Compulsive sexual behaviour disorder

ICD-10F52.7	Excessive sexual drive
DSM-5-TR—	No DSM-5-TR equivalent

1. Definition and nosology

Compulsive Sexual Behaviour Disorder (ICD-11: 6C72) — a persistent pattern of failure to control intense, repetitive sexual impulses and behaviors, causing significant distress or functional impairment. Included in the impulse control disorders category in ICD-11.

DSM-5-TR has no separate diagnosis (“Hypersexual Disorder” was not included in DSM-5). The term “Sex addiction” is controversial in the scientific community.

2. History

1. Krafft-Ebing (1886) — “hyperaesthesia sexualis”.
2. 1980s–1990s — concept of ‘sexual addiction’ (Carnes P.) became popular, but remained controversial within the scientific community.
3. DSM-5 (2013) — “Hypersexual Disorder” not included.
4. ICD-11 (2019) — Compulsive Sexual Behavior Disorder (impulse control, not addiction) added as an official category.

3. Epidemiology

• Prevalence: 1–6% (broad range, depending on assessment tools).
• Sex: higher in males (5:1 in clinical populations).
• Comorbidity: MDD, anxiety, BPD, substance use, OCD, ADHD.

4. Etiology and pathogenesis

• Multiple factors — impulsivity, compulsivity, cognitive-emotional dysregulation, trauma.
• Neurobiological similarities with substance use disorders and OCD.
• Social-cultural — accessibility of internet pornography.

5. Clinical features

• Excessive time spent on sexual fantasies, urges, or behaviors.
• Failure of attempts to reduce behavior despite negative consequences.
• Use of sexual behavior to reduce distress or achieve emotional acceptance.
• Significant functional impairment due to impaired control of sexual behavior (relationships, work, health, legal).
• Typical forms — compulsive masturbation, multiple sexual partners, patronizing commercial sex services, problematic pornography use.

6. Diagnosis

6.1 Unified diagnostic criteria (ICD-11)

A. Pattern of persistent failure to control intense sexual impulses and behaviors.

B. ≥ 1 of the following:

• Repeated sexual activity leads to impairment in other areas of the individual’s life (health, relationships, responsibility);
• The patient has made repeated and significant efforts to regain control — unsuccessfully.
• The behavior continues despite negative consequences;
• The behavior persists even when it does not produce significant pleasure.

C. Duration ≥ 6 months.

D. Significant distress or functional impairment.

E. Distress arising entirely from moral or religious judgment and disapproval does not satisfy the criterion; functional impairment, or distress independent of that judgment, is required.

6.2 Differences between sources

1. ICD-11: impulse control disorders; “sex addiction” term not used.
2. DSM-5-TR: no distinct diagnosis; in clinical practice falls under ‘Other Specified Disruptive, Impulse-Control, and Conduct Disorder.’
3. Diagnosis should not be based solely on spiritual-religious distress.

6.3 Diagnostic algorithm

• Clinical interview.
• Scale — CSBI (Compulsive Sexual Behavior Inventory).
• Comorbidity (MDD, anxiety, BPD, substance, OCD).
• Screening for sexually transmitted infections (STIs).
• Legal and relationship consequences.

6.4 Differential diagnosis

7. Examination and assessment

1. CSBI.
2. Comorbidity scales.
3. STI screening.

8. Treatment

• First-line psychotherapy — CBT, ACT, mindfulness-based approach. Evidence base is developing.
• Naltrexone off-label — opioid antagonist; modest effect in some studies.
• SSRIs — for comorbid MDD/anxiety.
• Group support (S-Anon, SAA) — adjunct.
• Relationship/couple therapy — in comorbid context.
• There is no specific FDA-approved pharmacotherapy.

8.1 Treatment methods

1. CBT and Acceptance and Commitment Therapy (ACT) — Trigger management, value-based behavior.
2. Naltrexone off-label — Craving reduction.
3. Compulsive Sexual Behavior Inventory (CSBI) — Severity scale.
4. Self-help (SAA, SLAA; S-Anon for family) — 12-step-based; evidence base limited.

8.2 Differences between sources

1. WHO — ICD-11 official category.
2. APA — DSM-5-TR does not have a separate diagnosis; controversial area.

9. Prognosis

• Significant improvement with CBT and ACT.
• Comorbidity treatment important.

10. Myths and misconceptions

Myth 1: “Sex addiction is a diagnosis like substance addiction”

Evidence: ICD-11 — impulse control disorder; ‘addiction’ concept controversial, not adopted in DSM-5.

Myth 2: “High sexual interest is a sign of sex addiction”

Evidence: Clinical diagnosis requires functional impairment and failure of control; mere high sexual activity is not a disease.

Myth 3: “Deviation from moral-religious norms is a basis for diagnosis”

Evidence: ICD-11 — religious/spiritual cause not sufficient; functional impairment or marked distress is required.

Myth 4: “Pornography use is always a disorder”

Evidence: Normal use and compulsive use are different; loss of control and functional burden are diagnostic.

Myth 5: “Chemical castration (testosterone suppression) is standard treatment”

Evidence: This approach is only applied in severe paraphilic disorders at high risk related to pedophilia according to the WFSBP guideline; not recommended for general compulsive sexual behavior.

11. Sources

• WHO. ICD-11. 6C72 Compulsive sexual behaviour disorder. 2024.
• APA. DSM-5-TR. 2022.
• Kraus S.W. et al. Compulsive sexual behaviour disorder in the ICD-11. World Psychiatry 2018;17(1):109–110.
• Grubbs J.B., Hoagland K.C., Lee B.N. et al. Sexual addiction 25 years on. Clin Psychol Rev 2020;82:101925.