REVIEW

Existential Issues in Sexual Medicine: The Relation Between Death

Anxiety and Hypersexuality
Daniel N. Watter, EdD

ABSTRACT

Introduction: Current sex therapy and sexual medicine protocols often ignore the existential dilemmas asso-
ciated with sexual dysfunction and other problematic sexual problems. This oversight is especially apparent when
assessing and treating the controversial phenomenon of hypersexuality, or “sexual addiction.” A deeper under-
standing of the existential concept of death anxiety could offer an alternative treatment paradigm that might lead
to a more effective treatment outcome.
Aim: To explore the relation between the existential phenomenon of death anxiety and hypersexuality (ie, sexual
addiction) and present an evaluation and treatment paradigm that is rooted in existential psychotherapy, a form
of psychotherapy that is a deeply life-affirming and dynamic approach to therapy that focuses on concerns rooted
in the individual’s existence.
Methods: A review of the literature focusing on the topics of hypersexuality, death anxiety, and existential
psychotherapy was undertaken and a treatment paradigm is offered.
Main Outcome Measures: Current treatment protocols for hypersexuality and sexual addiction were reviewed,
as were current concepts in existential therapy. These were integrated into an assessment and treatment paradigm.
Results: Although sexual medicine and traditional sex therapy techniques can often alleviate sexual suffering,
there are times when a more in-depth psychotherapy is needed to get to the root cause and ultimate assuagement
of the presenting sexual symptoms. Existential psychotherapy is one such form of treatment that allows clinicians
to probe the subterranean depths of the human psyche and make meaning of one’s sexual behavior and its
vagaries.
Conclusion: Although certainly not all cases of hypersexuality are precipitated by a confrontation with mortality
and death, there are cases in which sex is imbued with meaning as an antidote to the fear of death. Existential
therapy is a form of treatment that could be particularly effective in many of these cases. Watter DN. Existential
Issues in Sexual Medicine: The Relation Between Death Anxiety and Hypersexuality. Sex Med Rev
2018;6:3e10.
Copyright
2017, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Existential Psychotherapy; Death Anxiety; Hypersexuality; Sexual Addiction; Sexual Medicine;
Sex Therapy

INTRODUCTION of sexual dysfunction. Since that time, sex therapy has evolved
Existential concerns have rarely been addressed in the sex into a combination of psychological practices similar to
therapy and sexual medicine literature,1,2 although early exis- cognitive-behavioral therapy and, most recently, an increasing
tentially oriented therapists have commented on the existential reliance on medical interventions.6 As a result of the emergence
dynamics associated with sexual dysfunctions.3,4 The early of medicine as the de facto leader in the sex therapy arena, many
groundbreaking days of sex therapy, pioneered by Masters and clinicians have feared the loss of the psychological dynamics in-
Johnson,5 focused mostly on a combination of corrective sex tegral to a complete understanding of sexual function and
education and behavioral interventions to alleviate the symptoms dysfunction and have advocated for a more integrated bio-
psychosocial model for assessing and treating sexual
Received September 10, 2017. Accepted October 22, 2017.
difficulties.7e9 Although each of these advances has had a sig-
Morris Psychological Group, PA, Parsippany, NJ, USA
nificant impact on the evolution of, and growth in, our under-
standing of sexuality and the treatment of sexual difficulties,
Copyright ª 2017, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved. there have been voiced concerns that the deeper psychological
https://doi.org/10.1016/j.sxmr.2017.10.004 underpinnings of much sexual distress are being subordinated to

