Sexual addiction

Mechanisms

Current research on sexual addiction within the context of the reward-reinforcement model indicates that it is well-characterized as an addiction and that it develops through the same biomolecular mechanisms that induce drug addictions. Specifically, sexual activity is an intrinsic reward that has been shown to act as a positive reinforcer, strongly activate the reward system, and induce the accumulation of ΔFosB in part of the striatum (specifically, the nucleus accumbens). Chronic and excessive activation of certain pathways within the reward system and the accumulation of ΔFosB in a specific group of neurons within the nucleus accumbens has been directly implicated in the development of the compulsive behavior that characterizes addiction.

In humans, a dopamine dysregulation syndrome, characterized by drug-induced compulsive engagement in sexual activity or gambling, has also been observed in some individuals taking dopaminergic medications. Current experimental models of addiction to natural rewards and drug reward demonstrate common alterations in gene expression in the mesocorticolimbic projection. ΔFosB is the most significant gene transcription factor involved in addiction, since its viral or genetic overexpression in the nucleus accumbens is necessary and sufficient for most of the neural adaptations and plasticity that occur; it has been implicated in addictions to alcohol, cannabinoids, cocaine, nicotine, opioids, phenylcyclidine, and substituted amphetamines. ΔJunD is the transcription factor which directly opposes ΔFosB. Increases in nucleus accumbens ΔJunD expression can reduce or, with a large increase, even block most of the neural alterations seen in chronic drug abuse (i.e., the alterations mediated by ΔFosB).

ΔFosB also plays an important role in regulating behavioral responses to natural rewards, such as palatable food, sex, and exercise. Natural rewards, like drugs of abuse, induce ΔFosB in the nucleus accumbens, and chronic acquisition of these rewards can result in a similar pathological addictive state. Thus, ΔFosB is also the key transcription factor involved in addictions to natural rewards as well, and sex addictions in particular, since ΔFosB in the nucleus accumbens is critical for the reinforcing effects of sexual reward. Research on the interaction between natural and drug rewards suggests that psychostimulants and sexual reward possess cross-sensitization effects and act on common biomolecular mechanisms of addiction-related neuroplasticity which are mediated through ΔFosB.

DSM

The American Psychiatric Association (APA) publishes and periodically updates the Diagnostic and Statistical Manual of Mental Disorders (DSM), a widely recognized compendium of mental health diagnostics.

The version published in 1987 (DSM-III-R), referred to "distress about a pattern of repeated sexual conquests or other forms of nonparaphilic sexual addiction, involving a succession of people who exist only as things to be used." The reference to sexual addiction was subsequently removed. The DSM-IV-TR, published in 2000 (DSM-IV-TR), did not include sexual addiction as a mental disorder. The DSM-IV-TR included a miscellaneous diagnosis called sexual disorders not otherwise specified, stating: "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." (Other examples include: compulsive fixation on an unattainable partner, compulsive masturbation, compulsive love relationships, and compulsive sexuality in a relationship.)

Some authors suggested that sexual addiction should be re-introduced into the DSM system; however, sexual addiction was rejected for inclusion in the DSM-5, which was published in 2013. Darrel Regier, vice-chair of the DSM-5 task force, said that "[A]lthough 'hypersexuality' is a proposed new addition...[the phenomenon] was not at the point where we were ready to call it an addiction." The proposed diagnosis does not make the cut as an official diagnosis due to a lack of research into diagnostic criteria for compulsive sexual behavior, according to the APA.

