It was hypothesised that ‘problematic’ sexual behaviour frequency and duration would reduce. Two reviews of methods for measuring OCSB recommended the measurement of behavioural symptoms of OCSB (Hook et al., 2010; Womack et al., 2013). While sexual behaviour was not specifically asked about in relation to whether it was considered to be problematic or not, the data analysis aimed to explore the level of various sexual activities in relation to distress and impairment (Zoldbrod, 1998).
While overall, certain behaviours did reduce, there were others that did not, and there was no clear pattern of change. There was a tendency for several participants’ baselines to be
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unstable, particularly for duration of variable sexual behaviours and especially for masturbation and fantasy. As noted, where behaviour trended down over baseline, it may have reflected the therapeutic effects of instilling hope, reduced distress, or the Hawthorne effect where simply monitoring behaviour can lead to behavioural change (Adair, 1984). Where it trended up may indicate the anxiety-provoking effects of engaging in therapy, as well as paying more attention to
one’s own sexual behaviour which can possibly increase sexual arousal (Barlow et al., 1983; Chambless et al., 1997). Results for the second hypothesis need to be interpreted in this context, although the focus was on participants where stable baselines were seen.
Frequency of Sexual Behaviour
Stable baselines were seen for eight of the ten participants who provided behavioural data for this analysis. There were clear reductions in terms of the frequency of some sexual behaviours. The most notable behaviour frequency that changed in frequency was masturbation, although for one participant, Dan, this remained constant across all phases of the study. This may have indicated this was not causing distress for him, as although this behaviour did not change, his distress level reduced consistently when treatment began. For Sam, Matt, Paul, Pita, and Rick, increases in partner sex over therapy coincided with a reduction in masturbation which may suggest a relationship between improvements in intimacy over therapy leading to increased partner sex, which may or may not be a preferred choice to masturbation.
There was a pattern for the frequency of sexual behaviour to coincide with level of reported distress pertaining to sexual behaviour, which makes intuitive sense given that distress was being monitored in relation to sexual behaviour rather than general distress. For example, Tom, Bill, Matt, and Rick reported distress levels that tended to coincide with their frequency of sexual behaviour, particularly for masturbation, with greater distress coinciding with more frequent masturbation. This suggests either pure coincidence or that the behaviours being monitored that fluctuated with distress level tended to be those that fell under the umbrella of OCSB for that
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individual. Alternatively, it could have been that distress about other features of sexual behaviour correlated with increased incidences of masturbating, for example, the content of sexual fantasy before masturbating, which was not captured in the current study.
Duration of Sexual Behaviour
There were only stable baselines for four participants when it came to their sexual behaviour duration and the remaining participants showed downward trends, with an upward trend for sexual fantasy and pornography for Sam and Paul. There were reductions in the
duration of time spent engaging in pornography viewing, sexual fantasy, internet sex, and ‘other’
sexual behaviour, which encompassed a range of other behaviours including receiving Thai massage, participating in group sex, and watching pornography in a sex shop, and only one participant reported these (Pita).
For the six participants who experienced instability in the duration of their sexual behaviour over baseline, the ability to draw conclusions about the effect of onset of therapy on sexual behaviour was limited. However, while sexual behaviour duration reduced for four of these participants (and frequency for some), it is interesting to note that their level of distress about their sexual behaviour did not reduce, which conversely was seen in participants with mostly high and stable distress at baseline. The exception to this was Dan whose distress dropped over baseline, which coincided with a large reduction in the duration of his sexual behaviour, Pita whose distress dropped alongside reduced time spent fantasising about sex, and Paul who identified being ill over baseline as reducing his sexual behaviour duration, frequency, and distress.
There were a variety of effect sizes in relation to the frequency and duration of sexual behaviour. Large positive effects were seen particularly for masturbation, pornography, sexual fantasy, internet sex, and distress, suggesting large reductions in these variability for most individuals. Large negative effects were evident for four participants in their rate of partner sex,
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indicating an increase in partner sex post-therapy. The tendency for the SMD3 effect size algorithms to be larger than SMDall indicated a greater reduction in behaviour towards the end of therapy as opposed to over the duration of therapy, although this did not occur unanimously, as in some instances a resurgence of baseline or early treatment levels of sexual behaviour occurred towards the end of therapy. Effect sizes from post-therapy to follow-up generally continued in the same direction that they did from baseline to post-therapy, with positive effects still seen for masturbation, pornography and sexual fantasy, although these tended to have more variability at this point.
