Behavioral Addictions _ _______________________________________________________________________
pattern. In 2014, nearly 50% of college-age men reported they were first exposed to Internet pornography before 13 years of age, compared with 14% in 2008 [176; 177]. Young adults with addictive Internet pornography use show greater impairments in sexual arousal and erectile function in intimate relation- ships, but not with pornographic material. ASSESSMENT In contrast to the body of research in other behavioral addic- tions, the published literature on sexual addiction is highly qualitative in nature. There are fewer controlled studies of treatment, but far greater material that examines the nuances of clinical assessment and care of these patients. In fact, a main criticism of research in other behavioral addictions is the lack of such qualitative work [178]. Areas to inquire about in order to identify hypersexuality subtypes during patient assessment include [138]: • Paraphilic interests • Behaviors that are not themselves sexual but may sug- gest a hypersexual subtype. For example: – Non-sexual forms of avoidance or procrastination (may suggest problematic sexual behavior as a mal- adaptive avoidance strategy) – Non-sexual symptoms of personality disorders, by embedding the problematic sexual behavior as a single feature of a more general problem – With distress attributed to sexuality, probe to determine if sexual behavior falls within peer norms and/or the individual’s distress unrelated to sexuality – Partner characteristics, such as recent or long- standing inhibitors of full sexual functioning Clients may lack the vocabulary to describe their sexual inter- ests, and it can be helpful to canvas and list the pornographic websites they prefer. Other general assessment questions for patients with sexual behavior concerns include [138]: • How much of your concern is about the amount of sex, what kind of sex, or the kinds of people you want sex with? • Some people hire sex workers for simple, physical sex, but other people want other kinds of relationships with the sex workers. What is your ideal? • Which porn websites do you prefer? • Masturbating several hours per day is certainly higher than average. What would you do with that time if not masturbating? • How do you deal with stress? What has worked for you? What has not? • Why did you get married? How has it matched up with what you expected?
• What would your partner’s sex life be like if you never met? • How does religion influence your life aside from sex? • How much of the problem is about risking harm to yourself (or others), and how much involves what it means about you as a person? • Finding sex is what attracts our attention, but for many people the problem is more about finding relationships. How do these go together for you?
According to the British Association for Sexual Health and HIV, sexual history- taking should take place in a confidential, private environment. (https://www.bashhguidelines.org/ media/1241/sh-guidelines-2019-ijsa.pdf.
Last accessed April 19, 2024.) Strength of Recommendation/Level of Evidence : 1D (Strong recommendation based on non-analytic evidence)
Sexual Dysfunction from Internet Pornography Use A simple assessment for Internet pornography-related sexual dysfunction is asking the patient whether he can achieve a satisfactory erection and climax when masturbating without Internet pornography. If he cannot, but can easily achieve these goals with Internet pornography, then his sexual dysfunction may be associated with its use. Healthcare providers should also screen for relationship problems, low self-esteem, depres- sion, anxiety, post-traumatic stress disorder, stress, and other mental health problems, but should avoid assuming a psycho- logical cause of otherwise unexplained sexual dysfunction in men younger than 40 years of age. The relationship between psychosocial factors and sexual dysfunction in younger men may be bidirectional and co-occurring or Internet pornography- induced [151]. Possible Medical Causes of Hypersexuality The first step in the treatment begins with accurate diagnosis that rules out medical causes of hypersexuality. Neurologic disorders associated with hypersexual behavior include Alzheimer disease (4.3% to 9% of these patients experience sexual disinhibition as a result of disease effects on the frontal and temporal lobes), frontotemporal degeneration (associated with impaired regulation of socially acceptable behaviors), and Kleine-Levin syndrome (causes hypersomnia that may lead to abnormal behavior, such as hypersexuality). Some medica- tions or illicit drugs can elevate sexual drive, such as cocaine, methamphetamine, and dopamine agonists used in Parkinson disease [140; 179; 180].
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