Can sex ever become compulsive? Like most behaviors, sex can be taken to its obsessive and compulsive extremes. Compulsive sexual behavior (CSB) has been defined as a clinical syndrome characterized by the experience of sexual urges, sexually arousing fantasies, and sexual behaviors that are recurrent, intense, and a distressful interference in one's daily functioning. CSB has also been referred to in the literature as sexual addiction, sexual compulsivity, sexual impulsivity, or paraphilia-related disorder.

Individuals with CSB often perceive their sexual behavior to be excessive but are unable to control it; they act out impulsively and/or are plagued by intrusive, obsessive thoughts and driven behaviors. Some have more problems with impulsivity and, for others, it is more of a problem of a compulsive drive. CSB can cause emotional suffering and potentially lead to social, ethical, and legal sanctions and increased health risks, such as HIV infection. Many people suffer with these problems, and finding consensus among sexual scientists or treatment professionals about terminology, etiology, or treatment has not been resolved. This makes it more difficult for those suffering from CSB to get the help they need. For those who want to know more about this problem, it is helpful to know more about the types of CSB, the various theoretical viewpoints, and treatment approaches. Although there are many types of CSB, they can be divided into two main types: paraphilic and nonparaphilic CSB. Sexual scientists have used various terms to describe this phenomenon: hypersexuality, erotomania, nymphomania, satyriasis, and, most recently, sexual addiction and compulsive sexual behavior. The terminology has often implied different values, attitudes, and theoretical orientations.

Paraphilic CSB
Paraphilic sexual behaviors are unconventional sexual behaviors that are obsessive and compulsive. They interfere with love relationships and intimacy. Although John Money (1986) described nearly 50 paraphilias, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000) has currently classified eight paraphilias, and these are generally considered the most common: pedophilia (sexual attraction to prepubescent children), exhibitionism (sexual excitement associated with exposing one's genitals in public), voyeurism (sexual excitement by watching an unsuspecting person), sexual masochism; sexual excitement from being the recipient of the threat or administration of pain), sexual sadism (sexual excitement from threatening or administration of pain), transvestic fetishism (sexual excitement from wearing the clothing of the opposite sex), and frotteurism (sexual excitement from touching or fondling an unsuspecting person. In the DSM-IV-TR, the paraphilias are defined as "recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving 1) nonhuman objects, 2) the suffering or humiliation of oneself or one's partner, or 3) children or other nonconsenting persons. The behavior, sexual urges, or fantasies cause clinically significant distress in social, occupational, or other important areas of functioning" (p. 566). Some behaviors, such as S-M, which may involve consensual suffering or humiliation and does not impair life functioning, may not necessarily be considered a paraphilia because it does not meet all the diagnostic criteria. There is intense debate going on whether some of these "disorders" should be declassified as mental illnesses in the next revision of DSM (DSM-V, anticipated publication date May 2012; American Psychiatric Association).

Nonparaphilic CSB
Nonparaphilic CSB involves conventional and normative sexual behavior, which when taken to an extreme end of the spectrum of expression, are recurrent, intense, distressing, and interfere in daily functioning. One example is given in the DSM- IV-TR under the category of Sexual Disorders Not Otherwise Specified. The authors of the DSM-IV-TR describe an example of "distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used" (2000, p. 582). Other forms of nonparaphilic CSB include compulsive cruising and multiple partners, compulsive fixation on an unattainable partner, compulsive masturbation, compulsive use of erotica, compulsive use of the Internet for sexual purposes, compulsive love relationships, and compulsive sexuality in a relationship (Coleman, 1992). Recently compulsive use of the Internet for sexual purposes has become a growing problem.

The Danger of Overpathologizing This Disorder
The possibility of overpathologizing this disorder is the main criticism given by those who do not believe in the idea of compulsive sexual behavior as a disorder. The pathologizing of sexual behavior may be driven by antisexual attitudes and a failure to recognize the wide range of normal human sexual expression. This caution is important when assessing whether a person is engaging in compulsive sexual behavior. It is important for professionals to be comfortable with a wide range of normal sexual behavior - both in types of behaviors and frequency. Sometimes individuals, with their own restrictive values, will diagnose themselves with this disorder, creating their own distress. Therefore, it is very important to distinguish between an individual who has a values conflict with their sexual behavior and those who engage in sexual behaviors that are driven by impulsive, obsessive, and/or compulsive mechanisms.

A Conflict Over Values
There is an inherent danger in diagnosing CSB simply because someone's behavior does not fit the values of the individual, group, or society. There has been a long tradition of pathologizing behavior that is not mainstream and that someone might find distasteful. For example, masturbation, oral sex, homosexual behavior, sado-masochistic behavior, or a love affair could be viewed as compulsive behaviors because someone might disapprove of these behaviors. However, there is no scientific merit to viewing these behaviors as disordered, compulsive, or "deviant." When someone is distressed about these behaviors, they are most likely in conflict with their own or someone else's value system rather than a function of compulsive sexual behavior.

