Sexual Compulsivity p. 1

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Topics in Human Sexuality: Sexual Compulsivity

Introduction

Case Vignette Consider the following case that involved a prominent politician:

Anthony Weiner, former seven-term congressman from New York, was implicated in multiple sex scandals both while in office and subsequent to his resignation. The initial scandal, known in the popular press as “Weinergate,” involved sending sexually explicit material by cell phone (“sexting”) by to a 21-year-old woman. After initial denials, he resigned from his congressional seat in 2011. In 2013 Weiner attempted to enter the New York mayoral race, a move thwarted when additional pictures surfaced and which were sent after his resignation from congress. In September 2016 Weiner was accused and eventually pled guilty to sexting with a 15-year-old. His wife filed for divorce on the day that charges against Weiner were filed.

Weiner’s case, and many like it, provide a basis for understanding sexually compulsive behaviors. Sexual compulsivity (also known as sexual addiction, , excessive sexuality, or problematic sexual behavior) is characterized by repetitive and intense preoccupations with sexual fantasies, urges, and behaviors that are distressing to the individual and/or result in psychosocial impairment (Derbyshire & Grant, 2015). These behaviors are often escalating, and can involve behaviors that range from solitary (such as uncontrollable masturbation or extensive use of pornography) to sexting, webcamming or obscene phone calls. Sexually compulsive behaviors may also involve illegal acts, such as exhibitionism.

While behaviors such as Weiner are often termed “sexual addiction” this label is somewhat controversial, both in the field of mental health/addiction and to the general public, and is not a clinical term per se but is often used in the field. Formal criteria for “Hypersexuality Disorder” was considered for inclusion in DSM-5, but was not adopted. While there may be a number of reasons for this, some people in the addiction field will only utilize the term “addiction” if a behavior involves ingestion of a psychoactive substance. This argument is somewhat weakened due to the inclusion of pathological gambling as a behavioral addiction rather than an impulse control disorder in prior DSM versions. Additionally there is the argument that a “sexual addiction” may be an excuse for infidelity. Others consider these behaviors to be more of a syndrome, with subtypes such as “compulsive sexual behavior,” “pornography addiction,” “compulsive

Ce4Less.com Sexual Compulsivity p. 2 masturbation,” etc. Above all, there has not yet been the type of empirical study devoted to sexually compulsive behaviors as there has been for other types of addiction, such as alcohol addiction. Hypersexual behaviors can also occur during the course of another major mental illness, such as a manic episode in . It is interesting to note that physiological disorders of low (such as and female sexual arousal disorder) are included in the DSM-5.

Diagnostic categorization notwithstanding, it is likely that many mental health professionals will encounter individuals with sexually compulsive behavior patterns in their practices. Prevalence statistics vary, with Ewald (2003) estimating that about 6% to 8% of Americans have sexual patterns indicative of a sexual compulsivity; Kuzma & Black (2008) estimate prevalence at 3% to 6% in the US adult population. The later study states that compulsive sexual behavior typically begins in late adolescence or early adulthood, is thought to be chronic or episodic, and is more common among men than women. While this gender difference continues to exist, more study is needed. One recent study recent study found that 3.1% of women who responded to an online survey were characterized as hypersexual (as measured by control of sexual thoughts, urges and behaviors, and the use of sex as a coping strategy) (Reid R. C., Garos S. & Carpenter, B.N., 2011). A study of gay, lesbian, and bisexual individuals in a community sample reported a compulsive sexual behavior rate of 27.9%, but that study included both paraphilic and non-paraphilic sexual behavior in it’s definition, likely accounting for the high percentages. Among psychiatric inpatients, rates of compulsive sexual behaviors are between 1.7% and 4.4% (Müller et al., 2011). Estimating the prevalence of compulsive sexual behavior is difficult, due to the embarrassment and shame frequently reported by those with compulsive sexual behavior. The majority of treatment-seeking individuals with hypersexuality are males (Coleman, Raymond & McBean, 2003).

Substance use, mood, anxiety, and personality disorders are common comorbid conditions with hypersexual disorders, as are impulse control disorders such as Attention Deficit Hyperactivity Disorder (Coleman, Raymond & McBean, 2003), pathological gambling and compulsive buying (Grant Levine & Potenza, 2005.) Sexual compulsivity is also seen in individuals with , including Asperger’s (Deepmala & Agrawal, 2014). Hypersexual behavior can lead to medical complications including genital trauma or sexually transmitted . Risk factors for Hypersexual Disorders include childhood sexual abuse (Kuzma & Black, 2008) and a family history of addiction (Carnes, 2001).

