The Life Course of a Woman with Compulsive Sexual Behavior: A Case Study

Introduction

Diversity in sexual preferences and practices in women compared to men has been relatively under-reported. Early accounts of excessive sexual desire in women encountered by Victorian-era clinicians attribute the cause to the sexual organs. ¹ Later, starting from the late nineteenth century, in the work of Krafft-Ebing and others, sexual perversions were attributed to characterological deficits. Further, with the advent of psychoanalysis, and later, it was attributed to a disordered psyche or functional disorder.^1,2 Presently, some categorize such behaviors as clinical conditions, while others consider them variants of the normal spectrum of sexual preferences. Today, terms such as “nymphomania” have become obsolete ² in terms of clinical classification. Newer inclusions like compulsive sexual behavior disorder (CSBD) are used instead in International Classification of Disease, 11th revision (ICD-11) (as disorders of impulse control), while in Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), no such equivalent category exists. On the other hand, paraphilias are described in both diagnostic systems. According to ICD-11, CSBD is a pattern of repetitive sexual behavior arising from recurrent sexual impulses or urges that one fails to control to the extent of interfering with other life goals and becoming the essential theme of life. Furthermore, obligatory for the diagnosis are unsuccessful attempts to reduce or stop the sexual activity despite adverse consequences or deriving little or no satisfaction from it. Neither the prevalence of CSBD in females is known accurately, nor is its extent across the lifespan.

CSBD in previous literature has been described commonly as hypersexuality (originally by Krafft-Ebing) and by some others as “nonparaphilic compulsive sexual behavior” or “sexual addiction.” ³ However, not much has been reported about CSBD comorbid with paraphilias in women.

Amidst such ambivalence in diagnostic categorization, we present a case of a 50-year-old woman who had been “promiscuous” in her early life and later went on to develop repeated, intense sexual urges, which became difficult to manage owing to guilt, psychological pain, and social embarrassment.

Case of Mrs. X

Mrs. X, a 50-year-old widow, part-time household help, was on the treatment for the past four years for the complaints of repetitive, intrusive sexual thoughts and images. She was treated as a case of obsessive-compulsive disorder (OCD) with fluoxetine 60 mg/d. Though irregular with outpatient follow-up, she reported being adherent to the medication for the past two to three years with poor response.

Concerned by her worsening symptoms, accompanied by her daughter, she consulted our outpatient clinic. She complained of experiencing vivid sexual images accompanied by intense sexual urges and arousal. Domestic animals would even trigger these urges. Her distress regarding such experiences had started in the last four years, accompanied by low mood, decreased interest in pleasurable activities, restlessness, and anxiety. Two months before the current presentation, her husband had succumbed to chronic kidney disease (CKD), and subsequently, she started expressing suicidal ideations. We admitted her to our inpatient facility, given the risk of self-harm. A further detailed workup revealed a different story, which she never revealed during outpatient visits due to fear of social embarrassment.

Mrs. X, as a young girl, lived in a single-room semi-pukka house with her parents and younger brother. At the age of eight, she started witnessing her parents repeatedly engaging in intimate sexual activities when, supposedly, it was assumed that the children were asleep. It triggered her curiosity about the sexual aspect of relationships. She attained menarche at the age of 12. She started having an urge for sexual intimacy and soon would be engaging in sexual practices (sic) by the age of 11 years. She also reported having sexual attraction to her own male sibling and peer group. By the age of 12, she was engaging in sexual acts with neighbors who were of the opposite gender and older than her. As she grew up, she felt the urges more intensely, experienced them as pleasurable, and had no distress regarding them. Later, she gained knowledge about masturbation and started masturbating several times a week as a response to her urges. She would actively indulge in pornographic or explicit content in magazines and newspapers and use them for masturbation. At the age of 16, she recalls having the desire to watch others engaging in sexual acts and would be peeping through the windows of her neighbors for the same. It would happen several times a week, and seeing such couples in the act would arouse her, and she would thereafter masturbate. She would spend a considerable amount of time fantasizing about various sexual encounters with a prospective suitable partner. She would have multiple partners during this period but no stable relationships. She also started taking money in exchange for the sexual favors she would perform for her partners. She expressed that such an arrangement helped her with her finances besides her pleasure-seeking motive.

During her early adolescence, she reports sexual arousal even when holding children or simply touching them. Although she had never acted upon such urges for gratification, she never felt distressed for these. She knew such an act would be socially unacceptable, so she never thought seriously about it. However, after the age of 16 years, she started experiencing repetitive images of her performing sexual acts with various people, such as individuals from her neighborhood, to whom she was attracted. Initially, it would be accompanied by an urge to perform sexual acts that would make her excited and not distressful, but later, in her 30s, she considered it distressing but never unwanted or excessive. Most of such fantasies would be followed by her masturbating at the end. It would occur frequently and sometimes interrupt the patient’s daily activities. She married at 19 but divorced six years later because of frequent altercations and interpersonal issues with her husband. During that time, the patient reports being attracted to her brother-in-law and having pleasurable sexual fantasies about him and, on occasion, engaging in sexual intercourse with him. She was also involved with other males in her locality during this time. Her other biological functions were normal throughout this period, and her predominant mood was stable.

