Behavioral Addictions _ _______________________________________________________________________
STANDARD TREATMENT OPTIONS FOR SEXUAL ADDICTION
Therapies
Treatment Target
Mechanisms
Disadvantages
Cognitive-behavioral therapy
Behavioral control, management of negative affect, social skills, relapse prevention
Functional analysis of sequence and triggers of behavior, thought records, skills building Exploration of personal meaning of symptoms in context of personal history Social support, group confrontation of denial, peer sharing of experiences Established treatments of comorbid conditions can reduce symptoms of sexual addiction Reduces dysphoric affect, may reduce sex drive Greatly reduces or eliminates sex drive
Does not address motivation, personal meaning, or underlying character structure Does not provide concrete skills to change behavior
Psychodynamic therapy Self-concept and interpersonal relationships, self-awareness, underlying personality organization
Group therapy
Shame, stigma, social isolation, denial, rationalization
Does not provide individualized, in-depth treatment
Medication treatment of comorbidity
Comorbid anxiety, depression, OCD, impulsivity, psychosis, mania Anxiety, depression, obsessional ideation, sex drive Destructive sex drive in male repeat sex offenders
Works best in sexual addiction secondary to or strongly exacerbated by comorbid condition Largely safe, but not without side effects Severe possible side effects such as pulmonary embolism, bone mineral loss
SSRIs
Anti-androgens
OCD = obsessive-compulsive disorder; SSRIs = selective serotonin reuptake inhibitors. Source: [76]
Table 2
Hypersexuality Subtypes In patients seeking help for problematic sexual behavior, clini- cians are repeatedly recommended to use a patient-tailored, multimodality approach, but there is little published guidance for matching clinical presentation with treatment options. Thus, a group of prominent sexual disorder researchers and cli- nicians developed a hypersexuality typology that links clinical profile and symptom clusters to suggested treatments. Diverse hypersexual behavioral patterns suggest they may be unrelated phenomena; assumed commonality is erroneous [138]. Paraphilic Hypersexuality The paraphilic hypersexuality subtype has key features of paraphilic interests and a high frequency of one or more hypersexuality behaviors. Many of these patients lack the strong, internal directedness most men have in their sexual interest(s). Instead, they tend to test out or go along with partners’ sexual interests. Interactions with sex workers are based on sex, and for many, a desire to become a part of the sex worker milieu [138]. Paraphilic hypersexuality is remarkable for the sizeable number reporting gynandromorphophilia, a rarely discussed erotic interest in persons with both male and female anatomy (usually full breasts and intact penis) typified by incompletely transitioned male-to-female transgender women. For many, this specific enduring erotic interest leads to confusion over sexual orientation or gender identity and hesitant self-reference as ‘‘mostly heterosexual’’ or as bisexual [138].
This clinical characterization of gynandromorphophilia risks pathologizing attraction to transgender women and the women themselves. Care should be taken to avoid doing so in practice settings. Methods to change paraphilic interests into euphilic attraction have no evidence or support. Treatment suggestions include integration of interests that can be expressed alone or with consenting partners, and harm reduction for those inter- ests that cannot. Medication may be highly relevant. SSRIs can reduce libido and impulsivity, but can also delay or prevent ejaculation and lead to seeking greater stimulation sufficient to trigger orgasm [138; 184]. Avoidant Masturbation The primary presenting complaint in patients with avoid- ant masturbation is the extreme time spent masturbating to pornography. These patients report masturbating many hours daily, job termination from online pornography or masturba- tion at work, academic failure, and social relationships and other important activities abandoned in favor of masturbation. Paraphilic interests are rare [138]. Many of these patients acknowledge masturbating to avoid tasks or chores. Anxiety or dysthymia are common; masturba- tion is the cause of, or the coping skill for, negative emotions. Avoidant masturbation does not always interfere with relation- ship satisfaction or sexual activity, but many have little interest in partnered sex and prefer masturbating to pornography [138].
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