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

• Krafft-Ebing (1886) — “hyperaesthesia sexualis”.
• 1980s–1990s — concept of ‘sexual addiction’ (Carnes P.) became popular, but remained controversial within the scientific community.
• DSM-5 (2013) — “Hypersexual Disorder” not included.
• 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:

1. Repeated sexual activity leads to impairment in other areas of the individual’s life (health, relationships, responsibility);
2. The patient has made repeated and significant efforts to regain control — unsuccessfully.
3. The behavior continues despite negative consequences;
4. 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

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

6.3 Diagnostic algorithm

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

6.4 Differential diagnosis

7. Examination and assessment

• CSBI.
• Comorbidity scales.
• STI screening.

8. Treatment

1. First-line psychotherapy — CBT, ACT, mindfulness-based approach. Evidence base is developing.
2. Naltrexone off-label — opioid antagonist; modest effect in some studies.
3. SSRIs — for comorbid MDD/anxiety.
4. Group support (S-Anon, SAA) — adjunct.
5. Relationship/couple therapy — in comorbid context.
6. 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

• WHO — ICD-11 official category.
• 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

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