Sex Med Rev 2018;6:3e10 3

4 Watter

the lure of symptom-focused treatments as opposed to those less effective by failing to appreciate the uniqueness of each in-
focused on the identification and amelioration of the more dividual and the psychological meaning given to that individual’s
profound etiologic psychological conflicts that activated such sexual functioning. Barker2 emphasized that existential psycho-
symptoms to begin with. therapy follows an approach that is somewhat antithetical to
Although the alleviation of problematic sexual symptomology current psychiatry. She stressed that diagnosis and treatment
is certainly appreciated and desired by most patients, many sex based on symptoms miss the essential existential meaning of
therapy and sexual medicine clinicians will tell of countless cases these symptoms and thus dehumanize the individual. Corre-
in which the dysfunction has resolved, but the patients continue spondingly, Kleinplatz11 and Spinelli12 stated that a focus on
to report disappointment that their sexual and relational lives simply relieving symptoms is likely to lead to only temporary
have not become more fulfilling and satisfying. Existential psy- symptom alleviation because crucial psychodynamic factors that
chotherapy posits that this is likely the result of the treatment are likely to be represented in the expression of the sexual
having neglected to address the often-concealed meaning(s) that dysfunction will remain unaddressed.
sexuality and sexual functioning might hold for this patient(s). According to Yalom,3 there are 4 primary existential concerns
Existential psychotherapy is a psychotherapy that focuses on the that plague human existence: freedom, isolation, meaningless-
meaning of our existence and as such the meaning that sexuality ness, and death (the focus of this article). Uncertainties related to
and our relationship with ourselves and others evoke. Regret- any of these can result in sexual difficulties, although a
tably, the existential texts and the sex therapy and sexual medi- comprehensive discussion of each is beyond the scope of this
cine texts rarely reference each other. Barker2 observed that even article. Death anxiety, or more precisely death terror, has been
within the existential therapy community, clinicians often see the implicated in disruptions in the sexual functioning of many.
understanding, exploration, and treatment of sexual problems as Indeed, much of Western society values the sexuality of youth
something apart from other concerns of human suffering rather and attempts to discount, perhaps out of fear, the sexuality of
than as another avenue of gaining entry into the patient’s psyche. aging and maturity. Congruently, given the reality of death in the
The aim of this article was to explore and delineate the existential lives of all humans, the fear of death is likely to be universal.
dilemmas that often manifest through disruptions in our sexual Callahan and Gaylin13 posited that all humans struggle with the
lives. Although a complete elucidation of the myriad pre- dilemma of rebellion vs acceptance of death. They asserted that
sentations of existential concerns that manifest as sexual diffi- in the current climate of medical intervention, rebellion is the
culties is beyond the scope of this article, one particular dominant force. This has culminated in some medical visionaries
existential dilemma, death anxiety, and its role in the construc- making the “elimination of death,” or its indefinite post-
tion of the controversial phenomenon of hypersexuality or ponement, their mission. Interestingly, some have even suggested
“sexual addiction” are scrutinized. that pharmaceutical interventions, such as sildenafil citrate,
might actually represent a disservice for aging men because such
interventions seek to promise the restoration of the sexuality of
EXISTENTIAL PSYCHOTHERAPY AND DEATH youth instead of supporting and nurturing the acceptance of
ANXIETY natural aging and the reality that sexual functioning in the
Existential psychotherapy is a deeply life-affirming and dy- mature years might be different but still highly enjoyable.
namic approach to therapy that focuses on concerns rooted in the Watter6 challenged sexual medicine specialists to look beyond
individual’s existence.3 That is, the works of eminent philoso- the rudimentary observation that men will be happy if their aging
phers heavily influence the existential approach to therapy and penises function like the penis of their youth and consider the
inform the treatment in assisting the individual to navigate the question of whether we are fostering unrealistic expectations
vagaries inherent in human existence. Problems are seen as a relative to the idea that we can, in essence, “cheat” death. That is,
puzzle that the patient and clinician work together to solve. is our use of sexual pharmaceuticals tantamount to encouraging
Barker2 stated that the existential approach to therapy does not the notion that our bodies need not age, that sexual functioning
concern itself with diagnosis per se. Although diagnosis is critical need not change, and that human life need not eventually end?
in those psychiatric conditions with a strong biological influence Clearly, death is seen by the masses as something to be avoided,
(ie, schizophrenia, bipolar disorder, etc), diagnosis could be yet it is one of the few certainties of life. Conversations about
counterproductive in psychotherapy of less psychiatrically death are frightening and feel risky, so much so that even psy-
impaired patients.10 This would include the bulk of patients in chotherapists and physicians are often reluctant to broach this
sex therapy. Barker2 and Yalom9 asserted that in many cases topic with their patients.
diagnosis can interfere with treatment because it can diminish or Yalom10 stated, “Though the physicality of death destroys us,
limit the therapist’s ability to view patients as “people” as the idea of death may save us.” Death awareness and death
opposed to “diseases.” Yalom10 took this a step further in anxiety can act as a powerful catalyst for change. That change can
essentially advocating a new therapy for each patient. He be life enhancing or life effacing. Take, for example, the character
lamented that standardization of treatment might render therapy of Ebenezer Scrooge in Charles Dickens’ story A Christmas

