Pebble Kranz，醫學博士； Daniel Rosen，LCSW，CST / 2024 年 7 月 31 日 /
評論 / Medscape Family Medicine
一名 25 歲男子因肌肉拉傷進來。你問他還有什麼要討論的嗎？他羞澀地表示，他對自己使用色情內容的視聽產品感到擔憂。
一位 45 歲的女性患有憂鬱症，她發現自己不斷地在長期關係之外尋求性行為。她的伴侶威脅要離開。她很傷心，並告訴你她不懂自己的行為。
這些患者是否有某種形式的性成癮？初級保健臨床醫師應如何介入？轉介治療性成癮的 12 步驟計畫是正確的選擇嗎？還存在哪些其他選擇？診斷（更不用說治療）是否可能或適當？
《誰是你所說的「異常」》？
「 正常」對於人類性行為來說並不是一個有意義的概念。引用性治療師馬蒂·克萊因博士的話：「正常只是烘乾機上的一個設定。」
伴侶之間也是如此：性關係中一個人的「正常」行為可能會讓另一個人感到不安。在伴侶關係中，我們在各種問題上都有分歧，從財務到育兒，再到如何裝載洗碗機。為什麼在性別、性慾和性頻率上應該與前述狀況不同？
請記住：羞恥、恐懼和保密往往會導致痛苦的行為長期存在。幫助我們的患者接受並擁抱他們的整個自我可以提供重要的治療，緩解焦慮，甚至可以幫助他們規範自己的行為。減少羞恥感、恐懼感和保密感可能有助於更安全地選擇性行為，以及性傳播感染 (STIs) 的檢測和治療。
國際疾病分類 11 將強迫性行為障礙 ( compulsive sexual behavior disorder , CSBD) 納入其中，試圖圍繞一個複雜且備受爭議的問題達成共識，以促進診斷和研究。與CSBD類似的症候群有許多名稱：「性慾亢進」、「性成癮」、「性強迫症」和「性行為失控」。性研究界的相當一部分人對 CSBD 是否是一種離散的診斷表示懷疑。
根據 ICD-11，CSBD 的特徵是「強烈、重複的性衝動或衝動，無法抗拒或無法控制」，並導致嚴重的痛苦或功能障礙。
此診斷有幾個重要的排除因素。首先，性慾倒錯被定義為一連串未經同意的性行為和興趣，被排除在外。另一個原因是，僅與道德判斷或社會不滿相關的痛苦不足以診斷 CSBD。最後，診斷取決於痛苦，而不依賴任何類型的性行為的頻率。有些人會對他們不經常從事的行為感到嚴重的痛苦，而有些人則可能不會因為他們經常從事的活動而感到痛苦。
德國的一項研究顯示，5% 的男性和 3% 的女性符合 CSBD 標準。美國的一項小型研究發現這一數字分別為 10% 和 7%。診斷並不簡單。強迫性性行為可能繼發於其他心理健康或醫療狀況。有時與 CSBD 混淆的行為可能是由神經系統疾病引起的，例如額葉腦損傷或額顳葉癡呆，以及使用增強多巴胺活性的物質和藥物。
對性衝動的控制受損發生在躁狂和輕躁症發作。強迫性性行為經常與情緒障礙、強迫症、注意力不足/過動症和物質使用障礙同時發生。符合 CSBD 標準的人可能會透過性行為來應對憂鬱、焦慮、無聊、孤獨或其他負面情緒狀態。
CSBD 的診斷可能對臨床醫生有用。然而，許多（也許是大多數）對其性行為表示擔憂的患者並無法滿足 CSBD 的大多數標準。他們的問題持續時間較短，與道德、外界的反對、缺乏性健康資訊以及對不同色情興趣的焦慮有關。讓他們了解自己並沒有受到終生疾病的困擾，而是正在經歷共同的生活挑戰，可能會有所幫助。
社會對露骨色情媒體（通常稱為pornography，色情內容作品）的擔憂是複雜的、相互衝突的和災難性的。一些研究顯示，露骨的性媒體對於個人的和關係性的性滿足都有正面作用。其他研究發現對性功能有負面影響。對色情內容作品的擔憂常常與單獨性活動（自慰）的禁忌混為一談。諷刺的是，使用色情內容作品與對色情內容作品成癮的恐懼有關，從而產生負面自我認知的螺旋式上升。
即使一個人不符合 CSBD 的標準，性行為的後果也可能會引起痛苦，例如婚姻可能會解體、失業、過度消費、性傳播感染、其他健康問題，甚至法律問題。性行為可能不是核心問題，而是關係著困擾、心理健康障礙或功能失調等問題的因應方式的一個分支。
內疚和羞恥感可以成為維持這些行為以及促進圍繞這些行為的秘密的有力因素。性醫學專家建議避免增加歧視和恥辱經驗的介入措施，並避免將性別多樣化個體的行為病態化。正如在醫療保健的許多方面一樣，我們必須站在病人的立場上思考，避免將我們自己的道德或宗教價值觀強加給他們。
初級衛生保健提供者可以做些什麼呢？
當患者擔心性行為失控時，初級保健提供者在評估神經系統疾病或與使用藥物或其他物質相關的副作用以及促進精神病學評估以評估心理健康合併症方面上發揮著重要作用，過去的創傷和相關的依戀障礙（attachment disorder）。
我們的患者需要資源來梳理解決可能出現的個人的和關係的問題。在您的社區中尋找訓練有素的性治療同事。美國性教育者、諮商師和治療師協會 (The American Association of Sexuality Educators, Counselors, and Therapists, AASECT) 是美國性治療的認證機構之一。
由於出現失控性行為的患者存在異質性，因此沒有一種治療方法適合所有人。十二步驟計畫，尤其是那些注重性「禁慾」的計畫，可能不是最好的選擇。許多心理治療方式都是有效的，並且通常專注於解決潛在的或未被認識到的心理健康問題，提供自我調節和衝動管理以及人際關係技巧方面的培訓。最重要的是，治療師需要了解性學知識並意識到自己對性的偏見。如果沒有同時進行心理介入，不建議進行藥物治療。
關係性治療可以幫助夫妻建立明確的關係協議，該協議對雙方（或在多角戀關係中，對每個參與者）都有效。關係困擾也可能刺激個別心理治療。
回到前述的這兩個病人
可以建議這名 25 歲的年輕人使用露骨的性媒體和單獨的性行為（自慰）本質上並不是壞事或具有破壞性。當用於愉悅和享受時，它們不會導致伴侶性行為問題或導致性功能障礙。建議他朝著社會參與和生活目標邁進，而不是遠離色情內容作品，可能就是所需要的。
