Early Maladaptive Schemas Are Highly Indicative of Compulsive Sexual Behavior

Abstract

Unlike the consequences of compulsive sexual behavior (CSB) and the profile of people with CSB that were extensively studied, the cognitive distortions that might be responsible to the development and maintenance of CSB are less understood. In Study 1 (n = 68), we examined intercorrelations between CSB and early maladaptive schemas among a sample with clinical CSB (Sexaholic Anonymous; SAs). In Study 2 (sex offenders; n = 103, and violence offenders; n = 81), we examined the intercorrelations between CSB and early maladaptive schemas among a sample with a sexual deviance but non-clinical levels of CSB. Results revealed that early maladaptive schemas are highly indicative of CSB severity. We discuss the implication of the study for the study and therapy of CSB.

Keywords

compulsive sexual behavior sex offenders early maladaptive schemas sexual deviance therapy

The World Health Organization (WHO), in the 11th edition of the International Classification of Diseases (ICD-11), has included Compulsive Sexual Behavior as a disorder (now called CSBD; classification number 6C72). According to ICD-11, CSB is an impulse control disorder characterized by a repetitive and intense preoccupation with sexual fantasies, urges, and behaviors, leading to clinically significant distress or impairment in social and occupational functioning and to other adverse consequences (ICD-11; Gola & Potenza, 2018; Kafka, 2010; WHO, 2018). CSB has been reliabliy identified in both adults (e.g., Fuss et al., 2019; Moisson et al., 2019; Reid et al., 2011) and adolescents (e.g., Efrati, 2018, 2019; Efrati & Gola, 2018c, 2019a). To date, most studies have focused on the negative outcomes of CSB (see Walton et al., 2017, for a recent review) and/or on the profile of people with higher levels of CSB with respect to factors such as gender (e.g. Castro-Calvo et al., 2020), religiosity (e.g. Grubbs et al., 2020), and personality dispositions (Efrati et al., 2019; Zilberman et al., 2018). Fewer studies have focused on the specific cognitive distortions that characterize people with higher levels of CSB, and especially on early maladaptive cognitive schemas that might be responsible to the development and maintenance of CSB. In the current research, we focused on the associations between CSB and early maladaptive cognitive schemas among people with clinical (Study 1) and non-clinical CSB levels (Study 2).

CSB

CSB is a disorder that characterizes between 3%–10% of adults (Carnes et al., 2010; Coleman, 1992; Dickenson et al., 2018) and 12%–18% of adolescents (Efrati & Dannon, 2018). Recently, Efrati and Mikulincer (2018) identified four facets of CSB that are in keeping with the definition of ICD-11 and that manifest both among adults (e.g., Efrati & Gola, 2018a, 2019b; Efrati et al., 2019) and adolescents (e.g., Efrati & Dannon, 2018; Efrati & Gola, 2018c): (a) Unwanted consequences because of sexual fantasies—how sexual fantasies, urges and behaviors carry harm to oneself (Reid et al., 2012) and/or to one’s close others such as family members (Reid et al., 2010), colleagues, and peers (Reid et al., 2011); (b) lack of behavioral control—constant uncontrolled engagement with sexual fantasies, urges, and behaviors with numerous unsuccessful efforts to significantly reduce repetitive sexual behavior; (c) negative affect—negative feelings and distress accompanied by guilt and shame because of sexual fantasies, urges and behaviors; and (d) affect regulation—escape to sexual fantasies, pornography, and sexual behaviors because of pain, stress, and distress.

These facets are also manifested in distorted cognition and emotion regulation strategies (Kalichman et al., 1994; Kalichman & Rompa, 1995; Reid et al., 2011). For example, Paunovic and Hallberg (2014) suggested that CSB may be related to a cluster of negative and distorted beliefs and interpretations about one’s sexual fantasies, urges, and behavior such that a person with CSB might conclude that “I can’t control my sexual behavior” and therefore “I am a bad person.” People with CSB are also known to hold maladaptive sexual cognitions regarding their capacity for controlling their sexual behavior and their inability to change their sexual behavior (Kraus et al., 2015; Pachankis et al., 2014; Reid, 2010; Reid, Temko, Moghaddam, & Fong, 2014). To date, however, only limited research has examined CSB-related distorted cognitions.

