Normal Versus Abnormal Sexual Behavior in Adolescents

©Nadezhda Sundikova

Over the past two decades, the internet has allowed instant access to a wide variety of content, including sexual content that portrays a variety of sexual activities such as masturbation, oral sex, vaginal and anal intercourse, and group sex. During the normal sexual developmental phase (usually between the ages of 9 and 16 years), one of the most common sexual activities is consumption of pornography, either intentional or accidental exposure. In the United Kingdom, 53% of adolescents aged 11 to 16 years have seen online pornography at least once, and the vast majority have viewed pornography before the age of 14.² In the United States, 20% to 30% of children aged 10 to 12 years have reported some exposure to pornography.³

In most cases, consumption of pornography does not promote the development of mental health disorders and reflects a normal exploration of sexuality.⁴ However, in 10% to 18% of all adolescents, consumption of pornography reflects compulsive sexual behavior. The disorder is characterized by extensive pornography use and masturbation, use of paid sexual services, risky sexual behaviors, and an intense preoccupation with sex. These behaviors often lead to impaired social or occupational functioning, distress, and negative affect.

How can we identify compulsive sexual behavior among adolescents? And, what are the best practices to treat compulsive sexual behavior?

Normative development

Human beings are sexual and beginning in childhood are capable of sexual responses.⁴ Many youngsters report experiencing sexual interest, arousal, and desire before puberty around the age of 10 years, when adrenal glands mature. Adolescence marks the onset of considerable changes in sexual and reproductive maturity that coincide with significant changes in cognitive, emotional, and social functioning.

The progression of sexual events among adolescents follows a fairly consistent sequence: kissing and holding hands, breast and chest fondling, manual genital contact, touching under clothes or without clothes, touching genitals directly, oral sex, and penile-vaginal intercourse. Sometimes these are followed by less common variations, such as anal sex. Although most adolescents show a normal sexual development, some develop compulsive sexual behavior.

Compulsive behavior

ICD-11 includes compulsive sexual behavior as a disorder. This impulse control disorder is characterized by a repetitive and intense preoccupation with sexual fantasies, urges, and behaviors that leads to clinically significant distress or impairment in social and occupational functioning and to other adverse consequences.⁵ Moreover, it compulsive sexual behavior often promotes sexual objectification of women and risky sexual behavior.

A recent study showed that consumption of pornography as part of compulsive sexual behavior predicted objectification of women over time by sexualizing women’s buttocks, breasts, belly, and body size.⁶ They also fond objectification of women affected adolescents’ courtship strategies (eg, girls say “no” but really mean “yes”).⁶ Findings from another study⁷ that comprised 967 adolescents aged 13 to 14 years indicate that exposure to pornography was linked with more permissive personal sexual norms (eg, sex before marriage is OK if you are in love), greater incidence of sexual harassment (eg, grabbed or pulled at a schoolmate’s clothing in a sexual way), and higher probability of oral sex and/or sexual intercourse two years later.

A series of studies explored the facets of compulsive sexual behavior among adults and adolescents.8 Four facets of compulsive sexual behavior were identified that are in keeping with the definition of compulsive sexual behavior disorder and that manifest among adults and adolescents.

1) Unwanted consequences because of sexual fantasies. Sexual fantasies, urges, and behaviors promote self-harm as well as harm to close others such as family members, colleagues, and peers.

2) Lack of behavioral control. Constant uncontrolled engagement with sexual fantasies, urges, and behaviors with numerous unsuccessful efforts to significantly reduce repetitive sexual behavior.

3) Negative affect. Negative feelings and distress accompanied by guilt and shame because of sexual fantasies, urges, and behaviors.

4) Affect dysregulation. Escape to sexual fantasies, pornography, and sexual behaviors because of pain, stress, and distress.

Efrati and Mikulincer⁸ identified two aspects of compulsive sexual behavior: individual-based and partner-based. Individual-based compulsive sexual behavior refers to inner conflicts of individuals who constantly engage in sexual fantasies, compulsive sexual thoughts, and masturbation. Partner-based compulsive sexual behavior includes interpersonal sexual conquests and repeated infidelity.

