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More mass debating: Compulsive sexual behaviour and the internet

The issue of sex addiction as a behavioural addiction has been hotly debated over the last decade. A recent contribution to this debate is a review by Shane Kraus and his colleagues in the latest issue of the journal Addiction that examined the empirical evidence base for classifying compulsive sexual behaviour (CSB) as a behavioural (i.e., non-substance) addiction. The review raised many important issues and highlighted many of the problems in the area including the problems in defining CSB, and the lack of robust data from many different perspectives (epidemiological, longitudinal, neuropsychological, neurobiological, genetic, etc.).

As my regular blog readers will know, I have carried out empirical research into a wide variety of different behavioural addictions (gambling, video gaming, internet use, exercise, sex, work, etc.) and have argued that some types of problematic sexual behaviour can be classed as sex addiction depending upon the definition of addiction used. I was invited by the editors of Addiction to write a commentary on the review and this has just been published in the same issue as the paper by Kraus and colleagues. This blog briefly looks at the issues in that review that I highlighted in my commentary.

For instance, there are a number of areas in Kraus et al.’s paper that were briefly mentioned without any critical evaluation. For instance, in the short section on co-occurring psychopathology and CSB, reference was made to studies claiming that 4%-20% of those with CSB also display disordered gambling behaviour. I pointed out that a very comprehensive review that I published with Dr. Steve Sussman and Nadra Lisha (in the journal Evaluation and the Health Professions) examining 11 different potentially addictive behaviours also highlighted studies claiming that sex addiction could co-occur with exercise addiction (8%-12%), work addiction (28%-34%), and shopping addiction (5%-31%). While it is entirely possible for an individual to be addicted to (say) cocaine and sex concurrently (because both behaviours can be carried out simultaneously), there is little face validity that an individual could have two or more co-occurring behavioural addictions because genuine behavioural addictions consume large amounts of time every single day. My own view is that it is almost impossible for someone to be genuinely addicted to (for example) both work and sex (unless the person’s work was as an actor/actress in the pornographic film industry).

The paper by Kraus et al also made a number of references to “excessive/problematic sexual behavior” and appeared to make the assumption that ‘excessive’ behaviour is bad (i.e., problematic).  While I agree that CSB is typically excessive, excessive sex in itself is not necessarily problematic. Preoccupation with any behaviour in relation to addiction obviously needs to take into account the context of the behaviour, as the context is far more important in defining addictive behaviour than the amount of the activity undertaken. As I have constantly argued, the fundamental difference between a healthy excessive enthusiasms and addictions is that healthy excessive enthusiasms add to life whereas addictions take away from them.

The paper also appeared to have an underlying assumption that empirical research from a neurobiological and genetic perspective should be treated more seriously than that from a psychological perspective. Whether problematic sexual behaviour is described as CSB, sex addiction and/or hypersexual disorder, there are thousands of psychological therapists around the world that treat such disorders. Consequently, clinical evidence from those that help and treat such individuals should be given greater credence by the psychiatric community.

shutterstock_cybersex

Arguably the most important development in the field of CSB and sex addiction is how the internet is changing and facilitating CSB. This was not even mentioned until the concluding paragraph yet research into online sex addiction (while comprising a small empirical base) has existed since the late 1990s including sample sizes of up to almost 10,000 individuals. In fact, there have been a number of recent reviews of the empirical data concerning online sex addiction including its treatment including ones by myself in journals such as Addiction Research and Theory (in 2012) and Current Addiction Reports (in 2015). My review papers specifically outlined the many specific features of the Internet that may facilitate and stimulate addictive tendencies in relation to sexual behaviour (accessibility, affordability, anonymity, convenience, escape, disinhibition, etc.). The internet may also be facilitating behaviours that an individual would never imagine doing offline such as cybersexual stalking.

