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Compulsive Sexual Behavior

This article explores two case studies of individuals with compulsive sexual behavior, examines the diagnostic criteria for addictive disorders, and provides an overview of the profile and types of compulsive sexual behavior.

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Compulsive Sexual Behavior

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  1. Compulsive Sexual Behavior Kevin E. Moore, M.D. MAJ(P), MC Residency Director NCC-DACH Family Medicine Residency

  2. Case 1 • 34 year-old female – marital discord • Hx of depression; sexually abused as child • Failing husband’s “sexual needs” • Husband: 4-6 hours daily internet pornography and online chatting • Raised in a male dominated, rigid family structure • Intervention: marriage counseling • Focused on communication • Outcome: irreconcilable, separation leading to divorce

  3. Case 2 • 42 year-old male - active duty officer • Stressful work environment • Inappropriate internet use at work • Accessing pornographic websites from work • Referred for medical evaluation • Intent/purpose? • Intervention: treatment of depression • SSRI with clinical improvement • Outcome: security clearance lost, reprimand, inability to advance career

  4. Uncommon Hypersexuality Fetishism Criminal activity Abusive Internet dependent Low job performance Unresponsive to treatment Patient choice Myths about CSB

  5. Defining Compulsive Sexual Behavior • Coleman “Recurrent and intense normophillic or paraphillic sexually arousing fantasies, urges, or behaviors that causes clinically significant distress in social, occupation, or other important areas of functioning. Not due to another medical condition, substance abuse, Axis 1 or 2 disorder, or developmental disorder.” Coleman E, Raymond N, McBean A. Assessment and treatment of compulsive sexual behavior. Minn Med. 2003;86:42-47

  6. Goodman CriteriaAddictive Disorders • Engaging in the behavior more intensely or frequently than intended • Persistent desire; unable to reduce behavior • Excessive time spent pursuing the behavior • Preoccupation with the behavior • Engaging in the behavior instead of fulfilling occupational, academic, domestic, or social obligations Goodman A. Addiction defined: diagnostic criteria for addictive disorder. Am J Prev Psychiatr Neruol.1989;2(1):253-63.

  7. Goodman CriteriaAddictive Disorders • Giving up important occupational or recreational activities • Continuing the behavior despite adverse consequences • Increased frequency/intensity for the behavior to give same effect • Restlessness or irritability if unable to engage in behavior Goodman A. Addiction defined: diagnostic criteria for addictive disorder. Am J Prev Psychiatr Neruol.1989;2(1):253-63.

  8. Keeping It Simple • Sexual behavior: • Compulsivity (loss of ability to freely choose) • Continued (despite adverse consequences) • Obsession (overrides basic needs) • Isolation (imposed by self or behavior) That results in: Impaired social relationships Inability to meet daily activities

  9. Profile of the Sexual Addict • 5-6% of the population (Coleman, 1992) • 3:1 ratio male:female (Carnes, 1998) • Family dysfunction (80% w/ addiction) • 40% chemical dependence • 36% sexual addiction • 33% eating disorder • 82% sexually abused as children (Carnes, 1991) • 11% of men reported sexual relationships with their mother • > 50% raised in rigid, emotionally disengaged family(Carnes, 1989) • Raised in home with heightened sexual atmosphere • Comorbid Axis 1 Disorders

  10. Comorbid Axis 1 Disorders Adapted from: Mick TM, Hollander E. Impulsive-Compulsive Sexual Behavior. CNS Spectrum. 2006;11(12):944-955.

