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The Psychobiology of Sexual Addiction

a a
Paul W. Ragan & Peter R. Martin
a
School of Medicine, Vanderbilt University , Nashville, Tennessee,
USA
Published online: 08 Nov 2007.

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Sexual Addiction & Compulsivity: The Journal of Treatment & Prevention, 7:3, 161-175, DOI:
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 Sexual Addiction & Cornpulsivity, 7:161-175, 2000
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The Psychobiology of Sexual Addiction

PAUL W. RAGAN, PETER R. MARTIN

School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
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Sexual addictions may be systematically studied using

operationalized diagnostic criteria in a variety of studies enzploy-
ing conventional research methodologies such as is being done in
the investigations of a variety of Axis I disorders. Although descrip-
tive investigations into the sexual addictions were on par with that
of other major mental disorders in the last century, further investi-
gations did not keep pace with that of other mental disorders. Pro-
grammatic research into the sexual addictions ispoised to beguided
by understanding both neurobiological mechanisms involved in
sexual behaviors and multicausal, biops-ychosocial approaches. A
comprehensive understanding of sexual addiction would involve
addressing issues in the areas of nosology, epidemiology, fami@
studies, diagnostic criteria,genetics, neurobiology, comorbidity, and
empirically based treatments. The authors suggest current research
questions and priorities that, when addressed, can contribute to
significant advances in the understanding and treatment of sexual
additions.

INTRODUCTION

The syndromes of paraphilic or nonparaphilic sexual behaviors, where there

is a loss of control over sex and a persistence in sexual behaviors despite
adverse social, psychological, and biological consequences, have been con-
ceptualized as obsessive-compulsive, impulsive, addictive, or posttraumatic
(Goodman, 1997; Black et al., 1997; Schwartz, 1992). For ease of reference,
in this article, the term sexual addiction will be used. If one substitutes

Address correspondence to Paul Ragan, MD, Division of Addiction Medicine, Department

of Psychiatry, Suite AA-2210 Medical Center North, 21st & Garland Avenues, Nashville, TN
37232-2647, USA.

161
 162 P a d W. Ragan and Peter R. Martin

sexual behaviors for substance use in the Diagnostic & Statistical Manual of
Mental Disorders, 4th Ed. (DSM-IV, American Psychiatric Association, 19941,
criteria for substance dependence, it appears to accurately describe the syn-
drome of sexual addiction (Schneider, 1994), and thus has some face valid-
ity. Those who object to using the term addiction for a behavioral syndrome,
where no chemical substance is ingested, are referred to Goodman’s discus-
sion of this topic (Goodman, 1997). The absence of DSM-IV criteria for sexual
addiction (“excessive sexual disorder”) probably relates to the relative pau-
city of studies of this syndrome employing conventional research method-
ologies. Such a scarcity of studies by research psychiatrists is curious, since
descriptions of sexual addictions have been noted in the medical literature
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for some time. For example, Benjamin Rush devoted a chapter in Medical
Inquires and Obseruations Upon the Disease of the Mind (1812) to the topic
entitled “Of the Morbid State of the Sexual Appetite.” Rush reported the case
of a man who

imputes his indisposition to his excessive devotedness to Venus, which he

thinks has been induced by a morbid state of his body. He has been
married three years, had no connection with sex before he married, and,
although he feels disgusted with his strong venereal propensities, he can-
not resist them. I advised him to separate himself from his wife by travel-
ling [sic],which he did, but without experiencing any relief from his dis-
ease. He has earnestly requested me to render him impotent, if I could
not give him command of himself in any other way (Rush, 1988).

By the end of the 19th Century, Krafft-Ebing published Psychopathia Sexualis

(1892), an extremely thorough study of the paraphilias and other sexual
disorders, illustrated with almost 200 case histories. Krafft-Ebing was the
older contemporary of Kraeplin, who is credited with describing and sepa-
rating the manic, depressed, and mixed conditions of “maniacaldepressive
insanity” from those of dementia praecox (Kraepelin, 1988). Thus, over a
century ago, sexual disorders received the same descriptive attention as bi-
polar disorder and schizophrenia. If one considers the extensive researches
investigating the epidemiology, phenomenology, genetics, neurobiology, and
treatments of the latter two groups of disorders, then the relative neglect of
sexual disorders by mainstream psychiatry is all the more striking.
Sexual addiction causes those afflicted with significant distress. This is
poignantly manifest in Rush’s case description. This is not to say that in the
earlier stages of sexual addiction, much like addiction to alcohol, cocaine, or
other substances, that there are not pleasurable experiences. But as Carnes
quotes Sharon Nathan’s observation about sexual addicts:

