some behavior undergoes a process same erotic material (Zuckerman, 1971). opposite to tolerance: sensitization. Sensitization Furthermore, those who regularly view is the enhancement of behavioral responsiveness pornography report the persistent need to seek with repeated stimuli exposure. In regards to out novel, and often more explicit, material. sexual behavior, this might include cues or This might include taboo subjects such as behaviors that bring one closer to sexual bestiality, “furry” porn, or material that relates gratification (e.g., turning on the computer or to fictional anthropomorphic animal characters, fantasizing about going home and surfing a and more intense and violent material such as pornographic website after work) The NAc has , sadomasochistic displays, been shown to exhibit hyper-reactivity to reward pornography, or material (Wilson, 2014). associated cues in self-identified sexual addicts This is comparable to a substance user’s need to (Wilson, 2014). increase dosages to maintain the same A reduction in grey matter is pharmacological effects. associated with reduced inhibition and decision Sexual behavior also displays making. Pornography use has been linked to a physiological tolerance. Sexual responses such reduction of grey matter in the along as local vasocongestion in the primary and with a disintegration of the neural pathways secondary erogenous zones, increased heart rate, between the mesolimbic dopamine system and and reported mental arousal all decrease with the prefrontal cortex (Wilson, 2014). The each exposure (Zuckerman, 1971). However, the impairment of this circuit may result in a physiology of erogenous zones is not well continuation of behavior, regardless of understood and is an area that requires future punishment (Inaba and Cohen, 2014). study. Furthermore, drug- or behavior-associated cues Unlike the hedonic effects experienced begin to take precedence over even basic drives with substance abuse, sexual behavior has the such as satiation and hydration through a unique ability to modify dopamine levels for process called incentive salience (Robinson and Page 5 of 9 Impulse: The Premier Journal for Undergraduate Publications in the Neurosciences Submitted for Publication January, 2018 Berridge, 1993; Kelley and Berridge, 2002; Dependence Hyman et al., 2006). As cues associated with Dependence is difficult to measure, as sexual behavior are reinforced, cravings may be sexual behavior is considered to be appetitive. It triggered at later exposure which could inhibit is often established through the presence of recovery and increase the likelihood of relapse withdrawal symptoms that occur during a period (Hyman et al., 2006). of abstinence or attempted cessation of sexual behavior, and tolerance. There are two branches Withdrawal of dependence: psychological and physiological. Withdrawal is often the result of a is defined by drug or reduction or discontinuation of drug/behavioral behavior seeking/taking without withdrawal use and is associated with a significant negative symptoms, and is most often seen in the affective state, or , characterized by beginning stages of drug use. Physiological psychosomatic abnormalities and an intense dependence, however, refers to the craving for the drug or behavior (Chao and pharmacological and physiological changes that Nestler, 2004). Symptoms vary between occur through repetitive drug/behavioral use. individuals, drug class, duration, and intensity. This is most often observed via tolerance and For example, withdrawal is characterized the presence of withdrawal symptoms following by pupillary dilation, sweating, lacrimation, abstinence. rhinorrhea, piloerection, tachycardia, vomiting, diarrhea, hypertension, yawning, fever, and Relapse tachypnea, opioid craving, restlessness, Relapse, or the continuation of drug irritability, increased sensitivity to pain, nausea, seeking and drug-related behavior after a period cramps, muscle aches, dysphoria, , and of prolonged abstinence, has unconscious, anxiety (Cammarano et al., 1998). Similar to automatic, and habitual influences (Tiffany, substance abuse, the cessation of sexual 1990; Everitt and Robbins, 2005; Milton and behavior after repetitive engagement in sexual Everitt, 2010). It is often preceded by exposure behavior results in a wide range of symptoms. to environmental stimuli and contexts previously These include, but are not limited to: anxiety, paired or conditioned with drug use. Cues , cravings for erotic material or associated with drug use can induce craving and actions, the inability to concentrate, and trigger previously activated limbic corticostriatal obsessive fantasizing or “erotic activity” processes (Ehrman et al., 1992; Grant et al., seeking, similar to that displayed during 1996; Childress et al., 1999; Garavan et al., substance abuse (Young, 2008; Bhatia, 2009; 2000; Litt et al., 2000; Sinha et al., 2000; Kilts Wilson, 2014; Grubbs et al., 2015). Most, if not et