Recently, Szumski et al. (2018) indicated in their Multi-Mechanism Theory of Cognitive Distortions that cognitive distortions are considered an important factor in the etiology and maintenance of sexual offending behavior and possibly any excessive sexual behavior. One factor that may influence the etiology, development and maintenance of CSB is Early Maladaptive Schemas (EMSs).

Early Maladaptive Schemas

Young and colleagues (2003) defined early maladaptive schemas as “extremely stable and enduring themes, comprised of memories, emotions, cognitions, and bodily sensations regarding oneself and one’s relationship with others, that develop during childhood and are elaborated on throughout the individual’s lifetime, and that are dysfunctional to a significant degree” (Young et al., 2003, p. 7). It is theorized that early maladaptive schemas develop as a result of negative childhood experiences and serve as an organizational system that is stable over time (Riso et al., 2006) through which people organize and interpret their feelings, behaviors, and emotions (Young, 1999). Early maladaptive schemas are believed to be at the core of the development and maintenance of psychopathology, particularly psychopathology that is chronic and enduring in nature (Young et al., 2003).

Young and colleagues (2003) proposed 18 early maladaptive schemas that could be grouped into five EMS domains: disconnection and rejection, which is characterized by a belief that one’s basic interpersonal needs will not be met; impaired autonomy and performance, which is based on the belief that one does not have the abilities to function or survive independently; impaired limits, which is characterized by an inability to maintain or understand appropriate internal and interpersonal limits; other directedness, which is characterized by concentrating and focusing on the needs of others at the expense of one’s own needs; and overvigilance and inhibition, which involves an excessive focus on setting and attempting to accomplish unrealistic, internal standards and values. A recent factor analytic study has confirmed these domains in a large mixed (clinical and non-clinical) sample of adults (Bach, Lockwood, & Young, 2018).

CSB and Early Maladaptive Schemas

The facets of CSB and those of early maladaptive schemas share several possible associations. People with CSB are afraid that their preoccupation with sexual fantasies and behaviors will harm them and other people around them (i.e. unwanted consequences because of sexual fantasies), which might be related to the “other directedness” and “overvigilance and inhibition” schemas—setting unrealistic standards on the one hand, and focusing on the needs of others at the expense of one’s own needs and mental health on the other hand. These schemas and especially “other directedness” might also be associated with CSB-related negative affect (such as shame and guilt) because of the tendency to do things at the expense of one’s own needs. In addition, people with CSB often lack the ability to control their sexual fantasies and behaviors, which might be related to an inability to maintain internal limits—i.e. the “impaired limits” schema. Finally, people with CSB tend to employ sexual behaviors (consumption of pornography, excessive masturbation, sexual conquests) in the hope of regulating distress and pain, often with a short-lived success in doing so. This facet might be related to “disconnection and rejection”—the belief that one’s needs will not be met—and to “impaired autonomy and performance”—the belief in the inability to function without the help of others.

We are aware of only a single study that examined the link between CSB and early maladaptive schemas (Elmquist et al., 2016). The study was conducted on patients with substance use disorder (alcohol, opioid or polysubstance dependence, and/or alcohol abuse) because of the high co-occurrence of substance use disorder and CSB (exact rates were not reported in the paper). Results indicated that substance users with CSB were significantly higher on “disconnection and rejection,” “impaired autonomy and performance” and “impaired limits” schemas, with marginal differences also in “other directedness” and “overvigilance and inhibition” schemas. The disorder of patients with substance abuse, however, does not revolve around sexuality. Therefore, the current research was designed to explore the possible associations between CSB and cognitive distortions in the form of early maladaptive schemas among two groups with sexual-related disorder: people who seek treatment for CSB [i.e. members of a Sexaholic Anonymous (SA) groups] (Study 1) and sex offenders (in comparison to violence offenders; Study 2). Although the disorder of SA members and sex offenders directly relate to sexual behavior, SAs often have clinical levels of CSB (e.g. Efrati et al., 2019; Efrati & Gola, 2019b; Efrati & Mikulincer, 2018), whereas sex offenders only subclinical levels (Briken, 2012; Efrati et al., 2019; Hanson et al., 2007; Kingston & Bradford, 2013). Thus, in the current research we were able to examine the association between CSB and early maladaptive schemas among clinical and non-clinical samples. We predict that early maladaptive schemas will be highly indicative of the level of CSB such that the higher the CSB the more maladaptive the early schemas.

