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Compulsive sexual behaviour disorder (CSBD), [1] is an impulse control disorder. CSBD manifests as a pattern of behavior involving intense preoccupation with sexual fantasies and behaviours that cause significant levels of psychological distress, are inappropriately used to cope with stress, cannot be voluntarily curtailed, and risk or cause harm to oneself or others. [1] [2] This disorder can also cause impairment in social, occupational, personal, or other important functions. [1] [3] CSBD is not an addiction. [4]
CSBD is recognised by the World Health Organization as an impulse control disorder, and is categorised as "Compulsive Sexual Behaviour Disorder" in the ICD-11. [5] CSBD is not categorised as a standalone diagnosis by the American Psychiatric Association in their DSM-5; [1] it was proposed for inclusion in 2010, but was ultimately not approved.
Sexual behaviours such as chemsex and paraphilias are closely related with CSBD and frequently co-occur along with it. [1] Psychological distress entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to diagnose CSBD. [1] A study conducted in 42 countries found that almost 5% of people may be at high risk of CSBD, but only 14% of them have sought treatment. [6] The study also highlighted the need for more inclusive research and culturally-sensitive treatment options for CSBD.
ICD-11 includes a diagnosis for "Compulsive Sexual Behaviour Disorder". [5] CSBD is not an addiction. [7] [8]
"Compulsive Sexual Behaviour Disorder" is defined as a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour.
Symptoms may include repetitive sexual activities becoming a central focus of the person's life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it.
Criteria:
It has been argued that the CSBD diagnosis is not based upon sex research. [9]
DSM-5 [10] and DSM-5-TR have no such diagnosis. [7] [11] [12]
As of end of 2019, FDA had approved no medicines for it. [13]
Some treatment guides suggest shame at the core of CSBD mechanism. The shame is associated with the cognitive schema of self-defectiveness, a feeling of social pain and isolation and functions in two ways. Firstly, chronic shame derived from social stigma or early traumatic experiences augments the soothing function of sexual behaviour. That makes sexual behaviour compulsive. Secondly, excessive or inappropriate sexual behaviour, as it is considered socially unacceptable, causes extra shame and forms a self-sustaining cycle of CSBD. Therefore, treatment is primarily aimed at shame reduction and social reintegration. [14] [15]
Hypersexual disorder was recommended for inclusion in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) by the Sexual and Gender Identity Disorders Workgroup (Emerging Measures and Models, Conditions for Further Study). It was ultimately not approved. [16] The term hypersexual disorder was reportedly chosen because it did not imply any specific theory for the causes of hypersexuality, which remain unknown. [17] A proposal to add sexual addiction to the DSM system had been previously rejected by the APA, as not enough evidence suggested to them that the condition is analogous to substance addictions, as that name would imply. [18] [19] [20]
Rory Reid, a research psychologist in the Department of Psychiatry at the University of California Los Angeles (UCLA), led a team of researchers to investigate the proposed criteria for Hypersexual Disorder. Their findings were published in the Journal of Sexual Medicine where they concluded that the given criteria are valid and the disorder could be reliably diagnosed. [21]
The DSM-IV-TR, published in 2000, includes an entry called "Sexual Disorder—Not Otherwise Specified" (Sexual Disorder NOS), for disorders that are clinically significant but do not have code. The DSM-IV-TR notes that Sexual Disorder NOS would apply to, among other conditions, "distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used". [22]
A paraphilia is an experience of recurring or intense sexual arousal to atypical objects, places, situations, fantasies, behaviors, or individuals. It has also been defined as a sexual interest in anything other than a legally consenting human partner. Paraphilias are contrasted with normophilic ("normal") sexual interests, though the definition of what makes a sexual interest normal or atypical remains controversial.
Hypersexuality is a presumed mental disorder that causes unwanted or excessive sexual arousal, causing people to engage in or think about sexual activity to a point of distress or impairment. It is controversial whether it should be included as a clinical diagnosis used by mental healthcare professionals. Nymphomania and satyromania were terms previously used for the condition in women and men, respectively.
Pyromania is an impulse control disorder in which individuals repeatedly fail to resist impulses to deliberately start fires, to relieve some tension or for instant gratification. The term pyromania comes from the Greek word πῦρ. Pyromania is distinct from arson, the deliberate setting of fires for personal, monetary or political gain. Pyromaniacs start fires to release anxiety and tension, or for arousal. Other impulse disorders include kleptomania and intermittent explosive disorder.