Borderline personality disorder

The APA uses the Diagnostic and Statistical Manual of Mental Disorders to define and classify mental illnesses and in the DSM-IV version of the document, it lists borderline personality disorder (BPD) as an Axis II – Cluster B personality disorder with the code 301.83. The DSM-5 dropped the multiaxial system, but BPD still retains the same numerical code of 301.83. The World Health Organization (WHO) produces the International Classification of Diseases (ICD) and lists BPD under the name "Emotionally unstable personality disorder". The latest version of the document (ICD-10) lists the disorder in Chapter X which is reserved for "Disorders of adult personality and behaviour" and has the code F60.3. The Chinese Society of Psychiatry uses the Chinese Classification of Mental Disorders (CCMD), which is in its third edition (CCMD-3) and has a diagnosis of "Nonorganic sexual dysfunction" (numerical code 52.9), of which sexual promiscuity may be a symptom. Personality disorders, Habit and impulse disorders, Psychosexual disorders in the CCMD-3 fall in Chapter 6 and under code 6.60 are listed the personality disorders. The CCMD-3 lists "impulsive personality disorder" (numerical code 60.4), which is equivalent to what the DSM refers to as "borderline personality disorder" and what the ICD-10 refers to as "emotionally unstable personality disorder". All three classification manuals and documents list sexual promiscuity as a prevalent and problematic symptom for patients with this particular pathology. Hypersexuality along with high-risk sexual behaviour, seductive behaviour, and promiscuity are an often due to the marked impulsivity common to this group of patients. Individuals with borderline personality disorder (emotionally unstable personality disorder or impulsive personality disorder) not only are prone to promiscuity, but in many cases, co-morbid paraphilias and fetishistic behaviour are commonly associated with their sexual behaviours. Common paraphilic compulsions among individuals with this diagnosis include urolagnia ("golden showers"), sadomasochism, voyeurism, autassassinophilia, partialism, and in some cases paraphilic drives may be more extreme and dangerous – such as erotophonophilia, necrophilia, biastophilia, pedophilia, and anthropophagy. Both males and females with this personality disorder often have a strong desire and compulsion to get involved in illicit sex, affairs, and relationships with married or otherwise pre-attached individuals. Consequently, individuals with borderline personality disorder often experience love and sexuality in perverse and violent qualities which they cannot integrate with the tender, intimate side of relationships.

ICD

The World Health Organization produces the International Classification of Diseases (ICD), which is not limited to mental disorders. The most recent version of that document, ICD-10, includes "excessive sexual drive" as a diagnosis (code F52.8), subdividing it into satyriasis (for males) and nymphomania (for females).

CCMD

The Chinese Society of Psychiatry produces the Chinese Classification of Mental Disorders (CCMD), which is currently in its third edition – the CCMD-3 and Chapter 5 of the document lists "Physiological disorders related to psychological factors" and under code 52 are disorders that are "Nonorganic sexual dysfuction," and within that category are listed a number of disorders, one of which is "other or unspecified sexual dysfunction" (numerical code 52.9). This is roughly equivalent to the ICD-10 diagnosis of "other sexual dysfunction not due to a substance or known physiological condition" (specifier excessive sexual drive) (F52.8) and "unspecified sexual dysfunction not due to a substance or known physiological condition" (F52.9).

Diagnostic criteria

Several mental health providers have proposed various, but similar, criteria for diagnosing sexual addiction, including Patrick Carnes, and Aviel Goodman. Dr. Carnes authored the first clinical book about sex addiction in 1983 based on his own empirical research. His diagnostic model is still largely utilized by the thousands of certified sex addiction therapists (CSATs) trained by the organization he founded. No diagnostic proposal for sex addiction has been adopted into any official government diagnostic manual, however.

During the update of the Diagnostic and Statistical Manual to version 5 (DSM-5), the APA rejected two independent proposals for inclusion.

The International Classification of Diseases (ICD-10) of the WHO, however, does include an entry for "excessive sexual drive." and another entry – applying to children and adolescents – "excessive masturbation"

In 2011, the American Society of Addiction Medicine (ASAM), the largest medical consensus of physicians dedicated to treating and preventing addiction, redefined addiction as a chronic brain disorder which for the first time broadened the definition of addiction from substances to include addictive behaviors and reward-seeking, such as gambling and sex.

