What Causes Out of Control Sexual Behavior?

Is Compulsive Sexual Behavior a "Sexual Addiction" or "Out of Control Sexual Behavior"?

The topic of compulsive sexual behavior (also known as hypersexuality) is a controversial topic in the mental health field because there are opposing views as to how to define it, what causes it and how to treat it. 

Treating Out of Control Sexual Behavior in Individual Sex Therapy

Some mental health experts believe compulsive sexual behavior is a sexual addiction and others see it as out of control sexual behavior (see my article: Treating Sexual Compulsivity: Is It a Sexual Addiction or Out of Control Behavior?).

As I mentioned in my previous article, language matters, especially in the mental health field.  

In the interest of being transparent about my professional views as a sex therapist who is sex positive, I want to emphasize that I do not see compulsive sexual behavior as an addiction, and I believe psychotherapists and other healthcare practitioners do clients a disservice by labeling it as an addiction.  

In my professional opinion (and the opinion of many contemporary sexual therapists in the field), not only is labeling sexual compulsivity as an addiction harsh and shame-inducing, it's also counterproductive in terms of treating it.  

Unlike alcohol and drug misuse, people who engage in compulsive sexuality can't be expected to give up sex.  Rather than pathologizing compulsive sexual behavior, a sexual health approach is more effective when a sex therapist looks for the underlying issues for each individual rather than taking a one-size-fits-all cookie-cutter approach that is often found in sexual addiction treatment.

The main proponents of the Out of Control Sexual Behavior (OCSB) perspective are Doug Braun-Harvey, LMFT and Michael A.  Vigorito, LMFT who wrote Treating Out of Control Sexual Behavior: Rethinking Sex Addiction.  

Instead of viewing this behavior as an addiction, they see it as sexual behavior that is out of control.  In their view it's a sexual problem but not a sexual disorder or an illness.  This is an important distinction between the OCSB and the sexual addiction approaches.

Other proponents of the OCSB view, like Dr. Neil Cannon, see sexual compulsivity as being related to unresolved trauma, unresolved mental health issues, relationship issues and problematic habits.

Out of Control Sexual Behavior (OCSB) and Problems With Self Regulation

The Out of Control Sexual Behavior perspective is a newer concept as compared to the sexual addiction model.  

The term OCSB, as defined by Braun-Harvey and Vigorito, refers to problems with self regulation of consensual sexual thoughts, urges and behavior despite negative consequences where the thoughts, urges and behavior feel out of control to the individual (the emphasis on "consensual" means that the OCSB model isn't meant for nonconsensual urges which lead to criminal behavior, like sexual assault or rape, which is treated by specialists in the mental health field who work with offenders).

OCSB focuses on hard to control sexual thoughts, urges and behavior rather than seeing the problem as a diagnosis or clinical disorder.  When someone engages in OCSB, they find it difficult to stop when they try to stop.  

Assuming that the sexual behavior is consensual, feeling out of control doesn't necessarily mean that an individual is out of control.  It's a subjective experience, so what feels out of control can mean different things to different clients.  This means that clinicians need to explore how each client experiences their sexuality.

What's the Difference Between Enjoying Sex and Out of Control Sexual Behavior (OCSB)?

Sex between consenting adults is a normal part of adult life among people who enjoy sex. Consensual sex is meant to be an enjoyable and pleasurable part of life.  

Out of Control Sexual Behavior, on the other hand, isn't about pleasurable sex. It's also not determined solely by sexual frequency because many people have pleasurable and frequent consensual sex which isn't problematic.  

OCSB involves repetitive thoughts, urges or behavior that create negative consequences including (but not limited to):

• Friction or conflict in a relationship, including the demise of a relationship due to infidelity (see my article: Why Do People in Happy Relationships Cheat?)

Treating Out of Control Sexual Behavior in Sex Therapy For Couples

• An excessive preoccupation with sex that interferes with daily activities, including work, studying and other activities

• Sexually inappropriate behavior on the job or in other areas of life, including sexual harassment or predatory behavior

What Causes Out of Control Sexual Behavior?