Obsessive–compulsive personality disorder (OCPD) is a cluster C personality disorder marked by a spectrum of obsessions with rules, lists, schedules, and order, among other things. Symptoms are usually present by the time a person reaches adulthood, and are visible in a variety of situations. The cause of OCPD is thought to involve a combination of genetic and environmental factors, namely problems with attachment.
Pornography addiction is the scientifically controversial application of an addiction model to the use of pornography. Pornography may be part of compulsive behavior with negative consequences to one's physical, mental, social, or financial well-being. While the World Health Organization's ICD-11 (2022) has recognized compulsive sexual behaviour disorder (CSBD) as an "impulsive control disorder", CSBD is not an addiction, and the American Psychiatric Association's DSM-5 (2013) and the DSM-5-TR (2022) do not classify compulsive pornography consumption as a mental disorder or a behavioral addiction.
Reasons for opposition to pornography include religious objections and feminist concerns, as well as alleged harmful effects, such as pornography addiction and erectile dysfunction. Pornography addiction is not a condition recognized by the DSM-5, the ICD-11, or the DSM-5-TR. Anti-pornography movements have allied disparate social activists in opposition to pornography, from social conservatives to harm reduction advocates. The definition of "pornography" varies between countries and movements, and many make distinctions between pornography, which they oppose, and erotica, which they consider acceptable. Sometimes opposition will deem certain forms of pornography more or less harmful, while others draw no such distinctions.
Impulse-control disorder (ICD) is a class of psychiatric disorders characterized by impulsivity – failure to resist a temptation, an urge, or an impulse; or having the inability to not speak on a thought. Many psychiatric disorders feature impulsivity, including substance-related disorders, behavioral addictions, attention deficit hyperactivity disorder, autism spectrum disorder, fetal alcohol spectrum disorders, antisocial personality disorder, borderline personality disorder, conduct disorder and some mood disorders.
Sexual addiction is a state characterized by compulsive participation or engagement in sexual activity, particularly sexual intercourse, despite negative consequences. The concept is contentious; neither of the two major mainstream medical categorization systems recognise sex addiction as a real medical condition, instead categorizing such behavior under labels such as compulsive sexual behavior.
Ego-dystonic sexual orientation is a highly controversial mental health diagnosis that was included in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) from 1980 to 1987 and in the World Health Organization's (WHO) International Classification of Diseases (ICD) from 1990 to 2019. Individuals could be diagnosed with ego-dystonic sexual orientation if their sexual orientation or attractions were at odds with their idealized self-image, causing anxiety and a desire to change their orientation or become more comfortable with it. It describes not innate sexual orientation itself, but a conflict between the sexual orientation a person wishes to have and their actual sexual orientation.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is the 2013 update to the Diagnostic and Statistical Manual of Mental Disorders, the taxonomic and diagnostic tool published by the American Psychiatric Association (APA). In 2022, a revised version (DSM-5-TR) was published. In the United States, the DSM serves as the principal authority for psychiatric diagnoses. Treatment recommendations, as well as payment by health care providers, are often determined by DSM classifications, so the appearance of a new version has practical importance. However, not all providers rely on the DSM-5 for planning treatment as the ICD's mental disorder diagnoses are used around the world and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions. The DSM-5 is the only DSM to use an Arabic numeral instead of a Roman numeral in its title, as well as the only living document version of a DSM.
Pornography has been defined as any material in varying forms, including texts, video, photos or audio that is consumed for sexual satisfaction and arousal of an individual or partnership. The effects of pornography on individuals or their intimate relationships have been a subject of research.
Behavioral addiction, process addiction, or non-substance-related disorder is a form of addiction that involves a compulsion to engage in a rewarding non-substance-related behavior – sometimes called a natural reward – despite any negative consequences to the person's physical, mental, social or financial well-being. In the brain's reward system, a gene transcription factor known as ΔFosB has been identified as a necessary common factor involved in both behavioral and drug addictions, which are associated with the same set of neural adaptations.
Martin Paul Kafka is an American psychiatrist best known for his work on sex offenders, paraphilias and what he calls "paraphilia-related disorders" such as sex addiction and hypersexuality.
Primarily obsessional obsessive–compulsive disorder, also known as purely obsessional obsessive–compulsive disorder, is a lesser-known form or manifestation of OCD. It is not a diagnosis in the DSM-5. For people with primarily obsessional OCD, there are fewer observable compulsions, compared to those commonly seen with the typical form of OCD. While ritualizing and neutralizing behaviors do take place, they are mostly cognitive in nature, involving mental avoidance and excessive rumination. Primarily obsessional OCD takes the form of intrusive thoughts often of a distressing, sexual, or violent nature.