Study 1

In Study 1, we examined the association between CSB and maladaptive cognitive schemas among people from the community who seek treatment for CSB [i.e. members of a Sexaholic Anonymous (SA) groups]. Research has indicated that the prevalence of clinical CSB among members of a Sexaholic Anonymous (SA) groups is exceptionally high ranging from 77.6% (Efrati et al., 2019) to 87.7% (Efrati & Gola, 2019b). To ensure the correct classification to clinical and non-clinical CSB we used two commonly used measures of CSB—the Individual-based Compulsive Sexual Behavior (I-CSB; Efrati & Mikulincer, 2018) scale, and the Hypersexual Behavior Inventory (HBI; Reid et al., 2011).

Method

Participants

Participants were Jewish Israeli members of a Sexaholic Anonymous (SA) groups (n = 68) who ranged in age from 18 to 61 years (M = 32.26, SD = 14.98). Approximately half were married (52.2%; the rest were single, 43.3%, or divorced, 4.5%) with number of children ranging from 0 to 9 (M = 2.22, SD = 2.55). As often the case with SA in Israel, most of the sample were religious (90.8%). Years of education ranged between 8 and 20 (M = 13.52, SD = 2.51). Participants volunteered to participate in the study.

Procedure

The study was presented as a study on sexuality. To sample SA members, the first author received a written consent from the Israeli SA organization to visit SA meetings held in Israel (Tel-Aviv, Jerusalem, and Zefat that cover the central, east and north of Israel; five groups overall), present the study, and request participation in the study. Next, a research assistant visited these groups and administrated the battery of questionnaires. Overall, 68 participants were approached, of whom all agreed to participate in the study (100% response rate). Questionnaires were printed onto hard copies. The questionnaires were authorized by Orot-Israel College’s Institutional Review Board (IRB). First, all participants signed an informed consent form that ensure anonymity of the procedure and the freedom to stop participation at any time. Next, questionnaires were administrated in the following order: Individual-based Compulsive Sexual Behavior, Hypersexual Behavior Inventory, Young Schema Questionnaire—Short Form-3, and socio-demographic questionnaire. Participants were then debriefed and thanked.

Measures. Individual-Based Compulsive Sexual Behavior (I-CSB)

Compulsive Sexual Behavior was assessed with the Hebrew version of the I-CSB (Efrati & Mikulincer, 2018). The I-CSB was constructed to assess distinct aspects of CSB, such as sexual fantasies, obsessive sexual thoughts, and spending a great deal of time watching pornography. The I-CSB is a self-report questionnaire with 24 items measuring the following factors: Unwanted consequences (e.g., “I feel that my sexual fantasies hurt those around me”); lack of control (e.g., “I waste lots of time with my sexual fantasies”); negative affect (e.g., “I feel bad when I don’t manage to control my sexual urges”); and affect dysregulation (e.g., “I turn to sexual fantasies as a way to cope with my problems”). Using a 7-point Likert scale, participants were asked to rate the degree to which each statement is descriptive of their feelings (1—not at all, 7—very much). The questionnaire was successfully used in previous research on non-clinical populations and on clinical populations of Sexaholics Anonymous Twelve-Step program patients (Efrati & Mikulincer, 2018; Efrati & Gola, 2018c, 2019b). Cronbach’s αs were .93 for unwanted consequences, .94 for lack of control, .88 for negative affect, and .91 for affect regulation. We also computed a total CSB score by averaging the 24 I-CSB items (Cronbach’s α = .97). The I-CSB measure has a clinical cut-off of 4.1 using the I-CSB total score (Efrati & Mikulincer, 2018).

Hypersexual Behavior Inventory (HBI)

The HBI (Reid et al., 2011) is a 19-item scale that assesses compulsive sexual behavior via three factors. Participants indicated their answers on a 5-point Likert scale (1 = Never; 5 = Very often). The coping factor (seven items) assesses sex and sexual behaviors as a response to emotional distress such as sadness, restlessness, and worries of daily life (e.g., “I use sex to forget about the worries of daily life”). The control factor (eight items) assesses the lack of self-control in sexuality-related behaviors, such as a failure in controlling one’s sexual behavior (e.g., “Even though I promised myself I would not repeat a sexual behavior, I find myself returning to it over and over again”). The consequences factor (four items) assesses the diverse consequences of sexual thoughts, urges, and behaviors, such as sexual activities that interfere with educational or occupational duties (e.g., “I sacrifice things I really want in life in order to be sexual”). Cronbach’s αs were .95 for coping, .96 for control and .95 for consequences. We also computed a total CSB score by summing the scores of the 19 HBI items (Cronbach’s α = .98). The HBI has a clinical cut-off of 53 in the HBI total score (Reid et al., 2011).