Finally, there is also the issue of why Internet Gaming Disorder was included in the DSM-5 (in Section 3 – ‘Emerging measures and models’) but sex addiction/hypersexual disorder was not, even though the empirical base for sex addiction is arguably on a par with IGD. One of the reasons might be that the term ‘sex addiction’ is often used (and arguably misused) by high profile celebrities as an excuse to justify their infidelity (e.g., Tiger Woods, Michael Douglas, David Duchovny, Russell Brand), and is little more than a ‘functional attribution’. For instance, the golfer Tiger Woods claimed an addiction to sex after his wife found out that he had many sexual relationships during their marriage. If his wife had never found out, I doubt whether Woods would have claimed he was addicted to sex. I would argue that many celebrities are in a position where they are bombarded with sexual advances from other individuals and have succumbed. But how many people would not do the same thing if they had the opportunity? Sex only becomes a problem (and is pathologised) when the person is found to have been unfaithful. Such examples arguably give sex addiction a ‘bad name’, and provides a good reason for those not wanting to include such behaviour in diagnostic psychiatry texts.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Bocij, P., Griffiths, M.D., McFarlane, L. (2002). Cyberstalking: A new challenge for criminal law. Criminal Lawyer, 122, 3-5.

Cooper, A., Delmonico, D.L., & Burg, R. (2000). Cybersex users, abusers, and compulsives: New findings and implications. Sexual Addiction and Compulsivity, 6, 79-104.

Cooper, A., Delmonico, D.L., Griffin-Shelley, E., & Mathy, R.M. (2004). Online sexual activity: An examination of potentially problematic behaviors. Sexual Addiction and Compulsivity, 11, 129-143.

Cooper, A., Galbreath, N., Becker, M.A. (2004). Sex on the Internet: Furthering our understanding of men with online sexual problems. Psychology of Addictive Behaviors, 18, 223-230.

Cooper, A., Griffin-Shelley, E., Delmonico, D.L., Mathy, R.M. (2001). Online sexual problems: Assessment and predictive variables. Sexual Addiction and Compulsivity, 8, 267-285.

Dhuffar, M. & Griffiths, M.D. (2015). A systematic review of online sex addiction and clinical treatments using CONSORT evaluation. Current Addiction Reports, 2, 163-174.

Griffiths, M.D. (2000).  Excessive internet use: Implications for sexual behavior. CyberPsychology and Behavior, 3, 537-552.

Griffiths, M.D.  (2001).  Sex on the internet: Observations and implications for sex addiction. Journal of Sex Research, 38, 333-342.

Griffiths, M.D. (2004). Sex addiction on the Internet. Janus Head: Journal of Interdisciplinary Studies in Literature, Continental Philosophy, Phenomenological Psychology and the Arts, 7(2), 188-217.

Griffiths, M.D.  (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10, 191-197.

Griffiths, M.D. (2012). Internet sex addiction: A review of empirical research. Addiction Research and Theory, 20, 111-124.

Griffiths, M.D. (2016). Compulsive sexual behaviour as a behavioural addiction: The impact of the Internet and other issues. Addiction, 111, 2107-2109.

Griffiths, M.D. & Dhuffar, M. (2014). Treatment of sexual addiction within the British National Health Service. International Journal of Mental Health and Addiction, 12, 561-571.

Kraus, S., Voon, V., & Potenza, M. (2016). Should compulsive sexual behavior be considered an addiction? Addiction 111, 2097-2106.

Orzack M.H., & Ross C.J. (2000). Should virtual sex be treated like other sex addictions? Sexual Addiction and Compulsivity, 7, 113-125.

Sussman, S., Lisha, N. & Griffiths, M.D. (2011). Prevalence of the addictions: A problem of the majority or the minority? Evaluation and the Health Professions, 34, 3-56.

Van Gordon, W., Shonin, E., & Griffiths, M.D. (2016). Meditation Awareness Training for the treatment of sex addiction: A case study. Journal of Behavioral Addictions, 5, 363–372.

 

Lust discussed: A brief overview of our recent papers on sex addiction

Following my recent blogs where I outlined some of the papers that my colleagues and I have published on mindfulness, Internet addiction, gaming addiction, youth gambling, exercise addiction, and shopping addiction, here is a round-up of recent papers that my colleagues and I have published on sex addiction.

Griffiths, M.D. & Dhuffar, M. (2014). Treatment of sexual addiction within the British National Health Service. International Journal of Mental Health and Addiction, 12, 561-571.

