Current Psychiatry Reports (2020) 22:30

https://doi.org/10.1007/s11920-020-01153-4

SEXUAL DISORDERS (LE MARSHALL AND H MOULDEN, SECTION EDITORS)

Pharmacotherapy of Sexual Addiction

Leo Malandain 1 & Jean-Victor Blanc 1 & Florian Ferreri 1 & Florence Thibaut 2,3

# Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Purpose of Review We reviewed recent data on sexual addiction and its treatment. We examined the different definitions of this
disorder, related to the pathophysiological mechanisms. We addressed the pharmacological treatment of sexual addiction.
Recent Findings Hypersexual behavior can be considered an addictive disorder. Sexual addiction is accompanied by significant psychi-
atric and addictive comorbidities and is responsible for life impairment. A comprehensive and efficient treatment must be proposed.
Summary Selective serotonin reuptake inhibitors seem the first-line pharmacological treatment for sexual addiction. Naltrexone
could be another therapeutic option. Psychotherapy and preferentially cognitive-behavioral therapy should be used in association
with pharmacotherapy and treatments of comorbidities.

Keywords Hypersexuality . Sexual addiction . Pharmacological treatment . SSRI . Chemsex . Compulsive sexual behavior

Introduction literature on pharmacological treatments for sexual addiction.

We systematically reviewed the literature, using MEDLINE/
Hypersexual behavior has a variety of names, numerous def- PubMed with the following keywords: “sexual addiction,” “com-
initions, and can be explained by several models [1••, 2••, 3]. pulsive sexual behavior,” “hypersexualism disorder,”
Over the past decades, there was a lack of consensus in the “hypersexuality,” “treatment,” and “pharmacologic treatment.”
assessment of this disorder, as well as in the understanding of All available articles in English or French were considered.
the pathophysiology. Despite their suffering, patients rarely
seek care due to shame and guilt or frequent denial associated
with this disorder. Personal distress, as well as personal, pro-
fessional, and family life impairments (77% of cases in a co- Definitions and Diagnosis
hort of 349 men) [4], and the frequent somatic or psychiatric
comorbidities encountered, make it a serious and severe ill- Sexual addiction, also called hypersexuality or compulsive
ness [5, 6••, 7, 8]. Despite a prevalence of 3 to 10% in the sexual behavior, refers to an uncontrolled frequency of sexual
general population, this disorder is often underdiagnosed and behavior, associated with compelling and irresistible craving,
poorly treated. This article attempts to review the current and which persists despite the subject’s experience of negative
consequences and suffering, psychically or physically [9]. It
This article is part of the Topical Collection on Sexual Disorders may be continuous or episodic. Based on the Kinsey report,
thresholds used to quantify the “excessive sexual consump-
* Leo Malandain tion” are usually the following: 7 or more orgasms per week
leo.malandain@aphp.fr for at least 6 consecutive months (after the age of 15 years)
[10], or more than one orgasm per day for 1 year or more [11].
Florence Thibaut
florence.thibaut@aphp.fr
De Alarcon and colleagues [12•] summarize the differ-
ent approaches of DSM-5 and ICD-11 to classifying hy-
1
Department of Adult Psychiatry and Medical Psychology, persexual behavior. For DSM-5, the conceptualization of
Saint-Antoine Hospital, Sorbonne Université, AP-HP, Paris, France hypersexual disorder is an addiction model but there is no
2
University Hospital Cochin (site Tarnier), Paris University, AP-HP, current hypersexual disorder diagnosis, due to insufficient
Paris, France evidence to categorize it as addiction. For ICD-11, hyper-
3
INSERM U1266, Institute of Psychiatry and Neurosciences, sexual behavior corresponds to an impulse control model,
Paris, France and is defined as compulsive sexual behavior disorder.
 30 Page 2 of 8 Curr Psychiatry Rep (2020) 22:30