Problematic vs. Compulsive Sexual Behavior
Behaviors that are in conflict with someone's value system may be problematic but not impulsive, obsessive, or compulsive. Having sexual problems is common. Problems are often caused by a number of nonpathological factors. People may make mistakes; they may be ignorant. They may, at times, act impulsively. Their behavior may cause problems in a relationship. Some people use sex as a coping mechanism similar to the use of alcohol, drugs, or eating. This pattern of sexual behavior may become problematic. Problematic sexual behavior is often remedied, however, by time, experience, education, or brief counseling. Impulsive, obsessive, and compulsive behavior, by its nature, is much more resistant to change.

Developmental Process vs. Compulsive Sexual Behavior
Some sexual behaviors might be viewed as impulsive, obsessive, or compulsive if they are not viewed within their developmental context. Adolescents, for example, can become "obsessed" with sex for long periods of time. They can act impulsively. In adulthood, it is common for individuals to go through periods when sexual behavior may take on impulsive, obsessive, and compulsive characteristics. In early stages of romance, there is a natural developmental period in which individuals might be obsessed with their partners and compelled to seek out their company and to express affection. These are normal and healthy developmental processes of sexual development and must be distinguished from CSB.

What Causes CSB?
Disagreement exists as to whether CSB is an addiction, a psychosexual developmental disorder, an impulse control disorder, a mood disorder, or an obsessive-compulsive disorder. Patrick Carnes (1993) popularized the concept of CSB as an addiction. He believes that people become addicted to sex in the same way they become addicted to substances or other behaviors. However, many dispute the idea that you can become addicted to sex in the same way that someone becomes addicted to alcohol or sex. Despite this criticism, sexual addiction has become a popular metaphor similar to "workaholism." Twelve-step programs of spiritual recovery (similar to Alcoholics Anonymous) and 30-day inpatient treatment centers have become popular solutions to those who view CSB as an addiction. Although there is general recognition that the "abstinence model" is useful for alcoholics, many believe this approach cannot be applied to sexuality because sexual expression is a basic appetitive drive. Again, critics view the addiction model as an oversimplification of CSB and potentially dangerous when proper medical and psychological treatment is called for. Robert Stoller (1975) was a strong advocate of psychodynamic mechanisms involved in CSB. His theories have been helpful to some in resolving inner conflicts fueling obsessive and compulsive drives. Others have suggested that CSB is basically an impulse control disorder (Barth & Kinder, 1987). Others have suggested complex mechanisms of anxiety, mood, and personality disorders with some individuals possessing more impulse control problem and others more of an obsessive- compulsive type problem (Coleman, Raymond & McBean, 2003; Raymond, Coleman, Benefield, & Miner, 2008). In some cases, CSB can be a manifestation of a bipolar mood disorder. In other cases, CSB can be caused by a neurological disorder, such as epilepsy or Alzheimer's. John Money (1986) assisted in the understanding of the complex interplay of biological, psychological, and environmental factors in CSB. With new understandings of obsessive-compulsive disorder, some have suggested that CSB is caused by irregular chemical functions in the brain and cause the repetitious nature of the self-defeating behavior (Coleman, 1991). In this model, CSB is driven by anxiety, in which certain sexual behaviors provide temporary relief of the anxiety but is followed by further anxiety and distress - creating a self-perpetuating cycle. Others feel that there is a dysregulation of neurotransmitters related to areas of the brain that are involved in mood states, impulse control, and pleasure (see Coleman, 1991). Because CSB is such a complex disorder, involving biological, psychological, and social factors, a careful assessment by a well-trained professional is necessary. Because of disagreements in theoretical approaches, the layperson should ask the professional about his/her own theories on CSB and consider other professional opinions.

Treatment of CSB
Although disagreement exists about the nature of CSB, treatment professionals have generally found a combination of psychotherapy and prescription drugs to be effective in treating CSB. Whereas medications that suppress the production of male hormones (anti-androgens) have been successfully used to treat a variety of paraphilic disorders, antidepressants that selectively act on serotonin levels in the brain have been effective in reducing sexual impulses, obsessions/ compulsions, and their associated levels of anxiety and depression. Other medications, such as mood stabilizers and other types of antidepressants, have been found to be useful alone or in combination with other medications. Naltrexone, an opioid antagonist, has also shown some promising effects (Raymond, Grant, Kim, & Coleman, 2002). These newer medications interrupt the obsessive-compulsive cycle of CSB and improve impulse control and help patients use therapy more effectively. The advantages of these antidepressants over older antidepressants or anti-androgens are their broad efficacy and relatively few known side effects (Kafka, 2000). However, in more severe cases of CSB, anti-androgens can be quite helpful (Bradford, 2000).