Young Schema Questionnaire—Short Form-3 (YSQ-S3)

The YSQ-S3 (Young & Brown, 2005) is a 90-item self-report measure that assesses 18 early maladaptive schemas that relate to cognitive distortions. Hebrew translation carried out by Young et al. (2010). The schemas are grouped into five general domains: (1) disconnection and rejection (includes abandonment/ instability, mistrust/abuse, emotional deprivation, defectiveness/shame, and social isolation /alienation schemas; e.g. “I haven’t had someone to nurture me, share him/herself with me, or care deeply about everything that happens to me”), (2) impaired autonomy and performance (includes dependence/incompetence, vulnerability to harm or ill-ness, enmeshment/undeveloped self, and failure schemas; e.g. “Almost nothing I do at work (or school) is as good as other people can do”), (3) impaired limits (includes entitlement/grandiosity, and insufficient self-control/self-discipline schemas; e.g. “I have a lot of trouble accepting “no” for an answer when I want something from other people”), (4) other-directedness (includes subjugation, self-sacrifice, and approval seeking/recognition seeking schemas; “I think that if I do what I want, I’m only asking for trouble”), and (5) overvigilance and inhibition (includes negativity/pessimism, emotional inhibition, unrelenting standards/hypercriticalness, and punitiveness schemas; “I find it embarrassing to express my feelings to others”). Cronbach’s α values for subscales ranged from .73 to .88.

Results

Correlations Between I-CSB, HBI and Early Maladaptive Schemas

To examine the pattern of associations between I-CSB, HBI and early maladaptive schemas (disconnection and rejection, impaired autonomy and performance, impaired limits, other-directedness, overvigilance and inhibition), we conducted a series of Pearson correlations. Coefficients are presented in Table 1. The analyses indicated that the I-CSB and the HBI were all moderately to strongly associated with all of the clusters of early maladaptive schemas (the magnitude of the I-CSB and HBI associations was almost identical).

Table 1.

Correlations Between I-CSB, HBI and Early Maladaptive Schemas (Study 1).

	I-CSB	HBI
Disconnection and rejection	.40	.42
Impaired autonomy and performance	.36	.38
Impaired limits	.50	.51
Other-directedness	.42	.45
Overvigilance and inhibition	.45	.47

Note. All correlations are significant at p < .001.

Differences in Early Maladaptive Schemas Between SAs With Clinical and Non-Clinical CSB

To examine the differences in the extent that participants’ early schemas are maladaptive between SAs with and without clinical CSB, we conducted a multivariate analysis of variance (MANOVA). In an initial step, we classified SAs into clinical and non-clinical with respect to CSB. SAs that were above the clinical cut-off of both the I-CSB and HBI were classified as having clinical CSB (n = 49, 71.0%); SAs that were below the clinical cut-off of both the I-CSB and HBI were classified as non-clinical (n = 10, 14.5%; nine additional participants were not classified to any of the groups). The average I-CSB and HBI scores of the clinical SA group were 5.69 (SD = 0.75) and 81.29 (SD = 10.82), respectively, and for the non-clinical SA group were 3.03 (SD = 0.91) and 34.40 (SD = 8.22), respectively [overall mean was 5.12 (SD = 1.23) and 69.99 (SD = 21.31), respectively].

The clinical classification then served as the independent measure and the dependent measures were the early maladaptive schemas clusters. Means, standard deviations, univariate test statistics and effect sizes are presented in Table 2. The analyses indicated that whereas impaired autonomy and performance characterizes SAs regardless of the clinical status of CSB, SAs with clinical CSB were higher on disconnection and rejection, impaired limits, other-directedness, overvigilance and inhibition than non-clinical SAs.

Table 2.

Means, Standard Deviations, Univariate Test Statistics and Effect Sizes for Comparing SAs With Clinical and Non-Clinical CSB in Early Maladaptive Schemas.