Sexual compulsivity and sexual anorexia, which Patrick Carnes (2015) describes as “sex in the extremes,” affects all facets of individuals’ lives. Reliance on sexual activities as maladaptive coping skills can be as destructive as addiction to chemical substances. People who engage in compulsive sexual behaviors may experience psychological distress, lose their livelihoods, and ruin meaningful relationships.

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While literature on sexual compulsivity/addiction is more limited than that of other substance/process addictions, it does provide insight into treating this difficult issue. There are many facets to treatment, including helping clients to recognize the function of the behavior in order to decrease the tremendous shame around it. Carnes (2015) attributes the etiology of sexual compulsivity disorders to a combination of psychodynamic and cognitive-behavioral factors. He stresses abstinence, shame reduction, and rebuilding the capacity for healthy intimacy as primary tasks of the first three years of treatment. The following discussion will expand upon these concepts.

Educational Objectives

1. Define sexual compulsivity. 2. Define sexual anorexia. 3. Describe prevalence and gender differences in sexual compulsivity. 4. Discuss the role of trauma in the development of sexual compulsivity. 5. List the components of healthy sexuality. 6. Discuss Internet sex and pornography addiction. 7. Describe treatment of sexual addiction.

Defining Sexual Compulsivity

The definition of sexual compulsivity previously discussed and endorsed by the National Council on Sexual Addiction and Compulsivity is that sexual compulsive behavior is characterized by “engaging in persistent and escalating patterns of sexual behavior acted out despite increasing negative consequences to self and others.” In other words, the person struggling with behaviors will continue to engage in these patterns despite facing potential health risks, financial problems, disrupted relationships or even arrest.

Sexually compulsive behaviors were first identified in the 1970s, but began to be a focus of study in the 1990s. Goodman (1998), in an early definition still employed by many experts, defined sexual addiction as a condition characterized by two key features: 1) recurrent failure to control the sexual behavior (i.e. failed attempts to quite or cut back), and 2) continuation of the sexual behavior despite significant harmful consequences (e.g., consequences to relationships, trouble at work or school, loss of interest in nonsexual activities, financial problems, loss of community standing, shame, , anxiety, legal issues.) Goodman points out that no form of sexual behavior in itself constitutes sexual addiction. The significant features that distinguish sexual addiction from other patterns of sexual behavior are: 1) the individual is not reliably able to control the sexual behavior, and 2) the sexual behavior has significant harmful consequences and continues despite these consequences. Experts in sexual addiction and compulsivity also include the element of sexual preoccupation to the point of obsession as another distinguishing trait (Weiss, 2016). Weiner’s case exemplifies these characteristics.

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Sexual compulsivity involves many types of problematic sexual behaviors. The most commonly reported compulsive sexual behaviors are masturbation (17–75%) (Reid, Carpenter & Lloyd, 2009) compulsive pornography use, including use of Internet pornography (48.7– 54%) (Briken et al., 2007), promiscuity and multiple relationships (22–76%) (Reid, Carpenter & Lloyd, 2009). While these behaviors are often seen in the literature, there may be other representations that are not listed in the findings above. Additionally these behaviors may occur in conjunction with one another, such as a person that compulsively masturbates while viewing pornography.

Carnes (2015), a leading expert in the field, utilizes a similar definition. He further adds that people who engage in sexually compulsive behaviors hold a number of universal core beliefs: 1. "I am basically a bad, unworthy person." 2. "No one would love me as I am." 3. "My needs are never going to be met if I have to depend on others." 4. "Sex is my most important need."

Additionally, compulsive sexual behavior is often triggered by negative mood states including sadness and depression.

Sexually compulsive behavior has been viewed through the lens of Griffiths’ (2005) components’ model of addiction: (i) salience (sexual behavior dominates the individual’s thinking, feelings, and behavior), (ii) mood modification (mood elevates as a result of engaging in hypersexual behavior), (iii) tolerance (the need for increased levels or intensity of the sexual behavior to achieve the desired effect), (iv) withdrawal (the person experiences a sense of withdrawal – such as irritability and moodiness – when they discontinue the pattern of sexual behavior), (v) conflict (conflict due to spending excessive amounts of time engaged in sex-related behavior), and (vi) relapse (the tendency for repeated reversions to earlier patterns of sexual behavior to recur after prolonged periods of abstinence or control) (Van Gordon, Shonin, & Griffiths, 2016).