What appears undeniable is that there are people who are troubled by a
sense that they cannot curb, control, or modify their sexual behavior,
even when they are aware of the negative social, medical, and/or finan-
cial consequences that attend their inability to do so (Carnes, 1996).
 7Ee Psychobiology of Sexual Addictiori 163

Clinicians who do not treat sexual addictions are often unaware of the de-
gree of distress it causes. Asking “Can too much sex be a bad thing?” (Stein
& Black, 2000) is like asking can too much alcohol be a bad thing. An
example of the distressed extremes an individua1 with sexual addiction can
be driven to came to the attention of one of the authors (PWR) recently at
the Vanderbilt Trauma Center. A 38-year-old man with sexual obsessions and
repeated sexual acting out professed continued love for his exwife. He had
failed to reconcile with her several times because of the recurrence of his
sexual symptoms. He came to medical attention after his most recent attempt
at reconciliation failed and, in sheer desperation, he had self-amputated his
genitals with a shotgun in hopes of ridding himself of his sexual obsessions.
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In addition to the enormous psychic and physical distress sexual addic-

tion can cause for the individual, it can yield a great cost for loved ones,
family, friends, employers, succeeding generations, and society at large. Just
as other medical disorders such as depression, diabetes, alcoholism, etc. can
be studied based on their psychological, legal, and economic cost to a par-
ticular society, so too should we be able to study similar costs of sexual
addiction. The anticipated magnitude of these costs alone justify the impor-
tance of studying sexual addiction with the prediction that improved treat-
ment and prevention would have salutary effects far beyond the alleviation
of individual suffering.
Carnes has called for the crystallization of a new paradigm that will
expand our understanding of sexual addiction. It appears that the Zeitgeist is
present for this paradigmatic leap forward (Kuhn, 1970). Two major currents
in American psychology and psychiatry can contribute to this new paradig-
matic understanding of sexual addictions.
The first is that of the neurosciences which, as the recent Decade of the
Brain has highlighted, are making rapid advances in understanding the neuro-
biological underpinnings of mental disorders. Specifically, it is suggested that
evolutionary neurobiology (Sarnat & Nevsky, 1981; LeDoux, 1996) can cast light
on understanding sexual addiction and sexually compulsive behaviors.
The other, more subtle, current is that of eschewing overly simplistic
biomedical models of mental disorders in favor of multicausal, biopsychosocial
theories (Kiesler, 1999). As Kiesler has noted:

Emerging theories of mental disorders have begun to emphasize the com-

plex interactions present among risk (vulnerability) and protective fac-
tors, whether the factors be genetic-biomedical, environmental, or psy-
chosocial. The importance of these risk and protective factors has
compellingly surfaced from the empirical findings in various subdisci-
plines of psychopathology, especially developmental psychopathology,
epidemiology, and prevention science (Kiesler, 1999, p. 142).

Kiesler outlines how research into the interactions of the areas of diathesis-
vulnerability, developmental psychopathology, risk and protective factors
 164 Paul W. Ragan and Peter R. Martin

analyses, and epidemiology all contribute to the causal understanding of

mental disorders. Therein lies the blueprint for understanding sexual addiction.
Thus, although the descriptive understanding of the sexual addictions
was on par with that of other mental disorders at the end of the last century,
research into the sexual addictions did not keep pace with the investigations
of the other mental disorders. For whatever reasons that the sexual addic-
tions were bypassed, it is a central tenet of this article that the very theoretical
and conceptual tools used to understand the brain-behavior relationships in
other mental disorders can and need to be used to investigate the sexual
addictions.
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EPIDEMIOLOGY
Prevalence
One is unaware of any epidemiological surveys of nontreatment seeking
populations addressing the prevalence of sexual addiction, paraphilic or
nonparaphilic. Levine notes that the ECA studies of the late 1980’s on the
prevalence of mental disorders did not include the sexual psychopatholo-
gies (Levine, 2000). Abel and Rouleau (1986) have noted that obtaining ac-
curate information is complicated by fears of disapproval, condemnation, or
even prosecution. Coleman estimated 5% of the population met criteria from
“sexual compufsivity” (Coleman, 1992) and Carnes (1991) estimated 3 4 % of
Americans suffer from sexual addiction. Exactly how these estimates were
arrived at is not entirely clear. Thus, we are left to infer the magnitude of the
problem based on the number of people who present for evaluation or
treatment, either in the clinical or legal setting. Carnes has reported the larg-
est study to date, of 932 subjects seeking treatment for sexual addictions
who completed a detailed sexual behavior inventory (Carnes, 1991). In stud-
ies of the clergy, Plante has noted that the “best estimate” is that 6% have
been involved in the sexual abuse of minors (Plante, 1999).
Recently, Cooper et al. surveyed 9,265 respondents who used the Internet
for sexual purposes and found 17% scored in the problematic range for
sexual compulsivity (Cooper et al., 2000). Thus, the indicators that are avail-
able suggest that a variety of different types of sexual addiction present a
substantial problem in the US.; it remains for population-based studies to
tell us the exact scope of the problem.

