Purpose of Review
Compulsive sexual behavior (CSB) is widely regarded as a “behavioral addiction,” and is a major threat to quality of life and both physical and mental health. However, CSB has been slow to be recognized clinically as a diagnosable disorder. CSB is co-morbid with affective disorders as well as substance use disorders, and recent neuroimaging studies have demonstrated shared or overlapping neural pathologies disorders, especially in brain regions controlling motivational salience and inhibitory control.
Clinical neuroimaging studies are reviewed that have identified structural and/or function changes in prefrontal cortex, amygdala, striatum, and thalamus in individuals suffering from CSB. A preclinical model to study the neural underpinnings of CSB in male rats is discussed consisting of a conditioned aversion procedure to examine seeking of sexual behavior despite known negative consequences. Using this preclinical model, a role of the medial prefrontal cortex was identified, including neural plasticity during comorbidity of CSB and psychostimulant abuse.
This review summarizes recent human behavioral and neuroimaging studies, in addition to preclinical models that can be used to study the underlying neurobiology of CSB.
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Derbyshire KL, Grant JE. Compulsive sexual behavior: a review of the literature. J Behav Addict. 2015;4:37–43.
Werner M, Stulhofer A, Waldorp L, Jurin T. A network approach to Hypersexuality: insights and clinical implications. J Sex Med. 2018;15:373–86.
Kingston DA. Moving forward on Hypersexuality. Arch Sex Behav. 2017;46:2257–9.
Walton MT, Cantor JM, Bhullar N, Lykins AD. Hypersexuality: a critical review and introduction to the "Sexhavior cycle". Arch Sex Behav. 2017;46:2231–51.
Kuhn S, Gallinat J. Neurobiological basis of Hypersexuality. Int Rev Neurobiol. 2016;129:67–83.
Kraus SW, Voon V, Potenza MN. Neurobiology of compulsive sexual behavior: emerging science. Neuropsychopharmacology. 2016;41:385–6.
Blais-Lecours S, Vaillancourt-Morel MP, Sabourin S, Godbout N. Cyberpornography: time use, perceived addiction, sexual functioning, and sexual satisfaction. Cyberpsychol Behav Soc Netw. 2016;19:649–55.
Lee K, Hutton HE, Lesko CR, Monroe AK, Alvanzo A, McCaul ME, et al. Associations of drug use, violence, and depressive symptoms with sexual risk behaviors among women with alcohol misuse. Womens Health Issues. 2018;
Reid RC, Dhuffar MK, Parhami I, Fong TW. Exploring facets of personality in a patient sample of hypersexual women compared with hypersexual men. J Psychiatr Pract. 2012;18:262–8.
Dhuffar MK, Griffiths MD. Understanding the role of shame and its consequences in female hypersexual behaviours: a pilot study. J Behav Addict. 2014;3:231–7.
K. Romer Thomsen et al. Impulsivity traits and addiction-related behaviors in youth. J Behav Addict. 2018;1–14.
Reid RC, Kafka MP. Controversies about hypersexual disorder and the DSM-5. Curr Sex Health Rep. 2014;6:259–64.
A. P. Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
•• Krueger RB. Diagnosis of hypersexual or compulsive sexual behavior can be made using ICD-10 and DSM-5 despite rejection of this diagnosis by the American Psychiatric Association. Addiction. 2016;111:2110–1. This commentary supports the clinical diagnosis of compulsive sexual behavior based on the ICD-10 and ICD-11, if not based on DSM-V.
Emond FC, Nolet K, Cyr G, Rouleau J-L, Gagnon J. Sexual impulsivity and problematic sexual behaviors in adults: towards innovative domain-specific behavioral measures. J Sexol. 2015;25:184–90.
Walton MT, Bhullar N. Compulsive sexual behavior as an impulse control disorder: awaiting field studies data. Arch Sex Behav. 2018;47:1327–31.
• Gola M, Potenza MN. The proof of the pudding is in the tasting: data are needed to test models and hypotheses related to compulsive sexual behaviors. Arch Sex Behav. 2018). This letter highlights the importance of empirically-defined definitions of compulsive sexual behavior, and calls for more neuroscientific studies of the disorder.;47:1323–5.
