The diagnostic criteria for sexual addiction are also useful in distinguishing sexual addiction from nonaddictive patterns of exploitative or aggressive sexual behavior that can occur with antisocial personality disorder.
Obsessions and compulsions with sexual content can occur in obsessive-compulsive disorder (OCD). Sexual obsessions are fairly common in OCD, and were reported in 32% of the patients who were studied by Rasmussen and Tsuang (1986). The content of these obsessions, however, consisted most often not of sexual fantasies, but of fears of acting on sexual impulses or fears of being a pervert. More generally, symptoms of sexual addiction differ from sexual obsessions and compulsions in that the former are associated with sexual arousal and sexual pleasure, while the latter typically are not.
A syndrome that meets the diagnostic criteria for sexual addiction can occur in the context of other psychiatric disorders, including manic-depressive conditions, schizophrenia, personality disorders and substance dependence.
When the diagnostic criteria for both sexual addiction and another psychiatric disorder are met, both diagnoses are warranted, regardless of whether sexual addiction might be secondary to the other psychiatric disorder. The diagnosis of sexual addiction is a descriptive designation of how a pattern of sexual behavior relates to and affects an individual's life. It does not presume a particular etiology, nor is it precluded by the presence of other conditions that may be etiologically relevant.
Clinical Examples
To illustrate the considerations that are involved in diagnosing sexual addiction, three clinical examples are presented.
Case 1: Harold. An executive in his mid-30s, Harold would say with a smile that his Achilles' heel was his "weakness for the fair sex." When an attractive woman indicated to Harold that she was interested in him sexually, he found himself unable to resist, or more accurately, he found himself unable to want to resist. He experienced himself almost as a victim, sexually drawn to women against his will. Harold's fiancée ended their engagement after he repeatedly broke promises to her that he would stop sleeping with other women. When Harold began to use his apartment in the city for midday sexual liaisons, his lunch breaks stretched longer and longer. His formerly superior work performance began to slacken and he did not receive an expected promotion. Harold's boss warned him that he could lose his job if he was unable to keep business and pleasure separate in his life.
Harold resolved that he would turn over a new leaf and for six weeks he kept his sexual behavior in check. Then, when he was out of town on business and had just finished dinner with his work team, he commented that his neck and back were tight. His secretary offered to give him a back rub, and he accepted the offer without a moment's thought. The back rub resulted in a sexual encounter. Upon returning to his office, Harold continued to engage in sexual activity with his secretary. Soon, she began to pressure him for an exclusive relationship. When he rebuffed her, she filed a suit against him for sexual harassment. He was fired immediately.
Case 2: Joe. An electrician in his mid-20s, Joe had masturbated nearly every night before going to sleep since his middle teens. When he quit using alcohol and other drugs in his early 20s, his sexual fantasies and urges became more frequent and more intense. He began to experience strong urges to masturbate in the morning, and he found that if he did not act on these urges, he would feel "horny" all day, which for him was associated with being restless, distracted and irritable. Consequently, he started to masturbate before work, even though he would sometimes arrive late as a result. Some months later, Joe began to masturbate at work as well.
