Sexual addiction
Sexual addiction is a state characterized by compulsive participation or engagement in sexual activity, particularly sexual intercourse, despite negative consequences. The concept is contentious; as of 2023 sexual addiction is not a clinical diagnosis in either the DSM or ICD medical classifications of diseases and medical disorders, the latter of which instead classifying such behaviors as a part of compulsive sexual behavior disorder.
There is considerable debate among psychiatrists, psychologists, sexologists, and other specialists whether compulsive sexual behavior constitutes an addiction – in this instance a behavioral 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. 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.
Classification
None of the official diagnostic classification frameworks list "sexual addiction" as a distinct disorder.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, erotomania, Don Juanism, and paraphilia-related disorders.
The ICD-11 created a new condition classification, compulsive sexual behavior disorder, to cover "a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour". However, CSBD is not considered to be an addiction, and the WHO does not support a diagnosis of sex addiction.
DSM
The American Psychiatric Association publishes and periodically updates the Diagnostic and Statistical Manual of Mental Disorders, a widely recognized compendium of mental health diagnostics.The version published in 1987, 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, 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 "lthough 'hypersexuality' is a proposed new addition... was not at the point where we were ready to call it an addiction." According to the APA, the proposed diagnosis was not included due to a lack of research into diagnostic criteria for compulsive sexual behavior.
DSM-5-TR, published in March 2022, does not recognize a diagnosis of sexual addiction.
ICD
The World Health Organization produces the International Classification of Diseases, which is not limited to mental disorders. The most recent approved version of that document, ICD-10, includes "excessive sexual drive" as a diagnosis, subdividing it into satyriasis and nymphomania. However, the ICD categorizes these diagnoses as compulsive behaviors or impulse control disorders and not addiction. The most recent version of that document, ICD-11, includes "compulsive sexual behavior disorder" as a diagnosis – however, it does not use the addiction model.CCMD
The Chinese Society of Psychiatry produces the Chinese Classification of Mental Disorders, 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 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 used by the thousands of certified sex addiction therapists trained by the organization he founded. No diagnostic proposal for sex addiction has been adopted into any official medical diagnostic manual, however.In 2011, the American Society of Addiction Medicine, 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.
ASAM does not support the diagnosis of sexual addiction.
Bipolar disorder
Patients with bipolar disorder can display hypersexual behaviour during mania periods. However, the literature is rather outdated and it cannot be concluded that it can be deemed as a sexual addiction.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 have 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, the official body for sex and relationship therapy in the United States, issued a position statement on sex addiction declaring that their organization "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.
On 16 November 2017 the Association for the Treatment of Sexual Abusers published a position against sending sex offenders to sex addiction treatment facilities.
Neuroscientists who are sex researchers state sex is not addictive. Addiction criteria were not met for sexual behaviours: "experimental studies do not support key elements of addiction such as escalation of use, difficulty regulating urges, negative effects, reward deficiency syndrome, withdrawal syndrome with cessation, tolerance, or enhanced late positive potentials." Аs well as evidence of a key neurobiological feature of addiction is scarce in case of sex.
Yet, despite these advances, research related to sexual addiction remains in its infancy. A lack of theoretical integration, deficits in methodological rigor, a paucity of clinical samples, over reliance on convenience samples, the complete absence of epidemiological studies, widespread inconsistencies in the definitions and measurements of CSB, and a lack of treatment studies all still plague the literature related to sexual addiction. If scientists, researchers, and clinicians in this domain want to bring the field forward and provide evidence-based care to people who report out-of control sexual behaviors, all of the above are needed.
Diagnosis
ICD-11
The Compulsive Sexual Behavior Disorder is determined by following criteria:- Persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour
- The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time
- Causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning
- Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement
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. 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.
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.