Age and Gender

Preliminary data gives one good estimates on the age and gender differences
in the sexual addictions. Goodman notes the problematic hypersexual be-
havior peaks between ages 20 and 30 and that, in the majority of cases, onset
is prior to age 18 (Goodman, 1997). Black et al. reported in their 36 patients
with compulsive sexual behavior (mean age 271, the mean age of the start of
 7he Psychobiology of Sexual Addiction 165

the behavior was age 18 (Black et al., 1797). Surveys of adult sex offenders
revealed that most committed their first offense during early adolescence
(Bremer, 1992). In fact, the number of juveniles with paraphilias and related
disorders coming to the attention of the courts is such that hundreds of
treatment programs have been created to meet the demand (Bremer, 1992).
The relationship of the age of onset of the sexually addictive behavior to the
severity of the disorder is an obvious question that has yet to be answered.
Carnes has reported the male to female ratio in sex addicts ranges be-
tween 4 to 1 (Carnes, 1991) and 3 to 1 (Carnes, 1998). The gender differ-
ences in sexual addiction, although superficially similar to the pattern seen
with alcohol dependence, may actually have an evolutionary basis related to
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the gender differences in biology. For example, if we define sexual desire as

1. spontaneous occurrence of sexual thoughts,

2. interest in initiating or accepting sexual activity,
3. recognizing and seeking out sexual cues (Bancroft, 1989a), then there are
overwhelming gender differences.

Blum has summarized many of the studies, which often include primates or
college students, demonstrating the increased frequency of arousal in a vari-
ety of settings in males compared to females (Blum, 1997). Ease of arousal
and progression to orgasm is seen as the biological basis for a successful
reproductive strategy in males, whereas there is not the same pressure from
natural selection to evolve such a strategy in women. Consequently, if baseline
sexual desire and arousal tend to be higher in males compared to females,
then it would seem logical that the various syndromes of hypersexuality
would occur more frequently in men than women.

Ethnic and Cultural Differences

If there is a paucity of epidemiological data regarding the sexual addictions
in general, then the specific ethnic and cultural differences in these behav-
iors are almost totally unknown. In Carnes’s sample of 932 sex addicts, 93%
were Caucasian (Carnes, 1791). Exploration of this unknown territory may
yield unexpected results. For example, indecent exposure and exhibitionism
are well-known in forensic circles in the U S . (Hackett et al., 1780) and
Britain (Bancroft, 1989b), where the behavior is listed as a separate offense,
but, as Bancroft notes, it is uncommon outside the U.S. and Western Europe
(Rooth, 1973).

Natural History
Yet another area disciplined epidemiological inquiry would elucidate would
be an accurate and comprehensive description of the variety of sexual addic-
tions and how they relate to one another throughout the lifespan, i.e., the
 166 P a d W. Ragan and Peter R. Martin

natural history of sexual addiction. Is there a clustering of certain sexual

addictions or is there a tendency for a sequential progression through stages
of certain sexual addictive behaviors?

Case Example of Lesser Known Hypersexual Syndrome

An example of a sexual practice that is too little understood, but to which the
individual returns in a seemingly addictive fashion, often progressing to more
elaborate rituals and often risking his life, is that of autoerotic asphyxia.
Rupp notes that the first direct reference to the production of partial anoxia
in order to heighten sexual gratification is in the novelJustine by the Marquis
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de Sade in 1791 ( R ~ p p 1780).

