Two kinds of pharmacological treatment may be used to treat addiction: endocrinological agents and affect-regulating agents.3 Endocrinological agents decrease the intensity of the sexual drive; thus, the person is more in control and less likely to act on paraphilic interests. These agents do not change the direction of the sexual interest, however. Their primary therapeutic function is to reduce sex drive to manageable levels in those individuals whose ability to control their behavioral impulses is so impaired as to put them at risk either to injure themselves or others, or to render them unresponsive to psychological interventions.
Endocrinological agents can lower the risk of problematic sexual behavior during the interval between the initiation of treatment and the consolidation of the changes that affect-regulating agents, behavior modification, group therapy, or psychotherapy can induce. Those currently in use include anti-androgenic agents and gonadotropin-releasing hormone (GnRH) agonists. However, of the 2 anti-androgenic agents, one is fraught with unpleasant or dangerous adverse effects, and the other is not commercially available in the United States.
Analogues of GnRH have been developed that have higher potency and longer duration of action than does naturally occurring GnRH. Triptorelin is injected once a month, and leuprolide is injected once every 3 months. Initial administration of these agents raises serum testosterone levels. However, continuous administration produces down-regulation of GnRH receptors on the pituitary gonadotropes, which leads to a decrease in secretion of leutinizing hormone and follicle-stimulating hormone, and a consequent decrease in the synthesis of testosterone.
Several reports of uncontrolled, open-label trials of GnRH agonists in the treatment of paraphilias and hypersexual disorders have all demonstrated significant positive effects.22-27 The main adverse effects were erectile dysfunction, hot flashes, and a decrease in bone density. These results suggest that GnRH agonists could prove to be a more effective, safer, and less noxious alternative to the direct anti-androgenic agents.
A number of case reports and open-label studies have provided evidence for the efficacy of affect-regulating agents (primarily antidepressants) in the treatment of paraphilias and nonparaphilic sexual addictions, even in patients who did not have a major affective disorder.28,29 While symptoms of paraphilic and nonparaphilic sexual addiction improved with antidepressant treatment in the absence of major depression, some studies found that paraphilic patients with comorbid depression showed a concurrent decrease in paraphilic behavior when their depressive symptoms improved.30,31
Agents that have been found to be effective include fluoxetine, sertraline, citalopram, paroxetine, fluvoxamine, venlafaxine, nefazodone, imipramine, desipramine, clomipramine, lithium, carbamazepine, topiramate, lamotrigine, divalproex, risperidone, buspirone.13-16,30,32-51 Electroconvulsive therapy has also been shown to be effective.52 Most of these studies reported a positive response rate in the range of 50% to 90%. Antidepressants, especially the serotonin reuptake inhibitors (SRIs), can produce diminished libido, but a number of the studies noted that antidepressants reduced the drive for symptomatic sexual behavior without decreasing the drive for healthy sexual behavior.
Augmentation of a 5-hydroxytryptamine reuptake inhibitor with bupropion or with a psychostimulant can further reduce sexual fantasies, urges, and behavior, particularly when concurrent depressive symptoms have not responded adequately to the SRI or when symptoms of attention-deficit disorder are present.53 I also have found that divalproex or lamotrigine can be helpful for sexual addiction symptoms that arise in the context of atypical manic-depressive conditions or “emotionally unstable character disorders,” and that gabapentin can alleviate accompanying irritability and feelings of being overwhelmed.
Psychiatric pharmacotherapy is direct intervention to enhance emotional and behavioral self-regulation; it also addresses other symptoms of comorbid psychiatric disorders. In sexual addiction, craving and urges to act out are expressions of dysregulated emotional states, and such urges are more likely to be acted out when behavioral regulation is impaired. Consequently, enhancement of affect regulation tends to diminish the frequency and intensity of addictive urges, while enhanced behavioral regulation reduces the likelihood that urges will lead to acting out.
A number of studies have indicated that antidepressant medications, particularly the SRIs, can reduce the frequency of addictive sexual behavior and the intensity of urges to engage in addictive sexual behavior, even when the patient does not have major depression.43 As may be imagined, the boundary between psychiatric pharmacotherapy and affect-regulating agents is indistinct and has to do more with the symptoms that the agents are intended to target than with the nature of the agents themselves.
Drugs Mentioned in This Article
Bupropion (Wellbutrin, Zyban)
Carbamazepine (Carbatrol, Tegretol, others)
Desipramine (Norpramin; Pertofrane)
Divalproex (Epival, Depakote)
Fluoxetine (Prozac, Sarafem, Symbyax)
Leuprolide (Lupron, others)
Lithium (Eskalith, Lithane, Lithobid)
1. Goodman A. Sexual addiction: diagnosis, etiology, and treatment. In: Lowinson JH, Ruiz P, Millman RB, Langrod JG, eds. Substance Abuse: A Comprehensive Textbook. 3rd ed. Baltimore: Williams & Wilkins; 1997:340-354.