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Death Anxiety and Hypersexuality 5

Carol.14 For those unfamiliar with A Christmas Carol, Ebenezer professional literature, and complaints patients bring into ther-
Scrooge is a miserly, bitter, isolated man who cares little for those apy, hypersexuality and sexual addiction were not seen as having
around him. Indeed, he is seen as a blight on the society in which adequate empirical support for inclusion in the Diagnostic and
he lives. He contributes none of his wealth to the betterment of Statistical Manual of Mental Disorders, 5th Edition.21
his community and displays little or no compassion for the The Chinese philosopher Confucius is said to have pro-
suffering of those around him. Interestingly, Scrooge is no nounced, “the beginning of wisdom is to call things by their
stranger to suffering and has been visited by the trauma of early proper name.”22 Inelegantly, the phenomenon of hypersexuality
death at several critical points throughout his life. Perhaps most has been referred to by many different names: hypersexuality,23
significantly, his mother dies while giving birth to him. In his sexual addiction,24 and out-of-control sexual behavior,25 to
grief, Scrooge’s father banishes him from the home and refuses to note a few. In commenting on the lack of specificity in the
have any contact with him. Only Scrooge’s sister, Fan, shows assessment and diagnosis of sexual addiction, Grubbs et al23
him any concern and compassion, but she, too, tragically dies in echoed Confucius when they pointed out the confusion that
childbirth. Her son, Fred, tries to engage Scrooge at every op- results from our inability to properly define the nature of
portunity, but Scrooge scorns him, much like he himself was hypersexuality.
scorned by his father. It is no wonder, then, that when Scrooge is
Most patients presenting with such difficulty will use the
compelled by the Ghost of Christmas Yet To Come to confront
popular “sex addiction” label to describe their situation.
his own demise, he is greatly affected and forever changed. Faced
Although academics and clinicians passionately debate the proper
with the awareness that he will be missed by no one, will have left
diagnostic label, existential psychotherapists do not expend much
no legacy of meaning, and will be nothing more than a sour
time and/or effort engaged in this argument. As mentioned
memory in the minds of those in his community, Scrooge is
earlier, existential psychotherapy does not concern itself with
propelled to change his life. He becomes the most generous and
diagnosis per se. To the existential therapist, the persons sitting
beloved man in town, helping those in need, and being
in the room with us have their own story and unique set of
thoughtful, charitable, and agreeable to all. “Though the physi-
circumstances. The polemic of diagnosis only distracts from the
cality of death destroys, the idea of death may save us.” Such is
distinctive nuanced narrative patients bring into the consultation
the fortunate fate of Ebenezer Scrooge. His confrontation with
room. The focus on diagnosis lends itself to the misleading
mortality and his deep-seeded terror of death save Scrooge from
assumption that any and all patients presenting with this type of
living his remaining days in isolation and meaninglessness. Many
problematic sexual behavior should be treated using essentially
are not so fortunate, and their death terror can send their
the same treatment protocol. This dilemma was well summed up
behavior spiraling out of control. Beck15 opined that slavery to
by Cantor et al26:
the fear of death affects every facet of the human experience,
without exception. He further stated that our fear of death is
often so deeply hidden and repressed that is it often difficult to Despite that the literature emphasizes that cases of
detect its existence and impact. hypersexuality are highly diverse with regard to clinical
Of course, not everyone feels terror at the prospect of the end presentation and comorbid features, the major models
of their existence, but for many the knowledge that one’s being for understanding and treating hypersexuality employ a
will ultimately end can provoke an extreme, uncharacteristic, and ‘one-size-fits-all’ approach. That is, rather than identify
problematic reaction. According to Becker,16 when the repres- which problematic behaviors might respond best to
sion of the terror of death breaks down, people will often behave which interventions, existing approaches presume or
in ways that might seem frenetic or even psychotic. Frequently, assert without evidence that all cases of hypersexuality
those reactions will manifest sexually. Yalom10,17 affirmed that (however termed or defined) represent the same un-
concerns about death can manifest in the preoccupation with derlying problem and merit the same approach to
sexual thoughts and behaviors. Freud,18 too, recognized the intervention. [p. 883]
powerful connection between the sex drive (Eros) and the death
instinct (Thanatos). For many, sex is experienced as a life force, As mentioned earlier, existential therapy strives to create a new
the antithesis of death that can neutralize the terror of the end of therapy for each person in an effort to recognize the individuality
one’s existence. Such cases are considered later in this article. of the patient and the meaning the behavior might have for that
patient.