, But for the purposes of this article, what is
most interesting about the observations by Rupp, a medical examiner, is
how this practice most likely is a form of sexual addiction. Investigations of
autoerotic asphyxia1 deaths have revealed they occur almost exclusively in
males, from early adolescence onward, and that these cases occur world-
wide in men of different ethnic backgrounds. The death scene often reveals
evidence of specialized accouterments for inducing the anoxia, of bondage,
of self-mutilation, and of crossdressing. Furthermore, what is most interest-
ing is the evidence that the practice becomes repetitive, more involved and
elaborate over time, suggesting an escalation of the behavior. The death
scenes of the early adolescents are the most simple, with the suspended
bodies fully clad with evidence of masturbation. This progresses in the older
teenager or young adult to complete nudity, with props, bondage, mirrors,
and pictures in evidence. Finally, in the older individual, the full spectrum of
often elaborate equipment, often well-worn, is present, suggesting a sus-
tained frequency of use. Finally, Rupp observes that autoerotic asphyxia
occurs in thousands of individuals who appear to discover the practice on
their own. This appears reminiscent of bulimics who most often learn to
purge on their own. The example of autoerotic asphyxia is included here to
illustrate how little is known about this disorder psychiatrically and how
much work needs to be done in the field if we are LO have a comprehensive
understanding of the sexual addictions.

Comorbidity
There is a high frequency of co-occurrence between paraphilic and
nonparaphilic sexual addictions (Goodman, 1777; Kafka & Prentky, 1772;
Black, 2000). Mood disorders, anxiety disorders, personality disorders, and
substance dependence are the most frequently diagnosed disorders comorbid
with the sexual addictions. Recently, Kafka and Prentky noted childhood
attention-deficit hyperactivity disorder occurred in 50% of paraphilic men
and 17% with nonparaphilic sexual addiction (Kafka & Prentky, 1978). Carnes
has especially noted the high frequency (7040%) of physical and sexual
abuse in childhood with frequent posttraumatic stress disorder (PTSD) in
 7'he Psychobiology of Sexual Addiction 167

adulthood in his sample of sexual addicts (Carnes, 1991). Recent studies of

the neurobiological changes seen in patients with PTSD (Weiss et al, 1999;
Bremner et al., 1999) suggest strategies for studying the same in the sexual
addictions. The relationship of the sexual addictions to the personality disor-
ders, although reported on, has implications that have yet to be studied. It
would seem particularly important to d o this since impaired control over
sexual behavior are involved in the specific criteria for the diagnosis of anti-
social (sexual promiscuity) and borderline (sexual impulsivity) personality
disorders (American Psychiatric Association, 1994). Thus, the empirical study
of comorbidity in the sexual addictions is at a nascent stage ripe for further
systematic study.
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Nosology
As noted in the introduction, sexual addictions have been conceptualized
from a number of different syndromal vantage points. It is not the purpose
of this article to argue the merits of each of these points of view. Rather, it is
the contention that valid diagnostic criteria may be established for sexual
addiction much the same way as it has been for other psychiatric disorders
(Feighner et al., 1972). Of note, Carnes's signs of sexual addiction have been
included in the latest edition of the Coinprehensive Textbook of Psychiatry,
7th edition (Sadock, 2000). Structured diagnostic interviews incorporating
proposed criteria for sexual addictions may be tested in various clinical popu-
lations. Out of these kinds of empirical efforts, definitive diagnostic criteria
can be established.

NEUROBIOLOGICAL UNDERPINNINGS OF SEXUAL BEHAVIOR

It is posited that studying the neural circuits that control sexual behavior and
the organic brain syndromes manifesting hypersexual behaviors will eluci-
date the brain pathways pertinent to the sexual addictions. What w e know of
the functional organization of the central nervous system (CNS) can be used
to predict that there would be both syndromes of hypo- and hyper-sexual
functioning. At each level of CNS organization, there are combinations of
inhibitory and excitatory systems at work. Much of the neurobiological un-
derstanding of psychiatric and neurological disorders involves decreased
inhibition (loss of inhibitory control and/or excessive excitation) or decreased
excitation (loss of excitation and/or excessive inhibition). Thus, it would be
predicted that there are brain mechanisms involved in both the excitatory
and inhibitory control of sexual behaviors. In some ways the DSM-IV de-
scription of sexual dysfunctions can be seen as focusing on sexual disorders
in which there is excessive central inhibition of sexual behaviors, causing
these same disorders: hypoactive sexual desire, sexual aversion, arousal dis-
orders, orgasmic disorders, sexual pain disorders, and medical conditions.
 168 Paul W. Ragan and Peter R. Martin

But neurobiology will also tell us that there ought to be a set of sexual
disorders involved in excessive central excitation and/or loss of inhibition of
sexual behaviors. Improved understanding of brain mechanisms of sexual
addiction, in turn, may suggest useful avenues to pursue for improved phar-
macological therapies.