  • At present, the prevalence of rates of sexual addiction in the UK is unknown. This study investigated what treatment services were available within British Mental Health Trusts (MHTs) that are currently provided for those who experience compulsive and/or addictive sexual behaviours within the National Health Service (NHS) system. In March and April 2013, a total of 58 letters were sent by email to all Mental Health Trusts in the UK requesting information about (i) sexual addiction services and (ii) past 5-year treatment of sexual addiction. The request for information was sent to all MHTs under the Freedom of Information Act (2001). Results showed that 53 of the 58 MHTs (91 %) did not provide any service (specialist or otherwise) for treating those with problematic sexual behaviours. Based on the responses provided, only five MHTs reported having had treated sexual addiction as a disorder that took primacy over the past 5 years. There was also some evidence to suggest that the NHS may potentially treat sexual addiction as a secondary disorder that is intrinsic and/or co-morbid to the initial referral made by the GP. In light of these findings, implications for the treatment of sex addiction in a British context are discussed.

Dhuffar, M. & Griffiths, M.D. (2014). Understanding the role of shame and its consequences in female hypersexual behaviours: A pilot study. Journal of Behavioural Addictions, 3, 231–237.

  • Background and aims: Hypersexuality and sexual addiction among females is a little understudied phenomenon. Shame is thought to be intrinsic to hypersexual behaviours, especially in women. Therefore, the aim of this study was to understand both hypersexual behaviours and consequences of hypersexual behaviours and their respective contributions to shame in a British sample of females (n = 102). Methods: Data were collected online via Survey Monkey. Results: Results showed the Sexual Behaviour History (SBH) and the Hypersexual Disorder Questionnaire (HDQ) had significant positive correlation with scores on the Shame Inventory. The results indicated that hypersexual behaviours were able to predict a small percentage of the variability in shame once sexual orientation (heterosexual vs. non-heterosexual) and religious beliefs (belief vs. no belief) were controlled for. Results also showed there was no evidence that religious affiliation and/or religious beliefs had an influence on the levels of hypersexuality and consequences of sexual behaviours as predictors of shame. Conclusions: While women in the UK are rapidly shifting to a feminist way of thinking with or without technology, hypersexual disorder may often be misdiagnosed and misunderstood because of the lack of understanding and how it is conceptualised. The implications of these findings are discussed.

Dhuffar, M. & Griffiths, M.D. (2015). A systematic review of online sex addiction and clinical treatments using CONSORT evaluation. Current Addiction Reports, 2, 163-174.

  • Researchers have suggested that the advances of the Internet over the past two decades have gradually eliminated traditional offline methods of obtaining sexual material. Additionally, research on cybersex and/or online sex addictions has increased alongside the development of online technology. The present study extended the findings from Griffiths’ (2012) systematic empirical review of online sex addiction by additionally investigating empirical studies that implemented and/or documented clinical treatments for online sex addiction in adults. A total of nine studies were identified and then each underwent a CONSORT evaluation. The main findings of the present review provide some evidence to suggest that some treatments (both psychological and/or pharmacological) provide positive outcomes among those experiencing difficulties with online sex addiction. Similar to Griffiths’ original review, this study recommends that further research is warranted to establish the efficacy of empirically driven treatments for online sex addiction.

Dhuffar, M. & Griffiths, M.D. (2015). Understanding conceptualisations of female sex addiction and recovery using Interpretative Phenomenological Analysis. Psychology Research, 5, 585-603.

  • Relatively little research has been carried out into female sex addiction. There is even less regarding understandings of lived experiences of sex addiction among females. Consequently, the purpose of the present study was to examine the experiences of female sex addiction (from onset to recovery). This was done by investigating the experiences and conceptualisations of three women who self-reported as having had a historical problem with sex addiction. An interpretative phenomenological analysis (IPA) methodology was applied in the current research process in which three female participants shared their journey through the onset, progression, and recovery of sex addiction. The IPA produced five superordinate themes that accounted for the varying degrees of sexual addiction among a British sample of females: (1) “Focus on self as a sex addict”; (2) “Uncontrollable desire”; (3) “Undesirable feelings”; (4) “Derision”; and (5) “Self help, treatment and recovery”. The implications of these findings towards the understanding and the need for the implementation of treatment are discussed.

Dhuffar, M., Pontes, H.M. & Griffiths, M.D. (2015). The role of negative mood states and consequences of hypersexual behaviours in predicting hypersexuality among university students. Journal of Behavioural Addictions, 4, 181–188.