Hook JN, Hook JP, Davis DE, Worthington EL Jr, Penberthy JK. Measuring sexual addiction and compulsivity: a critical review of instruments. J Sex Marital Ther. 2010;36:227–60.
Tull MT, Gratz KL. Major depression and risky sexual behavior among substance dependent patients: the moderating roles of distress tolerance and gender. Cognit Ther Res. 2013;37:483–97.
Weiss NH, Tull MT, Sullivan TP, Dixon-Gordon KL, Gratz KL. Posttraumatic stress disorder symptoms and risky behaviors among trauma-exposed inpatients with substance dependence: the influence of negative and positive urgency. Drug Alcohol Depend. 2015;155:147–53.
Weiss NH, Tull MT, Dixon-Gordon K, Gratz KL. Assessing the negative and positive emotion-dependent nature of risky behaviors among substance dependent patients. Assessment. 2016:107319111666590.
Tull MT, Gratz KL, Weiss NH. Exploring associations between borderline personality disorder, crack/cocaine dependence, gender, and risky sexual behavior among substance-dependent inpatients. Personal Disord. 2011;2:209–19.
Torrisi M, Cacciola A, Marra A, de Luca R, Bramanti P, Calabrò RS. Inappropriate behaviors and hypersexuality in individuals with dementia: an overview of a neglected issue. Geriatr Gerontol Int. 2017;17:865–74.
Bronner G, Aharon-Peretz J, Hassin-Baer S. Sexuality in patients with Parkinson's disease, Alzheimer's disease, and other dementias. Handb Clin Neurol. 2015;130:297–323.
Schenck CH, Arnulf I, Mahowald MW. Sleep and sex: what can go wrong? A review of the literature on sleep related disorders and abnormal sexual behaviors and experiences. Sleep. 2007;30:683–702.
Reid RC, Harper JM, Anderson EH. Coping strategies used by hypersexual patients to defend against the painful effects of shame. Clin Psychol Psychother. 2009;16:125–38.
Weiss NH, Tull MT, Viana AG, Anestis MD, Gratz KL. Impulsive behaviors as an emotion regulation strategy: examining associations between PTSD, emotion dysregulation, and impulsive behaviors among substance dependent inpatients. J Anxiety Disord. 2012;26:453–8.
Watter DN. Existential issues in sexual medicine: the relation between death anxiety and Hypersexuality. Sex Med Rev. 2018;6:3–10.
Chatzittofis A, Arver S, Öberg K, Hallberg J, Nordström P, Jokinen J. HPA axis dysregulation in men with hypersexual disorder. Psychoneuroendocrinology. 2016;63:247–53.
Jokinen J, Boström AE, Chatzittofis A, Ciuculete DM, Öberg KG, Flanagan JN, et al. Methylation of HPA axis related genes in men with hypersexual disorder. Psychoneuroendocrinology. 2017;80:67–73.
Walton MT, Lykins AD, Bhullar N. Sexual arousal and sexual activity frequency: implications for understanding Hypersexuality. Arch Sex Behav. 2016;45:777–82.
Kingston DA, Graham FJ, Knight RA. Relations between self-reported adverse events in childhood and Hypersexuality in adult male sexual offenders. Arch Sex Behav. 2017;46:707–20.
Liljegren M, Naasan G, Temlett J, Perry DC, Rankin KP, Merrilees J, et al. Criminal behavior in frontotemporal dementia and Alzheimer disease. JAMA Neurol. 2015;72:295–300.
Mendez MF, Shapira JS. Hypersexual behavior in frontotemporal dementia: a comparison with early-onset Alzheimer's disease. Arch Sex Behav. 2013;42:501–9.
M. R. Lo Monaco et al., Prevalence of impulsive-compulsive symptoms in elderly Parkinson's disease patients: a case-control study. J Clin Psychiatry. 2018;79.
De Sousa SM, Chapman IM, Falhammar H, Torpy DJ. Dopa-testotoxicosis: disruptive hypersexuality in hypogonadal men with prolactinomas treated with dopamine agonists. Endocrine. 2017;55:618–24.
Frohmader KS, Pitchers KK, Balfour ME, Coolen LM. Mixing pleasures: review of the effects of drugs on sex behavior in humans and animal models. Horm Behav. 2010;58:149–62.