The causes of OCSB are not well understood and the sex therapy field could benefit from more research in this area.

Here are some of the current day hypotheses about what causes OCSB:

    OCSB and Attention Deficit Hyperactivity Disorder

Many mental health experts believe there is a correlation between OCSB and Attention Deficit Hyperactivity Disorder (ADHD).  

However, this doesn't apply across the board to everyone with ADHD. 

Some people with ADHD experience hypersexuality, which is a very high sex drive and others experience hyposexuality, which is a very low sex drive or lack of interest in sex.  

Both hypersexuality and hyposexuality can cause problems in a relationship.  

Hypersexuality related to ADHD can also cause problems with 

• Impulsive and compulsive sex 
• Risky sexual behavior
• Unprotected sex
• Unwanted pregnancy
• Cheating on partners in both monogamous and consensually nonmonogamous relationships
• Other related problems

It has been hypnothesized that the connection between OCSB and ADHD can be linked to:

• A Need For Stimulation: Some people with ADHD have a strong need for stimulation which can lead to excessive urges for new and exciting sexual activities that lead to higher stimulation.

• A Propensity For Risky Behavior: ADHD can involve an increased risk of sexually compulsive behavior as well as substance abuse.

• Escapism: People with ADHD often use sex as a form of self-regulating behavior to escape or self-medicate for stress and anxiety.

A comprehensive psychological assessment by a psychologist or a knowledgeable psychiatrist is necessary to either diagnosis ADHD or rule it out.

Currently, children who exhibit ADHD symptoms can be evaluated through their school psychologist and treated accordingly.

However, many adults with ADHD were not diagnosed when they were children because ADHD was either unrecognized or not understood, so many individuals with adult ADHD need to seek out their own assessment, diagnosis and treatment by ADHD mental health professionals.

    OCSB and Mood Disorders: Anxiety and Depression

Although many people with ADHD suffer with OCSB, not all OCSB involves ADHD.

Many people with anxiety or depression have problems managing their emotions, and they engage in hypersexuality as an attempt to regulate their emotions (see my article: Developing Skills to Manage Your Emotions).

They engage in hypersexuality as a way to seek temporary relief from their depressive or anxiety-related symptoms.  In those cases, what appears to be a sexual craving is often a maladaptive way of coping.

Hypersexuality can relieve symptoms related to the mood disorder, but since it only provides temporary relief, individuals with mood disorders will feel the urge to  be hypersexual again when their symptoms of anxiety or depression re-emerge.

    OCSB and Existential Anxiety

Existential anxiety is a dread or panic when an individual confronts the limitations of their existence.

Out of Control Sexual Behavior and Fear of Aging and Death

Dr. Daniel N. Watter, an existential psychologist and sex therapist, writes eloquently about the connection between men with existential anxiety and Out of Control Sexual Behavior in his book, The Existential Importance of the Penis.

Among other topics, Dr. Watter discusses how a fear of aging and death can precipitate uncharacteristic out of control sexual behavior among men.

Existential anxiety and Out of Control Sexual Behavior will be the topic of my next article.

Getting Help in Sex Therapy

Out to Control Sexual Behavior is treated in sex therapy because most other mental health professionals have no training or expertise in OCSB (see my article:  What is Sex Therapy?).

Sex Therapy is talk therapy. There is no physical exam, nudity or sex during sex therapy sessions (see my article: What Are the Most Common Misconceptions About Sex Therapy?).

Fear, shame and guilt often prevent people from getting help in sex therapy.  This is one reason why it's important to choose a sex therapist who has a sexual health perspective instead of an addiction or illness perspective.  

Understanding the unconscious underlying reasons for OCSB is key to achieving sexual health.

Whether the underlying issues involve anxiety, depression, ADHD, trauma, existential dread or other issues, once the underlying issues are discovered, a skilled sex therapist can help you to resolve these issues so you can have a pleasurable sex life without feeling out of control.

