Hypersexuality and Sex Addiction: When Does Sex Become Problematic?

In this context, it’s pertinent to discuss hypersexuality, sex addiction and compulsive sexual behaviour.

The subject of sex addiction is a difficult one to understand, as contrary to psychoactive substances or games of chance, sex is an innate behaviour. The difficulty, therefore, lies in the distinction between normal sexual expression and pathological behaviour.

The concept of sex addiction came to light around the 1980s, most notably due to the work of Patrick Carnes, who described a form of behavioural dependence characterised by compulsively seeking out sexual activity despite the negative consequences they may have (Carnes, 1992).

This disorder is a result of the interaction between the difficulty to control one’s impulses, compulsive behaviour and emotional deregulation (Kraus et al., 2018 ; Brand et al., 2022). That is to say, sex is used as a way to regulate difficult emotions (Kafka, 2010).

Nevertheless, it’s important to make clear that having a high sex drive or having sex often does not mean one is ‘addicted to sex’. The frequency with which a person partakes in sex, porn consumption and the number of sexual partners a person has alone cannot diagnose the disorder. Above all, sex addiction is characterised by a loss of control, suffering and the negative consequences on one’s daily life.

The prevalence of hypersexuality affects between 2% and 8.6% of the general population (Ciocca et al., 2018 ; Dickenson et al., 2018). A sizeable study from the United States conducted upon 2300 adults showed that 8.6% of participants reported significant amounts of distress regarding not being able to control their thoughts, desires or sexual behaviours (Dickenson et al., 2018). This figure doesn’t constitute a conclusive diagnosis, but it does show us that the difficulties surrounding sexual control are far from marginal.

Clinical studies note a higher percentage of men amongst those who consult for such a motive: around 78% compared to 22% of women (Black et al., 1997). Social and cultural factors may influence this disparity. Women are often underrepresented in studies on this type of subject, due to stigma and unidentified forms of the disorder (Sahithya & Kashyap, 2022).

Such a disorder typically presents itself relatively early on in life, during adolescence or at the beginning of adulthood (Black et al., 1997 ; Reid et al., 2012). Early difficulties can sometimes remain hidden for many years before an individual decides to seek help, this is often due to feelings of shame and guilt, or the fear of being judged.

The central criteria of compulsive sexual behaviour disorders is a loss of control. It is entirely possible to have an active yet balanced sex life. On the contrary, it is also possible to have less frequent sex yet feel unable to stop oneself.

In order to diagnose compulsive sexual behaviour disorder (CSBD), there are many things to consider (OMS, 2019 ; Kraus et al., 2018);

• Repeated sexual thoughts, urges or behaviours that are difficult to control;
  
• repeated yet unsuccessful attempts to minimise such behaviour;
  
• excessive importance attributed to sex, detrimentally to other aspects of one’s life;
  
• continued behaviour despite its negative consequences on one’s life;
  
• significant suffering or altered daily functioning.
  

This change can take various forms: conflicts within a couple, social isolation, professional difficulties, financial problems, loss of interest in hobbies, feelings of shame, loss of self-esteem… That being said, it’s important to distinguish between suffering due to mismatched desire between partners, or personal and cultural norms, from a real clinical disorder. One may feel guilty of certain sexual behaviours due to their religion, values, upbringing etc., without it necessarily being linked to CSBD. Diagnosis is always reached through a global evaluation of the situation (Kraus et al., 2018).

Compulsive sexual behaviour disorder can take various forms depending on the individual. The most common manifestations of CSBD include:

• Compulsive pornography consumption;
  
• compulsive masturbation;
  
• frequently searching for new sexual partners;
  
• excessive use of dating apps;
  
• cybersex, or partaking in sexual exchanges online;
  
• risky sexual behaviour.
  

Through the development of the internet, permanent access to sexual content and sexual interactions has profoundly modified the way in which certain problematic behaviours manifest themselves. Instant accessibility, anonymity and the diversity of sexual stimuli in the digital world can accentuate some addictive mechanisms in those already vulnerable (Brand et al., 2019).

However, the majority of those who consume sexual content online do not develop compulsive behaviours. Individual factors such as emotional difficulties, psychological vulnerability, stress-management habits or a particular situation may contribute to problematic use.

Craving is one of the behaviours observed in cases of addiction. When it occurs, the person describes a craving that is difficult to ignore, sometimes experienced as an internal urge to consume (Goodman, 1997). These impulses cause relapses that sustain addiction.

Many questionnaires exist to evaluate CSBD, in particular the Hypersexual Behaviour Inventory (HBI ; Reid, Garos & Carpenter, 2011) and the Sexual Compulsivity Scale (SCS ; Kalichman & Rompa ; 1995). These tools help to evaluate the intensity of certain difficulties and their progress during the treatment period, but they don’t replace global clinical analysis.

Current research shows that there is no one thing that causes CSBD. It tends to arise through the intersection of multiple factors. One of the most well-studied factors is emotional regulation. Numerous people report using sex as a way to reduce stress, anxiety, solitude or the feeling of inner emptiness. Thus, such behaviour provides temporary relief, but it does not resolve the initial problem (Brand et al., 2022). Over time, a vicious circle can take hold: negative emotions, an intense need for sex, brief reprieve, then guilt or stress, before the cycle starts again.