Personality disorders (PD) are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual's culture. These patterns develop early, are inflexible, and are associated with significant distress or disability. The definitions vary by source and remain a matter of controversy. Official criteria for diagnosing personality disorders are listed in the sixth chapter of the International Classification of Diseases (ICD) and in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).
The ICD-11 is the eleventh revision of the International Classification of Diseases (ICD). It replaces the ICD-10 as the global standard for recording health information and causes of death. The ICD is developed and annually updated by the World Health Organization (WHO). Development of the ICD-11 started in 2007 and spanned over a decade of work, involving over 300 specialists from 55 countries divided into 30 work groups, with an additional 10,000 proposals from people all over the world. Following an alpha version in May 2011 and a beta draft in May 2012, a stable version of the ICD-11 was released on 18 June 2018, and officially endorsed by all WHO members during the 72nd World Health Assembly on 25 May 2019.
Wendy Maltz is an American sex therapist, psychotherapist, author, educator, and clinical social worker. She is an expert on the sexual repercussions of sexual abuse, understanding women's sexual fantasies, treating pornography-related problems, and promoting healthy sexuality. She has taught at the University of Oregon and, up until her retirement in 2016 from providing counseling services, was co-director with her husband, Larry Maltz, of Maltz Counseling Associates therapy practice in Eugene, Oregon.
Sexual sadism disorder is the condition of experiencing great sexual arousal in response to the involuntary extreme pain, suffering or humiliation of other people. Several other terms have been used to describe the condition, and it may overlap with other conditions that involve inflicting pain. It is distinct from situations in which consenting individuals use mild or simulated pain or humiliation for sexual excitement. The words sadism and sadist are derived from the French writer and libertine Marquis de Sade, who wrote several novels depicting sexualized torture and violence.
Sexual masochism disorder (SMD) is the condition of experiencing recurring and intense sexual arousal in response to enduring moderate or extreme pain, suffering, or humiliation. The Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association indicates that a person may have a masochistic sexual interest but that the diagnosis of sexual masochism disorder would only apply to individuals who also report psychosocial difficulties because of it.
Proposals for two constructs related to compulsive sexual behaviors , sexual addiction and hypersexual disorder, have been repeatedly rejected from inclusion in recent editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) for lack of empirical support and lack of consensus as to definition. [...] (CSBD), has been included in the International Classification of Diseases, 11th edition (ICD-11), under impulse control disorders rather than as an addiction disorder. CSBD has significant differences from substance use disorders (SUD) [...]
'Sex addiction' is also referred to as a diagnosis or presenting problem. Sex addiction is not a diagnosis in the DSM-5-TR and identified as Compulsive Sexual Behavior in the ICD-11 rather than an issue of addiction.
... materials in ICD-11 make very clear that CSBD is not intended to be interchangeable with sex addiction, but rather is a substantially different diagnostic framework
Given that we do not yet have definitive information on whether the processes involved in the onset and maintenance of the disorder are equivalent to substance abuse disorders, gambling, and gaming (Kraus et al. 2016), CSBD is not included in the grouping of disorders due to substance and addictive behaviors, but rather in that of impulse control disorders (Kraus et al. 2018).
"Materials related to the ICD-11 make very clear that CSBD is not intended to be interchangeable with 'sex addiction', but rather is a substantially different diagnostic framework." ICD-11. World Health Organization.
Excessive use of the Internet not involving playing of online games (e.g., excessive use of social media, such as Facebook; viewing pornography online) is not considered analogous to Internet gaming disorder, and future research on other excessive uses of the Internet would need to follow similar guidelines as suggested herein. Excessive gambling online may qualify for a separate diagnosis of gambling disorder.
In addition to the substance-related disorders, this chapter also includes gambling disorder, reflecting evidence that gambling behaviors activate reward systems similar to those activated by drugs of abuse and that produce some behavioral symptoms that appear comparable to those produced by the substance use disorders. Other excessive behavioral patterns, such as Internet gaming (see "Conditions for Further Study"), have also been described, but the research on these and other behavioral syndromes is less clear. Thus, groups of repetitive behaviors, sometimes termed behavioral addictions (with subcategories such as "sex addiction," "exercise addiction," and "shopping addiction"), are not included because there is insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions needed to identify these behaviors as mental disorders.