Sexual addiction, sexual compulsivity, sexual impulsivity, or what? Toward a theoretical model

Journal of Sex Research, August, 2004 by John Bancroft, Zoran Vukadinovic

Increasing attention is being paid to the concept of sexual behavior that is, in some way, out of control. Much of the recent literature has employed two currently fashionable concepts: compulsive sexual behavior and sexual addiction. At this time, both concepts are of uncertain scientific value. Barth and Kinder (1987) argued for the use of impulse control disorder as a description, which in contrast with the compulsivity and addiction labels is consistent with DSM criteria but which has little explanatory value beyond inferring a problem of self-control. In the past, other labels such as nymphomania, satyriasis, and hyper-sexuality have been used (Rinehart & McCabe, 1997)

A crucial issue that has received little attention is the extent to which out of control sexual behavior can be understood as a behavioral pattern at the extreme of the normal range, or rather a behavioral pattern that is qualitatively different from the norm in ways that are problematic (see Orford, 1978, for earlier discussion of this issue).

The literature on sexual compulsivity and sexual addiction has been preoccupied with issues of definition, particularly pertaining to DSM-IV, and has paid very little attention to possible causal explanations for why, in such cases, sexual behavior becomes problematic. Researchers often make statements about likely mechanisms (e.g., anxiety reduction or mood regulation), but these are more often based on clinical impression than on reported data. This discrepancy led Gold and Heffner (1998) to title their review paper "Sexual Addictions: Many Conceptions, Minimal Data."

Of the few data-based studies to date, three have examined potentially relevant comorbidity. Quadland (1985) compared 30 gay men presenting for treatment for compulsive sexual behavior with an age-matched group of 24 gay men who were presenting for treatment for nonsexual problems. While he found differences in their patterns of sexual behavior (e.g., number of sexual partners and duration of sexual relationships), he found no group differences in mood or personality disorder. Raviv (1993) found that 32 self-identified sex addicts had higher mean scores than 38 controls on Symptom Checklist-90-R (SCL-90-R) scales for anxiety, depression, obsessive-compulsiveness, and interpersonal sensitivity. In an uncontrolled study of 37 subjects with self-defined "out-of-control" sexual behavior, Black, Kehrberg, Flumerfelt, and Schlosser (1997) found a high prevalence of comorbidity with psychiatric conditions, most notably lifetime histories of substance use disorders (64%), anxiety disorders (50%), and mood disorders (39%).

Researchers are paying more attention to the fact that out of control sexual behavior can be reduced with mood elevating drugs such as the SSRIs (Fedoroff, 1993; Kafka, 2000; Stein et al., 1992). As yet, we do not know the extent to which such pharmacological benefits, when they occur, result from improvement in mood or specific inhibition of sexual response or both.

The best review of the literature in terms of theoretical models is by Goodman (1997); we consider some of his conclusions further in the discussion. However, few of these theoretical ideas have been formulated in ways suitable for testing. In this project we explored the relevance of a new theoretical model to out of control sexual behavior, testing some preliminary hypotheses with a small study of self-defined sex addicts. We followed this with a more detailed discussion of the theoretical possibilities and some further development of our own eminently testable theoretical ideas, particularly relating to the impact of negative mood.

If we assume that anxiety reduction or mood improvement is a key factor in many cases of out of control sexual behavior, we need to reconcile this with the conventional wisdom that most people experience a decline in sexual interest and/or responsiveness in negative mood states (Araujo, Mohr, & McKinlay, 2003; Beck, 1967; Cassidy, Flanagan, Spellman, & Cohen, 1957; Kennedy, Dickens, Eisfeld, & Bagby, 1999). In addition, we must ask why such behavioral patterns persist and even worsen if the mood-enhancing effects are not only transient but have such negative consequences.

Some evidence exists that the relationship between negative mood and sexuality is paradoxical in some individuals, with increased sexual interest occurring in association with negative mood (Angst, 1998; Mathew & Weinman, 1982; Nofzinger et al., 1993). We have been studying this relationship at The Kinsey Institute using a simple trait measure, the Mood and Sexuality Questionnaire (MSQ, see below), which asks respondents to rate on a bipolar scale what typically happens to (a) their sexual interest and (b) their sexual responsiveness when they are depressed or experiencing anxiety. We have reported our initial findings for 919 heterosexual men (Bancroft, Janssen, Strong, Carnes, et al., 2003a) and 662 gay men (Bancroft, Janssen, Strong, & Vukadinovic, 2003). Whereas the majority in both samples reported a decrease in sexual interest when depressed or anxious, a minority (15-25%) reported an increase, somewhat higher with anxiety than with depression. Qualitative data from these two studies indicate a more complex relationship between depression and sexuality than between anxiety and sexuality. Thus, increased sexual interest when depressed can indicate increased desire for sex or the need for personal contact or validation by another person. Conversely, those with a negative association between depression and sexual interest may experience a simple reduction in sexual interest, or a mood-related need to avoid personal contact because of low self-esteem. With anxiety, the typical patterns are either a preoccupation with the cause of the anxiety or stress, so sex goes "out of mind," or sex emerges as a means for achieving at least transient reduction of anxiety following orgasm. The idea that some individuals may be more likely to pursue sexual interaction or stimulation or to become sexually aroused when in a negative mood state is of considerable potential relevance to understanding out of control patterns of sexual behavior.