Neuronal Control of Sexual Behaviors

The hypothalamus occupies a central position in the mediation of sexual
behaviors. Hypothalamic control and regulation of these behaviors occurs
through three functional domains.
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1. 7he autonomic nervous system: The neurons that affect the preganglionic
motor neurons of the sympathetic and parasympathetic nervous system
originate in the hypothalamus (Nauta & Feirtag, 1986). Efferents of the
sympathetic nervous system limit blood tlow to the penis, thereby pre-
venting an erection. Conversely, excitatory signals from the brain medi-
ated via the parasympathetic efferents result in nitric oxide and acetyl-
choline release and penile tumescence (Goldstein et al., 2000). There
also exists an “erection-generating center” in the spinal cord between the
twelfth thoracic and third sacral vertebrae that receives penile afferents
via the pudendal nerve, which synapse onto spinal interneurons that
stimulate parasympathetic efferents. Thus, as long as this reflex arc is
intact, erection is possible even in spinal cord injuries (Goldstein et al.,
2000).
2 . Pituita y complex: Certain hypothalamic neurons terminate in the median
eminence where their releasing factordhormones are secreted into the
hypothalamopituitary portal system and sent to the anterior lobe of the
pituitary. In 1971, the decapeptide gonadotropin-releasing hormone
(GnRH) was identified. GnRH neurons in primates, including humans,
are located in the arcute nucleus of the medial basal hypothalamus (MBH)
and the preoptic area of the anterior hypothalamus (Yen, 1991). GnRH is
released in pulsatile fashion and regulates the release of LH and FSH by
the pituitary gonadotrope. Of interest is that GnRH neurons also project
to the circumventricular organs associated with the third ventricle and to
the limbic system. Tumors in this area of the brain-namely, optic or
hypothalamic gliomas, astrocytomas, ependymomas, and craniopharyn-
giomas-can cause precocious puberty, probably by damaging neuronal
inhibition of GnRH secretion (Styne & Grumback, 1991. Other neurons in
the suproptic and paraventricular nuclei send axons directly to the post-
erior lobe of the pituitary, where vasopressin and oxytocin are stored in
the axonal terminals for release directly into the systemic circulation. Of
note is de Wied, who especially has studied the affects of vasopressin on
memory and learning, which may have important applications to persis-
tent sexual behaviors (Yen, 1991, pp. 94-95). With regards to sexual be-
 The Psychobiology of Sexual Addiction 169

havior, plasma vasopressin is significantly elevated in men during sexual

arousal with oxytocin not increasing until ejaculation. In women, the
pattern is different with oxytocin increasing earlier during arousal and
peaking during orgasm (Yen, 1991, pp. 93-94).
3. The limbic system: Brain tumors, lesion studies, and electrical stimulation
of certain areas of the hypothalamus result in emotional changes and
displays. The work of Olds and Milner further provided evidence for
hypothalamic involvement in affect and emotion (Weiss et al., 1999, pp.
121-122). Near the preoptic area of the anterior hypothalamus is a sexu-
ally dimorphic nucleus discovered originally in rodents, but also identi-
fied in humans, that is 2.5 times larger in the male (Bancroft, 1989a, p.
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69). Its functional significance is not well understood.