If you believe you're suffering with OCSB, seek help from a licensed mental health professional who is a sex therapist.

Taking the first step of contacting a sex therapist is often the most challenging, but it can also bring you a step closer to feeling in control and having a pleasurable sex life.

About Me

I am a licensed New York City psychotherapist, hypnotherapist, EMDR, AEDP, EFT, Somatic Experiencing and Sex Therapist.

I work with individual adults and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.

What Are the Most Common Issues Discussed in Sex Therapy?

Many people who have sexual problems feel too ashamed to get help in sex therapy or they don't know what sex therapy is (see my article: What is Sex Therapy?).

Common Issues in Sex Therapy

To shed light on some of the most common issues clients discuss in sex therapy, I'm writing this article to help reduce the stigma related to sexual problems and encourage people to seek help.

What Are the Most Common Issues Discussed in Sex Therapy?

The following are just some of the most common issues discussed in sex therapy in no particular order:

• Mismatched Libidos/Discrepant Sexual Desire Between Partners: The initial stage of a relationship is the limerence stage when people experience that heady in love feeling and sex tends to be passionate and exciting.  But it's a common occurrence that the limerence stage only lasts for a relatively short time and then the relationship develops into a more mature phase of love, which is often less exciting. This is normal, but many people think there's something wrong with their relationship when the excitement wanes. When this happens and one person desires sex more often than the other, there is a mismatch in sexual desire, which is called discrepant sexual desire. The mismatch can involve any type of difference. This mismatch can involve sexual frequency or the type of sex each person wants to have. Sex therapy can help couples to reignite the spark in their relationship (see my article: Relationships and Mismatched Sex Drives: What is Discrepant Sexual Desire?).

Common Issues in Sex Therapy: Sexual Desire Discrepancy

• Differences in Sexual Responsiveness in a Relationship: Related to discrepant sexual desire is a difference in sexual responsiveness.  This can occur at any stage in a relationship.  This means that each person in the relationship experiences sexual arousal in a different way.  One person experiences spontaneous desire and the other person needs more time to get turned on, which is called responsive desire.  Again, this is common and normal. Neither type of desire--spontaneous nor responsive--is better than the other. They're just different. Sex therapy can help people struggling with this issue, especially if both people are willing to work on getting to know their turn-ons and turn-offs, which are often referred to as sexual accelerators and sexual brakes (see my articles: Spontaneous Sexual Arousal and Responsive Sexual Arousal Are Both Normal and Understanding Your Sexual Accelerators and Brakes).

• Frustration About a Sexless Relationship: There are relationships where neither partner is bothered by the fact that they're not having sex because sex isn't important to them. If both people feel the same way, there's no problem. But in most relationships sex is important and if sexual frequency has dwindled down to several times a year or to nothing, one or both partners are often dissatisfied.  Sex therapy can help people to get to the root of their sexless relationship so they can enjoy sex (see my article: Have You and Your Partner Stopped Having Sex?).
• 
  

Common Issues in Sex Therapy: Frustration About a Sexless Relationship

• Loss of Trust and Sexual Desire After Infidelity: After one or both people in a relationship discover infidelity, they often find it difficult to reestablish trust so that they can enjoy emotional and sexual intimacy.  Even if the person who cheated is genuinely remorseful, the person who feels betrayed often associates sex with anger, resentment, sadness, betrayal and suspicion.  This can make having sex challenging. Sex therapy can help these individuals to work on regaining trust and intimacy (see my article: Learning to Trust Again After an Affair).

