Compulsive Sex & HIV

Research Update

A compulsion is an irresistible and irrational repeated impulse to perform some act (2). Compulsive sex interferes with daily life activities and can threaten lives.

Compulsive sexual patterns are often characterized by: 1) inability to feel a choice about engaging in sex or a specific sexual activity; 2) inability to manage sexual expression in the context of one's life; and 3) inability to avoid self-destructive feelings that arise based on sexual thoughts or behaviors.

Case studies have found that sexual compulsion affects people of various socioeconomic and cultural backgrounds,without regard to gender or sexual orientation. People who are sexually compulsive do not fit a stereotyped image, nor can a person's behavior be defined as compulsive based on the number of sex partners or the frequency of sex. For instance, a person may have sex daily with a different partner each time and not necessarily have a pattern of sexually compulsive behavior, while another person may have sex relatively infrequently, yet have a compulsive behavior pattern. A person may be compulsive about behaviors such as masturbation and sexual fantasy that are considered normal and healthy, as well as harmful behaviors such as unsafe sex.

Studies have found that sexually compulsive people do not necessarily have higher sex drives or cravings for sex than those who are not compulsive (3). Rather, the sexually compulsive person focuses on sexual behavior to such an extent that it becomes a priority, and the sexual high, or relief that occurs as a result of sexual expression, can become this person's primary reason for living. Sexually compulsive people may engage in compulsive behaviors without understanding, or giving thought to, this process.

Studies have reported that people who engage in compulsive sex report feeling out of control not only in their sexual expression but also in their daily lives. Their compulsion perpetuates feelings of shame, despair, and guilt, all of which relate to their core feeling of low self-worth. Many feelings experienced by those addicted to alcohol or other drugs. Some mental health providers and others use the terms "sexual addiction" and "sex addict" to describe someone who is sexually compulsive.

Multiple Addictions and Compulsive Sex

abuse of alcohol or other drugs        39%
workaholism                            38%
eating disorder                        31%
compulsive gambling or spending        18%
no other addictions                    16%

Prevalence

Compulsive sex is a relatively new area of study, and it is difficult to accurately assess its prevalence. Additionally, studies of the topic require subjects to disclose details about their sexual lives -- which is generally considered a private matter. Sexually compulsive people typically feel shame discussing this area of their lives.

Societal standards related to what is considered "appropriate" sexual behavior have historically complicated researchers' efforts to classify behaviors as compulsive. Compulsive sexual behavior has been considered socially and morally offensive, characterized by judgment-charged labels such as "deviant." This has begun to change only as an increasing number of people have begun to understand sexual compulsion in terms of psychological, and perhaps physiological, phenomena.

The emergence of HIV infection as a life-threatening, sexually transmitted disease in the 1980s has brought urgency to understanding sexual compulsion. Much of the research has focused on gay and bisexual men because this population has been so thoroughly affected by the HIV epidemic, and has perhaps been more willing to be studied.

Multiple Addictions

The study of sexually compulsive behavior has revealed correlations to other compulsive and addictive behaviors. In a study of 75 self-identified "sex addicts" in recovery, only 17% reported no other addictions. Thirty-nine percent of those studied were recovering from chemical dependency, 38% identified as workaholics, 32% had an eating disorder and 18% identified as compulsive gamblers or compulsive spenders (4).

Sexually compulsive behavior becomes more dangerous when it is combined with other addictive patterns, especially substance abuse. A study of gay and bisexual men found a direct relationship between substance abuse and the frequency of unsafe sex (5). Of particular interest in this study was the relationship between perceived risk, actual risk and sexual behavior. Men who consistently engaged in safer sex perceived themselves to be at higher risk than they actually were, while men engaging in unsafe sex perceived themselves to be at less risk than they actually were. Those who were at high-risk often rationalized their behavior, using denial, which is characteristic of sexually compulsive people (5). Men who engaged in high-risk behavior reported feeling less in control of their lives.