At 25, she remarried and had a cordial relationship throughout the marriage. Her partner generally met her sexual needs, but at times, they would become excessive. When her partner would not be able to satisfy her sexual appetite, she would get involved with other men. After two years of marriage, she had a baby girl, and she began experiencing urges and arousal towards the child, leading to limiting contact and refraining from being with her all day long. Over time, these urges had somewhat settled, but then she felt ashamed of such desires as they were not in harmony with her role as a mother. With time, she would intermittently have exaggerated urges and repetitive images with sexual content, though they were not unwanted, excessive, or distressing. Over the next 15 years or so, her sexual engagement with other men decreased; she would indulge in masturbatory acts and spend a considerable amount of time viewing and enjoying pornographic content (more recently on the Internet). These acts made her feel good, with no guilt, and helped her to maintain a fulfilling sexual life.

Four years ago, her husband started having repeated health-related issues and was diagnosed with CKD. It led to a decline in sexual intimacy with her husband. Again, she started having similar pleasurable repetitive images of sexual acts, now including domestic animals. Later, it would be followed by distress and guilt. Mrs. X, at this time, was working as a part-time household help in neighboring houses where she would have increased sexual desires throughout the day, with urges and fantasies intensifying on seeing male members or pet animals causing apprehension, restlessness, and decreased concentration, leading to difficulty completing assigned tasks. She would experience arousal even while holding babies and feared she might act inappropriately. The distress intensified when she started experiencing sexual urges for her pet dog, with an increased frequency of arousal (seeing the pet or imagining it). She would fear acting upon her urge, prompting her to refrain from spending time with or touching her pet. Similar urges started arising on seeing roadside animals, too, which would be initially arousing and pleasurable, with subsequent anxiety and restlessness followed by fear and shame.

There was no history of other anomalous sexual preferences, such as exhibitionism, frotteurism, sexual activity involving pain or suffering, or fetishism or transvestism. She did not report any homosexual attraction.

Following her husband’s death two months back, the above symptoms have escalated in addition to low mood, decreased interest, and death wishes. She now perceived herself as a sinner for engaging in these thoughts/behaviors over the past many years and wished to die by jumping in a river (the holy Ganges—a nearby river) or by other means. Despite such active death wishes, she had never attempted to do so. She also slept less, averaging three to four hours per night with delayed onset. Her appetite had decreased with a 2-3 kg weight loss in the past two months.

On mental status examination, she denied having repetitive, intrusive, distressful images altogether. She admitted to having sexual urges, feelings of arousal, and excitement in the moment of the sexually intoned thoughts; however, she would be distressed after the thoughts had passed, along with ideas of guilt and feeling sinned. Besides domestic animals, repetitive sexual urges towards inanimate objects (like tables, carrots, paper, and pens) were also reported. It was associated with fear of acting upon them and causing harm to them. She also confessed to the inability to fulfill her sexual needs after the death of her husband, causing her distress. She clarified that the distress was about the consequence of acting upon her urges rather than the repetitive thoughts. When given a hypothetical scenario where the norms would be less restrictive, sexual fantasies can be played out and not considered taboo, and societal perspectives liberal on sexuality, then she acknowledged such thoughts would not trouble her.

Investigations ruled out organic conditions (Klüver-Bucy syndrome, Kleine-Levin syndrome); mania, substance use disorder, and other paraphilic disorders were negated. Viral markers and serology came out to be negative. Mrs. X scored 16 on the Hamilton Depression Rating Scale (HAM-D).

Considering the poor response to fluoxetine, we initiated Mrs. X on tab sertraline, which was optimized to 125 mg/day in two weeks, along with tab. buspirone 5 mg and tab. clonazepam 0.5 mg twice a day. Mrs. X started reporting some improvement in the anxiety symptoms, biological functions, and restlessness, but urges and arousal persisted. In the initial period, a diagnosis of OCD versus paraphilic disorder was considered, with a differential diagnosis of CSBD with comorbid severe depression with anxious distress.

Tab. naltrexone was initiated after around ten days, titrated to 50 mg/ day, in keeping with the comorbid diagnosis of paraphilia with CSBD. The week following this, she had marked improvement in urges and arousal, along with improvement in mood. On day 18 of admission, the HAM-D score was 7. We discharged Mrs. X at this point with a plan of regular follow-up at short intervals. She revisited the outpatient clinic a week later with no further deterioration. After two weeks of this visit, she was followed up and reported further improvement. Over the next month following discharge, she rejoined her work, regained her previous baseline mood, had decreased fear of interacting with her pet, and decreased sexual urges and arousal.

