What are the links between sexual compulsivity and the transmission of HIV?
Key take-home messages
- Prevention programs could use sexual compulsivity scales or community-based participatory research methods to collect and assess sexual health data on sexual behaviour that could be used to (4;12):
- Encourage clients to assess their sexual behaviors and decide to test for HIV and other STIs.
- Help health providers identify the psychological thought processes, psychiatric and biomedical disorders, personality dispositions, addiction patterns, and socio-cultural realities that contribute to high risk sexual behaviors (7).
- Influence how sexual compulsivity can be treated by leading to new intensive, population-specific therapeutic models or interventions (e.g., behavioral and psychopharmacological treatments to reduce stress and its impact on health and quality of life) (2;13). Studies also showed that sexual compulsivity manifests itself in many different ways which makes it more resistant to ‘simple therapies’ (1;12).
- Treatment for sexual compulsivity should include some form of HIV prevention/risk reduction. To provide the best health care for clients, clinicians should implement proper assessment and identification tools, learn more about community resources, and integrate interventions techniques for sexual compulsivity into their clinical practice. (1).
The issue and why it’s important
Sexual compulsivity or “compulsive sexual behavior” or “sexual addiction”, is characterized by sexual fantasies and behaviors so frequent and intense that they interfere with a person’s personal, interpersonal, or vocational pursuits (1). Sexual compulsivity has been conceptualized as an addiction disorder, an obsessive-compulsive spectrum disorder, an affective disorder, and an impulse control disorder. This lack of clinical coherence limits treatment options for a sizeable portion of those with sexual compulsivity because it makes it difficult to assign a diagnosis, obtain proper treatment, and obtain insurance coverage for treatment.(2). Although the use of the term “sexual compulsivity” has been criticized as a way to limit individual freedom to experiment sexually, research over the past ten years indicates that sexual compulsivity is a discrete clinical problem with a clear onset and course (1).
Symptoms of sexual compulsivity include exaggerated expressions of sexual behaviors, such as compulsive masturbation, excessive use of pornography, sex with multiple anonymous partners, excessive use of the Internet for sexual purposes, and disproportionate amounts of time thinking about sex or obsessing about a particular sexual partner (1). Other symptoms may include low self-esteem, social anxiety, feelings of loneliness, intimacy problems, impaired social skills, guilt, sensation-seeking, and other impulse control issues (2).
What we found
We identified 19 published studies of which 14 focused exclusively on research with gay and bisexual men and most contained data from the United States.
Sexual compulsivity can be related to HIV risk in the following ways:
- Sexual compulsivity is associated with more sexual partners, which is a significant factor for acquiring HIV (1)
- Losing control of one’s sexual behavior can result in direct HIV-related risks (1)
- Links between sexual compulsivity and substance use may increase exposure to HIV-related risks (1)
- Over time, with increased acclimatization or “tolerance”, people with sexual compulsivity could put themselves at greater risk as they continue to engage in sex with multiple partners; (1)
- People with sexual compulsivity are increasingly likely to engage in sex with other sexually compulsive individuals which increases risks for transmission of sexually transmitted diseases.(1)
Findings Among Gay and Bisexual American Men
- Compulsive sexual behaviour can be a form of coping with feelings of shame about one’s identity due to stigma related to ethnicity and sexual orientation. Stigma has also been shown to contribute to risk behavior, including substance use and unprotected intercourse (3).
- Men who scored high on sexual compulsivity scales reported higher levels of sexual risk behavior (with both male and female partners), were significantly more likely to have been diagnosed with sexually transmitted infections (STIs), and were less likely to have been tested for STIs (4).
- Accessing the internet for cyber-sex and fantasy can reduce the need for
real sex and potentially HIV transmission risks, but it can also trigger and/or exacerbate sexual compulsivity (5).
- Gay and bisexual men identified the following reasons for developing sexual compulsivity: emotional neglect, sexual abuse, drug/alcohol abuse, or the availability and accessibility of sexual partners. All these factors can put them at increased risk for contracting or spreading HIV (5;6).
- “Sexualized” venues were better indicators of higher sexual compulsivity scores among men than more “social” venues. Within the “sexualized” venues, men were more likely to have casual sex and unprotected insertive sex with men of HIV-negative or unknown status, and less likely to have disclosed serostatus with their primary partners and others. They also reported feeling less personally responsible for disclosing their HIV status (7 -9).
- Men who have sex with men and men with a history of sex with a transgender person were more likely to be sexually compulsive and at greater risk for contracting HIV. They were also more likely to serve as a “bridge” for HIV transmission to (as opposed to from) the transgender population (10).
Findings among American College Students
A study of the effect of sexual compulsivity, sensation seeking, and alcohol use on HIV risk behaviours among college students found that, as students and people in younger age groups progressed through a period of new personal freedom, experiences and relationships, they reported a high incidence of unprotected sexual activity, multiple sexual partners and were more likely to abuse alcohol, putting them at increased risk for contracting HIV (11).
Factors that may impact local applicability
- 14 of the 19 studies (2-10;13-17) we reviewed focused exclusively on research of gay and bisexual men; the remaining five (1;11;12;18;19) discussed sexual compulsivity in the context of a wider population.