Volkow ND, et al. Stimulant-induced enhanced sexual desire as a potential contributing factor in HIV transmission. Am J Psychiatry. 2007;164:157–60.
Ahmadi K, Javadinia SA, Saadat SH, Ramezani MA, Sedghijalal H. Triangular relationship among risky sexual behavior, addiction, and aggression: a systematic review. Electron Physician. 2017;9:5129–37.
Johnson MW, Bruner NR. The sexual discounting task: HIV risk behavior and the discounting of delayed sexual rewards in cocaine dependence. Drug Alcohol Depend. 2012;123:15–21.
•• M. S. Berry, M. W. Johnson, Does being drunk or high cause HIV sexual risk behavior? A systematic review of drug administration studies. Pharmacol Biochem Behav 164, 125–138 (2018). This systematic review summarizes the recent links within the published literature, in both men and women, between substance use and compulsive sexual behavior.
Rawson RA, Washton A, Domier CP, Reiber C. Drugs and sexual effects: role of drug type and gender. J Subst Abus Treat. 2002;22:103–8.
Semple SJ, Grant I, Patterson TL. Female methamphetamine users: social characteristics and sexual risk behavior. Women Health. 2004;40:35–50.
Semple SJ, Patterson TL, Grant I. A comparison of injection and non-injection methamphetamine-using HIV positive men who have sex with men. Drug Alcohol Depend. 2004;76:203–12.
Zapata LB, Hillis SD, Marchbanks PA, Curtis KM, Lowry R. Methamphetamine use is independently associated with recent risky sexual behaviors and adolescent pregnancy. J Sch Health. 2008;78:641–8.
Cartier JJ, Greenwell L, Prendergast ML. The persistence of HIV risk behaviors among methamphetamine-using offenders. J Psychoactive Drugs. 2008;40:437–46.
Mausbach BT, Semple SJ, Strathdee SA, Patterson TL. Predictors of safer sex intentions and protected sex among heterosexual HIV-negative methamphetamine users: an expanded model of the theory of planned behavior. AIDS Care. 2009;21:17–24.
Saw YM, Saw TN, Chan N, Cho SM, Jimba M. Gender-specific differences in high-risk sexual behaviors among methamphetamine users in Myanmar-China border city, muse, Myanmar: who is at risk? BMC Public Health. 2018;18(209):209.
Mitchell SG, Kelly SM, Brown BS, O'Grady KE, Schwartz RP. HIV sex-risk behaviors among in- versus out-of-treatment heroin-addicted adults. Am J Drug Alcohol Abuse. 2012;38:328–33.
Hartzler B, Beadnell B, Calsyn DA. Use of sexual risk assessment and feedback at intake to promote counselor awareness of subsequent client risk behavior during early treatment. Subst Use Misuse. 2014;49:1270–7.
Mastroleo NR, Operario D, Barnett NP, Colby SM, Kahler CW, Monti PM. Prevalence of heavy drinking and risky sexual behaviors in adult emergency department patients. Alcohol Clin Exp Res. 2015;39:1997–2002.
Wray TB, Celio MA, Kahler CW, Barnett NP, Mastroleo NR, Operario D, et al. Daily co-occurrence of alcohol use and high-risk sexual behavior among heterosexual, heavy drinking emergency department patients. Drug Alcohol Depend. 2015;152:109–15.
MacKillop J, Celio MA, Mastroleo NR, Kahler CW, Operario D, Colby SM, et al. Behavioral economic decision making and alcohol-related sexual risk behavior. AIDS Behav. 2015;19:450–8.
• M. W. Johnson, P. S. Johnson, E. S. Herrmann, M. M. Sweeney, Delay and probability discounting of sexual and monetary outcomes in individuals with cocaine use disorders and matched controls. PLoS One 10, e0128641 (2015). This study demonstrates that individuals with cocaine use disorders make impulsive choices for less-favorable outcomes, such as risky sexual behavior without a condom, in both sexual and monetary hypothetical delay discounting tasks.
Semple SJ, Strathdee SA, Zians J, Patterson TL. Life events and sexual risk among HIV-negative, heterosexual, methamphetamine users. J Sex Res. 2010;47:355–63.