我們的第二位患者可能需要更強化的治療，包括對她的情緒進行藥物管理，以及轉介給一位在處理失控性行為方面擁有專業知識且經過認證的性治療師。當她在後續中回來見你時，她理想地表達了減少的羞恥感、更多的自主權以及與她的價值觀的新聯繫，並且她在不犧牲性需求的情況下保持了她的關係協議。
引用此內容：性行為何時失控？ – Medscape – 2024 年 7 月 31 日。
When Is Sexual Behavior Out of Control?
Pebble Kranz, MD; Daniel Rosen, LCSW, CST / July 31, 2024 / COMMENTARY / Medscape Family Medicine
A 25-year-old man comes in with a pulled muscle. You ask if he has anything else to discuss. Sheepishly, he says he is concerned about his use of pornography.
A 45-year-old woman struggling with depression finds herself persistently seeking sex outside the bounds of her long-term relationship. Her partner is threatening to leave. She is devastated and tells you she doesn’t understand her own behavior.
Do these patients have some form of sex addiction? How should a primary care clinician intervene? Is a referral to a 12-step program for sex addiction the right choice? What other options exist? Is a diagnosis — let alone treatment — possible or appropriate?
‘Who Are You Calling “Abnormal”‘?
Normal is not a meaningful concept in human sexual behavior. To quote the sex therapist Marty Klein, PhD: “Normal is just a setting on the dryer.”
The same goes among partners: What is “normal” for one person in a sexual relationship may discomfit another. In partnerships, we have differences around all sorts of issues, from finances to parenting to how to load the dishwasher. Why should sex, sexual desire, and sexual frequency be different?
Remember: Shame, fear, and secrecy often play a role in perpetuating behaviors that cause distress. Helping our patients accept and embrace their whole selves can provide important healing, relief from anxiety, and may even help them regulate their actions. Feeling less shame, fear, and secrecy may facilitate safer choices about sex, as well as testing and treatment for sexually transmitted infections.
The International Classification of Diseases-11 includes compulsive sexual behavior disorder (CSBD) as an attempt to create consensus around a complicated, and hotly debated, problem to facilitate diagnosis and research. Syndromes similar to CSBD have had many names: “hypersexual disorder,” “sexual addiction,” “sexual compulsivity,” and “out-of-control sexual behavior.” A sizable cohort of the sexuality research community casts doubt on whether CSBD is even a discrete diagnosis.
According to the ICD-11, CSBD is characterized by “intense, repetitive sexual impulses or urges that are experienced as irresistible or uncontrollable” and result in significant distress or functional impairment.