- All of the articles reviewed were exclusively U.S.-based studies, several with particular focus on the Latino male population.
- Most articles were based on primary research studies, with little systematic review of other literature due to the limited research available on the subject.
- The research identified was largely cross-sectional and mainly consisted of questionnaire surveys and scales for assessing “sexual compulsivity” and collecting sexual health data.
- Research participants tended to be actively and passively recruited from mainstream gay venues or communities, AIDS service organizations, prevention programs and substance abuse support groups.
What we did
We searched for systematic reviews in the Cochrane Library, health-evidence.ca and the Database of Abstracts of Reviews of Effects (DARE) and were unable to locate any systematic reviews on this topic. We then searched PubMed using combinations of terms related to sexual compulsivity and sex addiction as well.
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- Parsons JT, Kelly BC, Bimbi DS, DiMaria L, Wainberg ML, Morgen- stern J. Explanations for the origins of sexual compulsivity among gay and bisexual men. Archives of Sexual Behavior 2008;37(5):817- 26.
- Smolenski DJ, Ross MW, Risser JM, Rosser BR. Sexual compulsivity and high-risk sex among Latino men: the role of internalized homonegativity and gay organizations. AIDS Care 2009;21(1):42-9.
- Dodge B, Reece M, Herbenick D, Fisher C, Satinsky S, Stupiansky N. Relations between sexually transmitted infection diagnosis and sexual compulsivity in a community based sample of men who have sex with men. Sexually Transmitted Infections 2008;84(4):324-7.
- Grov C, Bamonte A, Fuentes A, Parsons JT, Bimbi DS, Morgenstern J. Exploring the internet’s role in sexual compulsivity and out of control sexual thoughts/behaviour: a qualitative study of gay and bisex- ual men in New York City. Culture, Health & Sexuality 2008;10(2):107 -25.
- Bimbi DS, Nanin JE, Parsons JT, Vicioso KJ, Missildine W, Frost DM. Assessing gay and bisexual men’s outcome expectancies for sexual risk under the influence of alcohol and drugs. Substance Use & Mis- use 2006;41(5):643-52.
- Halkitis PN, Wilton L, Wolitski RJ, Parsons JT, Hoff CC, Bimbi DS. Barebacking identity among HIV- positive gay and bisexual men: demographic, psychological, and behavioral correlates. AIDS 2005;19(Suppl 1):S27-S35
- Satinsky S, Fisher C, Stupiansky N, Dodge B, Alexander A, Herbenick D et al. Sexual compulsivity among men in a decentralized MSM community of the Midwestern United States. AIDS Patient Care & STDs 2008;22(7):553-60.
- Semple SJ, Zians J, Grant I, Patterson TL. Sexual compulsivity in a sample of HIV-positive metham- phetamine-using gay and bisexual men. AIDS & Behavior 2006;10 (5):587-98.
- Bockting W, Miner M, Rosser BR. Latino men’s sexual behavior with transgender persons. Archives of Sexual Behavior 2007;36(6):778- 86.
- Gullette DL, Lyons MA. Sexual sensation seeking, compulsivity, and HIV risk behaviors in college students. Journal of Community Health Nursing 2005;22(1):47-60.
- Kalichman SC, Rompa D. The Sex ual Compulsivity Scale: further development and use with HIV- positive persons. Journal of Personality Assessment 2001;76(3):379- 95.
- Kalichman SC, Greenberg J, Abel GG. HIV-seropositive men who engage in high-risk sexual behav- iour: psychological characteristics and implications for prevention. AIDS Care 1997;9(4):441-50.
- Sexual addiction being studied. AIDS Patient Care STDS 2003;17 (1):45-6.
- Benotsch EG, Kalichman SC, Kelly JA. Sexual compulsivity and sub- stance use in HIV-seropositive men who have sex with men: prevalence and predictors of high-risk behaviors. Addictive Behaviour 1999;24 (6):857-68.
- Kalichman SC, Johnson JR, Adair V, Rompa D, Multhauf K, Kelly JA. Sexual sensation seeking: scale development and predicting AIDS- risk behavior among homosexually active men. Journal of Personality Assessment 1994;62(3):385-97.
- O’Leary A, Wolitski RJ, Remien RH, Woods WJ, Parsons JT, Moss S et al. Psychosocial correlates of trans- mission risk behavior among HIV- seropositive gay and bisexual men. AIDS 2005;19(Suppl 1):S67-S75.
- Kalichman SC, Rompa D. Sexual sensation seeking and Sexual Compulsivity Scales: reliability, validity, and predicting HIV risk behavior. J Pers Assess 1995 December;65(3):586-601.
- Schneider JP, Irons RR. Assessment and treatment of addictive sexual disorders: relevance for chemical dependency relapse. Substance Use & Misuse 2001;36 (13):1795-820.
OHTN Rapid Response Service. Rapid Review: Linking sexual compulsivity and HIV transmission. Ontario HIV Treatment Network, Toronto, ON, April, 2009
Program Leads / Editors
Michael G. Wilson, PhD
Sean B. Rourke, PhD