Development of an addiction is determined by a combination of biological, social and psychological elements. One leading researcher has suggested that the addictive cycle is a self- perpetuating one that begins with painful and obsessive thoughts (1). Obsessive thoughts are defined as haunting or troubling ideas, desires or emotions that preoccupy a person. In an attempt to relieve the pain of these thoughts and the anxiety and negative self-images they can produce, a person finds and engages in behaviors that become routine and habitual. Compulsive sex temporarily suppresses pain; a person may experience a "sexual high" and, for a moment, a positive self-image. However, a person than feels regret, remorse, and a loss of control over life, thus reinforcing a negative self-image and restarting the cycle.

For many gay and bisexual men, issues related to compulsive and addictive behaviors are complicated by society's negative attitudes toward homosexuality. They psychological issues involved with being a member of a group that is generally oppressed by society have predisposed many gay and bisexual men to feelings of worthlessness (6). These feelings may lead to substance abuse, and, because of the stigma attached to sexual expression between men, a pattern of compulsive sex may develop. Substance abuse and compulsive sex further erode a sense of self-worth and may leave a person with little power or reason to avoid unsafe sex.

Origins of Compulsive Behavior

The origins of compulsive sex patterns have been closely linked to childhood trauma characterized by abuse, environments of repressed sexuality, and dysfunctional family attitudes about sex and intimacy (7). A child who has been sexually abused often learns at an early age that sex and affection are the same and, in adulthood, may seek to satisfy previously unmet or ignored emotional needs through sex.

Some research proposes that negative self-images intertwine with emotional needs and lead some people to compulsively engage in sex. This research suggests that, despite an attempt to eliminate negative self-images through sex, these images may instead persist and intensify, and accelerate the progression of the addiction (8).

Reports have indicated that people who were sexually abused as children or who were raised in sexually restrictive environments develop negative self-images related to sexuality. One survey of men, both heterosexual and homosexual, found one of every six had been sexually abused before age 18 (9).

Female incest survivors are less likely than male survivors to recreate abusive feelings through compulsive sex and often resort to compulsive eating behaviors instead. However, sexual compulsion can and does occur in women (10).

For male and female survivors of abuse, a major issue that emerges is the dynamic of power in negotiating sex. For people who have not been abused, sexual negotiation allows them to define boundaries of sexual experiences and express sexual desires. Sexually abused children, however, have been forced against their will to engage in sex and have felt powerless over the situation. As adults, they often reinforce feelings of powerlessness by assuming passive and nondictating roles in sexual encounters. This dynamic can have an important role in increasing one's risk of HIV infection.(7).

Incest survivors, as well as survivors of rape, may seek to reenact abusive experiences through compulsive sex. In the compulsive environment, they recreate the dynamic of being forced against their will to engage in sex. Uncovering childhood experiences that may include sexual abuse can be an important part of therapy for the sexually compulsive person.

Treatment

The key concern in treating sexual compulsion is not necessarily abstaining from sex, rather, it is interrupting the compulsive behavior pattern that is part of the addictive cycle. It may be necessary to refrain from certain types of sexual activity or avoid certain environments so the compulsion can be inhibited or blocked altogether. Breaking this pattern and resetting priorities will help to reestablish sexual boundaries.

The sexually compulsive person must find a balance by which he or she can regain control over sexual behavior. This process is often difficult and takes a prolonged period. To aid in this process, many sexually compulsive people in treatment or recovery programs do choose celibacy for a certain period or indefinitely.

It is extremely unlikely that a person will eradicate compulsive sex patterns without intervention. Researchers have found group therapy and 12-step recovery programs, such as Sex and Love Addicts Anonymous (SLAA), Sexual Compulsive Anonymous (SCA), and Sex Addicts Anonymous (SAA) to be effective in initially treating sexual compulsion (11). Groups help people break free from isolation by realizing others share, and therefore understand, their feelings and struggle. Individual therapy for inpatient treatment is also used. Some physicians prescribe antidepressants in combination with other forms of therapy or group support (12).

Researchers report it is necessary for service providers to recognize the role of family relationships in the addictive cycle for the person who is sexually compulsive. In addition, it is important to pay attention to the abuse of substances such as alcohol and other drugs. A sexual addiction is unlikely to be effectively managed if a person continues to abuse substances. Most important in the treatment of sexual compulsion is getting a person to accept and acknowledge the loss of control over sexual behavior.