Abstract
Sexual addiction, also known as sex addiction, is a state characterized by [[compulsive]] participation or engagement in [[Human sexual activity|sexual activity]], particularly [[sexual intercourse]], despite negative consequences. Proponents of a [[diagnostic model]] for sexual addiction, as defined here, consider it to be one of several sex-related disorders within an umbrella concept known as [[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 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 amongst [[psychiatrists]], psychologists, [[sexologist]]s, and other specialists whether compulsive sexual behavior constitutes an addiction, and therefore its classification and possible diagnosis. , sexual addiction is not a clinical diagnosis in either the [[Diagnostic and Statistical Manual of Mental Disorders|DSM]] or [[International Statistical Classification of Diseases and Related Health Problems|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 [[Slut-shaming|pathologise normal behavior]] and cause harm
Neuroscientists, pharmacologists, molecular biologists, and other researchers in related fields have identified the [[transcription factor|transcriptional]] and [[epigenetic]] mechanisms of addiction [[pathophysiology]]. Diagnostic models, which use the pharmacological model of addiction (this model associates addiction with drug-related concepts, particularly [[physical dependence]], [[drug withdrawal]], and [[drug tolerance]]), do not currently include diagnostic criteria to identify sexual addictions in a clinical setting. In the brain disease model of addiction, which uses neuropsychological concepts to characterize addictions, sexual addictions are identifiable and well-characterized. In this model, [[addictive drugs]] are characterized as those which are both [[reinforcing]] and [[reward system|rewarding]]. Addictive behaviors (those which can induce a compulsive state) are similarly identified and characterized by their rewarding and reinforcing properties.
In "Sexual Addiction and Compulsivity", authors Taylor and Francis argue that: "Obsessive sexual behavior illness is defined by a continual pattern of failure to control intense, repetitive sexual impulses or urges."
Mechanisms
Current neuroscience research on compulsive sexual behavior indicates that it is well-characterized as an addiction and that it develops through the same biomolecular mechanisms that induce drug addictions. 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 vector|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 [[alcoholism|alcohol]], [[cannabinoid]]s, [[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.
Diagnosis
None of the official diagnostic classification frameworks list "sexual addiction" as a distinct disorder.
Diagnosis | 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 [[paraphilia|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.
Diagnosis | 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). However, the ICD categorises these diagnoses as compulsive behaviors or impulse control disorders and not addiction.
Diagnosis | 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.
Diagnosis | Other diagnostic criteria
Some mental health providers have proposed various, but similar, criteria for diagnosing sexual addiction, including [[Patrick Carnes]], and [[Aviel Goodman]]. 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.
Diagnosis | Borderline personality disorder
The ICD, DSM and CCMD list promiscuity as a prevalent and problematic symptom for [[Borderline personality disorder|Borderline Personality Disorder]]. Individuals with this diagnosis sometimes engage in sexual behaviors which can appear out of control causing distress to the individual or attracting negative reception 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
Diagnosis | 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 which 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 November 16, 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.
Treatment | Counselling
As of 2017, none of the official regulatory bodies for [[Sex therapy|Psychosexual Counselling]] or [[Relationship counseling|Sex and Relationship therapy]], have accepted sex addiction as a distinct entity with associated treatment protocols. Indeed, some practitioners regard sex addiction to be 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 than psychosexual specialists.
[[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 Therapist]]s (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.
Treatment | Medications | Antiviral drugs
The term "pre-exposure prophylaxis" (PrEP) is generally used to refer to the use of [[antiviral drugs]] which can help in [[prevention of HIV/AIDS]]. PrEP is an optional treatment which may be taken by people who are HIV-negative, but who have substantial risk of getting an HIV infection.
In the US, most insurance plans cover these drugs.
Treatment | Medications | Sexual-addiction medications
There exist some medications which can be useful specifically for treating sexual addiction.
Alternatively, doctors can prescribe general-purpose medications which have been found to be useful for a variety of behavioral addictions.
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 [[twelve-step program|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
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 "[[International Institute for Trauma and Addiction Professionals#Resources|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."
Society and culture | 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 (film)|Black Snake Moan]]", "[[Confessions of a Porn Addict]]", "[[Shame (2011 film)|Shame]]", "[[Thanks for Sharing]]", "[[Choke (film)|Choke]]".