Here lies one of the key differences between adults and adolescents in the manifestation of compulsive sexual behavior. Whereas adults often exhibit both individual-based and partner-based compulsive sexual behavior, individual-based compulsive sexual behavior is much more prevalent than partner-based among adolescents because most of the experiences during adolescence do not include physical intimacy.⁹

Identifying the behavior

The range of human sexual activity is quite variable and it is difficult to differentiate normal from abnormal sexual behavior in form and frequency. Compulsive sexual behavior is not so much mere form or frequency of sexual behavior; rather, it is a pattern of sexual behavior that is initially pleasurable but becomes unfulfilling, self-destructive, and one that the individual is unable to stop. Compulsive sexual behavior refers to a loss of control over one’s sexual thoughts and behaviors that causes negative consequences in one’s life.

The ability to differentiate normal from abnormal sexual behavior among adolescents is even more challenging. For example, Adelson and colleagues argued that “in defining hypersexuality [another term for compulsive sexual behavior], it is crucial to acknowledge the challenges to establishing norms of child and adolescent sexual development and the complexity of variables that influence it.”¹⁰

One of the most reliable ways to identify compulsive sexual behavior among adolescents is the self-report Individual-Based Compulsive Sexual Behavior (I-CSB) Scale.¹⁰ The I-CSB comprises 24 items that quantify the aforementioned four facets of compulsive sexual behavior.

1) Unwanted consequences. “I feel that my sexual fantasies hurt people around me.”

2) Lack of control. “Although I promised myself that I would stop thinking about sexual desires, I find myself doing it again and again.”

3) Negative affect. “I feel bad after being exposed to sexual content on the internet.”

4) Affect dysregulation. “When I’m stressed or restless, exposure to sexual content on the internet relaxes me.”

The I-CSB has a clinical cut-off that helps identify compulsive sexual behavior with a high degree of certainty.

Treating the behavior

Excessive and uncontrolled use of pornography is one reason for seeking professional help among both youths and adults.¹¹ Despite the high prevalence of compulsive sexual behavior, research shows that a majority of clinicians have received little to no training in the treatment of compulsive sexual behavior. In addition, many do not feel competent or comfortable treating this disorder.¹² This lack of training and education may promote misperceptions about the difficulties associated with problematic sexual behavior among clinicians, how to recognize these issues, and/or what factors to target in treatment. When seeking to refer a patient for compulsive sexual behavior, psychiatrists should look for a therapist who specializes in treating sexual disorders.

To date, there are no placebo-controlled studies on any treatment modality for compulsive sexual behavior. Most recommendations are based on case studies and/or on studies using small samples without control groups; the studies mainly comprise adults. The most promising modalities are cognitive behavioral therapy (CBT), cognitive analytic therapy (CAT), and mindfulness.

The aim of CBT is to identify underlying dysfunctional thoughts and utilizing cognitive tasks and behavioral interventions allow patients to avoid the triggers for compulsive sexual behavior. (See Birchard¹³ for a detailed review.) It begins by a formulation of therapeutic goals to create a blueprint for the intervention, to prevent therapeutic drift, and to keep the work on target. Diagrammatic explanations of the history and function of a problematic sexual behavior are used to bring order into what would otherwise be chaos and uncertainty. During this phase, factors that cause the patient to turn to their harmful behavior are recognized. Next, using various cognitive techniques these factors are targeted to break the link between them and the harmful behavior. For example, therapist may use the Socratic questioning method to elicit new understandings for the patient, helping them to think about the problem in a new way.

CAT is a relational and collaborative three-phase, time-limited psychotherapy that integrates cognitive and analytic principles.¹⁴ The first phase is assessment, which leads to a narrative reformulation of the patient’s difficulties. The next phase is enhancing the recognition of the problematic states and procedures. This recognition is gained via production of a sequential diagrammatic reformulation accompanied by self-monitoring between sessions to enhance self-awareness of the problematic patterns. The third and final phase is revision, which focuses on change and culminating in an exchange of farewell letters between therapist and patient. CBT and CAT share commonalities; the main difference is the cognitive versus the narrative construction of the problematic behavior (eg, history of relations with parents).

