Compulsive Sexual Behavior Disorder Among Dating Apps Users: A Case Report

Introduction

Compulsive sexual behavior disorder (CSBD), a new diagnostic of ICD-11, ¹ is characterized by intense and repetitive sexual impulses that lead to a recurring pattern of sexual behavior accompanied by distress or impairment. The patients consistently fail to control these urges and the behavior might manifest in several ways such as engaging in repetitive sexual acts with others, masturbation, use of pornography, and internet/phone sex, in the previous six months or more. This pattern of behavior has marked consequences on the patient’s social, relational, familial, professional, and financial life. However, patients might endure this sexual behavior and neglect these negative impacts even when they get little to no pleasure from their conduct.

The largest study evaluating the prevalence of CSBD according to the ICD-11 guidelines found a lifetime CSBD prevalence of 4.9% [95% CI = 3.9–6.1] and reported a 12-month-prevalence of 3.2% in men. ² There are no officially or internationally accepted guidelines for its treatment but psychotherapy is commonly proposed as first-line therapy and treatment can be supplemented with off-label pharmacotherapy to improve serotoninergic transmission (e.g., SSRIs), work as anti-androgens, better impulse control (e.g., naltrexone, antipsychotics), or address mood stabilization. ³ Discussion about CSBD in queer patients is an ongoing topic of interest as sociocultural context seems to curb clinical presentation ⁴ and several risk factors, such as the use of geosocial networking apps (GNAs) or drug usage during sex, have been associated with it. The authors present a clinical case with severe symptoms of CSBD and high dysfunctionality in a young male patient.

Case Description

A 22-year-old male university student, who is living with his partner, presented to a first sexology appointment. The patient was initially complaining about anxious symptoms—feeling tense and frightful in the past weeks, worrying most of the day—along with short-lasting periods of shortness of breath and increased heart rate without panic features or marked impairment. As the patient became increasingly cooperative, he reported a daily pattern of intense sexual activity related to the use of sex-seeking mobile apps (GNAs) and sex workers. The behavior started three years ago when the patient left his parent’s house and started living in the city. He reported an uncontrollable urge to engage in daily sexual encounters with other men that lead to the daily use of cyber dating applications. During periods of greater symptomatic expression, mood instability was present, but never fulfilled the criteria for an affective disorder. The patient rarely watched pornography and multiple risky and life-threatening behaviors accompanied the sexual meetings, with prior reports of aggression. The patient felt “trapped to the apps, I know that I will find someone there to have sex with” which he omitted to his boyfriend. Marked erotophilia was present. Internalized homophobic thoughts were common and the patient justified the use of apps as he did not want to be perceived as a gay man offline, despite identifying as gay. A pattern of repetitive, uncontrollable, daily sexual behavior was found, with compromised functional capacity and high repercussions on personal life—inability to maintain previous relationships because of infidelity, guilt, and infidelity in the current relationship, debts of thousands of euros, academic failure and retention, incapacity for work. He had no previous follow-up in psychiatry and reported no substance use. The patient had a family history of psychotic illness in a first-degree relative (brother), although he had no history of psychotic symptoms. A workup with blood, urine, and toxicology analysis and an electrocardiogram (EKG) showed no findings.

The patient was diagnosed with CSBD and began follow-up. An initial course of treatment with venlafaxine 75 mg and paliperidone 1.5 mg daily was prescribed. Four weeks later, the anxious symptoms had diminished in intensity but the sexual behavior symptoms were still present despite adherence to the pharmacological regimen. Both impulses and GNAs use were present most days. The reduction in the use of dating apps was consistently approached and behavioral techniques were employed. The patient refused an increase in the dosage of paliperidone because he feared gaining weight. Topiramate 50 mg bid was added and the patient was referred to cognitive-behavioral psychotherapy.

During the following four months, a progressive improvement in impulse control was observed, with a gradual recovery of functioning in social, occupational, and relational areas. The patient started going to classes and found a part-time job that helped him pay the debts of sex workers, which he stopped looking for. He was adhering to the prescribed regimen, despite occasionally forgetting to take paliperidone. He started reporting difficulties in his sexual performance with his partner: he missed the excitement of someone new, he was in love with his partner but complained about being difficult to have an erection because he felt pressured “If I have an erection he knows I love him” (sic). The patient also struggled with his sexual role in the relationship “he makes me feel feminine because as I’m the one having receptive anal sex (…) I was doing it with the other men too but I felt more masculine” (sic).