Excessive sexual concerns, a “sexual filter” applied in Explanatory Models

interpersonal relationships, a feeling of loss of control
(especially in frequency, time or financial cost) and de- The mechanisms of sexual addiction remain a source of debate
pressive symptoms [2••] are also associated features. and study [3, 30], as does its pathophysiology, and therefore
The disorder can be subdivided into three clinical elements: its treatment. Its terminology is not consistent and may include
repeated sexual fantasies, repeated sexual impulses, and re- hypersexuality, compulsive sexual behavior, sexual disorder
peated sexual behaviors (e.g., masturbation, problematic por- with loss of control, or sexual addiction [15, 25, 31–33].
nography use, sexual behavior with multiple consenting However, it has to be distinguished from paraphilias, which
adults, cybersex, telephone sex, strip clubs, etc.) [2••, 13]. are defined as sexual disorders that are characterized by “re-
Clinically, sexual life is dissociated from the feeling of current, intense sexually arousing fantasies, sexual urges, or
love, characterized by a feeling of permanent dissatisfaction, behaviors involving sexual activity with (1) non-human ob-
and preoccupation with thoughts of sex, with concentration jects, (2) the suffering or humiliation of oneself or one’s part-
difficulties in other daily domains [14]. ner, or (3) a prepubescent child or children or other non-
consenting persons” [34, 35•].
Interestingly, in a cohort of 47 hypersexuals as compared
Epidemiology with 38 healthy controls, Engel and colleagues [36•] reported
a higher prevalence of paraphilias (e.g., exhibitionism, voy-
The prevalence of hypersexual behavior is around 2 to 6% in eurism, masochism, sadism, fetishism, frotteurism, or trans-
the general population [15–18]. vestism: 47 vs. 3%). Men with hypersexual disorder were also
The sex ratio is in favor of men, with a ratio from 2 to 3 more likely to report sexually coercive behavior (70 vs. 20%)
men to 1 woman [9], with estimates up to 5:1 [2••, 16]. and a higher rate of viewing images of child abuse at least
However, in women, the prevalence of this disorder is 3.1% once in their lives (81% vs. none in healthy controls). In sex-
in the general population [19, 20], and in the population of ual addiction, the risk of deviant sexual behavior such as voy-
patients with sexual addiction, the proportion of women eurism, exhibitionism, or rape remains poorly understood.
ranges between 3 and 40% [6••]. A recent survey of women We are still accumulating knowledge about the nature of
(n = 1174) and men (n = 1151) has found that 7% of women human sexual behavior. For sexual addiction, three major
and 10.3% of men in the USA showed distress and/or impair- models have been proposed, based on the models of impulse
ment due to difficulties in controlling sexual urges, feelings, control disorder (ICD), obsessive-compulsive disorder
and behaviors [21••]. In 2017, Rissel and colleagues [22•] (OCD), or addictive disorder. These three distinct models
reported that among 20,094 Australian participants, 1.2% of highlight the difficulties encountered in the diagnosis and
women considered themselves addicted to problematic por- treatment of these patients. The first model proposed by
nography use vs. 4.4% of men. Barth and Kinder [37] is based on a compulsive-impulsive
The average age of onset is 18.7 years old [23]. However, model, characterized by a lack of resistance to an impulse or
most individuals do not engage in treatment until 37 years old a temptation to perform an act harmful to oneself and/or
[17]. In most cases, access to care is difficult and patients others. This model explains excessive sexual behavior as an
seeking therapeutic assistance are often motivated either by inability to resist an impulse of sexual activity, as described in
legal problems, conjugal disorders, and professional issues or the DSM definition of the ICD [38].
by somatic or psychiatric comorbidities [1, 24•]. To reinforce this hypothesis, of 204 hospitalized patients,
Approximately 88% of patients with sexual addiction have a 31% met criteria of ICD, of which 4.9% presented with ex-
comorbid psychiatric disorder [25]. These are mainly mood cessive sexual behavior [39]. Accordingly, the ICD-11 has
disorders (72%), and anxiety disorders (38%) [26], a history conceptualized hypersexual behavior as an impulse control
of suicide attempts (19%) [27], personality disorders (17%) disorder, and named it compulsive sexual behavior disorder,
[28], or other addictive disorders (40–71%) [25–27]. Impulse which is confusing for clinicians.
control disorders (5–6%) [25] or obsessive-compulsive disor- The second model [13] proposes the term compulsive sex-
der (12–14%) [29] could be observed. In contrast, attention ual behavior, pointing to the parallel between OCD and sexual
deficit disorder with hyperactivity (ADHD) is noted in 17– addiction, particularly with respect to the intrusive and irre-
19% of cases. In men with high levels of hypersexuality or pressible thoughts and behaviors. The association with anx-
pornography use, ADHD should be systematically assessed. ious symptomatology or psychic tension associated with the
Physically, these patients are at an increased risk of intrusive thoughts that define OCD is also sometimes found in
contracting a sexually transmitted disease such as HIV, hepa- sexual addiction [40]. Two studies can support this model.
titis B and C, as well as syphilis or gonorrhea. They are also at Black and colleagues [27] showed that in 36 patients (28
risk for physical injuries due to repetitive sexual activity (e.g., men and 8 women) reporting sexual addiction, 42% reported
anal and vaginal trauma or penile abrasions) [24•]. repetitive and intrusive sexual fantasies, and 67% reported
Curr Psychiatry Rep (2020) 22:30 Page 3 of 8 30