HYPERSEXUALITY AND SEXUAL ADDICTION

The assessment and treatment of hypersexuality, or sexual RELATION BETWEEN SEX AND DEATH
addiction, is a controversial and fervently debated topic in cur- To reiterate, Yalom10,17 stated that concerns about death can
rent sex therapy and sexual medicine. Indeed, its very existence manifest in the preoccupation with sexual thoughts and behav-
has been questioned.19,20 Despite the frequent references to iors. For many, sex is experienced as a life force, the antithesis of
sexual addiction in the press, popular literature, much of the death that can neutralize the terror of the end of one’s existence.

Sex Med Rev 2018;6:3e10

6 Watter

He described sex as “death-defeating” for some people because It was no doubt naïve of me to think it possible to feel
death is connected with banality and ordinariness, whereas sex sexual when facing such a battle and such choices. But
promises to be exciting and magical. In addition, an increase in at the moment it seemed logical that the basic act of
sexual activity in those diagnosed with life-threatening illnesses is procreation was the best antidote to destructive forces.
often observed, and for these people their uncharacteristically
amplified sexual behavior can be understood as an attempt at Elie Wiesel31 wrote that on the train ride to the Nazi death
repression of their overpowering death anxiety.3 Ford et al27 camps:
reported on a study of college students who completed mea-
sures of death anxiety and risk taking. They found that when Freed of normal constraints, some of the young let go
viewed in the context of defensive behavior, an increase in of their inhibitions and, under cover of darkness,
willingness to engage in risky sexual behavior as a result of raising caressed one another, without any thought of others,
the issue of personal mortality could be conceptualized as a alone in the world. The others pretended not to notice.
denial-based defensive reaction designed to ward off conscious
anxiety aroused by the issue of death. This is consistent with In describing the relation between sex and death, Yalom32
study by Miller and Mulligan28 who investigated the effects of noted:
mortality salience and locus of control on risk taking. They, too,
found that mortality salience increased the likelihood of risk- Sex, the vital life force, often counters thoughts of
taking behaviors in certain populations. Becker16 alleged that death. I’ve encountered many instances of this mech-
in the face of danger there always lurks the basic fear of death, a anism: the patient with a severe coronary who was so
fear that is complex in its presentation and manifests in many sexually driven that in an ambulance carrying him to the
indirect ways. emergency room, he attempted to grope an ambulance
Such instances of increased sexual behavior as a result of a attendant; or the widow who felt overcome with sexual
confrontation with mortality and the terror of death have been feelings while driving to her husband’s funeral; or the
noted by others in the psychological and literary worlds. Psy- elderly widower, terrified by death, who became un-
chologist Gurit Birnbaum29 wrote: characteristically sexually driven and had so many
sexual affairs with women in his retirement community
The awareness that death is inescapable, coupled with and created such divisiveness that the management
the instinctive desire to live, can constitute an unbear- demanded he seek psychiatric consultation. Still
able paradox. To escape this potentially paralyzing terror another elderly woman, after her twin sister had died
and to maintain psychological equanimity, some people from a stroke, become so overcome with multiple or-
may employ certain defense mechanisms, which are gasms while using a vibrator that she feared she too
designed to remove the awareness of death from would suffer a stroke. Worried lest her daughters
conscious thoughts by imbuing the world with mean- discover the vibrator next to her body, she decided to
ing, order, and permanence. Often people will reach for dispose of it.
symbols of immortality. And sex can be a big one.
Similarly, University of Washington Professor of Nursing,
Writer Stephanie Waxman30 voiced the story of Big Tessa: Patricia MacElveen-Hoehn, observed:

During the week that Big Tessa faced the decision to . the sexually conservative woman who returns home
undergo a risky (with no guarantees) bone marrow for the funeral of a parent or some close relative and
transplant to thwart the greater evil, an aggressive takes with her a diaphragm and uncharacteristically
cancer, we took a walk in the desert on the outskirts of engages in a sexual relationship with a stranger or ca-
Palm Springs. It was early April and scarlet blooms sual friend; or the man who has a severe coronary and
were already popping open on the paddle cactus and on the way to the hospital fondles his wife’s breasts
the air was filled with the scent of sage. After walking in and presses for some sexual exchange; or the man
silence for a while, she stopped, and in her usual frank who, with a child dying of leukemia, becomes highly
way, asked my advice: in the face of cancer and the promiscuous.3
transplant—and in either case and in all probability, in Note that in these examples a salient feature of each instance is
the face of death—what action could she take to affirm the uncharacteristic manifestation of the person’s sexual
life? The answer came to me in a thunderbolt of ab- behavior. Each of these individuals had no history of problem-
solute certainty and I offered it without hesitation and atic, impulsive, or compulsive sexual acting out. It was only in
with great conviction: “Have lots of sex.” the presence of death, and the terror that resulted from an

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Death Anxiety and Hypersexuality 7

unconscious confrontation and consideration of their mortality, If I remain still, if I am alone and silent long enough to
that their sexual behavior aggressively presented in an apparent hear the sound of my own blood or breathing or
attempt to ward off the dread and anxiety of death. digestion above the rustling of leaves or the whir of the
Consider the following case presented by Yalom3: refrigerator, my father is likely to turn up. He just ar-
rives unbidden in the long running film of my thoughts,
Tim was a 30-year-old patient whose wife was dying of like Hitchcock in his pictures, and he looks for all those
leukemia. Tim began therapy not because of overt grief 40-plus years of disembodiment much like himself, big
but because of an alarming degree of sexual preoccu- and sandy haired with freckles on the backs of his
pation and compulsivity. He had led a monogamous life hands, perhaps a bit more diffident in the way he holds
prior to his wife’s illness, but as she approached death, himself than I remember. He doesn’t stay long, and as
he began compulsively to visit pornography films and far as I can tell his visits have no message. Yet—even
singles’ bars (running great risks of public exposure) though years of therapy have led me to make the dark
and masturbated several times a day, often while in bed whistling claim that he’s finally dead and gone—my
with his dying wife. On the night of his wife’s funeral he father, who died when I was 17, continues to be my
sought out a prostitute. principal ghost, a lifelong eminence grise, and only my
own end will finish it.33
Note the uncharacteristic escalation and intensity of sexual
behavior displayed by Tim. It is significant that his sexual Wainwright’s words clearly express the petrifying sensations of
behavior appeared to be in direct relation to his dealing with his being pursued by the menacing shadow of death that is charac-
wife’s illness and impending death. For Tim, not only was he teristic of so many of the patient narratives we will examine.