Green AI, Halkitis PN. Crystal methamphetamine and sexual sociality in an urban gay subculture: an elective affinity. Culture, Health & Sexuality. 2006;8:317–33.
Halkitis PN, Parsons JT, Stirratt MJ. A double epidemic: crystal methamphetamine drug use in relation to HIV transmission among gay men. J Homosex. 2001;41:17–35.
Mckirnan DJ, Vanable PA, Ostrow DG, Hope B. Expectancies of sexual "escape" and sexual risk among drug and alcohol-involved gay and bisexual men. J Subst Abus. 2001;13:137–54.
Peugh J, Belenko S. Alcohol, drugs and sexual function: a review. J Psychoactive Drugs. 2001;33:223–32.
Fisher DG, Reynolds GL, Napper LE. Use of crystal methamphetamine, Viagra, and sexual behavior. Curr Opin Infect Dis. 2010;23:53–6.
Somlai AM, Kelly JA, McAuliffe TL, Ksobiech K, Hackl KL. Predictors of HIV sexual risk behaviors in a community sample of injection drug-using men and women. AIDS Behav. 2003;7:383–93.
Frosch D, Shoptaw S, Huber A, Rawson RA, Ling W. Sexual HIV risk among gay and bisexual male methamphetamine abusers. J Subst Abus Treat. 1996;13:483–6.
Zenilman JM. Behavioral interventions--rationale, measurement, and effectiveness. Infect Dis Clin N Am. 2005;19:541–62.
Semple SJ, Patterson TL, Grant I. The context of sexual risk behavior among heterosexual methamphetamine users. Addict Behav. 2004;29:807–10.
Springer AE, Peters RJ, Shegog R, White DL, Kelder SH. Methamphetamine use and sexual risk behaviors in U.S. high school students: findings from a national risk behavior survey. Prevention science : the official journal of the Society for Prevention Research. 2007;8:103–13.
Semple SJ, Patterson TL, Grant I. Motivations associated with methamphetamine use among HIV men who have sex with men. J Subst Abus Treat. 2002;22:149–56.
Schilder AJ, Lampinen TM, Miller ML, Hogg RS. Crystal methamphetamine and ecstasy differ in relation to unsafe sex among young gay men. Canadian journal of public health. 2005;96:340–3.
Lyons T, Chandra G, Goldstein J, Ostrow DG. Breaking the bond between stimulant use and risky sex: a qualitative study. Subst Abus. 2010;31:224–30.
Sánchez J, Comerford M, Chitwood DD, Fernandez MI, McCoy CB. High risk sexual behaviours among heroin sniffers who have no history of injection drug use: implications for HIV risk reduction. AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV. 2002;14:391–8.
Fisher DG, Reynolds GL, Ware MR, Napper LE. Methamphetamine and Viagra use: relationship to sexual risk behaviors. Arch Sex Behav. 2009;
Raj A, Saitz R, Cheng DM, Winter M, Samet JH. Associations between alcohol, heroin, and cocaine use and high risk sexual behaviors among detoxification patients. The American Journal of Drug and Alcohol Abuse. 2007;33:169–78.
Crowe LC, George WH. Alcohol and human sexuality: review and integration. Psychol Bull. 1989;105:374–86.
Herrmann ES, Hand DJ, Johnson MW, Badger GJ, Heil SH. Examining delay discounting of condom-protected sex among opioid-dependent women and non-drug-using control women. Drug Alcohol Depend. 2014;144:53–60.
•• Johnson MW, Herrmann ES, Sweeney MM, LeComte RS, Johnson PS. Cocaine administration dose-dependently increases sexual desire and decreases condom use likelihood: the role of delay and probability discounting in connecting cocaine with HIV. Psychopharmacology. 2017;234:599–612. This study demonstrates that accute cocaine intoxication directly increases sexual desire and impulsive choice (delay discounting) in hypothetical behavioral economics tasks.
Johnson MW. An efficient operant choice procedure for assessing delay discounting in humans: initial validation in cocaine-dependent and control individuals. Exp Clin Psychopharmacol. 2012;20:191–204.