The case vignette below illustrates many of the core beliefs that Carnes describes, and also further illustrates the difficult nature of sexually compulsive behaviors. Research (Parsons, Grov, and Golub, 2012) has shown that individuals with sexually compulsive behaviors are also likely to engage in high risk behaviors including those that could result in HIV transmission (e.g., condomless anal sex and multiple sexual partners).

Case Vignette

John, a 28-year-old gay man is presented for treatment with a specializing in sexual compulsivity. In exploring John’s goals, he stated that he knew that his self- esteem had always been low, that he felt “horrible” about his body, and while he wanted nothing more than a committed relationship he did not actually believe that he would

Ce4Less.com Sexual Compulsivity p. 5 find someone who really loved him. He spent evenings either webcamming online or "cruising" local parks, public restrooms, and pornographic bookstores for sexual contacts. This activity consumed numerous hours each day. His primary outlet was sex with multiple anonymous partners. When he learned of a recent increase in the number of local gay men that had tested positive for HIV, he began to worry constantly about his risk of contracting the virus. Still, he was unable to change his unsafe sexual practices despite repeated promises to himself to do so. While he is seeking change through therapy, he reported feeling overwhelmed and as if he could not possibly be helped.

DSM-5/ICD 10 Diagnosis

In attempting to formally diagnose sexually compulsive behaviors, clinicians who treat these disorders frequently struggle with diagnostic categorization. Despite a successful field trial supporting the validity of the criteria for “Hypersexual Disorder” (Reid et al., 2012) the APA rejected the diagnosis for inclusion in the DSM-5. According to Piquet- Pessôa et al. (2014) cited concerns involved the lack of research including anatomical and functional imaging, molecular genetics, pathophysiology, epidemiology, and neuropsychological testing. There were also concerns that a diagnosis of Hypersexual Disorder could lead to forensic issues or produce false positive diagnoses, given the absence of clear distinctions between normal and pathological levels of sexual desires and behaviors (Moser, 2013).

Similar to the DSM-5, the ICD-10-CM (2017) does not include “Excessive Sexual Drive” as a diagnosis. The recommendation was to use the diagnostic code F52.8 (Other Not Due to Substance or Known Physiological Condition.) Weiss (2016) comments that this diagnosis continues to utilize terminology that is both dated and potentially offensive to people with sexual compulsivity, such as the descriptors “nymphomania,” and “satyriasis.”

The DSM-5 contains similar diagnostic entities: Other Specified Sexual Dysfunction and Unspecified Sexual Dysfunction.

Other Specified Sexual Dysfunction (302.79), is defined as follows, which indicates a sexual disorder that causes clinically significant distress but does not meet full criteria for another sexual dysfunction and which allows for the person making the diagnosis to include a specific reason such as “sexual compulsivity.” Another option is the selection Unspecified Sexual Dysfunction (302.70), which is essentially the same diagnosis but does not require the clinician to include a specifier (typically used in contexts in which there is insufficient information).

The diagnosis “Compulsive Sexual Behavior Disorder” is being studied inclusion in ICD- 11 (scheduled for publication in 2018). Weiss (2016) cites the following definition posted on the ICD-11 beta draft website.

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Compulsive sexual behavior disorder is characterized by persistent and repetitive sexual impulses or urges that are experienced as irresistible or uncontrollable, leading to repetitive sexual behaviors, along with additional indicators such as sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other activities, unsuccessful efforts to control or reduce sexual behaviors, or continuing to engage in repetitive sexual behaviors despite adverse consequences (e.g., relationship disruption, occupational consequences, negative impact on health). … The pattern of sexual impulses and behavior causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning.

For the present time, there are limitations to formal diagnostic coding.

Prevalence and Gender Differences

Case Vignette

Naomi, a 27-year-old woman is seeking treatment due to severe depression. During her assessment, she shared with her therapist that she does not seem to have trouble finding relationships, but does have difficulty sustaining them. Naomi has had “relationships” with 10 men this month alone, all of them sexual and none of them lasting more than two weeks. She seems confused when her clinician suggests that she may have difficulties with sexual compulsivity.