al., 2001; Bonson et al., 2002; Milton and all of these, cease at least temporarily once the Everitt, 2010). Research, however, regarding behavior resumes. sexual addiction and its relapse potential is Wilson (2014) suggests that anxiety, scarce, and is yet another area for further study. depression, lack of focus, loss of appetite, and That being said, the hedonic state loss of often occur after a period of resulting from sexual behavior has shown abstinence from habituated sexual behavior. associative properties (Pfaus et al., 2001). However, it is difficult to decipher whether Furthermore, unlike drug use, explicit material these symptoms fit into the “withdrawal” model is widely available and accessible virtually of addiction. Withdrawal is defined as a set of anywhere due to modern day technology. As symptoms initiated by abstinence, but these such, avoiding such cues may be near symptoms may also occur due to a break in impossible, further complicating the treatment routine, as many addicts experience anxiety process. Though there is a lack of empirical when habits are interrupted. Further research is data, the overlap in brain circuitry and the necessary to determine the underlying cause of presence of associative properties suggest that these symptoms. sexual addiction could share a comparable relapse potential to substance use. Page 6 of 9 The Addictive Potential of Sexual Behavior Submitted for Publication January, 2018 Without a concrete understanding of the the behavior does not result in harm or distress, sexual process, it is difficult to determine what in general terms, it cannot be categorized as a biological component underlies relapse and disorder. craving. The mechanisms underlying sexual Another hurdle and criticism of sexual relapse is an area that requires future study. addiction is the resulting confusion between “social disapproval and morality with issues of health and disorder” (Wakefield, 2012). A sexual behavior or interest may be contradictory Discussion to an individual’s moral standing, such as sex out of wedlock within a Christian or Catholic

household, which may cause distress, but would One of the biggest hurdles facing sexual not qualify for sexual addiction. Establishing the addiction is the lack of peer-reviewed evidence criteria for sexual addiction to include related necessary to establish a diagnostic criteria and symptoms of drug addiction differentiates moral course of treatment. By examining potential conflicts with the pathology associated with similarities among the neurophysiological and sexual addiction. behavioral underpinnings of drug addiction and The stigma surrounding sexual disorders sexual addiction, a case can be made for a is a massive hurdle that both researchers and formal diagnosis of sexual addiction. Both clinicians alike must battle. Once considered a categories of disorder demonstrate continuation moral fallacy, it has grown to be a disorder of the drug or behavior despite risk or harm, worthy of scientific and public attention. The preoccupation, tolerance, withdrawal, acceptance of sexual addiction as a formal dependence, and relapse even after prolonged disorder is invaluable to research, treatment abstinence. Sexual behavior and psychoactive options and availability, teaching paradigms, substances are both processed via the and education of the general public. mesolimbic dopamine system, an area responsible for mood regulation, motivation, and reward. This shared neurophysiology provides the groundwork for further research regarding Acknowledgements sexual behavior and how prolonged, repetitive use affects dopamine regulation and synaptic The author would like to thank Dr. Patricia plasticity in key reward areas of the brain. Abbott and Dr. Todd Walter for their Reluctance and clinical hesitation has encouragement, patience, and support plagued sexual addiction since its inception. throughout the production of this manuscript. Critics have challenged the diagnosis of sexual addiction, claiming that the “criteria do not adequately distinguish normal range high levels Corresponding Author of and activity from pathological levels of sexual desire and activity” (Wakefield, Heather Bool 2012). However, by examining sexual addiction D’Youville College as it compares to other DSM-recognized 320 Porter Ave, Buffalo, NY 14201 addictions, the distinctions between healthy sexual desire and behavior and sexual addiction [email protected] become apparent. Sexual addiction carries a wide range of negative consequences to social, financial, psychological, occupational, References academic, and physical aspects of the individual’s life (Goodman, 1993; Kafka, 2010). American Association of Sexuality Educators, The presence of harm and distress is a key piece Counselors and Therapists (2016) AASECT of diagnosing a , and sexual Position on Sex Addiction. Available at: addiction is no exception (Association, 2013). 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