• Erectile Unpredictability: When medical issues have been ruled out, most cases of erectile unpredictability, including erectile dysfunction, premature ejaculation, delayed ejaculation, an inability to sustain an erection, are psychological in nature.  The man who experiences erectile unpredictability often experiences shame and guilt, and the significant other sometimes blames themselves or believes their partner doesn't find them sexually desirable.  However, sexual desirability usually isn't the problem.  The problem often involves anxiety about maintaining an erection or a self consciousness about sexual performance. Sexual anxiety often leads to spectatoring. Spectatoring, which can happen to a man or a woman, means they get stuck in their head and they lose focus of their own and their partner's sexual pleasure (see my article: Are Negative Thoughts About Yourself During Sex Distracting You?).
• 
  

Common Issues in Sex Therapy: Erectile Unpredictability

• Sexual Performance Anxiety: People who are preoccupied with performance anxiety during partnered sex often have problems with sexual self esteem.  Their preoccupation with their performance, body image issues, and other inhibitory factors often bring about the problems they fear in terms of erectile unpredictability (as mentioned above), problems with orgasms (for both men and women), and other sex-related problems. Rather than focusing on pleasure, they're focused on performance. Sex therapy can help these individuals to reorient their focus to sexual pleasure rather than on performing in a certain way (see my article: What is Performative Sex?).

• Unresolved Sexual Abuse That Has a Negative Impact on Solo and Partnered Sex: Unresolved sexual abuse trauma can get triggered during solo or partnered sex. Individuals with a history of sexual abuse, which include women and men, can experience anything from flashbacks to overall feelings of revulsion when they have sex. Some people are aware of their history of sexual abuse. Others might have fleeting memories or fragments of memories.  Others might have no conscious memories of it, but they have a sense of it. These individuals can be helped in sex therapy with a therapist who also specializes in psychological trauma (see my article: Overcoming the Trauma of Sexual Abuse).

Common Issues in Sex Therapy: Sexual Abuse

• Painful Sex For Women: Even though as many as 1 in 5 women suffer with some form of pain during sexual intercourse (penis in vagina sex), many of these women don't know that this is a common problem. They suffer in silence or they avoid sex altogether.  They also don't know that sex therapy can help them (see my article: Getting Help For Painful Sex in Sex Therapy).

• An Orgasm Gap Between Heterosexual Women and Men:  The orgasm gap refers to differences experienced by heterosexual women as compared to heterosexual men in terms of having an orgasm during partnered sex.  Many women are able to have an orgasm during solo sex (masturbation), but they're unable to have an orgasm during partnered sex with men.  This is usually due to the fact that many women don't have an orgasm from sexual intercourse alone.  They need clitoral stimulation, and many men and some women are unaware of this. Unfortunately, there's also still a double standard when it comes to sexual satisfaction: Some men don't value a woman's sexual pleasure as much as much as they value their own. In addition, some women are also focused more on their male partner's sexual satisfaction.  Or, sex is so unsatisfying for some women that they just want to get it over with as quickly as possible. Often poor sexual communication between the man and the woman having sex is an issue.  In addition, poor sex education in the United States is a contributing factor (see my articles: Closing the Orgasm Gap Between Men and Women - Part 1 and Part 2).

• Compulsive and Out of Control Sexual Behavior:  Sexually compulsive behavior includes an excessive preoccupation with sexual thoughts, urges or behavior. These compulsive thoughts, urges or behavior are disruptive. They often have a significant negative impact on a person's health, relationships, work and other important areas of their life. Compulsive or out of control sexual behavior is not the same as feeling ashamed or guilty about sex in general.  Sexually compulsive behavior can be treated in individual sex therapy or in couples sex therapy (see my article: Treating Sexually Compulsive Behavior in Sex Therapy).

• Lack of Sexual Experience: There are men and women who, for a variety of reasons, have either limited sexual experience or no sexual experience as adults. Shame and guilt are often at the root of this problem, including poor body image.  There might also be cultural factors. Sex therapy can help adults overcome shame and guilt so they can have a healthy sex life (see my article: (see my article: Is a Negative Body Image Ruining Your Sex Life?).