confronted with the terror that accompanies the early death of a Each of the following cases presented as self-identified sex
loved partner, but also it likely resonated in Tim’s unconscious addicts. Although they could not identify a death-terrore
that if this could happen to his wife, his own existence was much inducing incident at intake, all eventually linked their unchar-
more tenuous than he had ever considered. acteristic progression into uncontrolled sexual behavior to a
Let us look more closely at some clinical presentations of this death-terroreinciting event. The particulars of each case have
phenomenon from my actual case presentations. Although the been altered to preserve the confidentiality of the patients.
details of the following cases have been altered to protect the
privacy of the patients, each of these narratives comes from Case 1: Simon
authentic patient accounts. Simon was a 54-year-old married man when I first saw him for
consultation. He reported a stable, conventional, monogamous
life. He and his wife had been married for approximately 25
CASE EXAMPLES OF DEATH ANXIETY AND years, and he reported a very satisfying work, family, and sexual
HYPERSEXUALITY OR SEXUAL ADDICTION life. Of note was the early death of Simon’s father from a
As articulated earlier, each individual in the cases discussed myocardial infarction (MI) at 53 years of age. Simon was deeply
below displayed an uncharacteristic escalation of sexual behavior affected by the unexpected and early loss of his father and re-
after a confrontation with mortality. In addition, there is often a ported that he often felt he would not live longer than 53 years.
foreboding sense of one’s existence being fragile, and that one Simon reported feeling from 50 years on that he was “just
will suffer an early death. Many of these men and women had waiting to die.” As Simon approached his 54th birthday, he
early life encounters with death. Similar to Ebenezer Scrooge, recalled feeling some optimism and relief thinking he was going
they experienced the early, and unexpected, death of a sibling, to live beyond the age of his father. One week before Simon’s
parent, or other person of significance in their younger years. 54th birthday he was diagnosed with prostate cancer and opted
Men whose fathers died young often live with the specter of early to undergo radical prostatectomy. Simon was stunned, and
death stalking them throughout their lives. One particularly approximately 5 months after surgery he began frequenting strip
poignant representation of this is embodied in the work of clubs, massage parlors, and prostitutes. This behavior escalated in
folksinger, Louden Wainwright III. Wainwright’s father died frequency with Simon reporting that it felt “obsessive” and
when he was young and Wainwright had long lived with the fear “uncontrollable.” He impulsively decided he had to leave his job
that he would not live longer than his father had. When he and his marriage and began a frenetic journey around the country
passed his father’s age of death, he was filled with emotion and seeking sexual adventure. He had sexual interactions with men
his next album release was a compilation of songs expressing his and women until he became so distraught at being unable to
unrestrained reactions to his own sense of death terror. In the achieve penile erection that he attempted suicide in a hotel room
liner notes from his album, Older Than My Old Man Now, he in Phoenix, Arizona. After a brief hospitalization he returned
wrote: home and began psychotherapy.

