Sexual addiction

**Sexual addiction**, also known as **sex addiction**, is a state characterized by compulsive participation or engagement in sexual activity, particularly sexual intercourse, despite negative consequences.

Proponents of a diagnostic model for sexual addiction consider it to be one of several sex-related disorders within hypersexual disorder. The term *sexual dependence* is also used to refer to people who report being unable to control their sexual urges, behaviors, or thoughts. Related or synonymous models of pathological sexual behavior include hypersexuality (nymphomania and satyriasis), erotomania, Don Juanism (or Don Juanitaism), and paraphilia-related disorders.

The concept of sexual addiction is contentious. There is considerable debate among psychiatrists, psychologists, sexologists, and other specialists whether compulsive sexual behavior constitutes an addiction, and therefore its classification and possible diagnosis. Animal research has established that compulsive sexual behavior arises from the same transcriptional and epigenetic mechanisms that mediate drug addiction in laboratory animals; however, as of 2018,[update] sexual addiction is not a clinical diagnosis in either the DSM or ICD medical classifications of diseases and medical disorders. Some argue that applying such concepts to normal behaviors such as sex can be problematic, and suggest that applying medical models such as addiction to human sexuality can serve to pathologise normal behavior and cause harm.

The ICD-11 created a new condition classification, compulsive sexual behavior, to cover "a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour".

## Classification

* **addictive behavior** – a behavior that is both rewarding and reinforcing
* **addictive drug** – a drug that is both rewarding and reinforcing
* **dependence** – an adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g., drug intake)
* **drug sensitization** or **reverse tolerance** – the escalating effect of a drug resulting from repeated administration at a given dose
* **drug withdrawal** – symptoms that occur upon cessation of repeated drug use
* **physical dependence** – dependence that involves persistent physical–somatic withdrawal symptoms (e.g., fatigue and delirium tremens)
* **psychological dependence** – dependence that involves emotional–motivational withdrawal symptoms (e.g., dysphoria and anhedonia)
* **reinforcing stimuli** – stimuli that increase the probability of repeating behaviors paired with them
* **rewarding stimuli** – stimuli that the brain interprets as intrinsically positive and desirable or as something to approach
* **sensitization** – an amplified response to a stimulus resulting from repeated exposure to it
* **substance use disorder** – a condition in which the use of substances leads to clinically and functionally significant impairment or distress

None of the official diagnostic classification frameworks list "sexual addiction" as a distinct disorder.

### 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.

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.

### ICD

The World Health Organization produces the International Classification of Diseases (ICD), which is not limited to mental disorders. The most recent approved version of that document, ICD-10, includes "excessive sexual drive" as a diagnosis (code F52.7), subdividing it into *satyriasis* (for males) and *nymphomania* (for females). However, the ICD categorizes these diagnoses as compulsive behaviors or impulse control disorders and not addiction. The most recent (yet unapproved) version of that document, ICD-11, includes "compulsive sexual behavior disorder" as a diagnosis (code 6C72)—it does not use the addiction model.

### CCMD

The Chinese Society of Psychiatry produces the Chinese Classification of Mental Disorders (CCMD), which is currently in its third edition – the CCMD-3 does not include sexual addiction as a diagnosis.

### Other

Some mental health providers have proposed various, but similar, criteria for diagnosing sexual addiction, including Patrick Carnes, Aviel Goodman, and the late Jonathan Marsh. 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.

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.

### Borderline personality disorder

Main articles: Borderline personality disorder
The ICD, DSM and CCMD list promiscuity as a prevalent and problematic symptom for Borderline Personality Disorder. Individuals with this diagnosis sometimes engage in sexual behaviors that can appear out of control, distressing the individual or attracting negative reactions from others. There is therefore a risk that a person presenting with sex addiction, may in fact be suffering from Borderline Personality Disorder. This may lead to inappropriate or incomplete treatment.

### Medical reviews and position statements

In November 2016, the American Association of Sexuality Educators, Counselors and Therapists (AASECT), the official body for sex and relationship therapy in the United States, issued a position statement on Sex Addiction that states that AASECT, "...does not find sufficient empirical evidence to support the classification of sex addiction or porn addiction as a mental health disorder, and does not find the sexual addiction training and treatment methods and educational pedagogies to be adequately informed by accurate human sexuality knowledge. Therefore, it is the position of AASECT that linking problems related to sexual urges, thoughts or behaviors to a porn/sexual addiction process cannot be advanced by AASECT as a standard of practice for sexuality education delivery, counseling or therapy."

In 2017, three new USA sexual health organizations found no support for the idea that sex or adult films were addictive in their position statement.

In 16 November 2017 the Association for the Treatment of Sexual Abusers (ATSA) published a position against sending sex offenders to sex addiction treatment facilities. Those centers argued that "illegal" behaviors were symptoms of sex addiction, which ATSA challenged they had no scientific evidence to support.

## Possible mechanisms

Animal research involving rats that exhibit compulsive sexual behavior has identified that this behavior is mediated through the same molecular mechanisms in the brain that mediate drug addiction. 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 sexual 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.
Template:Addiction-related plasticity

## Treatment

### Counseling

As of 2017, none of the official regulatory bodies for Psycho-sexual Counseling or Sex and Relationship therapy, have accepted sex addiction as a distinct entity with associated treatment protocols. Indeed, some practitioners regard sex addiction as a potentially harmful diagnosis and draw parallels with gay conversion therapy. As a result, treatment for sex addiction is more often provided by addiction professionals in the counseling field than psychosexual specialists. These counseling professionals typically hold advanced degrees of education including Master's degrees or Doctorates in counseling or a related field like psychology. These counselors can also hold certifications like Licensed Professional Counselors (LPC-S) who are required to hold a Master's degree or higher level of education. Therapists and Psychologists usually also hold a Master's in a related field of study.

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. Their treatments have yet to be subject to peer-review, so it is unclear if they help or harm patients.

### Medications

#### Antiviral drugs

Main articles: Pre-exposure prophylaxis
The term "pre-exposure prophylaxis" (PrEP) generally refers to the use of antiviral drugs to help prevent AIDS. PrEP is an optional treatment for people who are HIV-negative, but have a substantial risk of getting an HIV infection.

In the US, most insurance plans cover these drugs.

## Epidemiology

According to a systematic review from 2014, observed prevalence rates of sexual addiction/hypersexual disorder range from 3% to 6%. Some studies suggest that sex addicts are disproportionately male, at 80%.

## 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.

## Society and culture

### Controversy

"**Nonconsensual sexual activity is sexual abuse. Treatment for sexual addiction generally will not address the factors that lead people to sexually abuse others.**"— *Association for the Treatment of Sexual Abusers*

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, some research suggests compulsive engagement in sexual behavior despite negative consequences 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. The Mayo Clinic considers sexual addiction 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. "Love addiction" falls into the same controversial area as well since it refers to a frequent pattern of intimate relationships which can be a by product of cultural norms and commonly accepted morals.

In a 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."