	Non-Clinical		Clinical
	M	SD	M	SD	F _(1,57)	η² _p
Disconnection and rejection	3.02	1.40	3.82	1.19	4.56*	0.06
Impaired autonomy and performance	2.59	1.35	3.18	1.16	2.08	0.04
Impaired limits	3.26	1.12	4.35	0.93	10.71**	0.16
Other-directedness	3.32	1.18	4.09	0.83	6.25*	0.10
Overvigilance and inhibition	2.98	1.30	3.97	0.89	8.76**	0.13

Note. *p < .05, **p < .01.

Discussion

Study 1 has indicated that CSB severity among people who self-define themselves as suffering from CSB is related to core cognitive distortions that are considered an important factor in the etiology and maintenance of sexual behavior (Szumski et al., 2018). Therefore, it seems that early maladaptive schemas and thus cognitive distortions are highly indicative of the severity of CSB. Specifically, people with CSB seems to expect that their needs for love, safety, nurturance and social belonging will not be met in a consistent manner (i.e. higher disconnection and rejection); they also perceive themselves as unable to function independently in everyday life, to perform successfully in areas of achievement, and to express their needs and feelings freely (i.e. higher impaired autonomy and performance; although this sensation is not indicative of clinical CSB per se); in addition, they have a deficiency in internal limits that cause them to have difficulties in respecting the rights of others, cooperating with them, making commitments, and controlling their emotions and impulses (i.e. higher impaired limits). Alongside these cognitive distortions, they also have unrealistic standards of themselves and others around them often at the expense of their own happiness, self-expression, relaxation, close relationships, or health (i.e. higher other-directedness, overvigilance and inhibition). The latter finding is also in keeping with recent research indicating that people with higher CSB also have higher pathological concern (Efrati et al., 2019)—a compulsive concern for other people’s welfare while denying one’s own feelings and needs (Barbanel, 2006)—as well as higher perfectionism (especially concern over mistakes; Reid et al., 2012).

Although Study 1 indicated that early maladaptive schemas are highly indicative of the severity of CSB, it comprised only a sample of participants who were self-defined as having CSB (i.e. restricting the range of CSB severity to medium to high). Are early maladaptive schemas indicative of the severity of CSB also among people with sexual-related deviance but lower levels of CSB? We designed Study 2 to address this question by examining whether early maladaptive schemas relate to CSB among sex offenders (as compared with a group of violence offenders).

Study 2

In Study 2, we examined whether early maladaptive schemas relate to CSB among sex offenders (as compared with a group of violence offenders). Using multitude of methods, recent research has indicated that the rates of CSB among sex offender is small ranging from 6% to 12% (Briken, 2012; Efrati et al., 2019; Hanson et al., 2007; Kingston & Bradford, 2013) although their early schemas are more maladaptive than those of other offenders and people of the community (e.g., Bach, Lockwood, & Young, 2018; Szumski et al., 2018). We hypothesize that that regardless of group affiliation (i.e. sex and violence offenders), CSB will be associated with higher sexual-related maladaptive schemas.

Also, in Study 2 we assessed sensation seeking and impulsivity to differentiate between sexual-related maladaptive schemas and general tendency for sensation seeking and impulsivity. Impulsivity is described as the failure to resist a drive or impulse without considering potentially negative outcomes (Moeller et al., 2001). Conversely, sensation seeking is the search for varied, novel, complex and intense experiences and feelings, and the readiness to take physical, social, legal, and financial risks for the sake of such experiences. Schiffer and Vonlaufen (2011) found that sexual offenders (specifically child molesters) appeared to be significantly more impulsive in a Go/No-go test (evaluating behavioral impulsivity) not only in comparison to healthy controls, but also in contrast with perpetrators of non-sexual crimes. In contrast, Ryan et al. (2017) found differences between 417 male offenders (293 sexual offense) across the measures of general impulsivity and sensation seeking were not statistically significant. Impulsivity and/or sensation seeking were more constantly linked with CSB among the general community (Antons & Brand, 2018; Miner et al., 2009; Reid et al., 2011; Voon et al., 2014; Walton et al., 2017, 2018). Because impulsivity and sensation seeking were not reliably linked with sexual offense, we predict that the I-CSB and HBI scales should not be significantly linked with these scales.