  11. TypesCompulsive Sexual Behavior • Paraphillic CSB – DSM-IV-TR • “Preoccupation with socially unconventional sexual behavior” • Non-human objects, children, nonconsenting adults, suffering/humiliation • Often considered “socially deviant” • Non-Paraphillic CSB • “Preoccupation with socially conventional behavior” • Normative behaviors

  12. Pedophilia Exhibitionism Voyeurism Sadism Masochism Transvestic Fetishism Frotteurism Fetishism ParaphillicCompulsive Sexual Behavior

  13. Nonparaphillic Compulsive Sexual Behavior • Cruising and Multiple Partners • Constantly searching for a potential partner • Fixation on Unattainable Partner • Fixation despite lack of reciprocal response • Love object is idealized and fictionalized • Autoeroticism • Obsessive drive towards self-stimulation • Cessation of masturbation caused by factors other than sexual satisfaction • Use of Erotica • Hiding/hoarding/collecting sexual erotica • Excessive time/money spent seeking/buying erotica

  14. Nonparaphillic Compulsive Sexual Behavior • Use of the internet • Obsessive use of the internet to seek sexual gratification • Compulsive chatting/seeking of fantasized sexual partners • Multiple love relationships • Obsession towards the intense feeling of a new relationship • Fantasy/role playing essential; reality intrusive • Sexuality in a relationship • Demanding sexual expression through manipulation, coercion, violence • Unending needs for sex, expression of love, attention to relieve anxiety

  15. Workplace WorriesOn-Line Sexual Activity • Carnes (1991): 1000 sex addicts • “Biggest losses were recorded in workplace” • Cooper (1999): 9,265 respondents • 20% men/12% women use computers at work for sexual pursuits • Cooper (2000): 40,000 adults surveyed • 20% engaged in OSA at work • McLaughlin (2004) • Sexual content sites 4th most visited websites at work • 70% of all sexual content internet traffic occurs 9-5

  16. Workplace WorriesOn-Line Sexual Activity • Cooper (2006): 3,466 respondents • 18.5% engage in OSA at work vs. 82% at home • Mean hours: work – 3.5; home - 3.9 • Affairs: work - 15%; home - 7.4% • Themes • Opportunity • Distress Cooper AL, Safir MP, Rosnemann A. Workplace worries: a preliminary look at online sexual activities at the office – emerging issues for clinicians and employers. Cyber Psychology and Behavior. 2006;9(1):22-29.

  17. Screening/Diagnosis • Are you overly preoccupied with sex? • Do you feel you must engage in sexual activity to decrease stress, anxiety, or depression? • Do you have problems because of your sexual behavior? • Are you ever guilty or ashamed about your sexual behaviors? • Do you fantasize or engage in “unusual” sexual behaviors? • Do you constantly “scan” for potential sexual partners?

  18. Screening/Diagnosis • Do you obsess about someone not interested in you? • Have you ever thought your masturbation patterns are excessive, driven, or dangerous? • Do you constantly search out erotica for sexual stimulation? • Do you spend large amounts of time on the internet engaging in sexual pursuits? • Have you had numerous love relationships that are short-lived, intense, and unfulfilling? • Do you have a constant need for sex or expressions of love in your relationships?

  19. Diagnosis • Clinical diagnosis – no confirmatory test at present • Provider bias, provider experience • Dependent – gender, sexual orientation, or sociocultural norms • Secondary gain – underlying motivation of the patient/organization

  20. Treatment • Team-based therapy • 12-step recovery group • Counseling – caution “experience” • Medical therapy • Pastoral counseling • Treat both CSB and related comorbidities • Issue of sexual abstinence • 1-3 months – can be significant concern with spouse • Importance of spouse • Relationship counseling • Realistic expectations • S-Anon

  21. 12-Step Recovery Programs • Sexaholics Anonymous • www.sa.org • Sex and Love Addicts Anonymous • www.slaafws.org • Sex Addicts Anonymous • www.saa-recovery.org • National Council on Sexual Addiction and Compulsivity • www.sash.net

  22. Drug Therapy • SSRI – initial therapy • Multiple case reports; cohort studies • Citalopram 20-60mg vs. placebo in 28 men with CSB • Significant decrease (p<0.05) in sexual drive, masturbation, pornography use • Naltrexone – second-line therapy • Case reports; case series • Dose ranges of 50-150mg daily • Topiramate • Case reports • Dosages up to 50mg daily

  23. Conclusions • We see patients with compulsive sexual behavior • Recognizing and managing as an addictive disorder may improve outcomes • Consider CSB when evaluating job-related issues, marital discord, and social dysfunction

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