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8 Watter

Simon’s case, although extreme in aspects of its presentation, consultation, Steven reported feeling increasingly “controlled” by
is not atypical of cases of hypersexuality after a confrontation his wife, saying his marriage had left him feeling a “loss of vitality.”
with mortality. Notable is the early death of his father, Simon’s He further reported feeling like a “ghost in his own home.”
fear that he, too, would die young, and the uncharacteristic, and Steven recalled being raised in a highly dysfunctional home.
seemingly uncontrollable, sexual spree that followed his cancer He recollected being the frequent mediator between warring
diagnosis. When asked about the uncharacteristic nature of his parents. He remembered crying uncontrollably as a child fearing
behavior (these were his first same-sex sexual experiences), Simon death and loss, the likely result of having such an unstable family
reported that he was looking to feel “alive” and sought out all life. As an adult, he continued to be preoccupied with thoughts
types of sex in an effort to feel a “spark.” of death. Approximately 2 years before consultation, Steven
unexpectedly lost his father-in-law because of unanticipated
Case 2: Oliver complications from a routine surgical procedure. He described
At 49 years of age, Oliver sought consultation because he was this as a tremendous loss, because he felt much closer to his
in the process of being divorced for the 3rd time. Each of his father-in-law than he did to his own father. After his father-in-
divorces was precipitated by his wives’ discovery of his sexual law’s death, Steven became preoccupied with the sense of
involvement with other women. The most recent infidelity “running out of time” and felt catapulted into a feverish pursuit
occurred with his current wife’s sister. Oliver reported that each of sexual excitement. Monogamous up to this point, Steven felt
of his wives knew about only a fraction of his extramarital sexual himself driven to “shock himself” and “be courageous and try
activities, and that he spent much of his non-working time new things.” He became increasingly preoccupied with the fear
engaged sexually with other women. Oliver estimated that he had that he was missing out on too much of life and needed to “do
had extramarital sexual relations with more than 100 women. something to feel alive.” He found himself focused on sex with
During our first psychotherapy session, Oliver was clearly dis- men and had multiple extramarital same-sex sexual experiences.
tressed. He was at a loss to explain his sexual behavior because he This behavior continued until his wife discovered his infidelities,
reported being deeply in love with each of his wives and having a and he agreed to seek psychotherapy.
very satisfying sex life with each. He said his sexual urges felt Steven’s story is significant for several reasons. His frequent
obsessive and irrepressible, and although he often vowed to stop, references to death (ie, feeling like a ghost in his own home, his
he was unable to do so. loss of vitality, and needing to do something to feel alive) are not
Oliver reported a difficult childhood. His mother had severe uncommon in these cases. Often there is a sense of being “dead”
mental illness and was often hospitalized for long periods. Even or “lifeless” that is expressed in the description of many of these
when she was home, her illness left her unable to provide much patients’ experience of their existence, and they present as
childcare or family engagement. Oliver’s father died young, and desperately seeking the verve of aliveness. Steven was acutely
this left much of the responsibility for childcare of his younger aware that he was getting older and that life could be taken when
brother and sister to Oliver as the oldest child. When asked if he least expected. This created a panic, or terror, in him that pro-
could recall when his sexual behavior began to feel unmanage- pelled him to urgently seek a more meaningful and fulfilling life.
able, Oliver quickly responded with, “Absolutely. It began right Earlier in this article, I wrote of Yalom’s10 observation that
before my 35th birthday.” Knowing that Oliver’s father died “though the physicality of death destroys us, the idea of death
young, I expected to discover that his death occurred at 35 years. may save us.” The leitmotif in this statement is that the fear of
However, Oliver reported that his father died of an MI at 62 death can be a powerful motivator for change. Often, as in the
years. In examining his father’s death more closely, Oliver case of Ebenezer Scrooge, that change can be life enhancing. For
stopped speaking mid-sentence and was stunned to recall that Steven, this also turned out to be the case. Through therapy,
although his father had, indeed, died at 62, the fatal MI had been Steven was able to come to terms with his desires for a life with
his 3rd MI. His first MI occurred at 35 years. another man. In his family of origin, being gay was considered
Of note in Oliver’s case is his clear recollection of the starting wholly unacceptable. Steven had internalized much of the ho-
point for his uncharacteristic sexual behavior. Too often, sex mophobic attitude of his family and denied his own authentic
therapists neglect to ask about the timeline of events or do not sense of himself as a gay man. The unexpected death of his
diligently mine the timeline for relevant details that illuminate father-in-law created a terror in Steven that he would live his
the meaning and significance of the sexual behavior. Rarely is the entire life in a disingenuous existence and his protective un-
timing of the activation of the altered pattern of sexual behavior conscious was empowered to thrust Steven into confronting the
insignificant. reality that he had long denied. The result was his courageously
engaging in a life that was genuine, meaningful, and fulfilling.
Case 3: Steven
Steven was a 44-year-old married man who had been with his Case 4: Patricia
wife for more than 18 years. He reported a companionable, Patricia was a 51-year-old woman who reported being happily
pleasant, but unsatisfying married life. In the years before married for 27 years. She reported marrying her high school