Common Issues in Sex Therapy: Lack of Sexual Experience

• Unrealistic Expectations About Partnered Sex: Due to the inadequacy of sex education in the United States, many people, especially those in their 20s and 30s, get their so-called "sex education" from mainstream pornography. Unfortunately, mainstream pornography gives false and misleading information about sex. People, who rely on mainstream pornography to learn about sex, forget they are watching actors in scripts. They forget that these sexual portrays aren't real.  Not only are these portrayals unrealistic, but the scripts are often very misogynistic in terms of how women are portrayed. Sometimes porn uses women as well as children who have been coerced into working on these films due to sex trafficking.  Pornography also has misleading information about what gets a woman turned on.  This is especially unfortunate because there are sources of ethical pornography that don't have these problems.  Sex therapy can help people, who have false and misleading information about sex and unrealistic expectations, to learn how to have healthier solo and partnered sex.

Common Issues in Sex Therapy: Exploring Kink or BDSM 

• Individuals or Couples Who Want to Explore Kink or BDSM: There are individuals and couples who want to explore kink or BDSM (Bondage, Dominance, Sadism, Masochism), but they might not know where to start. Or, one person in a relationship wants to explore kink and the other is hesitant. Sex therapy can help individuals and couples to start with their sexual fantasies as a way to explore their sexual turn-ons. From there, they can decide if they want to act on their fantasies or if the fantasies are enough without engaging in the behavior (see my articles: Destigmatizing Fantasies About BDSM and What is Power Play?)

• Disagreements About Opening Up a Relationship: Many people who are currently in monogamous relationships would like to have an open relationship, but their partner doesn't want it.  Couples who have a conflict around this issue could benefit from sex therapy where this issue can be negotiated. Other couples both want to open up the relationship, but they don't know how. There are many forms of consensual nonmonogamy. A couple can work out an agreement that suits both of them or they can acknowledge they're not compatible and end the relationship amicably. Sex therapy can help with all of these issues (see my article: What is Consensual Nonmonogamy?)

Common Issues in Sex Therapy: Disagreements About Consensual Nonmonogamy

The categories listed above are just some of the most common reasons why people seek help in sex therapy.  There are many other sexual issues that bring individuals and couples to sex therapy.

Why Couples Therapy is Often Not the Right Therapy for Sexual Problems

Many couples therapists aren't trained sex therapists.  

Worse still, many couples therapists, who were trained in more traditional or outdated forms of couples therapy, don't know how to talk about sex with their clients. Many others collude with couples by avoiding the topic of sex altogether. In cases like this, a couple can go through an entire couples therapy with neither the couple nor the therapist bringing up anything about sex.

Couples therapists who weren't trained in sex therapy believe that if they help the couple to fix romantic problems, sex will naturally improve.  And while this might be true for many couples, it's definitely not true for all couples.  

In fact, there are lots of couples, who love each other and get along well, but there are problems in their sex life.  If a couples therapist doesn't know this, the sexual problems either never get addressed or the couples therapist unintentionally gives misleading or false information.  

In short, many couples therapists, who have no additional training in sex therapy, don't know how to help individuals with contemporary sexual issues.  This often leads to more harm than good.

When to Seek Help in Sex Therapy

Sex therapy is a form of psychotherapy, also known as talk therapy. 

There are no physical exams, no touching and no nudity in sex therapy (see my article: Common Misconceptions About Sex Therapy).

If you have attempted to resolve sexual problems on your own without success, you could benefit from working with a sex therapist.

Rather than allowing hurt, shame and resentment to grow, seek help in sex therapy so you can have a more fulfilling sex life.

About Me

I am a licensed New York City psychotherapist, hypnotherapist, EMDR, AEDP, EFT, Somatic Experiencing and Sex Therapist.

I am also a trauma therapist who has helped clients to overcome problems related to sexual abuse (see my article: What is a Trauma Therapist?).

I am a sex positive therapist who works with individual adults and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.

Treating Sexual Compulsivity in Sex Therapy - Is It a Sexual Addiction or Out of Control Sexual Behavior (OCSB)?

Language matters, especially in the field of mental health.  When mental health professionals pathologize compulsive sexual behavior by defining it as a "sexual addiction," they do clients a disservice.  