This diagnosis has several important rule-outs. First, paraphilias, defined as a set of nonconsensual sexual behaviors and interests, are excluded. Another is that distress exclusively related to moral judgment or social disapproval is not sufficient for a diagnosis of CSBD. Finally, the diagnosis hinges on distress and does not rely on frequency of any type of sexual behavior. Some people experience significant distress over behaviors in which they engage infrequently, whereas others may have no distress from activities in which they engage quite frequently.
In one study from Germany, 5% of men and 3% of women met criteria for CSBD. A small US study found the number to be 10% and 7%, respectively. The diagnosis is not simple. Compulsive sexual behavior can be secondary to other mental health or medical conditions. Behaviors sometimes confused with CSBD can result from neurologic diseases, such as frontal brain lesions or frontotemporal dementia, as well as the use of substances and medications that enhance dopaminergic activity.
Impaired control over sexual impulses occurs in manic and hypomanic episodes. Compulsive sexual behavior frequently co-occurs with mood disorders, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, and substance use disorders. Those meeting criteria for CSBD may engage in sexual behaviors as a way of coping with depression, anxiety, boredom, loneliness, or other negative affective states.
The diagnosis of CSBD may be useful for clinicians. However, many, perhaps most, patients who present with concerns about their sexual behavior will fail to meet most criteria for CSBD. Their problem is of shorter duration, related to morality, external disapproval, lack of sexual health information, and anxiety about diverse erotic interests. It may be helpful for them to understand that they are not in the grip of a lifelong disorder but are experiencing common life challenges.
Societal concerns about sexually explicit media, often called pornography, are complex, conflicting, and catastrophizing. Some studies indicate that sexually explicit media are positive for both individual and relational sexual satisfaction; other studies have found negative effects on sexual function. Concerns about pornography often are conflated with taboos about solo sexual activity. Ironically, use of pornography is associated with fear of addiction to pornography, creating a spiral of negative self-perception.
Consequences of sexual behavior may induce distress, even if a person doesn’t meet criteria for CSBD, such as potential dissolution of a marriage, loss of a job, excessive spending, sexually transmitted infections, other health concerns, and even legal problems. Sexual behavior might not be the central issue but rather an offshoot of relational distress, a mental health disorder, or a dysfunctional coping style.
Guilt and shame can act as potent contributors to maintaining the behaviors as well as promoting secrecy around them. Sexual medicine experts recommend avoiding interventions that increase the experience of discrimination and stigma and avoiding the pathologization of the behaviors of sexually diverse individuals. As in so many aspects of medical care, we must walk in our patients’ shoes and avoid imposing on them our own moral or religious values.
What Can a Primary Care Provider Do?
When a patient is concerned about sexual behavior that feels out of control, primary care providers have an important role in evaluating for neurologic disease or side effects related to the use of medication or other substances, and facilitating psychiatric assessment to evaluate for mental health comorbidities, past trauma, and associated attachment disorders.
Our patients need resources to tease out the individual and relational problems that may arise. Seek out well-trained sex therapy colleagues in your community. The American Association of Sexuality Educators, Counselors, and Therapists (AASECT) is one certifying body in the United States for sex therapy.
Because of the heterogeneity of those who present with out-of-control sexual behavior, no one treatment fits all. Twelve-step programs, especially those with a focus on sexual “abstinence,” may not be the best choice. Many psychotherapeutic modalities are effective and often focus on addressing underlying or unrecognized mental health concerns, provide training on self-regulation and urge management, and relationship skills. Most important, the therapist needs to be sexologically informed and aware of their own biases around sexuality. Medical treatments are not recommended without concurrent psychological intervention.
Relational sex therapy can help couples create clear relational agreements that work for both parties (or, in polyamorous relationships, everyone involved). Relational distress also may be a stimulus for individual psychotherapy.
Back to these two patients.
The 25-year-old could be counseled that use of sexually explicit media and solo sex are not inherently bad or damaging. When used for pleasure and enjoyment, they do not lead to problems with partnered sex or cause sexual dysfunction. Counseling him to move toward social engagement and life goals, rather than away from pornography, may be all that is necessary.
Our second patient probably will need more intensive treatment, including medication management for her mood and referral to a certified sex therapist who has expertise in working with out-of-control sexual behavior. When she returns to see you in follow-up, she ideally expresses reduced shame, more autonomy, and renewed connection to her values, and she is keeping her relational agreements without sacrificing her sexual needs.
Cite this: When Is Sexual Behavior Out of Control? – Medscape – July 31, 2024.