In contrast to the variety in reductions in the frequency and duration of sexual behaviour, the Compulsive Sexual Behaviour Inventory – Control Scale findings were unanimous (Coleman et al, 2001). CSBI-Control scores unequivocally increased for all participants post-therapy, indicating that an improved level of control over sexual behaviour was obtained for all. This finding offers support for the term OCSB, which by its definition suggests a perceived difficulty in controlling some elements of sexual behaviour (Reid & Woolley, 2006). Further increases to the level of control over sexual behaviour was seen at 1-month follow-up, suggesting that treatment gains were not only were sustained but also continued post-therapy for this period of time. The 3- month follow-up indicated that control over sexual behaviour was improved more than at pre- therapy, although was somewhat reduced for two participants suggesting this effect was dissipating for some. A comparison of the post-therapy to 3-month follow-up found that control over sexual behaviour was indeed less at follow-up except for Jim who continued to make gains.
The findings regarding frequency and control of sexual behaviour, together with a general reduced level of distress about sexual behaviour and negative consequences experienced, support the hypothesis that ‘problematic’ sexual behaviour frequency would reduce over therapy, however not so much in terms of the duration of sexual behaviour which had more varied results, and suggest that future research should focus on control, distress and impairment rather than
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quantity or duration of sexual behaviour (Reid & Woolley, 2006). Alternatively, future research could focus on monitoring clients own targeted behaviours rather than their sexual behaviour per se.
Questions that were raised from these findings pertain to the individual goals of therapy each participant had and what they considered to have been an effective outcome. According to the unsolicited supplementary information, there were diverse goals suggested by both therapists and participants, and comments suggest that these goals had been met for some individuals. For
example, Saul’s therapist said his goal had been assessment and formulation, which was why the
therapy ended at three sessions, while Saul perceived his goal to have been to “share and confide”. Tom and his therapist stated their goal was to increase control over his pornography use, with the therapist saying there was less of a focus on developing intimacy, although Tom’s
fear of intimacy scores were the most improved at post-therapy (93 – 57). Behavioural scores suggest control over pornography did occur over the first half of therapy; however over the second half his viewing made a resurgence, suggesting less control over this time. Reduced pornography viewing was also the goal reported by Jim, who stated he had reduced his
pornography use and “gained emotional balance” post-therapy, although his scores indicated low levels of pornography viewing was occurring at baseline as well as over therapy. This supports another study’s suggestion that the length of time spent engaged in sexual behaviour is perhaps less important to determining a problem than other factors such as distress about the behaviour (Långström & Hanson, 2006).
Dan’s therapist said the opposite, that behavioural change had been made over the period of self-monitoring over baseline (which his scores clearly supports) and that developing intimacy skills was the focus of treatment. Matt reported a desire to promote healing to himself and others (as a result of participating in research that might help develop the treatment field). Rick did not
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outcome scores suggest he improved substantially in terms of control. One other goal that was mentioned came from Pita who had sought treatment not attached to religious beliefs. He aimed to reduce the impact of his use on his family which appear to have been met according the CSBCS reductions post-therapy, which included negative impacts on family or relationships (30 –
8).
In addition to having limited data on participant goals and how outcomes aligned with goals, the role of content of sexual behaviours was overlooked, such as the content of sexual fantasy or pornography imagery and whether changes to the type of fantasy or imagery made an impact on level of distress about sexual behaviour. While these were likely covered within the confines of therapy as part of IFT, they have not been captured by the current study and should be included in further research.
The reason for this relates to the literature on the definition for OCSB which posits that it is the distress or impairment resulting from sex that determines the presence or absence of a problem rather than the quantity or frequency (Långström & Hanson, 2006; Reid & Woolley, 2006). Also, the details of the sexual behaviour the men were seeking help for was not identified, and this limits the understanding that can be extrapolated from the data collected on frequency or duration. For example, whether partner sex was with multiple partners or within a primary relationship was not collected but may have been clinically relevant although the frequency of partner sex may not have changed. A high level of sex with a stable partner has been associated with improved psychological and psychosocial functioning, while high frequencies of impersonal sex has been related to problematic psychological and psychosocial functioning (Långstöm & Hanson, 2006). Thus, increases in partner sex may or may not have been associated with perceived problems or improvements for an individual. As individual goals were not collected
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Hypothesis 3: Intimacy will increase over therapy and be maintained over 3-month follow-