Evidence-Based Reviews

Compulsive sexual behavior: A nonjudgmental approach

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Despite limited evidence, this disorder can be accurately diagnosed and successfully treated


 

References

Compulsive sexual behavior (CSB), also referred to as sexual addiction or hypersexuality, is characterized by repetitive and intense preoccupations with sexual fantasies, urges, and behaviors that are distressing to the individual and/or result in psychosocial impairment. Individuals with CSB often perceive their sexual behavior to be excessive but are unable to control it. CSB can involve fantasies and urges in addition to or in place of the behavior but must cause clinically significant distress and interference in daily life to qualify as a disorder.

Because of the lack of large-scale, population-based epidemiological studies assessing CSB, its true prevalence among adults is unknown. A study of 204 psychiatric inpatients found a current prevalence of 4.4%,1 while a university-based survey estimated the prevalence of CSB at approximately 2%.2 Others have estimated that the prevalence is between 3% to 6% of adults in the United States,3,4 with males comprising the majority (≥80%) of affected individuals.5

CSB usually develops during late adolescence/early adulthood, and most who present for treatment are male.5 Mood states, including depression, happiness, and loneliness, may trigger CSB.6 Many individuals report feelings of dissociation while engaging in CSB-related behaviors, whereas others report feeling important, powerful, excited, or gratified.

Why CSB is difficult to diagnose

Although CSB may be common, it usually goes undiagnosed. This potentially problematic behavior often is not diagnosed because of:

  • Shame and secrecy. Embarrassment and shame, which are fundamental to CSB, appear to explain, in part, why few patients volunteer information regarding this behavior unless specifically asked.1
  • Patient lack of knowledge. Patients often do not know that their behavior can be successfully treated.
  • Clinician lack of knowledge. Few health care professionals have education or training in CSB. A lack of recognition of CSB also may be due to our limited understanding regarding the limits of sexual normality. In addition, the classification of CSB is unclear and not agreed upon (Box7-9), and moral judgments often are involved in understanding sexual behaviors.10

Box
Classifying compulsive sexual behavior


Various suggestions have been proposed for the classification of compulsive sexual behavior (CSB). It may be related to obsessive-compulsive disorder (OCD), forming an “obsessive-compulsive spectrum;” to mood disorders (“an affective spectrum disorder”)7,8; or as a symptom of relationship problems, intimacy, and self-esteem. Grouping CSB within either an obsessive-compulsive or an affective spectrum is based on symptom similarities, comorbidities, family history, and treatment responses. Similar to persons with OCD, CSB patients report repetitive thoughts and behaviors. Unlike OCD, however, the sexual behavior of CSB is pleasurable and often is driven by cravings or urges. Given these descriptions, CSB also may share features of substance use disorders, and has generated a theory of sexual behavior being an addiction. There is still much debate as to how best to understand this cluster of symptoms and behaviors—as a separate disorder or as a symptom of an underlying problem. DSM-5 did not find sufficient reason to designate sexual addiction as a psychiatric disorder.9

No consensus on diagnostic criteria

Accurately diagnosing CSB is difficult because of a lack of consensus about the diagnostic criteria for the disorder. Christenson et al11 developed an early set of criteria for CSB as part of a larger survey of impulse control disorders. They used the following 2 criteria to diagnose CSB: (1) excessive or uncontrolled sexual behavior(s) or sexual thoughts/urges to engage in behavior, and (2) these behaviors or thoughts/urges lead to significant distress, social or occupational impairment, or legal and financial consequences.11,12

During the DSM-5 revision process, a second approach to the diagnostic criteria was proposed for hypersexuality disorder. Under the proposed criteria for hypersexuality, a person would meet the diagnosis if ≥3 of the following were endorsed over a 6-month period: (a) time consumed by sexual fantasies, urges, or behaviors repetitively interferes with other important (non-sexual) goals, activities, and obligations; (b) repetitively engaging in sexual fantasies, urges, or behaviors in response to dysphoric mood states; (c) repetitively engaging in sexual fantasies, urges, or behaviors in response to stressful life events; (d) repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, or behaviors; and (e) repetitively engaging in sexual behaviors while disregarding the risk for physical or emotional harm to self or others.9

These 2 proposed approaches to diagnosis are somewhat similar. Both suggest that the core underlying issues involve sexual urges or behaviors that are difficult to control and that lead to psychosocial dysfunction. Differences in the criteria, however, could result in different rates of CSB diagnosis; therefore, further research will need to determine which diagnostic approach reflects the neurobiology underlying CSB.

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