At six months, repetitive sexual behaviors were reduced and the patient was attending cognitive behavioral psychotherapy sessions twice per month, with a focus on impulse control, emotional regulation, internalized stigma, strategies for coping with stress and anxiety, reacquiring control of sexual behavior and fostering a healthier approach to sexuality. The patient was very resistant to increasing the dosage of medication but later agreed to take paliperidone 3 mg. He struggled with the constant availability of cyber dating apps but was now willing to delete them. At 8 months, the patient had stopped using the cyber dating apps, felt more in control over his sexual behavior, and at 10 months the patient insisted on stopping medication because he felt better. He was advised that in doing so the symptoms could return and that it was still too early to stop the medication. Venlafaxine was stopped by the patient, and he was reevaluated six weeks after—no recurrence of sexual symptoms was found.

At one-year follow-up, the patient remained stable, with no recurrence of symptoms. Internalized homophobic thoughts and feelings had decreased, the patient was working on his relationship, reported that the urge for sexual encounters was less common and more easily controllable and the episodes of sexual dysfunction were less common and distressing. He viewed his sexual orientation and sexual life in a more positive, guilt-free, and healthier way.

Discussion

Most published cases report increased masturbation or use of pornography but the presented case reveals an interplay between repetitive sexual behavior, the use of GNAs and sex workers. The report illustrates the difficult management of these patients, how it might manifest differently in gay men, the role of the excessive use of GNAs for sexual encounters in CSBD, and how the presence of proximal and distal stressors might module the clinical presentation and lead to a difficult balance in maintaining a healthy sexual life.

In this case, venlafaxine was used for its serotoninergic effect and paliperidone was prescribed as the patient presented severe symptoms related to impulse control. The patient was referred to psychotherapy after the first reevaluation—referral was difficult because of the scarce number of psychotherapists available.

CSBD patients show increased offline and online sexual activity and the use of GNAs has been simultaneously proposed as a risk factor for CSBD and a mean for its manifestation. ⁵ Its excessive use has been associated with mental health problems. ⁶ Recently, it was highlighted the putative role of sexual sensation seeking in the use of GNAs and how these apps can provide an unrestricted source of sexual encounters and new experiences. ⁶ The use of GNAs by gay men seems to be fueled by stigma and fear of discrimination (distal stressors) ⁶ as minority stress plays a relevant role in CSBD in nonheterosexual patients. ⁷ (p. 11)

In this case, the patient’s internalized homophobia and fear of being “out” (proximal stressor) might have also played a role in modeling the form of presentation of the CSBD through the excessive use of GNAs. On the other hand, the accessibility and addictive behavior regarding GNAs enabled an increase in symptomatic expression. Therapeutically targeting the use of GNAs and internalized homophobia played a synergic role along with psychotherapy and medication to achieve a progressive remission of symptoms.

On another aspect, keeping a balance between the management of sexual urges/reduction of compulsive behaviors, and maintaining a healthy sexual life can be challenging. Gay men also have higher rates of sexual and erectile dysfunction related to specific activators such as minority stress or anal sex. ⁸ In this case, the patient reported troubles with erection and dysfunction at a certain point of follow-up. He suffered with the compulsive symptoms, did not want his partner to find out about the infidelity, had distressing thoughts about his sex role, and felt pressured to have an erection that—in his view—symbolized affection. This set of aspects is already of particular interest in MSM ⁹ and its presence in patients with CSBD requires additional research. In follow-up, the patient benefits from supplementary attention to sexual dysfunction and the implementation of a strategy to prevent relapse.

In conclusion, CSBD approach needs further characterization and development of treatment guidelines. The predominant sexual behavior or dysfunctional activity may manifest differently between sets of patients and present specific needs for management in MSM—pharmacological, psychotherapeutic, and related to social-cultural factors. The reporting of clinical cases and the need for studies in this clinical population are paramount to elucidate future practice.