Johnson MW, Bruner NR. Test-retest reliability and gender differences in the sexual discounting task among cocaine-dependent individuals. Exp Clin Psychopharmacol. 2013;21:277–86.
•• Koffarnus MN, Johnson MW, Thompson-Lake DGY, Wesley MJ, Lohrenz T, Montague PR, et al. Cocaine-dependent adults and recreational cocaine users are more likely than controls to choose immediate unsafe sex over delayed safer sex. Exp Clin Psychopharmacol. 2016;24:297–304. This study confirms that in addition to individuals with cocaine use disorders (see Johnson et al. 2015 PLoS One ), recreational cocaine users also demonstrate impulsive, risky sexual decision making compared to controls in a hypothetical delay-discounting task.
Monga TN, Monga M, Raina MS, Hardjasudarma M. Hypersexuality in stroke. Arch Phys Med Rehabil. 1986;67:415–7.
De Giorgi R, Series H. Treatment of inappropriate sexual behavior in dementia. Curr Treat Options Neurol. 2016;18(41):41.
Eghwrudjakpor P, Essien A. Hypersexual behavior following craniocerebral trauma an experience with five cases. Libyan J Med. 2008;3:192–4.
Miller BL, Cummings JL, McIntyre H, Ebers G, Grode M. Hypersexuality or altered sexual preference following brain injury. J Neurol Neurosurg Psychiatry. 1986;49:867–73.
Kile SJ, Ellis WG, Olichney JM, Farias S, DeCarli C. Alzheimer abnormalities of the amygdala with Kluver-Bucy syndrome symptoms: an amygdaloid variant of Alzheimer disease. Arch Neurol. 2009;66:125–9.
Strahler J, Kruse O, Wehrum-Osinsky S, Klucken T, Stark R. Neural correlates of gender differences in distractibility by sexual stimuli. Neuroimage. 2018;176:499–509.
•• J. W. Seok, J. H. Sohn, Neural Substrates of Sexual Desire in Individuals with Problematic Hypersexual Behavior. Front Behav Neurosci 9, 321 (2015). This study measures fMRI activity correlating with viewing sexual stimuli, and observed greater activation in the caudate nucleus, inferior parietal lobe, dorsal anterior cingulate gyrus, thalamus, and dorsolateral prefrontal cortex, i.e. areas that are also activated in drug-users when exposed to drug cues.
Voon V, Mole TB, Banca P, Porter L, Morris L, Mitchell S, et al. Neural correlates of sexual cue reactivity in individuals with and without compulsive sexual behaviours. PLoS One. 2014;9:e102419.
•• Schmidt C, Morris LS, Kvamme TL, Hall P, Birchard T, Voon V. Compulsive sexual behavior: prefrontal and limbic volume and interactions. Hum Brain Mapp. 2017;38:1182–90. This study is a first step in identifying functional brain connectivity in compulsive sexual behavior subjects at resting state, and demonstrates a decrease in resting state functional connectivity between prefrontal cortex and amygdala which correlated with greater left amygdala gray matter volume.
Kuhn S, Gallinat J. Common biology of craving across legal and illegal drugs - a quantitative meta-analysis of cue-reactivity brain response. Eur J Neurosci. 2011;33:1318–26.
Chang L, Alicata D, Ernst T, Volkow N. Structural and metabolic brain changes in the striatum associated with methamphetamine abuse. Addiction. 2007;102(Suppl 1):16–32.
Goldstein RZ, Volkow ND. Dysfunction of the prefrontal cortex in addiction: neuroimaging findings and clinical implications. Nat Rev Neurosci. 2011;12:652–69.
Childress AR, Ehrman RN, Wang Z, Li Y, Sciortino N, Hakun J, et al. Prelude to passion: limbic activation by "unseen" drug and sexual cues. PLoS One. 2008;3:e1506.
Moeller SJ, Zilverstand A, Konova AB, Kundu P, Parvaz MA, Preston-Campbell R, et al. Neural correlates of drug-biased choice in currently using and abstinent individuals with cocaine use disorder. Biol Psychiatry Cogn Neurosci Neuroimaging. 2018;3:485–94.
Kuhn S, Gallinat J. A quantitative meta-analysis on cue-induced male sexual arousal. J Sex Med. 2011;8:2269–75.