This article will focus on the difference between treating sexual compulsivity as out of control sexual behavior (OCSB) as defined by Doug Braun-Harvey, LMFT and Michael A. Vigorito, LMFT in their book Treating Out of Control Sexual Behavior: Rethinking Sex Addiction and treating the problem as a "sexual addiction," as in the work of Dr. Patrick Carnes (see my article: What is Sexual Health?).

Treating Sexual Compulsivity in Sex Therapy

What is Sexually Compulsive Behavior?

Let's start by defining sexually compulsive behavior.

Sexually compulsive behavior is an excessive preoccupation with sexual thoughts, urges and behavior where this behavior is disruptive and has a significant negative impact on a person's health, relationships, work and other important areas of life, including (but not limited to) the following issues:

• Recurrent sexual thoughts, urges and behaviors take up a lot of your time.

• These thoughts, urges and behaviors feel out of control to you.

• Despite repeated attempts, you have been unable to reduce or control these thoughts, urges and behavior on your own.

• Despite serious consequences, you continue to engage in out of control sexual thoughts, urges and behavior.

• You have problems establishing and maintaining relationships, jobs or other important areas in your life because of your sexually compulsive behavior.

Sexual Addiction vs Out of Control Sexual Behavior (OCSB)

As of this writing, there is a heated debate in the mental health field about whether sexually compulsive behavior should be seen as a sexual addiction or as out of control sexual behavior (OCSB).

Treating Out of Control Sexual Behavior in Sex Therapy

Proponents of the sexual addiction perspective see compulsive sexual behavior as similar to other forms of addiction, including alcoholism and drug addiction.  In this model people who engage in compulsive sex are seen as "powerless" over their behavior.  Dr. Patrick Carnes, who has written extensively about "sexual addiction" is one of the biggest proponents of this view.

The main proponents of the out of control sexual behavior (OCSB) perspective are Doug Braun-Harvey, LMFT and Michael A.  Vigorito, LMFT.  They define six principles of sexual health in their book, Treating Out of Control Sexual Behavior: Rethinking Sex Addiction.  Instead of viewing this behavior as an addiction, they see it as sexual behavior that is out of control.  In their view it is a sexual problem but not a sexual disorder or an illness.

Treating Out of Control Sexual Behavior in Sex Therapy

Other proponents of the OCSB view, like Dr. Neil Cannon, see sexual compulsivity as being related to unresolved trauma, unresolved mental health issues, relationship issues and problematic habits.

Treating Out of Control Sexual Behavior in Sex Therapy

OCSB is not a diagnostic term.  The term OCSB refers to problems with self regulation of sexual thoughts, urges and behavior despite negative consequences.

Why Does It Matter How Compulsive Sexual Behavior is Labeled?

In my opinion (and the opinion of many others in the sex therapy field), labeling someone who engages in compulsive sexual behavior as an "addict" is harsh and shame inducing.  

Treating Out of Control Sexual Behavior in Sex Therapy

People who are labeled in such a shame-inducing way are often too embarrassed to admit they have a problem or to get professional help.

Unlike drug and alcohol misuse, people who engage in sexually compulsive behavior cannot be expected to give up having sex so labeling behavior as a sexual addiction is counterproductive to resolving the problem.

Getting Help For Sexually Compulsive Behavior

If you are struggling with sexual compulsivity, you're not alone.  Help is available to you.

Depending upon the particular circumstances, sexually compulsive behavior can be treated in individual sex therapy or in couples therapy with a sex therapist.

Working with a sex positive sex therapist who treats sexual compulsivity as out of control sexual behavior (OCSB) rather than as an addiction is affirming to your sexual health and overall well-being.

About Me

I am a licensed New York City psychotherapist, hypnotherapist, EMDR, AEDP, EFT, Somatic Experiencing and Sex Therapist.

I am a sex positive therapist who works with individual adults and couples (see my article: What is Sex Therapy?).

I have helped many clients to overcome psychological trauma (see my article: What is Trauma Therapy?

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist.

To set up a consultation, call me at (917) 742-2624 during business hours or email me.