  • The issue of whether hypersexual behaviours exist among university students is controversial because many of these individuals engage in sexual exploration during their time at university. To date, little is known about the correlates of hypersexual behaviours among university students in the UK. Therefore, the aims of this exploratory study were two-fold. Firstly, to explore and establish the correlates of hypersexual behaviours, and secondly, to investigate whether hypersexuality among university students can be predicted by variables relating to negative mood states (i.e., emotional dysregulation, loneliness, shame, and life satisfaction) and consequences of hypersexual behaviour.

Van Gordon, W., Shonin, E., & Griffiths, M.D. (2016). Meditation Awareness Training for the treatment of sex addiction: A case study. Journal of Behavioral Addictions, in press.

  • Sex addiction is a disorder that can have serious adverse functional consequences. Treatment effectiveness research for sex addiction is currently underdeveloped, and interventions are generally based on guidelines for treating other behavioural (as well as chemical) addictions. Consequently, there is a need to clinically evaluate tailored treatments that target the specific symptoms of sex addiction. It has been proposed that second-generation mindfulness-based interventions (SG-MBIs) may be an appropriate treatment for sex addiction because in addition to helping individuals increase perceptual distance from craving for desired objects and experiences, some SG-MBIs specifically contain meditations intended to undermine attachment to sex and/or the human body. To date, no study exploring the utility of mindfulness for treating sex addiction has been conducted. This paper presents an in-depth clinical case study of a male individual suffering from sex addiction that underwent treatment utilising an SG-MBI known as Meditation Awareness Training (MAT). Following completion of MAT, the participant demonstrated clinically significant improvements regarding the addictive sexual behaviour, as well less depression and psychological distress. The MAT intervention also led to improvements in sleep quality, job satisfaction, and non-attachment to self and experiences. Salutary outcomes were maintained at six-month follow-up. The current study extends the literature exploring the applications of mindfulness for treating behavioural addiction, and findings of this case study indicate that further clinical investigation into the role of mindfulness for treating sex addiction is warranted.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Griffiths, M.D. (2000). Excessive internet use: Implications for sexual behavior. CyberPsychology and Behavior, 3, 537-552.

Griffiths, M.D. (2001). Addicted to love: The psychology of sex addiction. Psychology Review, 8, 20-23.

Griffiths, M.D. (2001). Sex on the internet: Observations and implications for sex addiction. Journal of Sex Research, 38, 333-342.

Griffiths, M.D. (2004). Sex addiction on the Internet. Janus Head: Journal of Interdisciplinary Studies in Literature, Continental Philosophy, Phenomenological Psychology and the Arts, 7(2), 188-217.

Griffiths, M.D. (2010). Addicted to sex? Psychology Review, 16(1), 27-29.

Griffiths, M.D. (2012). Internet sex addiction: A review of empirical research. Addiction Research and Theory, 20, 111-124.

Griffiths, M.D. (2012). The use of online methodologies in studying paraphilia: A review. Journal of Behavioral Addictions, 1, 143-150.

Griffiths, M.D. & Dhuffar, M. (2014). Collecting behavioural addiction treatment data using Freedom of Information requests. SAGE Research Methods Cases. Located at: DOI: http://dx.doi.org/10.4135/978144627305014533925

The must of lust discussed: Why isn’t sex addiction in the DSM-5?

Please note: A shorter and slightly different version of this blog first appeared on addiction.com

Sex addiction appears to be a highly controversial area among both the general public and those who work in the addiction field. Some psychologists adhere to the position that unless the behaviour involves the ingestion of a psychoactive substance (e.g., alcohol, nicotine, cocaine heroin), then it can’t really be considered an addiction. But I’m not one of them. If it were up to me, I would have given serious consideration to including sex addiction in the latest (fifth) edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Given that ‘gambling disorder’ was reclassified from a disorder of impulse control to a behavioural addiction in the DSM-5, there is now no theoretical reason why other behavioural addictions can’t be added in the years to come. So why wasn’t sex addiction included in the latest DSM-5? Here are some possible reasons.