The hypothalamus receives input from neuronal groups projecting from

all levels of the brain stem. Examples of these are monoaminergic neuronal
groups, including dopaminergic, norepinephrinergic, and serotonergic. The
lateral hypothalamus also receives input from numerous forebrain areas,
including the limbic system. Projections arise from basal forebrain areas in-
cluding the olfactory tubercle, septum, piriform cortex, amygdala, and hip-
pocampus. Of note, there are also direct neocortical projections to the hypo-
thalamus (Bloom, 1991). These neurotransmitter systems and neuronal
pathways may well form the neural substrate through which psychotropic
medications affect sexual behaviors.
One of the early theories of an anatomic basis for emotion was the
Papez circuit (hippocampus, fornix, mammillary body, mammillothalamic
tract, anterior thalamic nucleus, cingulate gyrus, and parahippocampal gy-
rus) (Papez, 1937). The Papez circuit was thought to be the crucial substrate
for the primary emotions that form basic instincts or drives, i.e., feeding,
aggression, flight, and sexual reproduction. Papez’s concept was expanded
by MacLean: he added other brain areas as important to emotional experi-
ence and expression, namely the amygdala, the septum and adjacent basal
forebrain, nucleus accumbens, and orbitofrontal cortex (MacLean, 1949).
The key historical significance of the work of Papez and MacLean was
to emphasize there were neural substrates to the memories and behaviors
associated with emotions. Neuroanatomical lesion studies also highlight this
fact. For example, bilateral anterior temporal lobe ablation leads to the Kluver-
Bucy Syndrome (Kluver & Bucy, 1939). Originally induced in male rhesus
monkeys, Kluver and Bucy observed a constellation of 5 changes: hyper-
sexuality, placidity, oral tendencies, visual agnosia (or psychic blindness),
and mandatory environmental exploration. The syndrome can also occur in
humans; for example, in Pick’s Disease with anterior temporal lobe degen-
eration, where part or all of the features of this syndrome are clinically in
evidence (Cummings & Duchen, 1981). Of note is that altered sexual inter-
ests can also be a part of the interictal personality changes that accompany
temporal lobe epilepsy (Bear & Fedio, 1977). The other major syndrome of
 170 Paul W. Ragan and Peter R. Martin

neurological damage, which in retrospect would be predicted by MacLean’s

limbic system theory of emotion, is the Orbitofrontal Syndrome. The classic
example that historically helped establish brain-behavior relationships was
that of Phineas Gage, first described by Harlow in 1868, who sustained a
bifrontal lesion from a 27 kg tamping rod that penetrated his skull. The
predominant feature of the orbitofrontal syndrome is disinhibition, wherein
patients engage in inappropriate social and sexual activities with a diminu-
tion of the usual social restraints garvie, 1954). Thus, these “accidents of
nature” may shed light on sexual addiction, especially in terms of its neural
substrates. Hypersexuality has been noted with a number of neurological
disorders such as epilepsy and certain types of dementia, as noted above,
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but also with stroke and organic causes of secondary mania. Likewise, ac-
quired paraphilic behavior has been associated with temporal lobe injury
and other neurological disorders. Transvestitism and fetishism are the two
most common paraphilias occurring with neurological disorders (Cummings
& Miller, 1774).

PHARMACOLOGICAL TREATMENTS

Psychological treatments of sexual addictions can be complicated by the

patient’s legal status (Schwartz, 1772), and to be successful, most often re-
quire a long-term commitment (Black et al., 1997; Carnes, 1991). The
psychiatrist’s role in treatment includes ruling out organic etiologies of hy-
persexuality, evaluating and treating comorbid psychiatric disorders, and
using adjunctive pharamcotherapy to help control distressing sexual behav-
iors. Pharmacotherapy generally falls into two categories: antiandrogen agents
and affect-regulating agents (Goodman, 1997).
The most commonly used antiandrogens, medroxyprogesterone acetate
(MPA) and cyproterone acetate (the latter is not available in the U.S.), have
been used to help decrease repetitive, intrusive, deviant sexual fantasies and
harmful sexual behaviors (Sadock, 2000; Kaka, 2000). Unfortunately, com-
pliance with these medications has been a serious problem because of the
numerous attendant side effects, with dropout rates sometimes over 50%
(Goodman, 1997). Testosterone levels can also be lowered with analogs of
GnRH. The GnRH analog triptorelin administered monthly in depot form has
been used successfully within minimal side effects in the treatment of
paraphilias (Thibaut et al., 1973).
Kafka, noting the high rate of mood disorders comorbid with paraphilic
and nonparaphilic sexual addictions, reported an improvement not only in
the depression of his patients but also in their excessive and distressing
sexual behaviors when treated with antidepressants (Kafka, 1971). Stein et
al., in a small retrospective study, looked at treatment response to serotonin
reuptake inhibitors (SRIs) in three groups, all with comorbid obsessive-
 n e Psychobiology of Sexual Addiction 171