Discussion

Mrs. X presented to us with significant distress and wanted help to alleviate her resultant emotional pain. Her life course suggested changing preferences in her sexual fantasies and arousal over time, often triggered by various life events. In her early life, she developed voyeuristic tendencies and precocious sexual indulgences. Studies have pointed out that family stressors, violence, abuse, unstable relationships of parents, and, importantly, disinhibited familial interactions (co-sleeping, co-bathing, family nudity, opportunities to look at adult movies/magazines, and witness intercourse) could lead to hypersexuality in children and as well as adolescents. ⁴ Similarly, Mrs. X recalled a childhood when she witnessed repeated sexual intimacy, triggering sexual curiosity and ensuing precautious sexual encounters. Such witnessing probably preceded what has been reported, considering the living arrangement, and it was in early puberty that the nature of the act was thus interpreted. She had early exposure to heterosexual encounters with partners older than hers (though the nature of these sexual encounters was not elaborated), and she actively indulged in pornography, excessive sexual fantasies involving real and imaginary partners often ending in masturbation. In mid-adolescence, she developed pedophilic arousal, although her social norms prevented her from engaging with such instincts. Married early, she continued with her sexual fantasies, often acting on them, and presumably developed complications in her marital relations (though not explicitly revealed by her), resulting in divorce. On her second marriage in early adulthood, she developed a more stable relationship, was more satisfied with her partner (husband), and was better able to manage her sexual life despite the occasional need for sexual satisfaction outside marriage. But then, with childbirth, her pedophilic urges reappeared, limiting her capacities as a mother to restrict her actions within the bounds of social norms. By her middle age, Mrs. X curtailed her sexual urges outside marriage and restricted them to pornography, gratifying herself through masturbation. Now in her late middle age, bereaving the gradual loss of a sexual partner (who gratified her and limited her sexual encounters within social norms), she had renewed and now more forceful sexual urges triggered by people encountered at the workplace and pet animals.

Confusing hypersexuality as sexual obsessions is common in busy clinical scenarios as such clinical material is rare, patients have difficulty discussing such intimate issues as rapport development is superficial, and the inherent “taboo” attached to such topics in the cultural context of India. The other aspect of such confusion is the overlap of psychopathology, that is the obsessive vis-à-vis impulsive nature of the spectrum. Finally, the comorbidity of mood, anxiety, and substance use disorder with disorders related to hypersexuality complicated the clinical scenario.

Hypersexuality as a symptom, disorder, or deviation beyond the prevailing cultural norm is considerably fluid ⁵ and is evident from how the two major diagnostic systems, ICD-11 and DSM-5, deal with it.

The key features in the clinical manifestation in our case suggesting hypersexuality are the apparent features of vivid and norm-defying fantasies, undue reliance on pornography, excessive masturbation, and promiscuity. Yet the superficial distress that was initially interpreted as obsessional was later clarified as pleasurable at the moment of the thought, physiologically enjoyable, providing sexual satisfaction. In the case of sexual obsessions, it would have been immediately distressing and would continue for some time, conveying a disgustful feeling about oneself for thinking so. ⁶ The distress in Mrs. X, on the other hand, appeared later once the pleasurable feeling had passed and appeared as shame due to self-judgment imposed by the surrounding societal norms.

Hypersexuality or “compulsive sexual behavior” has been discussed often along with paraphilic disorders due to the overlap of phenomenology. ³ The reporting of hypersexuality (such as compulsive masturbation, sexual promiscuity, and pornography dependence) significantly co-occurs with paraphilias. ⁷ Additionally, the co-occurrence of multiple paraphilias is more common than the presence of a single paraphilia. ³ The present case typifies such findings. Moreover, these multiple paraphilias, some of which coexisted and others appeared somewhat sequentially, are also noted in the literature. ⁸ Another important aspect in the present case is the female gender, which is scarcely reported, both for paraphilias and hypersexuality. ³ Remarkably, the initial voyeuristic tendencies, marking the beginning of the paraphilic carrier, suggest the initial phase of courtship behaviors in what has been termed “courtship disorder” by Freund and Kolarsky. ⁹

The common comorbidities with CSBD include major depressive disorder (also reported in the present case) and substance use disorder. ¹⁰

From the point of view of treatment, the patient was adequately treated with serotonin selective reuptake inhibitors (SSRI; fluoxetine) for the sexual complaints (presuming them as sexual compulsions) with poor response. While we treated the patient with sertraline (targeting her depressive symptoms), the addition of naltrexone did provide significant relief of compulsive sexual symptoms. Though no controlled trial exists for the support of naltrexone in such cases, clinical evidence in hypersexuality ¹¹ and trials in similar conditions do exist. ¹²

Conclusion

The concept of hypersexuality has been fluid, owing to the changes in its understanding across different times and, importantly, the changing social norms defining the boundary of normal versus abnormal sexuality. The case of Mrs. X helps us peak at the conundrum of hypersexuality and perversions that are norm-defying yet do not violate the boundaries of others. The case helps us understand the life trajectory of an individual with sexual deviation and the interaction of such deviation with various life events. Mrs. X sought treatment to alleviate her embarrassment, considering the social circumstances she was presently in (aging, loss of a stable sexual partner, and overarching social pressure), for complaints that never bothered her much for most of her life. When in the clinic, it brings us to the question: should we treat hypersexuality, or should we treat it only when it is the reason for other morbidities? Or treat hypersexual behaviors (within the law-enforcement system) when they violate the boundaries of a non-consenting individual?