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

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

Hypothesis 4 (in general, out of control sexual behavior is more likely in men with a combination of high SES and low SIS2) was partially supported. Overall, our sex addicts scored higher on SES than our controls, but they did not differ on SIS2. There was an interesting exception to this general pattern: The sex addicts who did not use masturbation as their principal form of sexual acting out--a small group of 9 men--fit our hypothetical profile in having significantly lower SIS2 than both the compulsive masturbators and the controls, as well as having relatively high SES.

We thus found little support for the idea that low inhibition as measured by SIS2 is a prerequisite for excitation transfer and the conditioning of sexual arousal in states of negative mood. There are at least two interpretations that might protect our hypothesis from refutation, apart from the inadequate power of this small sample. First, low inhibition may only be relevant in some cases, with other mechanisms playing a crucial role in the remainder. Second, the questions making up our SIS2 scale may not be addressing the most appropriate situations.

Apart from our preliminary hypotheses, there were other findings in this study worthy of comment.

Dissociation. Fourteen of the 31 sex addicts (45%) described a state of mind during their acting out which could be regarded as a form of dissociation from reality. We had not anticipated this pattern and, therefore, did not include any appropriate trait measure of dissociative tendency. We also found no obvious association between this dissociative pattern and other aspects of the acting out (e.g., mood regulation, compulsive masturbation), nor any significant difference between the dissociators and the other participants on our various trait measures. It is possible that a dissociative tendency has an enabling effect on the establishment of out of control patterns of sexual behavior, reducing the self-regulatory component that would be expected in most people. We should also consider the possibility that this self-description may be reinforced through the culture of sex addicts groups (e.g., SAA), providing a form of excuse, if not justification, for their inappropriate behavior. However, 6 of the 14 dissociators had little or no experience of such groups. Future research should more systematically investigate this tendency (e.g., using the Dissociative Experience Scale or DES; Carlson & Putnam, 2000).

Obsessive-compulsive disorder? The concept of compulsivity warrants consideration. A few studies have looked for evidence of obsessive-compulsive disorder (OCD) among sex addicts, usually finding a small minority in this category (e.g., Black et al., 1997, 15%; Shapira, Goldsmith, Keck, Khosia, & McElroy, 2000, 15%). The compulsivity approach to conceptualizing out of control sexual behavior is usually criticized because it conflicts with the DSM-IV, which excludes such behaviors from the obsessive-compulsive category on the grounds that "the person usually derives pleasure from the activity and may wish to resist it only because of its deleterious consequences" (American Psychiatric Association, 2000, p. 422). Compulsive thoughts of the OCD type often do have sexual content, but they are typically accompanied by negative mood and no sexual arousal. We would anticipate that most people with obsessive-compulsive personalities and a propensity for mood disorders would experience a decline in sexual arousability during negative mood states, as is the case for most people. Warwick and Salkovskis (1990) described two men whose obsessive-compulsive symptoms included intrusive sexual thoughts accompanied by penile erection. The awareness of the erection intensified the anxiety and, hence, reinforced the process. Is it possible that occasionally there is a combination of obsessive-compulsive tendencies and a low propensity for inhibition and/or high propensity for excitation of sexual response, with an atypical, sexualized type of compulsive behavioral pattern resulting? If so, one would expect to find evidence of other obsessive-compulsive phenomena in such individuals. In this study, we found two men with such personalities combined with what could be described as compulsive and sexually arousing behavior patterns. Both had high SES scores (69 and 63), but one SIS2 score was elevated (35) and the other normal (28). This pattern is clearly not relevant to the majority of individuals with out of control sexual behavior, but may be relevant to a minority. Future research should aim to assess this pattern more systematically, both in terms of the specific acting out sequence and in other aspects of obsessive-compulsive personality.