compulsive disorder o r major depression: patients with paraphilias,

nonparaphilic sexual addictions, or sexual obsessions and compulsions (Stein
et al., 1992). They found n o improvement in the paraphilias, modest im-
provement in the middle group, and the most improvement in patients with
sexual obsessions and compulsions. In contrast, Kafka, in a review of the
literature, has found significant treatment response to SRIs in paraphilias and
nonparaphilic sexual addictions even in the absence of comorbid mood
disorders (Kafka, 1991). When effective, Kafka has found a relatively selec-
tive effect with the SRIs of decreasing the distressing or unconventional
sexual desires while preserving regular partner sex.
With one exception (Kruesi et al., 19921, the studies of antidepressant
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medication use in paraphilias, sexual addictions, or compulsive sexual be-

haviors have all been case reports, open-labeled, or retrospective with no
control groups. Both Goodman and Kafka have noted the absence of con-
trolled studies (Goodman, 1997; Kafka, 2000). It is concluded that a current
major imperative is for the design and execution of randomized, double-
blind, placebo-controlled clinical trials in the treatment of these disorders.
To obtain accurate measures of treatment response, one would like to high-
light the need for delineating measures of specific outcomes. The criteria
need to be established for distinguishing between responder and nonre-
sponder groups in clinical trials. A whole host of approaches present them-
selves. Not only do there need to be agreed-upon measures of changes in
sexual psychopathology, but also measures of the changes in the quality of
sexual life for both the patient and their partner. Specifying the goals of
treatment is important. Are the goals complete sexual abstinence or modera-
tion or maturation? In this regard, it is suggested that the treatments for
modifying sexual behaviors may have more in common with treatments for
modifying eating behaviors. Thus, the goals of treatment need to be just as
rigorous, but may not be as easily defined as they are, for example, in the
treatment of chemical dependencies. Longitudinal approaches also need to
be adopted. Where is the patient with regards to the natural history of their
sexual addiction and how do treatment interventions relate to the stage of
their sexual disorder? In addition, how do treatment outcomes relate to the
patient’s readiness for change? Besides short-term improvement, can treat-
ment interventions alter o r improve the natural history of the sexual addic-
tion? This latter question has particular pertinence to the fact that sexually
addictive behavior appears to most often have its onset in adolescence. What
changes in social, economic, and legal functioning are important to include
in treatment outcome measures? The influence of comorbid conditions on
treatment response is of obvious importance. Finally, which combination of
treatments work best, i.e., which combinations of medications in conjunc-
tion with which psychological treatments work best for which groups of
patients?
 172 Paul W. Ragan and Peter R. Martin

TABLE 1. Research Priorities and/or Questions ~

1. Proposed criteria for addictive or excessive sexual disorders need to be operationalized

into structured diagnostic interview instruments which can become the common cur-
rency permitting interstudy comparisons.
2. Epidemiological studies of sexually compulsive behaviors/sexual addictions of sufficient
scale are needed to establish the different patterns and magnitude of this syndrome.
Particular attention needs to be paid to issues of comorbidity, gender differences, and age
of onset.
3. What is the neurobiological basis for coinpiiIsive/addictive sexual behaviors?
4. How does family history influence the development o f sexually compulsive behaviors/
sexual addictions? What are the risk factors for the development of sexually compulsive
behaviors/sexual addictions?
5 . What is the role and significance of trauma in the development of sexual coinpulsions or
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sexual addictions?
6. What are the genetic Factors that contribute to a diathesis for paraphilic and nonparaphilic
sexual addictions?
7 . Controlled clinical trials in patient groups fairly homogeneous for sexual disorder, stage
of disorder, presence of comorbid conditions, age and gender, and with adequate control
groups.
8. How do Axis I or Axis I1 comorbid disorders improve o r adversely affect treatment out-

CONCLUSION

The advantage of viewing excessive or compulsive sexual behaviors as an

addiction is heuristic. It provides one with a starting point and framework
within which to understand these behaviors. With a tool for conceptualizing
these disorders, one can overcome the inertia that has been attendant during
the time when systematic investigations of the other mental disorders were
underway. The advantage in the delay in studying sexual addiction is that
there currently exists the research methodologies, neuroscientific concepts,
and multicausal, biopsychosocial models to guide a wide-reaching research
program into the sexual addictions. The field is poised for a rapid expan-
sion. The research priorities and questions lay before us (see Table l),which
can provide the disciplined inquiry that will allow for this rapid expansion of
scientific knowledge and the development of new and iiiiproved treatments
for the sexual addictions.

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