Due to the secrecy and shame associated with sexual compulsivity, it is difficult to get a reliable estimate of the rate of hypersexual behavior and prevalence statistics are likely underestimated. The National Association of Sexual Addiction Problems estimates that 6 to 8 percent of Americans are sexually compulsive (Ewald, 2003). About 8% of men and 3% of women from the population in the US are sexually compulsive. This constitutes over 15 million people. The literature suggests that like other addictions sexual compulsivity is nonselective and spans all ages, religions, and social stratas, and that both genders and all sexual orientations are represented. It is important to assess clients presenting with sexually compulsive behaviors within the context of age and other life factors. For example, college students living away from home for the first time may be more likely to engage in “excessive sexual exploration” due to being away for the first time (Cohen, 2008).

In working with male and female sex addicts, one anecdotal difference often cited by clinicians is male addicts’ objectification of sexual partners (e.g., exploitive sex, paid sex), and their use of sex as a way to feel powerful (Carnes, Nonemaker, and Skilling, 1991). In contrast, some women appear to seek “relationships” through their sexual

Ce4Less.com Sexual Compulsivity p. 7 activities. A National Council on Sex Addiction and Compulsivity position paper (2000) on female sex addicts suggests that most sexually compulsive women have not had appropriate role models to teach them how to achieve emotional intimacy in nonsexual ways.

Causal Theories/Etiology Of Sexually Compulsive Behavior

Case Vignette

James, a 40-year-old man struggling with Internet-based sexual compulsions has been in treatment working on the behaviors. In looking at the types of sites and pornography he is seeking, his therapist comments that there seems to be a pattern of him selecting older women with fair complexions. In asking whether that reminds him of anyone, James breaks down and talks about his relationship with his mother, who was overly sexual, such as wearing only underwear around the house when James was a young boy. He often wonders if that had affected him in any way.

Psychological

While it is difficult to generalize, research has shown that sexual compulsivity is often rooted in adolescence or childhood, especially in experiences of abuse. Sixty percent of sexual addicts were abused by someone in their childhood (Book, 1997). Children who become sexually addicted may have grown up in harsh, chaotic or neglectful homes, or they may have been emotionally starved for love and affection. Boundaries in the family may have been overly rigid or permissive, which inhibited personal growth and individuality. For children growing up in these environments, sex may become a replacement for any kind of need, from escaping boredom, to feeling anxious, to being able to sleep at night. Sexual compulsivity may begin as the child turns to masturbation for diversion (Ewald, 2003). In other cases, the child maybe introduced to sex in inappropriate ways, such as through sexual abuse by a trusted adult or by an older child (Carnes, 2001).

Oftentimes, early trauma results in confusion about sexuality and sexual expression. People with hypersexuality are acting on a compulsion to act out sexually. Those struggling with sexual compulsivity often do not understand why they are acting out.

Trauma also affects one’s ability to be intimate sexually and the act of sex become confusing. Sexual compulsivity instead recreates the original act of abuse by misusing power or exploitation (Ewald, 2003). There is also little comprehension among many abuse survivors that certain behaviors are risky or degrading. There is often a secretive aspect to sexual compulsivity.

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Emotional Dysregulation and Impulsivity

Case Vignette

Larry is a 23-year-old male college student. Somewhat of a late bloomer with a history of ADHD, Larry initially presented for treatment of a binge . During the course of the treatment, Larry disclosed what he terms a “sexual addiction.” He describes spending more and more time surfing the web for hook up opportunities such as on Tinder. Many of these encounters are with older women. When asked to describe some of the functions of these “hookups,” he stated that while he used to feel a sense of relief after binging, that is no longer the case. After the encounters with anonymous partners he describes feeling “calm” and “more relaxed.” Larry has tried multiple times to stop this behavior but has not met with success.

Emotional dysregulation is a state in which affective responses are poorly modulated. Emotional dysregulation can be associated with early psychological trauma, brain injury, or chronic trauma, attachment disorders, attention deficit hyperactivity disorder, bipolar disorder, borderline , and complex post-traumatic disorder. Emotional dysregulation is also found among those with disorders. It is interesting that the aforementioned conditions are associated with hypersexual disorder, and may be an important mechanism in the etiology and treatment of sexual compulsivity.

