Peter R. Martin: Historical Vocabulary of Addiction

Sexual Addiction

        The term sexual addiction cannot be found in the current electronic version of the Oxford English Dictionary (OED), possibly because these words convey a controversial and evolving concept that is not appreciated or fully accepted in psychiatry.  However, understanding the histories of each word component of the term, sexual and addiction, allows a rather good sense of the evolution of the concept that conveys when the words are joined together.  Additionally, it can be instructive to understand the origins of several other terms that have been employed historically to portray essentially the same meaning as sexual addiction, namely the loss of control over harmful sexual activity.

        According to OED the noun and adjective sexual is a borrowing from post-classical Latin sexualis (“of a woman…, of, relating to, or arising from the fact or condition of being either male or female”), which, in turn, is derived from compounding of the classical Latin sexus and a suffix -ālis (“Forming adjectives with the sense ‘of or relating to that which is denoted by the first element’”).  The Latin sexus is the u-stem of noun sex meaning, “Either of the two main categories (male and female) into which humans and many other living things are divided on the basis of their reproductive functions; (hence) the members of these categories viewed as a group; the males or females of a particular species, especially the human race, considered collectively.”  

        The first use of the word sexual in the English language (in a meaning that is now obsolete) was as an adjective by Thomas Adams (1583–1652), an English clergyman who was called “The Shakespeare of the Puritans” (Adams 1622): “That blessed Queene… who, as by her Sexuall graces shee deserued to bee the Queene of women, so by her masculine vertues to bee the Queen of men.”  The word has continued to evolve and the following of some subtly different meanings seem particularly relevant to addiction: “Relating to, tending towards, or involving sexual intercourse, or other forms of intimate physical contact”; “Of or relating to sexuality as a social or cultural phenomenon; regarding sexual conduct”; and “Characterized by sexual instincts or feelings, or the capacity for these; possessing or displaying sexuality.”  This sense of the word was first used in the English language in An essay on celibacy (Anonymous 1753): “Sexual commerce is natural, and, when it is the consequence of marriage, virtuous.”  William Wordsworth (1770–1850), the English Romantic poet, who with Samuel Taylor Coleridge helped launch the Romantic Age in English literature with their joint publication Lyrical Ballads, described sexuality therein as an appetite (Wordsworth and Coleridge 1800): “From this principle the direction of the sexual appetite, and all the passions connected with it take their origin.” 

        This last meaning of sexual naturally fits with and, therefore, can readily be understood when combined with the term addiction, to obtain the concept of interest here.  This union of words is reasonable because addiction is now accepted as not only pertinent to drug use disorders but also encompasses out-of-control and self-destructive behaviors (Martin and Petry 2005).  This distinction has become accepted in psychiatric nosology as enunciated in the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (American Psychiatric Association 2013).

        These two forms of addiction are defined in OED from the perspective of a drug use disorder (“Immoderate or compulsive consumption of a drug or other substance; specifically, a condition characterized by regular or poorly controlled use of a psychoactive substance despite adverse physical, psychological, or social consequences, often with the development of physiological tolerance and withdrawal symptoms…”) or of a behavioral addiction (“The state or condition of being dedicated or devoted to a thing, especially an activity or occupation; adherence or attachment, especially of an immoderate or compulsive kind”). However, whereas the concept of a behavioral addiction is considered to include gambling disorder according to APA nosology, out-of-control and self-destructive sexual behavior remains to be recognized as such.  This decision of not including sexual addiction as a behavioral addiction by APA has been highly contentious (Carnes 1992; Goodman 1998; Kraus, Voon and Potenza 2016).  In part this is because it has been argued that if one substitutes sexual for substance use behaviors in the criteria for drug use disorders outlined in the DSM (American Psychiatric Association 2013), they accurately describe the syndrome of sexual addiction, and thus the concept does have face validity and its exclusion seems somewhat arbitrary.

        Examining the origins of several other terms that have been employed historically to represent essentially the same meaning as sexual addiction can be instructive.  The following are among many such terms that have been employed: sexual dependence, problematic hypersexuality, hypersexual disorder, compulsive sexual behavior, hypersexuality (nymphomania and satyriasis), erotomania, Don Juanism, and paraphilia-related disorders. 