2. Goodman A. Sexual Addiction: An Integrated Approach. Madison, CT: International Universities Press; 1998.
3. Goodman A. Sexual addiction: Nosology, diagnosis, etiology, and treatment. In: Lowinson JH, Ruiz P, Millman RB, Langrod JG, eds. Substance Abuse: A Comprehensive Textbook. 4th ed. Baltimore: Lippincott Williams & Wilkins; 2004:504-539.
4. Carnes PJ. Contrary to Love: Helping the Sexual Addict. Minneapolis: CompCare Publishers; 1989.
5. Kalichman SC, Rompa D. Sexual sensation seeking and Sexual Compulsivity Scales: reliability, validity, and predicting HIV risk behavior. J Pers Assess. 1995;65:586-601.
6. Carnes PJ, Delmonico DL. Sexual Dependency Inventory, Revised. Minneapolis: Positive Living Press; 1996.
7. Mercer JT. Assessment of the Sex Addicts Anonymous Questionnaire: differentiating between the general population, sex addicts, and sex offenders. Sex Addict Compulsivity. 1998;5:107-117.
8. Coleman E, Miner M, Ohlerking F, Raymond N. Compulsive sexual inventory: a preliminary study of reliability and validity. J Sex Marital Ther. 2001;27: 325-332.
9. Goodman A. Neurobiology of addiction. An integrative review. Biochem Pharmacol. 2008;75:266-322.
10. Chirban JT. Integrative strategies for treating internet sexuality: a case study for paraphilias. Clin Case Stud. 2006;5:126-141.
11. Valenti SAM. Use of object relations and self psychology as treatment for sex addiction with a female borderline patient. Sex Addict Compulsivity. 2002;9: 249-262.
12. Cox RP, Howard MD. Utilization of EMDR in the treatment of sexual addiction: a case study. Sex Addict Compulsivity. 2007;14:1-20.
13. Elmore JL. Psychotropic medication control of non-paraphilic sexual addiction in a female. Sex Rel Ther. 2005;20:211-213.
14. Marazziti D, Dell’Osso B. Topiramate plus citalopram in the treatment of compulsive-impulsive sexual behaviors. Clin Pract Epidemiol Ment Health. 2006;2:9.
15. Gulsun M, Gulcat Z, Aydin H. Treatment of compulsive sexual behaviour with clomipramine and valproic acid. Clin Drug Investig. 2007;27:219-223.
16. Schupak C. Case report: lamotrigine/fluoxetine combination in the treatment of compulsive sexual behavior. Prog Neuropsychopharmacol Biol Psychiatry. 2007;31:1337-1338.
17. Wainberg ML, Muench F, Morgenstern J, et al. A double-blind study of citalopram versus placebo in the treatment of compulsive sexual behaviors in gay and bisexual men. J Clin Psychiatry. 2006;67:1968-1973.
18. Kafka MP, Hennen J. Psychostimulant augmentation during treatment with selective serotonin reuptake inhibitors in men with paraphilias and paraphilia-related disorders: a case series. J Clin Psychiatry. 2000;61:664-670.
19. Klontz BT, Garos S, Klontz PT. The effectiveness of brief multimodal experiential therapy in the treatment of sexual addiction. Sex Addict Compulsivity. 2005;12: 275-294.
20. Spooner L, Lyddon WJ. Sandtray therapy for inpatient sexual addiction treatment: an application of constructivist change principles. J Constructivist Psychol. 2007;20:53-85.
21. Marshall WL, Marshall LE, Serran GA. Strategies in the treatment of paraphilias: a critical review. Ann Rev Sex Res. 2007;17:162-182.
22. Thibaut F, Cordier B, Kuhn JM. Effect of a long-lasting gonadotrophin hormone-releasing hormone agonist in six cases of severe male paraphilia. Acta Psychiatr Scand. 1993;87:445-450.
23. Thibaut F, Cordier B, Kuhn JM. Gonadotrophin releasing hormone agonist in cases of severe paraphilia: a lifetime treatment? Psychoneuroendocrinology. 1996;21:411-419.
24. Rösler A, Witztum E. Treatment of men with paraphilia with a long-acting analogue of gonadotropin-releasing hormone. N Engl J Med. 1998;338:416-422.
25. Briken P, Nika E, Berner W. Treatment of paraphilia with luteinizing hormone-releasing hormone agonists. J Sex Marital Ther. 2001;27:45-55.
26. Krueger RB, Kaplan MS. Depot-leuprolide acetate for treatment of paraphilias: a report of twelve cases. Arch Sex Behav. 2001;30:409-422.
27. Saleh F. A hypersexual paraphilic patient treated with leuprolide acetate: a single case report. J Sex Marital Ther. 2005;31:433-444.