Carnes (2009) theorizes that sexual compulsivity may be used as a means of self- soothing. “Contrary to enjoying sex as a self affirming source of physical pleasure, the addict has learned to rely on sex for comfort from pain for nurturing or relief from stress” (Carnes, 2009b, pp 34). The need for excitement distracts from the individual’s internal pain.

Emotional dysregulation and its connection to hypersexuality has also been a subject of research. Dhuffar, Pontes & Griffiths (2015) studied the role of emotional dysregulation and negative mood states as predictors of sexual compulsivity in a group of 165 British university students. They found that negative mood states and affective dysregulation significantly predicted hypersexual behaviors. Previous studies (e.g., Bradley, 2000) have also suggested that the use of sex allows for the distraction or the contraction of negative .

Role of Neurotransmitters

There is also emerging evidence that looks at the role of neurotransmitters in sexually compulsive behavior. The primary neurotransmitters that have been a focus of study have been the monoamines, namely serotonin, dopamine, and norepinephrine (Kafka, 2003). Cases of hypersexual behavior have also been shown to be induced by

Ce4Less.com Sexual Compulsivity p. 9 for Parkinson's , implicating dopamine systems in compulsive sexual behaviors (Riley, 2002).

Pornography and Internet Sexual Compulsivity

The term pornography refers to written material or pictorial content of a sexually explicit nature that is intended to elicit sexual arousal in the reader or viewer (Kraus, Martino & Potenza, 2016). According to surveys, 30%–70% of heterosexual and gay/bisexual men report recreational use pornography. In women this statistic is significantly lower (<10%) (Wright, 2013). Researchers agree that not all use of pornography is either negative or compulsive.

Researchers Hald and Malamuth (2008) studied the self-perceived effects of pornography consumption in a large sample of young adult Danish men and women aged 18-30. They assessed participants' reports of how pornography has affected them personally in areas including their sexual knowledge, attitudes toward sex, attitudes toward and perception of the opposite sex, sex life, and general quality of life. Participants reported only small, if any, negative effects with men reporting slightly more negative effects than women. Moderately positive effects were generally reported by both men and women, with men reporting significantly more positive effects than women. The researchers concluded that pornography may be a healthy sexual outlet for many people. There are, however, some individuals for whom pornography use becomes both excessive and problematic. This is particularly true for Internet-based pornography, sex chat rooms and webcamming.

Rosenberg (2010) lists the following signs of Internet Sexual Addiction

• Spending progressive amounts of time on the Internet • Behavior begins to affect other areas of the individuals life, such as work, family, hobbies • Binge-style of sexual or Internet behavior • Unsuccessful efforts to cut down, or stop altogether • Experiencing guilt and shame following the sexual behavior • Others indicate that the person spends too much time on the Internet • Experiencing money or legal problems because of Internet use • Thoughts of "getting online", or of sexual behavior, are compulsive even when not online or engaged in sexual behavior (i.e. work, with family, etc.) • Lies or excuses for behavior • Using sexually explicit material to cope with anxiety or dysphoric mood

Problematic use of pornography is frequently reported by those seeking treatment for compulsive sexual behavior (Kraus, Potenza et al., 2015), although this behavior also has to be assessed within the context of the individual’s age and life situation. Consider the following case:

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Case Vignette

Marcus is a 16-year-old teen who has been experiencing feelings of attraction to some of the boys he is in baseball with. He feels confused and overwhelmed. He has been frequently perusing online gay pornography, and this has become a source of conflict in his household between his parents. Lately the behavior has been occurring multiple times per day and often impede on his ability to accomplish other tasks such as school work.

In this case it would be important to consider Marcus’ entire life context. Is this a way of exploring his sexuality or is it indicative of a compulsive behavior? In contrast, consider the following case:

Gerald is a 30-year-old man recently mandated to treatment for sexually compulsive behavior. He reports spending up to 6 hours a day viewing both print-based and online pornography. While he recognizes that the behaviors are problematic, and has tried to stop them, he has not been successful. Gerald lives alone, and his housing is paid for by his parents. The impetus for treatment was that Gerald had visited Internet sites that he did not realize contained sexually explicit content related to minors. He has opted for a chance at rehabilitation rather than punishment, and appears motivated to working on what is underlying the compulsive pornography use.