        The notion of hypersexuality has been discussed within the construct of dependence (Orford 1978), the precursor of the current terminology in DSM.  Although the word dependence (defined in OED as, “The relation of having existence hanging upon, or conditioned by, the existence of something else; the fact of depending upon something else”) is still appropriate in the context of the dependence syndrome (Edwards and Gross 1976), the term has been superseded in DSM by drug use disorder and non-drug addictive disorder, or behavioral addiction (American Psychiatric Association 2013). 

        Use of such qualifiers as problematic (“Of the nature of a problem; constituting or presenting a problem or difficulty; difficult to resolve; doubtful, uncertain, questionable”), compulsive (“Acting from, related to, or typical or suggestive of a compulsion [An insistent impulse to behave in a certain way, contrary to one's conscious intentions or standards]”) as well as -hyper (“…the prefix [which] has the prepositional force of ‘over, beyond, or above’…) are clearly consistent with the notion of behavior that is sufficiently salient (Sinke, Engel, Veit et al. 2020) within the behavioral repertoire that there is little room for anything else, namely the sexual behavior can be considered out-of-control, and hence likely self-destructive. Importantly, there is little consensus on pathogenic mechanisms that underpin the syndrome, which have been considered as obsessive-compulsive, impulsive, addictive, or posttraumatic (Ragan and Martin 2000; Kafka 2010; Kraus, Voon and Potenza 2016).

        Another element to be considered in addition to the time devoted to sexual behavior relative to the other aspects of the repertoire is that of the “normalcy” of the object of sexual activity. The disorder here termed sexual addiction has been described in conventional psychiatric thinking (although not strictly in DSM) as a syndrome of paraphilic (“Sexual desires regarded as perverted or irregular; specifically attraction to unusual or abnormal sexual objects or practices…”) or nonparaphilic sexual disorders with an emphasis conceptually on a loss of control over sex and a persistence in sexual behaviors despite adverse social, psychological and biological consequences (Ragan and Martin 2000). 

        The concept conveyed by sexual addiction has a very long history.  The plethora of terms that have been used to describe problematic hypersexuality suggests not only that the condition was well recognized, but also reveals historical iterations toward eventually understanding this well-known collection of symptoms as a clinical syndrome.  These iterations also demonstrate that that there has been significant ambivalence about pathologizing behavior like sexual activity that human kind has considered rewarding, lyrical, an expression of love and procreation but nevertheless, so subjective, while governed by mores.  It may well be that extremes in sexual behavior have been more difficult to resolve in human consciousness than those of drink and drugs, although there are striking similarities among all of these that are only now becoming recognized. 

        Literary descriptions much preceded attempts to view the syndrome of problematic hypersexuality from a psychiatric perspective.  For example, the figure Don Juan was predominantly characterized in literature by his intense preoccupation with sexual conquests, romanticized to be sure, but also with the effect of bringing such proclivities to the awareness of society.  According to OED, “the name of Don Juan, a legendary Spanish nobleman whose dissolute life was dramatized by Gabriel Tellez in his Convivado de Piedra (Stone Guest); the name was adopted in various popular imitations of this play and by Byron in his well-known poem.” Tellez (1583–1648), better known as Tirso de Molina, was a Spanish Baroque dramatist, poet and Roman Catholic monk who wrote the play in which Don Juan was the protagonist (Molina 1986). The name of Don Juan has subsequently acquired the meaning, according to OED, of “A rake, libertine, roué” and the name is used attributatively, namely Don Juanism as an expression to depict an extreme of human heterosexual behavior.  An example of this meaning as first used in the English language by the novelist William Makepeace Thackeray (1811–1863) can be found in Vanity Fair (Thackeray 1848): “Don't trifle with her affections, you Don Juan!”