This mechanism explains why the simple idea of ‘holding oneself back’ rarely functions in the long term. When a particular behaviour serves as the main means of emotional relief, its removal brings to light the underlying difficulties that have not been addressed. Thus, therapy often consists of responding to the key question: ‘What is this behaviour aiming to regulate or avoid?’.

Previous traumatic experiences or early relationship difficulties are also common amongst those concerned by CSBD, particularly experiences of neglect, emotional insecurity or abuse (Chatzittofis et al., 2016). These factors, however, do not provide us with a systematic explanation: a lot of those having lived through trauma never develop this disorder.

Compulsive sexual behaviour disorders share certain mechanisms with behavioural addiction. Brain imaging studies show, in particular, that when exposed to sexual stimuli, some people with this condition exhibit greater activation in regions involved in the processing of reward, motivation and the salience of stimuli (Voon et al., 2014).

This reactivity doesn’t necessarily mean more intense pleasure, rather higher motivational value attached to sexual stimuli via the dopaminergic pathways. Thus, daily factors (an emotion, a moment of solitude, or an advert for a porn site) can be enough to trigger a craving, sometimes unrelated to the pleasure actually experienced during the act itself. It is therefore important to make the distinction between craving, wanting and liking (Brand et al., 2022 ; Toates, 2022).

Treating compulsive sexual behaviour disorders relies mainly upon psychotherapy. Abstinence isn’t the aim, unless the patient chooses that for personal reasons. Rather, the main aim is to break away from sex that is automatic, invasive and causes suffering.

CBT is based on the idea that problematic behaviour is sustained by identifiable mechanisms: triggering situations, automatic thoughts, difficult emotions and repeated habits (Kaplan & Krueger, 2010). Therapeutic work most notably consists of:

• Identifying high-risk situations,
  
• identifying the thoughts and emotions that precede behaviour,
  
• learning to handle intense desires differently (behavioural regulation strategies),
  
• anticipating relapses.
  
  

CBT is therefore not aimed solely at eliminating the behaviour, but at changing the underlying mechanisms that sustain it (Kaplan & Krueger, 2010). For example, a person who systematically watches pornography when they experience solitude or anxiety can help the sufferer learn to identify this emotion and develop better adapted thoughts and behaviours (sport, getting out of the house etc.).

ACT is based on a different principal: constantly fighting against sexual thoughts and desires can sometimes heighten their importance. The aim, rather, is to learn to observe these thoughts without responding automatically.

The patient gradually develops a larger capacity to act in line with their personal values, instead of reacting immediately to an emotion or an impulse (Crosby & Twohig, 2016). This approach can be particularly interesting when a person feels intense shame or is constantly struggling with their own thoughts, including sexual ones.

Ambivalence is common in addiction. Some people wish to change because they suffer from the consequences of their actions, all whilst fearing the loss of a considerable source of pleasure and reassurance. Motivational interviewing helps one to explore this ambivalence in a judgement-free setting, as well as accompanying the individual in their reflections so that they can construct their own goals for change.

In this model, relapse constitutes an integral part of the therapy process and the route for surpassing addiction in steps (Miller & Rollnick, 2013). It is, in effect, common for relapses to occur, particularly during periods of stress, solitude, or emotional difficulties. These relapses should not be seen as failures, but as an occasion to better understand the vulnerability factors still at play (Briken, 2020).

To complement individual therapy sessions with health experts, some people find extra help through support groups. Group therapy sessions are accessible through the NHS and various charitable organisations. The aim is for participants to gain better control over their sexual behaviour, come out of isolation, benefit from the support of their peers experiencing similar issues and develop new strategies for coping with at risk situations. You can find more information and access to help here.

As of now, no medication has received specific authorisation to treat compulsive sexual behaviour disorder. However, some treatments such as selective serotonin reuptake inhibitors (SSRIs) can be used to reduce sexual impulses and invasive sexual thoughts in certain patients (Briken, 2020).

Naltrexone, a medication used to treat other addictions, has also shown promising results in various studies, but the data remain limited and do not constitute standardisation of treatment (Kraus et al., 2015). In all cases, any medication must be assessed and prescribed by a psychiatrist or an addiction specialist, and will complement the psychotherapeutic treatment.

The prognosis depends on numerous factors: how long one has been suffering, the presence of other psychological difficulties, how motivated one is to change, the quality of treatment and social support. As with other addictive behaviours, relapse can occur. This isn’t necessarily a failure, and can help one to identify those situations that are still difficult and the trigger mechanisms that require more work.

The best results are observed when treatment doesn’t focus solely on the sexual behaviour itself, but instead when it focuses on the person as a whole: emotions, relationships, self-esteem, eventual trauma and overall mental health. Once again, the aim isn’t to control sex in the strict sense of the term, but instead to reestablish the ability to choose.

Compulsive sexual behaviour disorder leads to a loss of control of one’s sexual behaviours, with sometimes extreme repercussions on an individual’s personal, emotional and professional life. Better understanding this disorder allows us to avoid two main pitfalls: trivialising very real suffering, or conversely, pathologising a sex life that goes beyond the average. It’s the freedom to choose, rather than the frequency of certain behaviours, which is now the best benchmark for distinguishing between an intense and fulfilling sex life and a disorder requiring treatment.