Some researchers think that sex addiction just doesn’t exist (for moral and theoretical reasons): Many scholars have attacked the whole concept of sex addiction saying it is a complete myth. It’s not hard to see why, as many of the claims appear to have good face validity. Many sociologists would argue that ‘sex addiction’ is little more than a label for sexual behaviour that significantly deviates from society’s norms. The most conventional attack on sex addiction is a variation on the position outlined in my introduction (i.e., that ‘addiction’ is a physiological condition caused by ingestion of physiological substances, and must therefore be defined physiologically). There are also attacks on more moral grounds with people saying that if excessive sexual behaviour is classed as an addiction it undermines individuals’ responsibility for their behaviour (although this argument could be said of almost any addiction).

The word ‘addiction’ has become meaningless: There are also those researchers within the social sciences who claim that the every day use of the word ‘addiction’ has rendered the term meaningless (such as people saying that their favorite television show is ‘addictive viewing’ or that certain books are ‘addictive reading’). Related to this is that those that work in the field don’t agree on what the disorder (e.g. ‘sex addiction’, ‘sexual addiction’, ‘hypersexuality disorder’, ‘compulsive sexual behaviour’, ‘pornography addiction’, etc.) should be called and whether it is a syndrome (i.e., a group of symptoms that consistently occur together, or a condition characterized by a set of associated symptoms) or whether there are many different sub-types (pathological promiscuity, compulsive masturbation, etc.). 

There is a lack of empirical evidence about sex addiction: One of the main reasons that sex addiction is not yet included in the DSM-5 is that the empirical research in the area is relatively weak. Although there has been a lot of research, there has never been any nationally representative prevalence surveys of sex addiction using validated addiction criteria, and a lot of research studies are based upon those people who turn up for treatment. Like Internet Gaming Disorder (which is now in the appendix of the DSM-5), sex addiction (or more likely ‘Hypersexual Disorder’) will not be included as a separate mental disorder until the (i) defining features of sex addiction have been identified, (ii) reliability and validity of specific sex addiction criteria have been obtained cross-culturally, (iii) prevalence rates of sex addiction have been determined in representative epidemiological samples across the world, and (iv) etiology and associated biological features of sex addiction have been evaluated.

The term ‘sex addiction’ is used an excuse to justify infidelity: One of the reasons why sex addiction may not be taken seriously is that the term is often used by high profile celebrities as an excuse by those individuals who have been sexually unfaithful to their partners (e.g., Tiger Woods, Michael Douglas, David Duchovny, Russell Brand). In some of these cases, sex addiction is used to justify the individual’s serial infidelity. This is what social psychologists refer to as a ‘functional attribution’. For instance, the golfer Tiger Woods claimed an addiction to sex after his wife found out that he had many sexual relationships during their marriage. If his wife had never found out, I doubt whether Woods would have claimed he was addicted to sex. I would argue that many celebrities are in a position where they were bombarded with sexual advances from other individuals and succumbed. But how many people wouldn’t do the same thing if they had the opportunity? It becomes a problem only when you’re discovered, when it’s in danger of harming the celebrity’s brand image.

The evidence for sex addiction is inflated by those with a vested interest: One of the real issues in the field of sex addiction is that we really have no idea of how many people genuinely experience sex addiction. Sex addiction specialists like Patrick Carnes claims that up to 6% of all adults are addicted to sex. If this was really the case I would expect there to be sex addiction clinics and self-help support groups in every major city across the world – but that isn’t the case. However, that doesn’t mean sex addiction doesn’t exist, only that the size of the problem isn’t on the scale that Carnes suggests. Coupled with this is that those therapists that treat sex addiction have a vested interest. Out simply, there are many therapists worldwide who make a living out of treating the disorder. Getting the disorder recognized by leading psychological and psychiatric organizations (e.g., American Psychiatric Association, World Health Organization) legitimizes the work of sex addiction counselors and therapists so it is not surprising when such individuals claim how widespread the disorder is.