The choice of sampling violence offenders as a control group has two main reasons: first, to examine differences in main study measures it is essential to know the level of these constructs among non-sexual-related control group. Second, the generalist position in criminological literature (Gottfredson & Hirschi, 1990; Lussier et al., 2007) holds that there are robust similarities between different types of offenders (such as sex offenders and non-sex offenders), which imply that there might be no specific characteristics for sex offenders (as opposed to other theorists that suggest that sex offenders are “specialists” and fundamentally different than non-sex offenders; Harris et al., 2009; Simon, 1997). For example, in support of the generalist position, a 10-year review of the literature from 1995 to 2005 found few differences between sex offenders and non-sex offenders on a wide range of variables, including exposure to domestic violence, psychopathology, use of drugs, relationship with parents, and/or problems with peer relations (van Wijk et al., 2006).

Method

Participants

In the sex offenders’ group, 106 prisoners were approached in group meetings in order to participate in the current research, of whom 103 responded positively (97% response rate). In the violence offenders’ group, 119 prisoners were approached, of whom 81 returned complete test protocols (68% response rate).

Procedure

Questionnaires were printed onto hard copies and administered by the researchers. The questionnaires were authorized by the institutional ethics committees (i.e., Orot-Israel College and Israel Prison Service research committees). The questionnaires were administered in three sex offender treatment units in different geographical locations in Israel. When the researchers arrived at the treatment units, a unit-wide meeting was held in which the rationale for the research and the research committees’ authorizations were presented, together with an opportunity to ask questions, and principles for participation in the research, namely anonymity and the right to end participation at any point without giving a reason. The prisoners signed Israel Prison Service participation agreements as part of the ethics committee’s requirements. Similarly, questionnaires were also administered to violent offense prisoners in four different treatment units of the Israel Prison Service, following the same procedure as that of the sex offender units.

Measures. Individual-Based Compulsive Sexual Behavior (I-CSB)

Compulsive Sexual Behavior was assessed with the Hebrew version of the I-CSB (Efrati & Mikulincer, 2018) as in Study 1. Cronbach’s αs were .93 for unwanted consequences, .94 for lack of control, .88 for negative affect, and .91 for affect regulation. We also computed a total CSB score by averaging the 24 I-CSB items (Cronbach’s α = .97) and use the 4.1 clinical cut-off of the total scale.

Hypersexual Behavior Inventory. (HBI)

Compulsive sexual behavior was also assessed with the HBI (Reid et al., 2011) measure as in Study 1. Cronbach’s αs were .95 for coping, .96 for control and .95 for consequences. We also computed a total CSB score by summing the scores of 19 HBI items (Cronbach’s α = .98) and used the clinical cut-off of 53 in the HBI total score (Reid et al., 2011).

Young Schema Questionnaire—Short Form-3 (YSQ-S3)

Sexual-related maladaptive schemas were assed with the YSQ-S3 (Young & Brown, 2005) measure as in Study 1. Cronbach’s α values for subscales ranging from .73 to .88.

Sensation Seeking and Impulsivity

Zuckerman’s (1979) Sensation Seeking questionnaire was constructed to measure the degree of need for seeking sensation and adventure, the need for new feelings and experiences, threshold of boredom, willingness to take risks, and the tendency toward uninhibited behavior. Participants are asked to mark whether they agree or not with the item (1—true, 0—false). In the present study, we used 19 items, which comprise the scales of impulsivity (7 items; “I tend to begin a new job without much planning on how I will do it”) and sensation seeking (12 items; “I like to have new and exciting experiences and sensations even if they are a little frightening”). We computed for each participant the scores of impulsivity (Cronbach’s α = .80) and sensation-seeking (Cronbach’s α = .82) by summing the number of “true” responses.

Results

Differences in Background SocioDemographic Measures

Differences between sex and violence offenders in socio-demographic measures (age, number of children, years of education) were examined using independent samples t-tests. Sex offenders were older (M = 42.48, SD = 12.95) and had more children (M = 2.48, SD = 2.45) than violence offenders (M = 35.67, SD = 9.98, t ₍₁₈₂₎ = 3.48, p < .01, Cohen’s d = 0.52 for age, M = 1.54, SD = 1.66, t ₍₁₈₂₎ = 2.70, p < .01, Cohen’s d = 0.40 for children). No differences were found in years of education, t ₍₁₈₂₎ = 1.82, Cohen’s d = 0.27. Accordingly, we controlled for age and number of children in subsequent analyses.