28. Federoff JP. Serotonergic drug treatment of deviant sexual interests. Sex Abuse J Res Treatment. 1993;6:105-121.
29. Greenberg DM, Bradford JMW. Treatment of the paraphilic disorders: a review of the role of selective serotonin reuptake inhibitors. Sex Abuse. 1997;9: 349-361.
30. Kafka MP. Successful antidepressant treatment of nonparaphilic sexual addictions and paraphilias in men. J Clin Psychiatry. 1991;52:60-65.
31. Stein DJ, Hollander E, Anthony DT, et al. Serotonergic medications for sexual obsessions, sexual addictions, and paraphilias. J Clin Psychiatry. 1992;53: 267-271.
32. Black DW, Kehrberg LL, Flumerfelt DL, Schlosser SS. Characteristics of 36 subjects reporting compulsive sexual behavior. Am J Psychiatry. 1997;154:243-249.
33. Bianchi MD. Fluoxetine treatment of exhibitionism. Am J Psychiatry. 1990;147:1089-1090.
34. Jorgensen VT. Cross-dressing successfully treated with fluoxetine. NY State J Med. 1990;90:566-567.
35. Emmanuel NP, Lydiard RB, Ballenger JC. Fluoxetine treatment of voyeurism. Am J Psychiatry. 1991; 148:950.
36. Lorefice LS. Fluoxetine treatment of a fetish. J Clin Psychiatry. 1991;52:41.
37. Perilstein RD, Lipper S, Friedman LJ. Three cases of paraphilias responsive to fluoxetine treatment. J Clin Psychiatry. 1991;52:169-170.
38. Greenberg DM, Bradford JM, Curry S, O’Rourke A. A comparison of treatment of paraphilias with three serotonin reuptake inhibitors: a retrospective study. Bull Am Acad Psychiatry Law. 1996;24:525-532.
39. Kafka MP. Sertraline pharmacotherapy for paraphilias and paraphilia-related disorders: an open trial. Ann Clin Psychiatry. 1994;6:189-195.
40. Hill A, Briken P, Kraus C, et al. Differential pharmacological treatment of paraphilias and sex offenders. Int J Offender Ther Comp Criminol. 2003;47:407-421.
41. Abouesh A, Clayton A. Compulsive voyeurism and exhibitionism: a clinical response to paroxetine. Arch Sex Behav. 1999;28:23-30.
42. Coleman E, Gratzer T, Nesvacil L, Raymond NC. Nefazodone and the treatment of nonparaphilic compulsive sexual behavior: a retrospective study. J Clin Psychiatry. 2000;61:282-284.
43. Kruesi MJ, Fine S, Valladares L, et al. Paraphilias: a double-blind crossover comparison of clomipramine versus desipramine. Arch Sex Behav. 1992;21:587-593.
44. Casals-Ariet C, Cullen K. Exhibitionism treated with clomipramine. Am J Psychiatry. 1993;150:1273-1274.
45. Clayton AH. Fetishism and clomipramine. Am J Psychiatry. 1993;150:673-674.
46. Torres AR, de Abreu Cerquiera AT. Exhibitionism treated with clomipramine. Am J Psychiatry. 1993; 150:1274.
47. Wawrose FE, Sisto TM. Clomipramine and a case of exhibitionism. Am J Psychiatry. 1992;149:843.
48. Bartova D, Nahunek K, Svestka J. Pharmacological treatment of deviant sexual behavior. Activs Nerv Sup (Praha). 1978;20:72-74.
49. Cesnik JA, Coleman E. Use of lithium carbonate in the treatment of autoerotic asphyxia. Am J Psychother. 1989;43:277-286.
50. Ward NG. Successful lithium treatment of transvestism associated with manic-depression. J Nerv Ment Dis. 1975;161:204-206.
51. Federoff JP. Buspirone hydrochloride in the treatment of transvestic fetishism. J Clin Psychiatry. 1988;49:408-409.
52. Eyres AE. Transvestism: (employment of somatic therapy with subsequent improvement). Dis Nerv Syst. 1960;21:52-53.
53. Kafka M. Psychopharmacologic treatments for nonparaphilic compulsive sexual disorders. CNS Spectr. 2000;5:49-59.
Sources for Further Information About Sexual Addiction
• Goodman A. Sexual addiction: diagnosis, etiology, and treatment. In: Lowinson JH, Ruiz P, Millman RB, Langrod JG, eds. Substance Abuse: A Comprehensive Textbook. 3rd ed. Baltimore: Williams & Wilkins; 1997:340-354.
• Goodman A. Sexual Addiction: An Integrated Approach. Madison, CT: International Universities Press; 1998.
• Goodman A. Sexual addiction: Nosology, diagnosis, etiology, and treatment. In: Lowinson JH, Ruiz P, Millman RB, Langrod JG, eds. Substance Abuse: A Comprehensive Textbook. 4th ed. Baltimore: Lippincott Williams & Wilkins; 2004:504-539.
• Goodman A. Sexual addiction. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Baltimore: Lippincott Williams & Wilkins. In press.