Behavioral therapy

Cognitive behavioral therapy is a common form of behavioral treatment for addictions and maladaptive behaviors in general. Dialectical behavior therapy has been shown to improve treatment outcomes as well. Certified Sex Addiction Therapists (CSAT) – a group of sexual addiction therapists certified by the International Institute for Trauma and Addiction Professionals – offer specialized behavioral therapy designed specifically for sexual addiction.

Support groups

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Online support groups

NoFap is an online community founded in 2011. It serves as a support group for those who wish to avoid the use of pornography, masturbation, and/or sexual intercourse.

In-person support groups

In-person support groups are available in most of the developed world. These groups include:

In places where none of the above are available, open meetings of Alcoholics Anonymous or Narcotics Anonymous may be a second-best option.

Support groups may be useful for uninsured or under-insured individuals. (See also: Alcoholics Anonymous § Health-care costs.) They may also be useful as an adjunct to professional treatment. In addition, they may be useful in places where professional practices are full (i.e. not accepting new patients), scarce, or nonexistent, or where these practices have waiting lists. Finally, they may be useful for patients who are reluctant to spend money on professional treatment.

Epidemiology

According to a systematic review from 2014, prevalence rates of sexual addiction and related sexual disorders ranges from 3% to 6%.

History

Sex addiction as a term first emerged in the mid-1970s when various members of Alcoholics Anonymous sought to apply the principles of 12-steps toward sexual recovery from serial infidelity and other unmanageable compulsive sex behaviors that were similar to the powerlessness and un-manageability they experienced with alcoholism. Multiple 12-step style self-help groups now exist for people who identify as sex addicts, including Sex Addicts Anonymous, Sexaholics Anonymous, Sex and Love Addicts Anonymous, and Sexual Compulsives Anonymous.

Controversy

The controversy surrounding sexual addiction is centered around its identification, through a diagnostic model, in a clinical setting. As noted in current medical literature reviews, compulsive sexual behavior has been observed in humans; drug-induced compulsive sexual behavior has also been noted clinically in some individuals taking dopaminergic drugs. Moreover, current medical research involving neuropsychological models has identified sexual addictions (i.e., the compulsive engagement in sexual behavior despite negative consequences) as a true form of addiction (i.e., it possesses all the necessary characteristics to classify it as one) in animal models. Since current diagnostic models use drug-related concepts as diagnostic criteria for addictions, these are ill-suited for modelling compulsive behaviors in a clinical setting. Consequently, diagnostic classification systems, such as the DSM, do not include sexual addiction as a diagnosis because there is currently "insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions needed to identify these behaviors as mental disorders". A 2014 systematic review on sexual addiction indicated that the "lack of empirical evidence on sexual addiction is the result of the disease's complete absence from versions of the Diagnostic and Statistical Manual of Mental Disorders."

There have been debates regarding the definition and existence of sexual addictions for decades, as the issue was covered in a 1994 journal article. According to a 2014 systematic review, sexual addiction (including excessive masturbation and pornography addiction) is a diagnosable behavioral addiction with estimable prevalence rates. The Mayo Clinic considers sexual addiction to be a form of obsessive compulsive disorder and refer to it as sexual compulsivity (note that by definition, an addiction is a compulsion toward rewarding stimuli). A paper dating back to 1988 and a journal comment letter published in 2006 asserted that sex addiction is itself a myth, a by-product of cultural and other influences. The 1988 paper argued that the condition is instead a way of projecting social stigma onto patients.

In a non-academic opinion report from 2003, Marty Klein, stated that "the concept of sex addiction provides an excellent example of a model that is both sex-negative and politically disastrous." Klein singled out a number of features that he considered crucial limitations of the sex addiction model and stated that the diagnostic criteria for sexual addiction are easy to find on the internet. Drawing on the Sexual Addiction Screening Test, he stated that "the sexual addiction diagnostic criteria make problems of nonproblematic experiences, and as a result pathologize a majority of people."

Popular culture

Sexual addiction has been the main theme in a variety of films including Diary of a Sex Addict, I Am a Sex Addict, Black Snake Moan, Confessions of a Porn Addict, Shame, Thanks for Sharing, Choke, and others.