        An important example of terms related to problematic hypersexuality is the noun satyriasis, which is partly a borrowing from Latin (“permanent erection of penis…, form of leprosy or elephantiasis…”) and the Greek σατυρίασι (“permanent erection of the penis, form of leprosy or elephantiasis,… already in ancient Greek denoting swelling of the glands about the ear”).  As exemplified in the writings of Guy de Chauliac (c. 1300–1368), the French physician and surgeon who wrote the influential treatise on surgery in Latin translated into many other languages (including Middle English) Chirurgia Magna (de Chauliac 1659), satyriasis was portrayed as the equivalent of an anatomical deformity priapism and hence, as a surgical condition (“Prolonged or painful erection of the penis, especially when associated with sexual stimulation; [in later use also] obsessive desire for erection… similar to priapism [now historical and rarely used]”): “The priapasme is vnwilfull stondynge of þe ȝerde, and it dyuerseth fro satiriasis…in þat þat þerynne is wille and desire of þat dede.” 

        A later, and now historial, sense of satyriasis focused predominantly on excessive sex drive (“Great or inordinate appetite for sex, especially in the male; specifically a medical condition occurring in men or male animals, characterized by sexual desire or activity judged to be excessive”) was from the English poet Francis Quarles (1592–1644) in his Argalus and Parthenia (Quarles 1629): “Now... euery eare Hath got the Saturyasis to heare This tragicke sceane.”  A more succinct statement, while still not fully acknowledging the very problematic nature of the behavior and its breadth of consequences for the individual, was from the English herald painter Randle Holme (1627–1700): “Satyriasis,..is an immoderate desire of venery, which upon Coition vanishes.” 

        The corresponding condition in women is nymphomania (“Uncontrollable or excessive sexual desire, specifically in a woman”).  This noun is a borrowing from Latin, a combination of the noun nympha (“in classical Latin nympha semi-divine spirit, young woman, maiden, larva of an insect, in post-classical Latin also labia minora… ancient Greek νύμϕη young bride, maiden, semi-divine spirit, larva of an insect, a type of mollusc, in Hellenistic Greek also clitoris, (in poetic use) water…”) and the combination form -mania (“Forming nouns referring to kinds of mental illness, desires, and passions marked by wild excess or delusion, enthusiastic [and often fashionable] participation in certain activities, or enthusiastic admiration for certain things or persons”).  The word was first employed in English by the professional lexicographer John Kersey the Younger (born c. 1660) in the Dictionarium Anglo-Britannicum: or, a general English dictionary (Kersey 1708): “Nymphomania, the same that Furor Uterinus.” Subsequently, the potential association of hypersexuality (not necessarily satyriasis or nymphomania) with other psychopathology such as depression was noted by the University of Edinburgh medical professor William Cullen (1710–1790), who was a central figure in the Scottish Enlightenment and translator of Synopsis of methodical nosology (Cullen 1830): “Melancholia..(c) With vehement love, without satyriasis or nymphomania.”  Sir David Ferrier (1843–1928), a Scottish neurologist and psychologist, expressed the notion that hypersexuality may be an expression of brain damage (Ferrier 1876): “The girl… in whom the cerebellum was absent suffered from nymphomania.”

        Others have viewed hypersexuality as something that was easily overcome and a rather trivial element of human development (Whitehead, Hoff and Stoll 1928): “It is said that maidens suffering from peculiar nervous diseases, such as nymphomania,..and some forms of hysteria, should marry, as a cure usually follows.” Importantly for both satyriasis and nymphomania, Alfred Charles Kinsey (1894–1956) the American sexologist considered such hypersexual disorders on a range of distribution of normal sexual appetites rather than a sexual disorder as expressed in his Sexual Behavior in the Human Male (Kinsey 1948): “The attempts to recognize such states as nymphomania and satyriasis as discrete entities, can, in any objective analysis, refer to nothing more than a position on a curve which is continuous.”