poor self-esteem after engaging in sexual behaviors. In addi- infected with HIV before [54]. However, in those who engage
tion, Raymond and colleagues [25] found in 25 patients (23 in chemsex activity, post-exposure prophylaxis (PEP) was re-
men and 2 women) suffering from sexual addiction, 83% re- ported to occur in 14% of cases, and pre-exposure prophylaxis
ported a decrease in mental tension, and 70% described a (PrEP) occurred in 4.5% of cases [55]. Vaux and colleagues
sense of gratification after engaging in sexual behavior. [54] have found that, compared with the general population,
They also note that the lifetime prevalence of compulsive chemsex users had more frequently used certain prevention
sexual behavior is 5.6% in patients with obsessive- strategies: HBV vaccination, PEP, or PrEP. Finally, according
compulsive disorder, indicating a common bedrock between to Maxwell [46••], 14 to 25% of chemsex participants reported
these two conditions [41]. that chemsex had a negative impact on their psychosocial
The third model evoked by Orford [42] and also proposed functioning. Few studies have looked at the prevalence of
by Potenza [43] proposes that hypersexuality be conceptual- other addictive comorbidities. However, there is an associa-
ized as an addictive disorder [44]. Craving appears as an early tion between chemsex, alcohol, and tobacco use disorder [51,
state, followed by a repeated behavior that produces transient 56]. For example, Sewell [52] found 12.9% of MSM with
pleasure or relief from psychic distress, and is accompanied by high risk of alcohol consumption. The link between sexual
a repeated failure to control the behavior and persistence in addiction or hypersexuality and chemsex is poorly investigat-
spite of negative consequences. In the Potenza study, 98% of ed even if the comorbidity between multiple use of SPA and
patients reported withdrawal symptoms when decreasing sex- sexual addiction is known. For example, Antonio and col-
ual behaviors, 94% reported difficulty or even failure to con- leagues [54] found those with polysubstance addiction had a
trol these behaviors, 92% reported excessive time spent on significantly higher risk of a screening positive for sexual
these behaviors, 94% reported excessive time to prepare or addiction (OR = 2.72, 95 CI 1.1–6.71).
recover from behaviors, and 85% continued to have addictive
activity despite negative physical or psychological conse-
quences [43]. The high prevalence of addictive comorbidities Neurological Pathways
further supports this hypothesis: alcohol and psychotropic and Neurotransmitters
drugs (42%), gambling (5%), work (28%), shopping (26%),
and eating disorders (38%) [45]. These comorbid disorders In healthy humans, the proposed model of sexual behavior
provide support for the same pathophysiological substratum. includes a cognitive component of stimulus processing, an
Substance use in a sexual context or “chemsex” is a good emotional component related to sexual arousal and pleasure,
illustration of the close relationship between hypersexual be- a motivational component and a physiological component
havior and addictive substance disorder. The term refers to the [57]. Brain regions intervening in these different aspects, such
use of specific psychoactive substances before or during as the inferior and superior parietal lobules, the temporal lobe,
planned sexual intercourse to facilitate, initiate, prolong, the insula, and the frontal cortex [58••, 59] involve the mirror
maintain, and intensify sexual activity and sexual performance neuron system [60, 61].
[46••, 47]. Chemsex is being increasingly reported mostly by In patients with sexual addiction, a major role of the
men who have sex with men (MSM), often in the context of mesolimbic dopaminergic system has been demonstrated [59].
group sexual activity, or sex parties. The most commonly used The dorsolateral prefrontal cortex (DLPFC), the ventral stria-
drugs are crystal methamphetamine, gamma-hydroxybutyric tum, the dorso-anterior cingulate cortex, and the amygdala play
acid/gamma-butyrolactone (GHB/GBL), mephedrone, and an important role in craving. Thus, the reward system, mediated
less often synthetic cathinones, cocaine, ketamine or alkyl by dopamine, is strongly implicated in the dependence cycle
nitrites (poppers). Some of the participating men report [62] with an initial activation of dopaminergic neurons in the
injecting these drugs (colloquially referred to as “slamming”) ventral tegmental region projecting to the nucleus accumbens.
[46••, 47, 48]. Most often there is a combination of drugs, The addictive cycle is linked to repeated exposures that increase
often combined with erection dysfunction agents [49, 50]. glutaminergic projections to the prefrontal cortex, alter brain
The estimated prevalence of chemsex in MSM is hard to de- function, and create neuronal pathways of addictive behavior.
fine, and ranges from 3 to 32% [51, 52]. For example, a recent Other systems and other neurotransmitters modulate dopa-
study of 1648 MSM [49] found a prevalence of 6%. mine release and have a role in the sexual addiction system.
Prolonged sexual sessions with substance use may cause trau- This is the case for opiates and the hypothalamic-pituitary-
ma (anal trauma, penis abrasions ...) [53, 54] and increase risk adrenal axis that play a role upstream of the main dopaminer-
of sexually transmissible infections, particularly HIV and hep- gic system [63]. In addition, serotonin, through its action on
atitis C [53, 54]. Furthermore, living with HIV seems to be a sexual motivation, and on the hypothalamic-pituitary-gonadal
risk factor for chemsex. Among men who report this practice, axis and testosterone, is also a mediator of sexual activity and
the prevalence of HIV is higher. In 90% of cases, the practice low levels of serotonin may be encountered in patients with
of slamming is carried out by patients who have already been sexual addiction [64••].
 30 Page 4 of 8 Curr Psychiatry Rep (2020) 22:30