Given Gerald’s example and others contained in this material it is helpful to understand what motivates some people to seek treatment for problematic use of pornography. Gola, Lewczuk, and Skorko (2016) found that negative symptoms (e.g., preoccupation, affect, and relationship disturbances because of sexual behaviors and impaired control) were significantly associated treatment-seeking.

Kraus, Martino and Potenza (2015) studied treatment-seeking behaviors among 1,298 men who frequently used pornography in order to identify factors (e.g., demographics and sexual history characteristics) associated with these individuals’ self-reported interest in seeking treatment. Out of the 1,298 individuals surveyed, 14.3% reported a interest in seeking treatment for use of pornography. Treatment-interested men were more likely to be single and to have made more “cut back” attempts with pornography, and more quit attempts with pornography. They were also more likely to have previously sought treatment for use of pornography. Findings suggested that interest in treatment may be explained, in part, by pornography users’ sense of “loss of control” over their sexual thoughts and behaviors related to pornography.

Dimensions of Healthy Sexuality

Due to the difficulties that those with sexual compulsivity have in understanding healthy sexuality, it is important to help them create a schema for what healthy sexual

Ce4Less.com Sexual Compulsivity p. 11 expression entails. Carnes (1997) presents the following dimensions of healthy sexuality:

• Nurturing ⎯ capacity to receive care from others and provide care for self. • Sensuality ⎯ mindfulness of physical senses that create emotional, intellectual, spiritual, and physical presence. • Self image ⎯ positive self-perception that includes embracing the sexual self. • Self-definition ⎯ clear knowledge of oneself (both positive and negative) and the ability to express boundaries and needs • Comfort ⎯ capacity to be at ease about sexual matters • Knowledge ⎯ knowledge base about sex and one’s unique sexual patterns. • Relationship ⎯ capacity to have intimacy and friendship with both those of the same gender and opposite gender. • Partnership ⎯ ability to maintain an interdependent, equal relationship that is intimate and erotic. • Nongenital sex ⎯ ability to express erotic desire without the use of the genitals. • Genital sex ⎯ ability to freely express erotic desire with the use of the genitals. • Spirituality ⎯ ability to connect and expression to the value and meaning of one’s life. • Passion ⎯ capacity to express deeply held feelings of desire and meaning about one’s sexual self, relationships, and intimacy experiences.

Differential Diagnosis

As mentioned earlier in this training material it is important to rule out medical causes of the hypersexuality. Compulsive sexual behaviors may be related to neurological disorders. For people affected by Alzheimer’s Disease and other illnesses of the frontal lobe, approximately 4-9% of patients experience sexual disinhibition (Cooper et al., 2009). Other diseases such as Pick’s Disease may impair the regulation of socially acceptable behaviors. Increased or extreme involvement in any sexual activity may also be a result of a psychiatric illness such as bipolar disorder or may be related to adverse effects of treatments (e.g. levodopa-treatment), substance-induced disorders (e.g. amphetamine substance use) (Sid et al., 2017).

Treatment of Sexual Compulsivity

Treatment of sexual compulsivity focuses on controlling the compulsive behavior and helping the person develop a healthy sexuality and healthy interpersonal relationships. Treatment generally includes:

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• Education about healthy sexuality, including the dimensions discussed above, and about possible health and other consequences associated with sexual compulsivity (Hart et al., 2016). Psychoeducational groups also often discuss the addictive/compulsive nature of these behaviors, the role of triggers, and alternate coping skills.

• Defining recovery. The person seeking to recover from sexual compulsivity must learn to develop his or her own definition of recovery. This may mean not masturbating, not engaging in sexual relationships outside a committed relationship, or not accessing Internet sites.