There may of course be other reasons why sex addiction is not considered a genuine disorder. Compared to behavioural addictions like gambling disorder, the empirical evidence base is weak. There is little in the way of neurobiological research (increasingly seen as ‘gold standard’ research when it comes to legitimizing addictions as genuine). But carrying out research on those who claim to have sex addiction can face ethical problems. For instance, is it ethical to show hardcore pornography to a self-admitted pornography addict while participating in a brain neuroimaging experiment? Is the viewing of such material likely to stimulate and enhance the individual’s sexual urges and result in a relapse following the experiment? There are also issues surrounding cultural norms. The normality and abnormality of sexual behaviour lies on a continuum but what is considered normal and appropriate in one culture may not be viewed similarly in another (what is often referred to by sociologists as ‘normative ambiguity’). Personally, I believe that sex addiction is a reality but that it affects a small minority of individuals. However, many sex therapists claim it is on the increase, particularly because the Internet has made sexual material so easy to access. Maybe if sex addiction does eventually make it into future editions of the DSM, it will be one of the sub-categories of Internet Addiction Disorder rather than a standalone category.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Dhuffar, M. & Griffiths, M.D. (2014). Understanding the role of shame and its consequences in female hypersexual behaviours: A pilot study. Journal of Behavioural Addictions, 3, 231–237.

Dhuffar, M. & Griffiths, M.D. (2015). A systematic review of online sex addiction and clinical treatments using CONSORT evaluation. Current Addiction Reports, DOI 10.1007/s40429-015-0055-x

Goodman, A. (1992). Sexual addiction: Designation and treatment. Journal of Sex and Marital Therapy, 18, 303-314.

Griffiths, M.D. (2000). Excessive internet use: Implications for sexual behavior. CyberPsychology and Behavior, 3, 537-552.

Griffiths, M.D. (2001). Sex on the internet: Observations and implications for sex addiction. Journal of Sex Research, 38, 333-342.

Griffiths, M.D. (2001). Addicted to love: The psychology of sex addiction. Psychology Review, 8, 20-23.

Griffiths, M.D. (2010). Addicted to sex? Psychology Review, 16(1), 27-29.

Griffiths, M.D. (2012). Internet sex addiction: A review of empirical research. Addiction Research and Theory, 20, 111-124.

Griffiths, M.D. & Dhuffar, M. (2014). Treatment of sexual addiction within the British National Health Service. International Journal of Mental Health and Addiction, 12, 561-571.

Kafka, M. P. (2010). Hypersexual disorder: A proposed diagnosis for DSM-V. Archives of Sexual Behavior, 39, 377–400.

Orford, J. (2001). Excessive sexuality. In J. Orford, Excessive Appetites: A Psychological View of the Addictions. Chichester: Wiley.

Sick note: A (very) brief overview of emetophilia

“I was drunk while out during New Year’s Eve and I saw a big heap of vomit. Normally this would make me vomit at the sight of it but because I was drunk I lay down on my side next to it and started licking it. I am worried because ever since this I have become addicted and I often go out in the early hours of the morning in the hope to discover vomit to fuel my addiction the more congealed the vomit the better” (Email enquiry to Yahoo! Answers, 2011)

To most people, the opening quote might seem quite sickening (no pun intended). Emetophilia (also called vomerophilia) is a rare paraphilia in which individuals are sexually aroused either by self-induced vomiting or watching others vomit (i.e., there is an erotic focus on the regurgitated contents of a person’s stomach). More specifically, emetophiliacs are reported to love vomiting on their sexual partners. This practice is sometimes referred to as a ‘Roman shower’ based on the often-quoted stories of Romans throwing up between courses so that they could eat even more, and the Roman ‘vomitoriums’.

However, Cecil Adams, in his column in The Straight Dope, briefly examined Roman ‘vomitoriums’ but went on to highlight what vomitoriums really were. Vomitoriums existed but were actually passageways in amphitheatres that opened into a tier of seats from below or behind. Adams claimed that “the vomitoria deposited mobs of people into their seats and afterward disgorged them with equal abruptness into the streets–whence, presumably, the name”. Adams went onto say that although the Romans were no strangers to vomiting, they never did so on purpose. Vomiting does appear to have been part of the fine-dining experience but not done between courses to make way for more space in the person’s stomach.

Although sex and vomiting are somewhat strange bedfellows especially as sex is typically pleasurable and vomiting is typically unpleasurable, there are a number of similarities (although these might be viewed as stretching it a little). Many internet sites quote the same three similarities that sex and vomiting both (i) trigger hormones to be released that make people feel better, (ii) are initiated by a reaction to a stimulus, and (iii) [for men at least] involve the expulsion of fluids through a bodily tube and out of a bodily orifice.