Comparing 19 subjects with sexual addiction and 19 Moreover, the study reported the use of citalopram to treat
healthy volunteers, Voon [58••] showed activation of the excessive masturbation and pornographic use [69, 70].
dorso-ventral cingular cortex, striatum, and amygdala during Fluoxetine also appears to be a promising treatment for
exposure to sexually explicit videos. Functional network con- excessive sexual behavior and its anxio-depressive comorbid-
nectivity between these three structures was also associated ities. In an open-label, 12-week trial, 10 men who met the
with greater desire in diseased subjects, with greater involve- DSM III-R criteria for sexual addiction received between 20
ment of corticostriatal limbic circuits. Another study using and 40 mg of fluoxetine. Most participants (95%) met the
functional MRI [65], found, as a result of sexual stimuli, great- criteria for dysthymia and 55% met criteria for a major depres-
er activation in the left caudate nucleus, lower parietal lobe, sive episode. After 4 weeks of treatment, a statistically signif-
dorsal anterior cingulate gyrus, bilateral thalami and DLPFC icant reduction of sexual addiction was found regardless of the
in a group of diseased subjects compared with the control level of mood improvement, while there was no pharmaco-
group. The left caudate nucleus, the right anterior cingulate logical effect on non-pathological sexual behavior [71].
cortex, and the right DLPFC are associated with the motiva- Although less rigorous, case studies have also shown promis-
tional component of sexual desire. Activation of the thalamus ing avenues for treatment. Elmore reported an improvement in
was related to physiological responses. symptomatology of sexual addiction in two patients: one treat-
ed by sertraline and one by paroxetine [72].

