Compulsive sexual behavior (CSB), also known as hypersexual disorder, is of emerging interest in the psychiatric research community. But data are shallow in terms of fully understanding CSB—often defined as difficulties in controlling inappropriate or excessive sexual fantasies, urges, or behaviors that interfere with key areas of daily life—as well as its relation to other mental health problems.
Researchers believe that CSB may be tied in some cases to PTSD, suicide risk, and other psychiatric concerns in the Veteran population. But not enough is known about the relationship. Even explaining why CSB is more prevalent among Veterans compared with non-Veterans, or diagnosing Vets with the disorder and figuring out how best to treat them, has been a challenge.
"Our Veterans have so many complex problems that sometimes...we're not always thinking right away about these other behaviors."
As Dr. Shane Kraus, a clinical psychologist at the Edith Nourse Rogers Memorial Veterans Hospital in Bedford, Massachusetts, puts it: "We're just scratching the surface" in researching CSB.
To learn more, Kraus led a team of researchers that conducted the most thorough Veteran study on compulsive sexual behavior to date. In the study, almost 14 percent of men and more than 4 percent of women acknowledged CSB-related symptoms. The study, published in March 2017 in Military Psychology, also indicates that gambling, suicidality, and sexually transmitted infections were associated with male CSB. (Due to the small percentage of women reporting the disorder, further analyses focused only on men.)
The results suggest "CSB may be prevalent among U.S. military Veterans post-deployment and associated with significant negative health indices in men," the researchers write. "Some Veterans may be having difficulty managing their sexual behavior, raising concerns about possible unmet treatment needs for soldiers after they transition back to civilian life. CSB warrants attention regarding screening and intervention."
At the Bedford VA, Kraus sees Veterans suffering from behavioral addictions such as compulsive sexual behavior, excessive gambling, and binge eating. He says a lack of research and training has led to uncertainty in the medical community about how to best treat Veterans with CSB.
"It even took me a while to learn," he says. "Our Veterans have so many complex problems that sometimes when we see them we're not always thinking right away about these other behaviors. We might be thinking about someone who's having difficulty with alcohol use or PTSD or something else. So you're more focused on that. These other areas kind of get ignored or pushed to the side, not intentionally. It just happens when you're working with someone who has a lot going on."
The Kraus-led study piggybacks on a 2014 VA study led by Dr. Philip Smith, an epidemiologist at Yale University (he's now at the City College of New York), that consisted of 258 male Veterans who had recently returned from Iraq and Afghanistan. Nearly 17 percent of the participants reported CSB symptoms, with researchers linking the disorder to PTSD and childhood trauma.
The conclusions in Smith's study sparked a more comprehensive look at the issue. Kraus' study included 820 Veterans—both male and female—who had combat exposure in Iraq and Afghanistan. The names were randomly drawn from the Survey of the Experiences of Returning Veterans (SERV), a VA-funded study that is looking at gender differences in coping behaviors of those returning from military service. Dr. Rani Hoff, director of VA's Northeast Program Evaluation Center, which is responsible for evaluating programs in VA Mental Health, and the lead investigator on the SERV study, co-authored the research led by Kraus and Smith.
The average age in Kraus' sample was 35, and nearly 80 percent of the participants were white. The researchers conducted phone interviews with the Veterans, who were guaranteed their names wouldn't be used in the study. The Vets screened positive for CSB by responding "yes" to either of two items in the Minnesota Compulsive Disorders Interview, which includes questions on compulsive gambling and sexual behavior:
"Do you or others that you know think that you have a problem with being overly preoccupied with some aspect of your sexuality or being overly sexually active?"
"Do you have frequent sexual fantasies, urges, or repetitive behaviors which you feel are out of your control or cause you distress?"
Sixty-eight of the 493 male Veterans (13.8 percent) reported CSB symptoms, compared with 14 of the 327 women (4.3 percent).
Kraus is unsure whether the percentage was much smaller for the women because they were perhaps more reluctant to speak out on a very sensitive subject.
"That's a really good question," he says. "It's kind of hard to know because there's a lot of shame. Any person would be naturally uncomfortable sharing any difficulties they're having, but we know when you're having problems with sexual behavior or substance abuse or other things, it's very difficult to talk about it. Women Veterans have lots of complex needs and are dealing with lots of things already, so this may be even more difficult for them to talk about."
He says he finds it interesting, though, that 4.3 percent of the women screened positive for CSB, compared with 1.2 percent of women in a 2013 non-VA survey of college-age people. The rate was 3 percent for men in the same survey.
"The college sample had "pretty young, pretty active men and women," he says. "Those college samples don't have the mental health problems that some of our returning Veterans are having, so it's not the same kind of population. But our rate is much higher than we would have expected."
Data suggest that CSB rates range from 3 percent to 6 percent in the general population. Kraus explains that the rates in his study may have been much higher, particularly among men, because of its low-threshold, two-question system for screening positive. He cautions that the study was intended only for screening purposes and didn't include more lengthy CSB assessment measures. He's now working on a paper that consists of data from a 19-item inventory that reliably assesses compulsive sexual behavior. Such data are needed to provide "more comprehensive, more robust ways to measure these problems among Veterans," he says.
In his latest study, many of the male Veterans who screened positive for CSB also provided information that identified possible risk factors for the disorder. Kraus wasn't surprised that gambling, suicidality, and sexually transmitted infections were "significantly associated" with male CSB. He says those findings were consistent with past literature. He says there was no breakdown on the types of gambling involved and notes that suicidality referred only to suicide ideation, or thoughts of taking one's own life.
Anonymous sex, pornography major forms of CSB
Engaging in anonymous or casual sex multiple times per month, whether or not one is married, and a "problematic" use of pornography were the most common forms of compulsive sexual behavior, Kraus says. The study did not assess whether participants engaged in heterosexual or homosexual acts, or if they showed forms of aggression such as rape, he says.
Last year, Kraus co-authored a paper that said young Veterans—36 percent of men and 9 percent of women—are using digital social media platforms to meet someone for casual sex. The paper also found ties between such behavior and PTSD, insomnia, depression, hypersexuality, suicide ideation, and sexually transmitted diseases.
But in a sign of the ambiguous nature of CSB, his latest study said PTSD symptom severity, anxiety disorder, impulse-control disorder, and mental health functioning were not "significantly associated" with the disorder. "I'm not 100 percent sure why," Kraus says. "I think it's hard to say. It's one of those things where we know they're highly comorbid, but why we didn't find them is unclear. We did see a basic association, but when we put the findings in a model we didn't see them come through. So it doesn't mean they're not associated with CSB. It just means that when you're looking at a whole group of factors, they're not coming out the strongest of the group."
In light of his group's findings, Kraus advocates more precise psychiatric evaluations to screen, for instance, for gambling, suicidality, and the possibility of acquiring sexually transmitted infections.
"Sometimes we're missing stuff," he says. "One of the things I'm curious about is [that] we're seeing a strong relationship between PTSD and sexual behavior. Some people use alcohol and other things to cope with PTSD and other problems. What if people are engaging in certain sexual behaviors to cope or to deal with PTSD or other mental health problems? It's kind of an avoidance behavior. We just don't know."
Kraus thinks his study and future research could help guide VA care.
"We want our research to have clinical outcomes, and we want those clinical outcomes to improve education, training, and implementation," he says. "We plan to roll out a clinical training plan sometime in the next two years. Some of that will be part of policy implementation. I'm working with the VA Central Office to say, `Here are some things that we're finding. How do we disseminate this more broadly?'
"But you've got to show it's a problem first," he says. "That's what we're doing."