Rates of Clinical CSB Among Sex and Violence Offenders

Using the same classification procedure in Study 1, we found that only 3.8% of the sex and violence offenders (n = 7; six sex offenders [7.0%] and one violence offender [1.4%]) were classified as having clinical CSB. The average I-CSB and HBI scores of the clinical group were 4.60 (SD = 0.21) and 68.29 (SD = 10.00), respectively, and for the non-clinical group were 1.87 (SD = 0.75) and 27.80 (SD = 9.20), respectively [overall mean was 2.05 (SD = 0.96) and 30.85 (SD = 14.19), respectively]. Thus, the association between CSB and early maladaptive schemas are essentially on a non-clinical sample with respect to the severity of CSB.

Correlations Between I-CSB, HBI and Early Maladaptive Schemas, Sensation Seeking and Impulsivity

To examine the pattern of associations between I-CSB, HBI and early maladaptive schemas (disconnection and rejection, impaired autonomy and performance, impaired limits, other-directedness, overvigilance and inhibition), sensation seeking and impulsivity, we conducted a series of partial correlations controlling for age and number of children. Coefficients are presented in Table 3. The analyses indicated that the I-CSB and the HBI were all moderately to strongly associated with the clusters of early maladaptive schemas (with the exception of I-CSB and impaired limits among violence offenders). In addition, the I-CSB and the HBI were not associated with sensation seeking and impulsivity.

Table 3.

Correlations Between I-CSB, HBI and Early Maladaptive Schemas (Study 2).

		I-CSB	HBI
Sex offenders	Disconnection and rejection	0.35	0.49
	Impaired autonomy and performance	0.29	0.43
	Impaired limits	0.3	0.42
	Other-directedness	0.25	0.38
	Overvigilance and inhibition	0.23	0.32
	Sensation seeking	0.01	0.1
	Impulsivity	0.11	0.15
Violence offenders	Disconnection and rejection	0.26	0.48
	Impaired autonomy and performance	0.39	0.6
	Impaired limits	0.21	0.31
	Other-directedness	0.32	0.4
	Overvigilance and inhibition	0.24	0.34
	Sensation seeking	−0.13	0.03
	Impulsivity	−0.06	0.05

Note. Bolded correlations are significant at p < .05. ∼p = .06, *p < .05.

Discussion

In Study 2, we examined whether early maladaptive schemas relate to CSB among sex offenders (as compared with a group of violence offenders) who have a sexual deviation on the one hand but low prevalence of clinical CSB on the other hand. The low percentage of clinical CSB among sex offenders is in keeping with research suggesting that although sex offenders are preoccupied with sex, only a minority reach the clinical diagnosis of CSB. Specifically, Kingston and Bradford (2013) found among 586 adult male sexual offenders that the average self-reported total sexual outlet (TSO; Kinsey et al., 1948) was low and that only 12% of individuals met the criterion for compulsive sexual behavior (≥7 orgasms per week). Similar studies found that 11.3% of their sample of adult male sexual offenders on community supervision met the criterion for sexual preoccupation (e.g., Hanson et al., 2007). Briken (2012) examined a representative sample of 244 adult male sexual offenders against child victims. Results indicated that approximately 9% met the diagnostic criteria for clinical compulsive sexual behavior as delineated in the proposed DSM-5 criteria. These rates are closely linked with the rates of clinical CSB among the sex offenders in Study 2.

Although the level of CSB was sub-clinical, the severity of CSB was nonetheless related to all the major early maladaptive schemas. In other words, sex and violence offenders with higher CSB have more distorted cognitions: they expect that their interpersonal needs will not be met, they are more dependent on others in daily functioning, they have more deficiencies in internal limits, and they have unrealistic standard of themselves and others. Therefore, Study 2 shows that early maladaptive schemas are highly indicative of CSB severity even in sub-clinical levels of CSB.

In addition, early maladaptive schemas seem to capture processes unrelated to impulsivity and/or sensation seeking—whereas early maladaptive schemas were highly related to CSB among sex and violence offenders, impulsivity and sensation seeking did not. This finding is in keeping with studies linking early maladaptive schemas with various addictions, behavioral and others. Early maladaptive schemas were found to be indicative of various addictions such as substance abuse (Zargar et al., 2011), food addiction (Imperatori et al., 2017), smartphone addiction (Arpaci, 2019), internet addiction (Shajari et al., 2016), and gambling (Katona, & Körmendi, 2012). Of specific interest is Elmquist and colleagues’s (2016) study that indicated that early maladaptive schemas relate to CSB among people with a substance abuse.