Pharmacological Treatment
Nefazodone
The first step in the pharmacological treatment of sexual ad-
diction is to clearly define its diagnosis in its primary form. Nefazodone is a phenylpiperazine antidepressant that selec-
There are many neurological conditions responsible for sec- tively blocks 5-HT2A post-synaptic receptors and moderately
ondary hypersexualism, especially those associated to frontal inhibits the reuptake of serotonin and norepinephrine. In an
and/or temporal dysfunctions [45, 66]. open study, 14 patients received nefazodone (average daily
In addition, it is important to rule out a manic episode, dose 200 mg); 6 reported improvement and 5 patients reported
hyperandrogenism, substance use including alcohol, cocaine, am- a remission of obsessions and sexual compulsions [13].
phetamines or hallucinogens, certain anesthetics (propofol in par-
ticular), as well as dopaminergic agonist treatments of Parkinson’s
disease, restless legs syndrome or prolactinomas which may be Topiramate
associated with symptoms of sexual addiction [67••, 68].
There are few controlled studies of pharmacological treatment Topiramate is an antiepileptic drug that appears to have
for sexual addiction. This literature review highlights several an “anti-impulsive” effect, particularly used in the treat-
open-label trials and a few case reports. It appears, however, that, ment of alcohol addiction, binge eating, and kleptoma-
as in any model of addiction, pharmacological treatment must be nia. It has different operating modes including an action
accompanied by psychotherapeutic care [24•]. on the voltage-dependent channels of sodium and calci-
Treatment of multiple possible psychiatric comorbidities is um ions, on GABA and on glutamatergic AMPA recep-
recommended, as well as possible infectious or traumatic tors. Two case reports were brought to our attention.
complications [1]. The first, in 2005, reported the case of a 32-year-old
patient, who had been treated with cognitive-behavioral
Selective Serotonin Reuptake Inhibitors therapy (12 sessions), fluoxetine (80 mg/day), and nal-
trexone (25 mg/day), without clinical improvement.
Selective Serotonin Reuptake Inhibitors (SSRIs) modulate After 6 weeks, treatment with 200 mg of topiramate
the concentration of pre- and post-synaptic serotonin. resulted in a significant reduction in the frequency of
They obviously have a place of choice in the treatment sexual activity, the money spent on sexual activities,
of depressive or anxious comorbidities. In addition, their and feelings of distress. After a spontaneous cessation
side effects on sexual behavior are well known and could of the treatment, he experienced a return of his symp-
be directly involved in the specific treatment of sexual tomatology, and following the reintroduction of the
addiction. A 12-week double-blind study, including 28 treatment, the same improvement [73]. In the second
homosexual or bisexual subjects with sexual addiction, case report [74], a treatment with 50 mg of topiramate
compared the efficacy of 20–60 mg citalopram versus per day for 4 months led to improvement in inappropri-
placebo. The results demonstrated a significant reduction ate sexual behavior. Interestingly, the same findings
in sexual desire, masturbation frequency, and use of por- were observed after the medication was termination,
nography, but not in the number of partners [64••]. and then subsequently restarted.
Curr Psychiatry Rep (2020) 22:30 Page 5 of 8 30