Stoleru S, Fonteille V, Cornelis C, Joyal C, Moulier V. Functional neuroimaging studies of sexual arousal and orgasm in healthy men and women: a review and meta-analysis. Neurosci Biobehav Rev. 2012;36:1481–509.
Clark VP, Beatty GK, Anderson RE, Kodituwakku P, Phillips JP, Lane TDR, et al. Reduced fMRI activity predicts relapse in patients recovering from stimulant dependence. Hum Brain Mapp. 2014;35:414–28.
Paulus MP, Tapert SF, Schuckit MA. Neural activation patterns of methamphetamine-dependent subjects during decision making predict relapse. Arch Gen Psychiatry. 2005;62:761–8.
Chu XA. A., Sociosexual interactions in rats: are they relevant for understanding human sexual behavior? International Journal of Psychological Research. 2016;9:76–95.
Le Moene O, Agmo A. The neuroendocrinology of sexual attraction. Front Neuroendocrinol. 2017;
Veening JG, Coolen LM, Gerrits PO. Neural mechanisms of female sexual behavior in the rat; comparison with male ejaculatory control. Pharmacol Biochem Behav. 2014;121:16–30.
Veening JG, Coolen LM. Neural mechanisms of sexual behavior in the male rat: emphasis on ejaculation-related circuits. Pharmacol Biochem Behav. 2014;121:170–83.
Persinger MA. Maintained hypersexuality between male rats following chronically induced limbic seizures: implications for bisexuality in complex partial epileptic seizures. Psychol Rep. 1994;74:647–52.
•• Davis JF, Loos M, di Sebastiano AR, Brown JL, Lehman MN, Coolen LM. Lesions of the medial prefrontal cortex cause maladaptive sexual behavior in male rats. Biol Psychiatry. 2010;67:1199–204. This study is the first description of conditioned sex aversion as a model for compulsive sexual behavior, in male rats, and demonstrates a critical role of the medial prefrontal cortex.
Peters RH. Learned aversions to copulatory behaviors in male rats. Behav Neurosci. 1983;97:140–5.
Agmo A. Copulation-contingent aversive conditioning and sexual incentive motivation in male rats: evidence for a two-stage process of sexual behavior. Physiol Behav. 2002;77:425–35.
Kwok DWS, Boakes RA. Situational relevance: context as a factor in serial overshadowing of taste aversion learning. Q J Exp Psychol (Hove). 2017:1–35.
Barker JM, Zhang H, Villafane JJ, Wang TL, Torregrossa MM, Taylor JR. Epigenetic and pharmacological regulation of 5HT3 receptors controls compulsive ethanol seeking in mice. Eur J Neurosci. 2014;39:999–1008.
Frohmader KS, Bateman KL, Lehman MN, Coolen LM. Effects of methamphetamine on sexual performance and compulsive sex behavior in male rats. Psychopharmacology. 2010;212:93–104.
•• Frohmader KS, Lehman MN, Laviolette SR, Coolen LM. Concurrent exposure to methamphetamine and sexual behavior enhances subsequent drug reward and causes compulsive sexual behavior in male rats. J Neurosci. 2011;31:16473–82. This study demonstrates the experience with methamphetamine concurrently with sexual behavior results in compulsive sexual behavior in male rats.
•• Kuiper LB, Frohmader KS, Coolen LM. Maladaptive sexual behavior following concurrent methamphetamine and sexual experience in male rats is associated with altered neural activity in frontal cortex. Neuropsychopharmacology. 2017). This study is a first preclinical study showing the neural correlates of conditioned sex aversion, and compulsive sexual behavior, in male rats.;42:2011–20.
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The authors declare that they have no conflicts of interest.
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This article does not contain any studies with human or animal subjects performed by any of the authors.
This article is part of the Topical Collection on Preclinical and Psychophysiology
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Kuiper, L.B., Coolen, L.M. Compulsive Sexual Behavior in Humans and Preclinical Models. Curr Sex Health Rep 10, 124–131 (2018). https://doi.org/10.1007/s11930-018-0157-2
- Compulsive sexual behavior
- Prefrontal cortex
- Limbic system
- Sexual behavior