Emetophiles appear to be diverse in which element of vomiting is the most erotic and/or most important. For some, it is the act of vomiting itself that is arousing. For these particular paraphiliacs, it has been claimed that the ‘spasm, ejaculation, relief’ sequence in vomiting is erotically charged. For others, sexual arousal is caused by either just talking about, collecting photographs/videos, seeing, and/or hearing others vomiting. In extreme cases, some individuals may get sexually aroused by their partner actually vomiting on them. Other extreme emetophile practices include the induction of vomiting in a partner (that in some cases may be forced). In these cases involving force, there are certainly shades of dominance and sadism (or if the wish is to be vomited upon by others, submission and masochism). The internet certainly acts as a catalyst to bring these people together (check out http://vomitonline.com/indepth.html) and the internet may also fuel emetophiles’ interest in celebrity vomiting as there are now loads of vomiting scenes from television and films circulating online.

Freud, arguably psychology’s most prolific writer on psychosexual issues, described vomiting as a substitute for moral and physical disgust. However, to my knowledge there is only one academic paper in the sex literature on the topic. This was by the renowned American psychiatrist and psychoanalyst Professor Robert Stoller (1924-1991) who published a 1982 paper in the Archives of Sexual Behavior and claimed it was a previously unreported aberration”. Although Stoller claimed that vomiting paraphilias can occur in both males and females, the three case studies he outlined were all female. He suggested that emetophilia may manifest itself in a variety of ways (real versus imagined; self versus others; facilitative versus obligatory). If individuals have a sexual attraction to the vomit itself (rather than the vomiting process), then the diagnosis would be fetishism.

The first case described a woman that didn’t actually vomit herself but claimed she could reach orgasm “by imagining someone vomiting in a hard, humiliating fashion”. The second woman experienced an orgasm every time she vomited. The third woman said that “vomiting for me is like an orgasm in that I’m tensed, I feel the intense flood of good feelings almost continually throughout the vomiting and experience relief and quiet warmth in my body when I’m finished. It is not identical to an orgasm. I do not feel it intensely in my genitals alone, but I do feel it there as well as the rest of my body and in my mouth”.

Professor Stoller noted that the problem with this particular paraphilia is that the accounts are not based on those requiring treatment and that the stories take on an almost mythic-like quality rather than being “true-to-life”. He went on to say that by “concentrating on exact, naturalistic data collecting would show us how much we do not know…erotic impulses are a never-ending source of ingenious, even wondrous constructions [and] almost every object or body function can be erotized”

No-one really knows how this particular paraphilia develops although the root of most paraphilias lie in maladaptive learning. One online site I came across (‘Frequently Asked Questions About Vomiting’) theorized that “vomiting was probably something either arousing or frightening to emetophiles at some point … it aroused powerful emotions, and the emetophile later called upon these emotions for purpose of sexual gratification”. Some allege that emetophilia is closely related to emetophobia (i.e., the fear of vomiting) since some of these individuals may have developed emetophilia as a result of emetophobia. The thinking here is that (somewhat ironically) many emetophiles continue to fear vomiting themselves despite the amount of time they spend fantasizing about other people vomiting.

No-one knows (empirically) how widespread the practice is and whether it is restricted to certain countries but I will leave you with another quote from an emetophile that I came across online:

“I believe that the way we are affected by our [vomiting] kink transcends international borders and cultural differences, and is something basic to our human nature. I feel strongly that emetophilia is more than ‘just’ a kink, and has deeper origins than most fetishes. However, as an English speaker on an English-speaking board it’s hard for me to confirm that, which is one of the reasons it’s so nice to hear from [non-English speaking emetophiliacs]. So far, everyone else who has posted is from the US, Europe and other Western cultures, but now we’re beginning to get a feel for how international our kink truly is.”

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Adams, C. (2002). Were there really vomitoriums in ancient Rome? The Straight Dope. November 1. Located at: http://www.straightdope.com/columns/read/2421/were-there-really-vomitoriums-in-ancient-rome

Aggrawal, Anil (2009). Forensic and Medico-legal Aspects of Sexual Crimes and Unususal Sexual Practices. Boca Raton: CRC Press.

Freud, S. (1953). Studies on Hysteria (Standard Edition). London: Hogarth Press.

Stoller, R.J. (1982). Erotic Vomiting”, Archives of Sexual Behavior 11: 361-365 (1982).