Naltrexone promising in GHB/GBL withdrawal in addition to benzodiaz-

epines. To our knowledge, there is no study that has investi-
Naltrexone is an inhibitor of endogenous and exogenous opi- gated the efficacy of baclofen in sexual addiction.
ates and blocks dopaminergic release in the nucleus accum- Lithium, valproate, or antipsychotics is used in cases of
bens, acting on the reward system. It has been shown to be psychiatric comorbidity (e.g., bipolar disorder or schizophre-
effective in the treatment of alcohol and opioid addiction [75, nia). However, it is important to keep in mind that several
76]. Following studies have reported its efficacy in the treat- antipsychotics (mainly aripiprazole, but also clozapine and
ment of sexual addiction. In monotherapy, Grant and Kim [77] risperidone) have been associated with hypersexuality. In this
reported a case of a patient with kleptomania and sexual ad- latter case, a switch to another compound is required. In cases
diction effectively treated with naltrexone. In polytherapy, of anxiety, behavioral therapy is recommended as benzodiaz-
several studies have shown a reduction of sexual addiction, epines might be associated with a higher risk of dependence in
especially after failed trials of SSRIs alone. In 2015, Kraus these patients [83–85].
reported the case of a patient with sexual addiction, who was
effectively treated with 50 mg per day of naltrexone mono-
therapy. During the 9 weeks of treatment, the intensity of his Conclusion
sexual urges significantly decreased and he also viewed por-
nography less often [78]. Sexual addiction has had many names, definitions, and ex-
Raymond and colleagues [79] reported two clinical cases in planatory models, and is now considered an addictive disorder
which the symptoms of sexual addiction were significantly by most of the clinicians, although controversies persist. Well-
improved with a combination of naltrexone (150 mg per designed studies conducted with large samples are lacking.
day) and fluoxetine (10 mg per day) in the first case, and a SSRIs appear to be an appropriate first-line pharmacological
combination of naltrexone (100 mg) and citalopram (40 mg) treatment for patients with sexual addiction, but again, larger
in the latter case. In both cases, symptoms were significantly and more sophisticated studies are needed. Pharmacological
reduced during a follow-up period of 8 months to 1 year. treatment should be considered part of a more comprehensive
Similarly, Bostwick and Bucci [80] reported the case of a care plan including psychotherapy, and in most cases,
patient treated with a combination of sertraline (100 mg daily) cognitive-behavioral therapy, specifically. In all cases, psychi-
and naltrexone (50–150 mg daily). Ryback [81], in an open atric and somatic comorbidities should be treated in parallel.
prospective study, investigated the efficacy of a treatment Self-help groups adapted from the 12-step model and practice
combining cognitive-behavioral therapy and naltrexone in of Alcoholics Anonymous may be helpful.
young patients with hypersexuality and pedophilic disorders.
Other treatments could be taken such as antidepressants, mood Compliance with Ethical Standards
stabilizers, antipsychotics, GhRH analogs, or stimulants. The
efficacy endpoint was a reduction of at least 30% in symptoms Conflict of Interest Leo Malandain, Jean-Victor Blanc, and Florian
over a period of more than 4 months. In 14 of the 21 patients Ferreri each declare no potential conflicts of interest. Florence Thibaut
is the Editor-in-Chief of Dialogues in Clinical Neuroscience. The journal
included, treatment was found to be significantly effective. receives a grant from Servier.
However, 13 of them showed a resurgence of symptomatolo-
gy when naltrexone was decreased below 50 mg per day. Five Human and Animal Rights and Informed Consent This article does not
out of six non-responders benefited from leuprolide therapy. contain any studies with human or animal subjects performed by any of
the authors.
Hormonal Treatments

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disorders are present. In this latter case, please refer to our • Of importance
guidelines with a recent update in 2019 [34, 82]. •• Of major importance

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