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Ragan 2000
Ragan 2000
To cite this article: Paul W. Ragan & Peter R. Martin (2000) The Psychobiology of Sexual Addiction,
Sexual Addiction & Compulsivity: The Journal of Treatment & Prevention, 7:3, 161-175, DOI:
10.1080/10720160008400216
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INTRODUCTION
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
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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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
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.
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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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.
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
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
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.
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.
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
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
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
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