        Benjamin Rush (1746–1813), a Founding Father of the United States who signed the United States Declaration of Independence and was also a physician who became a professor of chemistry, medical theory and clinical practice at the University of Pennsylvania carefully examined this topic in a chapter entitled, “Of the Morbid State of the Sexual Appetite,” in his classic Medical Inquires and Observations Upon the Disease of the Mind (Rush 1812).  Rush described the case of a man who:

“imputes his indisposition to his excessive devotedness to Venus, which he thinks has been induced by a morbid state of his body. He has been married three years, had no connection with sex before he married, and, although he feels disgusted with his strong venereal propensities, he cannot resist them. I advised him to separate himself from his wife by travelling [sic], which he did, but without experiencing any relief from his disease. He has earnestly requested me to render him impotent, if I could not give him command of himself in any other way.”  

        At the end of the 19^th century, Richard Freiherr von Krafft-Ebing (1840–1902), a German psychiatrist and author of the foundational Psychopathia Sexualis, devoted his academic career to a thorough study of the paraphilias and other sexual disorders, illustrated with almost 200 case histories (Krafft-Ebing 1892).  He described a case of abnormally increased sexual appetite:

“to such an extent that permeates all his thoughts and feelings, allowing no other aims in life, tumultuously, and in a rut-like fashion demanding gratification and resolving itself into an impulsive, insatiable succession of sexual enjoyments. This pathological sexuality is a dreadful scourge for its victim, for he is in constant danger of violating the laws of the state and of morality, of losing his honor, his freedom, and even his life.”

        Problematic hypersexuality still remains a “foster child of sorts” within psychiatric nosology.  Because the pathogenesis of the syndrome is uncertain and problematic sexual behavior is not widely appreciated as a psychiatric disorder, the syndrome has not gained acceptance in psychiatric nosology, despite the fact that it really does seem to fit into the conceptual understanding of behavioral addictions which has recently gained acceptance within the DSM (American Psychiatric Association 2013).  Emphasis has been on dysfunction of the motivations underpinning the behavior, not the behavior itself, a distinctly different perspective from that for drug use disorders and non-drug addictive disorders.  Not only has problematic hypersexuality been documented in clinical work, elements of the syndrome can be identified as a complication of a range of psychopathologic conditions, including bipolar disorder, personality disorders, traumatic and neurocognitive deficits among others and the side effects of various psychopharmacologic agents (Finlayson, Sealy and Martin 2001).  These can result from disturbances in the physiology of sexual activity which in large strokes involve: the autonomic nervous system; the hypothalamic/pituitary complex; and the limbic system, in particular, inhibitory connections derived the frontal cortex and accentuation by activation of the reward circuits of the brain (Ragan and Martin 2000; Kühn and Gallinat 2016).  

        Lack of acceptance in psychiatric nosology has not deterred attempts to study the underpinnings of problematic hypersexuality using the latest approaches in neuroscience.  These have of necessity required the development of clinical criteria elicited using a reliable psychometric diagnostic instrument (Bőthe, Bartók, Tóth-Király et al. 2018).  Neuroimaging methods have been used to identify abnormalities of brain functioning, including brain activation by sexual stimuli (Antons, Brand and Potenza 2020), impulse regulation (Gola and Draps 2018), decision making, sexual templates and personality characteristics (Bőthe, Tóth-Király, Potenza et al. 2019), among other mechanisms.  

        The microstructure of white matter in anatomic substrates of the relevant neural pathways have been demonstrated as atypical in patients with problematic hypersexuality (Draps, Kowalczyk-Grębska, Marchewka et al. 2021).  It is of tremendous importance that most of these neuroimaging studies have shown strong parallels with gambling disorder, which in turn, resembles drug use disorders (Gola and Draps 2018).  Dysregulation of the hypothalamic/pituitary axis, foundational in stress responses, have been demonstrated in problematic hypersexuality (Chatzittofis, Boström, Ciuculete et al. 2021), as well as impairment of regulation of the bonding hormone oxytocin (Flanagan, Chatzittofis, Boström et al. 2022).  An indication that hypersexuality is a disease entity that has tremendous adverse consequences to both the person who is affected as well as those with whom they are close, is that there is increasing interest in pharmacotherapy of the condition, always drawing on parallels with drug use disorders and behavioral addictions (Chamberlain and Grant 2019; Malandain, Blanc, Ferreri et al. 2020; Savard, Öberg, Chatzittofis et al. 2020).

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June 9, 2022