• Individual counseling, to better understand the reasons behind sexual compulsion, triggers to compulsive behaviors, support abstinence from compulsive behaviors, and reinforce coping skills. Individual counseling also involves helping with shame reduction and rebuilding the capacity for healthy intimacy

o Cognitive Behavioral Treatment - focus on helping the person to identify core triggers and beliefs about sexual compulsions and to develop healthier choices and coping skills to minimize urges and deal with the preoccupation of sexual compulsions. Cognitive Behavioral Therapy also aims to help the individual to reshape cognitive distortions about sexual behaviors (e.g., “I'm not really cheating on my wife if I look at online pornography/frequent chat rooms”). Cognitive Behavioral Therapy also emphasizes relapse prevention. (Fong, 2006; Hart et al., 2016; Shraga & O’Donahue, 2003).

o Mindfulness Awareness Training – One intervention that can be utilized to support a decrease in cravings associated with sexual compulsivity is Mindfulness Awareness Training. The authors of a case discussion of the application of this approach (Van Gordon, Shonin, & Griffiths, 2016) propose that “contemplative observance of cravings and negative affective states helps to objectify these psychological phenomena, such that they become less consuming and can be let go of.” Van Gordon, Shonin, & Griffiths’ (2016) case, as well as mindfulness applications to a range of addictive/compulsive behaviors make this another area to explore with regard to treatment.

o Psychodynamic Therapy - Psychodynamic Therapy for compulsive sexual behavior explores the core conflicts that drive dysfunctional sexual expression. Some of the common themes explored by the therapist and client include shame, avoidance, , and impaired self-esteem and efficacy (Fong, 2006).

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• Marital and/or family therapy, to resolve issues caused by the sexual compulsion and to develop and strengthen family boundaries.

• Support groups and 12 step recovery programs for people with sexual compulsions (like Sex Addicts Anonymous, Sexaholics Anonymous, Sex and Love Addicts Anonymous) are very helpful, especially in reducing shame around the behaviors.

• Medications used to treat obsessive compulsive disorder may be used to treat the compulsive nature of the disorder. These include selective serotonin reuptake inhibitors (Prozac, Paxil) or medications specifically indicated for OCD such as Anafranil.

Sexual Anorexia or Sexual Interest/Arousal/Desire Disorder

Sexual compulsivity is one end of the addictive spectrum; at the other end of sexual anorexia. The DSM identifies a sexual disorder known as Hypoactive Sexual Desire Disorder. The features are a deficiency or absence of sexual fantasies and desire for sexual activity. This is considered a disorder if it causes distress for the patient or problems in the patient's relationships. If the sexual partner of a patient with suspected hypoactive sexual desire disorder feels that this is a problem within the relationship, that concern should be sufficient for the individual to seek support.

Carnes (2009) first coined the term sexual anorexia, which is similar to the DSM disorder but broader in scope. He uses the term to describe a loss of "appetite" for romantic-sexual interaction (Carnes, 1998). Sexual anorexia is an obsessive state in which the physical, mental, and emotional task of avoiding sex dominates one’s life. Like self-starvation with food, sexual deprivation can make one feel powerful and defended against all hurts.

Like other compulsive behaviors the preoccupation with avoiding sex can become a way to cope with life’s difficulties. For the sexual anorectic, the aversion to things sexual is a way to manage anxiety and avoid more painful life issues. Food anorexia and sexual anorexia share a number of similarities including the essential loss of self, distortion of thought, and struggle for control over self and others.

The sexual anorexic typically experiences the following:

1. A dread of sexual pleasure 2. A morbid obsession and persistent fear of sexual contact 3. Obsession and hypervigilance around sexual matters 4. Avoidance of anything connected with sex 5. Preoccupation with being sexual Ce4Less.com Sexual Compulsivity p. 14

6. Distortions of body appearance 7. Extreme shame and loathing about sexual experiences, their bodies, and sexual attributes. 8. Obsessive self-doubt about sexual adequacy 9. Rigid, judgmental attitudes about sexual behavior

As with the sexual compulsive, the sexual anorexic’s aversion affects their work, hobbies, friends and families. They obsess about sex so much it interferes with normal living. They may also have periods of sexual bingeing or periods of sexual compulsivity.

Female Sexual Interest/Arousal Disorder

In the DSM IV, such disorders were termed “Hypoactive Sexual Disorders”; DSM-5 introduces a new term “Sexual Interest/Arousal Disorder” and divides the category into gender-specific disorders. The primary criteria of Female Sexual Interest/Arousal Disorders include:

1. Absent/reduced interest in sexual activity 2. Absent/reduced sexual/erotic thoughts or fantasies 3. No/reduced initiation of sexual activity, and typically unreceptive to a partner’s attempts to initiate 4. Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75%-100%) sexual encounters. 5. Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual) 6. Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (approximately 75%-100%) sexual encounters (in identified situational contexts or, if generalized, all contexts).

These symptoms must cause clinically significant distress.