Sex Med Rev 2018;6:3e10

Death Anxiety and Hypersexuality 9

sweetheart and always being monogamous. As she passed her sexual behavior, and it was only through the mindful realization
50th birthday, the last of her 3 children left for college, and she of the role that death terror played in their lives did they regain
was preparing to downsize her home, she began to experience control and manageability over the expression of their sexuality.
uncharacteristic panic attacks. She was aware of being preoccu-
pied with thoughts of aging, running out of time, and feeling
suffocated by her life. She was overpowered with an urge for CONCLUSION
freedom, autonomy, and independence that culminated in a The central thesis throughout this article is that sex therapists
splurge of extramarital sexual activity that felt obsessive and and other sexual medicine specialists need to retain a discerning
reckless. Her husband discovered her affairs, and she decided to view of the complex psychological dynamics and dilemmas that
seek consultation. can fuel problematic sexual behavior. Oftentimes, existential is-
Patricia did not recall any early death experiences in her his- sues such as freedom, responsibility, isolation, meaninglessness,
tory. However, she reported feeling very constrained in her and death can create a disruption in sexual behavior that can be
family of origin and was raised with the admonition that “good confusing, disconcerting, and seemingly impenetrable. Although
girls don’t display negative emotions.” As a result, she often felt sexual medicine and traditional sex therapy techniques can often
obligated to do what she believed was expected of her. She alleviate sexual suffering, there are times when a more in-depth
married, in large part, to get out of the house and conform to her psychotherapy is needed to get to the root cause and ultimate
family of origin’s value system. Although she described her assuagement of the presenting sexual symptoms. Existential
husband as being a very good man, she found her marriage happy psychotherapy is one such form of treatment that allows clini-
but dull and unfulfilling (ie, lifeless). As she became more acutely cians to probe the subterranean depths of the human psyche and
aware of the passage of time and her own aging, she was plagued make meaning of one’s sexual behavior and its vagaries.
by thoughts that she had yet to live the life she craved. The In this article, we examined the existential issue of death terror
theme of running out of time became palpable, and her attempts as a trigger for hypersexuality, or sexual addiction. Although
to repress those feelings exploded in the form of panic attacks. certainly not all cases of hypersexuality are precipitated by a
Eventually, her efforts to suppress her desires for freedom, in- confrontation with mortality and death, there are cases in which
dependence, and the life she coveted gave way to the surge in sex is imbued with meaning as an antidote to the fear of death.
sexual feelings that made her feel alive, vibrant, and free. When evaluating cases of hypersexuality, clinicians should care-
fully explore the timeline of the change in sexual behavior and
inquire about the timing of the behavior’s origination and its
TREATMENT relation to terror regarding death. Future articles will explore the
As mentioned earlier, existential psychotherapy focuses less on existential issues that can manifest in the etiology of other sexual
the presenting symptom(s) per se and more on the meaning the difficulties and dysfunctions.
symptom(s) has for the individual. In the cases described earlier,
the changes in sexual behavior appear to be the result of a ACKNOWLEDGMENTS
confrontation with mortality and the ensuing terror of death. For The author acknowledges Irvin D. Yalom, MD, for his
these patients, their uncharacteristic sexual behavior represents an inspiration and encouragement in the development of these
attempt to find vitality and solace through the explosive ideas.
expression of sexuality. As the death terror persists, the behavior
Corresponding Author: Daniel N. Watter, EdD, Morris
increases in intensity, frequency, and variety. As a result, treat-
Psychological Group, PA, 50 Cherry Hill Road, Parsippany, NJ
ment is aimed not at the sexual behavior directly but rather at the
07054, USA. Tel: þ1-973-257-9000; Fax: þ1-973-257-0506;
fear of death that precipitated and fueled the unmanageable and
E-mail: drwatter@morrispsych.com
problematic sexual activity.
In existential therapy, the belief is that symptoms are often Conflicts of Interest: The author reports no conflicts of interest.
overdetermined and are expressions of attempts to defend the
Funding: None.
individual against existential anxieties (ie, in these cases, the
terror of death). Therefore, treatment focuses on soothing
the death terror and loss as opposed to the sexual behavior per se. STATEMENT OF AUTHORSHIP
Therapy looks to give “meaning” to the symptom(s), and it is
Category 1
through an in-depth exploration of the meaning of the pre-
(a) Conception and Design
senting symptom(s) that the healing takes place. In each of the
Daniel N. Watter
cases described earlier, the uncharacteristic expression of un- (b) Acquisition of Data
manageable sexual behavior was triggered by an unanticipated Daniel N. Watter
confrontation with mortality or the threat of non-existence. (c) Analysis and Interpretation of Data
None of the individuals were aware of what was driving their Daniel N. Watter

Sex Med Rev 2018;6:3e10

10 Watter

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