Mindfulness-based therapy focuses attention to thoughts, emotions, and bodily sensations in the present in a nonjudgmental manner. It is often taught through a variety of meditation techniques. Mindfulness may be a meaningful component of successful therapy among patients seeking help for compulsive sexual behavior by improving affect regulation, stress coping, and increasing tolerance for desires to act on maladaptive sexual urges and impulses.¹⁵ The main focus of mindfulness-based therapies is the reduction of shame-related cognitions; by doing so, it allows for decreased sexual dysfunction and increased enjoyment from sexual exploration.

Conclusion

Adolescents explore their sexuality. In most cases, this exploration is normative and has no negative consequences. At times, however, compulsive sexual behavior is developed and maintained. In these cases, it needs to be treated or it will affect functioning and relationships in adulthood.

Although several modalities of therapies have been examined, avoiding compulsive sexual behavior is even more important than treating it. Research highlights one key factor that relates to avoiding compulsive sexual behavior-open communication about sexuality between parents and children.¹⁶ Communication reduces shame, promotes sexual exploration in a supportive environment, and enables the development of healthy romantic relationships. Healthy sexuality promotes a health society.

Disclosures:

Dr Efrati is Founder and Head of the Israeli Center for Healthy Sexuality, and Assistant Professor, Beit-Beri College, Kfar Saba, Israel. He reports no conflicts of interest concerning the subject matter of this article.

References:

1. Livingstone S, Haddon L, Görzig A, Ólafsson K. EU Kids Online II: Final Report; 2011.

2. Romito P, Beltramini L. Watching pornography: gender differences, violence and victimization. Violence Against Women. 2011;17;1313-1326.

3. Efrati, Y. Problematic and non-problematic pornography use and compulsive sexual behaviors among understudied populations: children and adolescents. Curr Addic Rep. (In press).

4. O’sullivan L, Thompson A. Sexuality in adolescence. In Tolman DL, Deborah L, Diamond LM, et al, Eds, APA Handbook of Sexuality and Psychology, Vol 1. Washington, DC: American Psychological Association; 2014: 433-486.

5. Gola M, Potenza MN. The proof of the pudding is in the tasting: data are needed to test models and hypotheses related to compulsive sexual behaviors. Arch Sex Behav. 2018;47;1323-1325.

6. Ward LM, Vandenbosch L, Eggermont, S. The impact of men’s magazines on adolescent boys’ objectification and courtship beliefs. J Adol. 2015;39;49-58.

7. Brown JD, L’Engle KL. X-rated: sexual attitudes and behaviors associated with US early adolescents’ exposure to sexually explicit media. Comm Res. 2009;36;129-151.

8. Efrati Y, Mikulincer M. Individual-based Compulsive Sexual Behavior scale: its development and importance in examining compulsive sexual behavior. J Sex Marit Ther. 2018;44;249-259.

9. Delmonico DL, Griffin EJ. Cybersex addiction and compulsivity. Internet Addiction: A Handbook and Guide to Evaluation and Treatment. New Jersey: John Wiley and Sons, Inc; 2011; 113-134.

10. Adelson S, Bell R, Graff A, et al. Toward a definition of “hypersexuality” in children and adolescents. Psychodyn Psychiatry. 2012;40;481-503.

11. Mitchell KJ, Wells M. Problematic internet experiences: primary or secondary presenting problems in persons seeking mental health care. Soc Sci Med. 2007;65;1136-1141.

12. Reissing ED, Giulio GD. Practicing clinical psychologists’ provision of sexual health care services. Prof Psychol. 2010;41;57.

13. Birchard T. CBT for Compulsive Sexual Behaviour: A Guide for Professionals. New York: Routledge; 2015.

14. Kellett S, Simmonds-Buckley M, Totterdell P. Testing the effectiveness of cognitive analytic therapy for hypersexuality disorder: an intensive time series evaluation. J Marit Sex Ther. 2016;6:1-16.

15. Reid RC, Bramen JE, Anderson A, Cohen MS. Mindfulness, emotional dysregulation, impulsivity, and stress proneness among hypersexual patients. J Clin Psychol. 2014;70;313-321.

16. Efrati Y, Gola M. Adolescents’ compulsive sexual behavior: the role of parental competence, parents’ psychopathology, and quality of parent-child communication about sex. J Behav Addic. 2019;8:420-431.