How Does One Know if They Need Help Regarding CSB?
If one can answer yes to some any of the following questions, it would be advisable to consult a professional who has the particular expertise in assessing and treating CSB.

1. Do you, or others who know you, find that you are overly preoccupied or obsessed with sexual activity?
2. Do you ever find yourself compelled to engage in sexual activity in response to stress, anxiety, or depression?
3. Have serious problems developed as a result of your sexual behavior (e.g., loss of a job or relationship, sexually transmitted diseases, injuries or illnesses, or sexual offenses)?
4. Do you feel guilty and shameful about some of your sexual behaviors?
5. Do you fantasize or engage in any unusual or what some would consider "deviant" sexual behavior?
6. Do you find yourself constantly searching or "scanning" the environment for a potential sexual partner?
7. Do you ever find yourself sexually obsessed with someone who is not interested in you or does not even know you?
8. Do you think your pattern of masturbation is excessive, driven, or dangerous?
9. Do you find yourself compulsively searching for erotica for sexual stimulation?
10. Do you find yourself spending excessive amounts of time on the Internet engaging in various sexual pursuits?
11. Have you had numerous love relationships that are short- lived, intense, and unfulfilling?
12. Do you feel a constant need for sex or expressions of love in your sexual relationship?

How Does Someone Find a Professional With Expertise in CSB Assessment and Treatment?
There are several ways to find qualified professionals in your area:

• Call your state licensing boards for psychologists, psychiatrists, social workers, or marriage and family therapists who have a specialized competence in treating compulsive sexual behavior.
• Inquire through college or university psychology, psychiatric or counseling departments.
• Contact your primary care physician or your health insurance.
• Ask professionals for the credentials in treating compulsive sexual behavior (e.g., AASECT certified sex therapist).

Summary
Compulsive sexual behavior is a serious psychosexual disorder that can be identified and treated successfully. CSB does not always involve strange and unusual sexual practices. Many conventional behaviors can become the focus of an individual's obsessions and compulsions. The exact mechanism of CSB is still under debate and various treatment approaches have been developed. Research is needed to further clarify the nature of the disorder, the mechanisms involved, and to test the most effective treatment approach. In the meantime, individuals who believe they may be suffering from CSB should not hesitate to seek professional guidance to properly assess their problem and to find help through counseling and treatment.

References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text-rev.). Washington, DC: Author.

Barth, R. J., & Kinder, B. N. (1987). The mislabeling of sexual impulsivity. Journal of Sex and Marital Therapy, 13, 15-23.

Bradford, J. M. W. (2000). The treatment of sexual deviation using a pharmacological approach. The Journal of Sex Research, 37, 248-257.

Carnes, P. (1983). Out of the shadows: Understanding sexual addiction. Minneapolis, MN: CompCare.

Coleman, E. (1991). Compulsive sexual behavior: New concepts and treatments. Journal of Psychology and Human Sexuality, 4, 37-52.

Coleman, E. (1992). Is your patient suffering from compulsive sexual behavior? Psychiatric Annals, 22, 320-325.

Coleman, E., Raymond, N., & McBean, A. (2003). Assessment and treatment of compulsive sexual behavior. Minnesota Medicine, 86, 42-47.

Kafka, M. (2000). Psychopharmacologic treatments for nonparaphilic compulsive sexual behaviors. CNS Spectrums, 5, 49-59.

Money, J. (1986). Lovemaps: Clinical concepts of sexual/erotic health and pathology, paraphilia, and gender transposition of childhood, adolescence, and maturity. New York: Irvington.

Raymond, N. C., Coleman, E., Benefield, C., & Miner, M. H. (2008). Psychiatric comorbidity and compulsive/impulsive traits in compulsive sexual behavior. Comprehensive Psychiatry, 44, 370-380.

Raymond, N. C., Grant, J. E., Kim, S. W., & Coleman, E. (2002). Treatment of compulsive sexual behaviour with naltrexone and serotonin reuptake inhibitors: Two case studies, International Clinical Psychopharmacology, 17, 201-205.

Stoller, R. J. (1975). Perversion. The erotic form of hatred. New York: Dell.

Acknowledgements
Written by Eli Coleman, PhD, Academic Chair in Sexual Health, Professor and Director of the Program in Human Sexuality, Department of Family Practice and Community Health, University of Minnesota Medical School, University of Minnesota, Minneapolis, MN 55454; President of the Society for the Scientific Study of Sexuality, 1989-1990.

Series Editor: Sandra L. Davis; Associate Editors: Patricia Barthalow Koch, PhD, and Clive M. Davis, PhD. The editors would like to thank several anonymous reviewers who have also contributed their time and talents to this series.

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