The DSM-5 clarifies that a “desire discrepancy,” in which a women has a lower sexual desire for sexual activity than her partner is not sufficient to make this diagnosis. Female Sexual Interest/Arousal Disorder is frequently associated with problems experiencing orgasm and/or pain experienced during sexual activity. Substance/ use may also be factors to look at (such as antidepressant medications) as are inadequate or absent sexual stimuli. The DSM-5 also considers that other factors may explain difficulties with sexual arousal/excitement. These factors include physical problems (e.g., hormonal imbalances, alcohol or , depression, certain medications that can reduce libido including antidepressant medications) and psychological causes (e.g., stress and anxiety, work pressures/home- life balance, guilt, relationship problems, past sexual trauma).

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While the DSM-5 does not cite prevalence statistics for Female Sexual Interest/Desire Disorder, Kingsberg and Rezaee (2013) conducted a literature review of the epidemiology, diagnosis, and treatment of low sexual desire/hypoactive sexual desire disorder. These rearchers found that low sexual desire is high, reaching 43%, although patterns meeting criteria for clinically significant distress comes close to 10%. The authors conclude that subclinical problems with sexual desire are the most prevalent sexual problem in women, making it important to determine more about treatment options.

Case Vignette

Anne, a 32-year-old married, mother of two, entered treatment due to what appeared to be a generalized . Within the course of therapy she revealed that this anxiety was actually due to constant fears of her husband’s (and other men’s) potential sexual advances. She reports anxiety in thinking about the weekend approaching, as this is the time that her husband may be most likely to initiate sexual activity. She states that she has “never” had an orgasm or initiated sexual contact with her husband. In exploring the precipitants of this condition, Anne describes a childhood history of growing up in an extremely religious conservative family in which signs of sexuality in women were severely punished.

Case Vignette

Dorthea, a morbidly obese 60-year-old woman is being treated for binge eating disorder. While she appears similar to many with this concern, her history and success in resolving the eating issue is complicated by the function that binge eating serves: her large body is a shield against potential sexual interest from others. Dorthea describes extreme fears of intimacy, especially sexual intimacy, although concurrently has obsessive thoughts of appearing overly sexual with many of the men she works with. She is unpopular with female coworkers due to often “policing” their dress and behaviors as “flirtatious” and “inappropriate.” When faced with the potential of genuine interest in dating from a male coworker, Dorthea becomes overwhelmed, and is uncertain how to proceed as she likes him as a person but cannot fathom why he would be interested.

Male Hypoactive Sexual Disorder

DSM-5 also contains a diagnosis reserved for men, which is called Male Hypoactive Sexual Disorder. As with Female Sexual Interest/Arousal Disorder, this disorder describes an abnormally low level of desire for sexual activities in a man. To meet for this diagnosis, the male must show, “persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity” to a degree that causes impairments in the man’s life or relationships. The diagnosing clinician

Ce4Less.com Sexual Compulsivity p. 16 should take into account various factors that could affect sexual functioning, such as age (e.g., sexual dysfunction associated with diseases of aging) and the context of the person’s life (partnered versus single, marital or relationship dysfunction, medical causes such as the presence of diabetes, kidney disease or other chronic issues, etc). For some men, there may also be performance anxieties that result in restriction of sexual interest.

Case Vignette

Carolyn is a 45-year-old married woman presenting for therapy due to relationship issues and low self-esteem. She reports that the difficulties are relatively recent, and are connected to her husband Bruce’s seeming sexual indifference. While they used to have an active sex life, recently this has stopped, and he redirects her advances or attempts to initiate. While she says that she loves Bruce, she is hurt by his lack of interest in her and his disinterest in going to a doctor, wonders if she is unattractive. She states that if things do not improve she may consider ending the marriage.

Summary

This training material has looked at the etiology and treatment of sexual compulsive and restrictive behaviors. While study of these complex behaviors continue, some important points are listed below:

• Healthy sexuality involves nurturing, sensual and consensual behavior

• Sexually compulsive behaviors should be assessed within the framework of age, life circumstances and presence of other diagnoses (physical and psychological).

• They are diagnosed only when they cause significant distress or impairment

• There is no one etiological factor to sexual compulsivity or sexual anorexia, but trauma may play a role

• Treatment may involve counseling, psychoeducation, group support, medication of a combination of the above

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