General Discussion

The purpose of the current research was to examine the cognitive distortions associated with CSB and especially the early maladaptive schemas that were found to relate to the etiology, development and maintenance of various psychopathologies that are chronic and enduring in nature (Young et al., 2003). Studies 1 and 2 indicated that early maladaptive schemas are highly indicative of CSB severity among members of Sexaholic Anonymous (SA) groups—people with clinical levels of CSB—and among sex and violence offenders—individuals with subclinical levels of CSB. Higher CSB severity (even within subclinical levels) is associated with distorted expectations that one’s basic social needs—love, warmth, safety and social belonging—will not be met. This expectation does not result in social distancing but paradoxically in greater dependency in other people for effective functioning. Thus, these two cognitive distortions clash together to create a vicious cycle in which a person is dependent on other people but perceive them as unable to fulfill his or her needs. These distortions might explain why CSB revolve around the attempt to regulate distress and pain by escaping to sexual fantasies, pornography, and sexual behaviors and not by intimate interpersonal relationships. Given that the additional cognitive distortions relate to setting unrealistic standards and focusing on the needs of others at the expense of one’s own needs, it could explains why negative affect, including shame and guilt, is constantly present for people with higher levels of CSB—not only that the emotion regulation strategy is not effective, one’s standards are unrealistic and harmful. Finally, we found that people with higher CSB (subclinical and clinical) have impaired internal and interpersonal limits that might explain, on the one hand, the lack of behavioral control and the constant uncontrolled engagement with sexual fantasies, urges, and behaviors. On the other hand, it may also explain the fear that sexual fantasies, urges and behaviors carry harm to oneself and/or to one’s close others such as family members, colleagues, and peers. Of importance, these cognitive distortions are not simply a manifestation of impulsivity and/or sensation seeking because whereas early maladaptive schemas were highly indicative of CSB, impulsivity and/or sensation seeking were not.

Clinical Implications

Knowing the cognitive distortions associated with CSB might improve the therapeutic interventions for CSB. CSB negatively impacts treatment outcomes; for example, people with CSB are more resilient to treatment than people with substance disorders (Hartman et al., 2012). To our best knowledge, there are no systematic, placebo-controlled studies on any treatment modality for CSB. However, several recent reviews examined theories of therapeutic methods and approaches for treating CSB (Derbyshire & Grant, 2015; Efrati & Gola, 2018b; Estellon & Mouras, 2012; Garcia et al., 2016; Miles et al., 2016; Weiss, 2004; Malandain et al., 2020). One promising modality is Cognitive-Behavioral Therapy (CBT). An initial step in CBT is identifying the external (e.g., things associated with sexual activity) and internal (e.g., dysfunctional thoughts) triggers for CSB and the underlying dysfunctional thoughts associated with a given disorder. Once identified, the aim of CBT is to modify the dysfunctional thoughts through cognitive tasks and behavioral interventions and to remodel the environment and habits in a way that allows triggers to be avoided. The strong associations between early maladaptive schemas and CSB might highlight several key cognitive distortions that could be the focus of CBT.

Limitations and Concluding Remarks

Although we have found promising associations between CSB and early maladaptive schemas, the current research has several limitations that needs to be acknowledged. First, Study 1 comprised SA participants; Study 2 comprised sex and violence offenders. Although sex and violence offenders experience symptoms related to individual-based compulsive sexual behavior, they differ from SAs not only in compulsive sexual behavior symptoms but possibly in other related domain such as depression, anxiety and social functioning. These domains might also account for part of the associations between CSB and early maladaptive schemas. Therefore, future studies might also examine these association while considering the effects of other related psychopathology such as depression, anxiety and stress. Second, the SAs in Study 1 self-defined themselves as having CSB. Although we have used two measures (I-CSB and HBI) with a clinical cut-off to examine rates of clinical CSB, we did not conduct a clinical interview to confirm this classification. Lastly, although we sampled unique samples of SAs and sex and violence offenders, the sample sizes are limited and not ideal. Future studies ought to replicate our results in bigger samples.

Despite these lacunae, we view this research as important in studying the cognitive distortions related to CSB. This knowledge may allow to better understand the inner world of people with CSB even when the symptoms of CSB are subclinical. In addition, the current research may help to better tailor interventions aiming at reducing CSB and its negative outcomes by targeting specific cognitive distortions that are highly indicative of CSB.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Yaniv Efrati

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