Compulsive Sexual Behaviour: Scientific Insights,Prevalence,Characteristics and the Ongoing Debate on Diagnosis and Classification

From Multiple Diagnostic Framing to Impulse Control Disorder

The concept of hypersexuality as a nosographic category is complex because the different symptoms, taken individually, have led to the hypothesis of a diagnostic framing in already existing categories: obsessive–compulsive disorder (OCD), impulse control disorders and pathological addictions. Furthermore, critical issues concerned the difficulty in distinguishing normal and abnormal in sexual behaviour, as well as the role of the social context in determining these differences. ¹

Coleman was among the first to name it ‘Compulsive Sexual Behaviour’, subsequently constructing a screening tool developed and refined over the years to assess the severity of symptoms. ² According to Coleman’s (1990) early hypothesis, the behaviour was elicited by anxiety, and the sexual act was the strategy implemented to reduce the intensity of the disturbing emotion. This strategy would provide temporary relief for the subjects, but its repetition would cause an increase in distress and, consequently, in the psychological suffering of the patients. This is why the first treatment proposals overlap with those of OCD. ³

In the International Classification of Diseases 11th Revision, hypersexuality is framed as an impulse control disorder, Compulsive Sexual Behaviour Disorder (CSBD), which is understood as an inability to resist an impulse, a compelling desire or the temptation to perform an action that is dangerous to oneself or others. In addition to negatively affecting the quality of other areas of life, the individual’s efforts to control or reduce the behaviour fail. The behaviour persists even in the situation where it is not a source of pleasure. The classification also reminds us that the disorder can manifest itself in different ways: masturbation, sexual behaviour with partners, pornography, cybersex and phone sex. Compulsions may, in certain cases, represent a response to negative affective states (e.g., depression and anxiety). It is essential that the symptoms occur over a sufficiently long period (6 months or more) for a diagnosis to be made. Other important features to be investigated, often related to the onset of the disorder, are adolescent behaviour in adult patients (e.g., excessive use of pornography, masturbation to self-regulate negative affective states), and the possible history of childhood sexual abuse in female patients with CSBD. ⁴

A recent international study investigated the prevalence of the disorder by administering a self-report instrument, the CSBD Scale, to a sample of subjects from 42 different countries. The results showed that almost 5% of the participants were at high risk of experiencing CSBD ⁵ However, estimates varied between 1.6% and 16.7% across countries, highlighting the importance of examining CSBD and other psychological problems outside of WEIRD (Western, Educated, Industrialised, Rich, and Democratic) nations, because sexuality and related values may be rooted in one’s background and cultural norms, supporting a research direction that recognises these differences.^6-8

Numerous researchers believe that hypersexuality can, in some cases, be defined as a sex addiction (SA), noting that its functioning has characteristics that fully overlap with other addictions. SA is defined as a form of sexual behaviour aimed at both producing pleasure and diminishing distressing situations, leading to clinically significant impairment or alterations. ⁹ Clinicians and researchers following this line of research have argued that SA is similar to another behavioural addiction, recognised by both the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) ¹⁰ and the International Classification of Diseases, 11th revision (ICD-11): gambling disorder (GAD). In this article, we investigated the work of colleagues who make a contribution in this direction, bearing in mind the need for further studies and insights into this evolving topic.

Historical Context

Since the early days of psychiatry and psychology, sexual behaviour have been a focus of attention and a privileged matter of study. It does not come as a surprise then that already three centuries ago the first clinical observations and considerations of what we would most likely ascribe to SA made their appearances on the manuals of those times. ¹¹

Benjamin Rush in ‘Medical inquiries and observations upon the diseases of the mind’ reported the case of a man that due to the psychological distress caused by an overwhelming libido requested to undergo surgery to become permanently impotent and deprived of sexual drive. ¹²

A few years later Richard von Krafft-Ebbing remarked how sexual pathology was a relevant parameter in psychiatric suffering and therefore it deserved clinical and scientific insight. He affirmed: ‘It (sex) permeates all (of the patient’s) thoughts and feelings, allowing of no other aims in life, tumultuously, and in a rut-like fashion demanding gratification without granting the possibility of moral and righteous counter-presentations, and resolving itself into an impulsive, insatiable succession of sexual enjoyments.…’ ¹³

A century later Jim Orford proposed for the first time the inclusion of hypersexuality within the spectrum of addictions disorders highlighting the numerous ‘excessive behaviours’ which until then were not taken into consideration since they were not associated with the use of psychoactive substances, resulting in constant challenges for clinicals for their recognition and conceptualisation.

Two main major criticalities arose and are still today topics of confrontation among experts both on a clinical and diagnostical level: first, it is complex to identify a ‘normal’ sexual behaviour and second, the cultural connotation associated with sex. ¹⁴

Since the end of the last century, research in the field has grown considerably and several experts have proposed different definitions of the phenomenon, with the intent of proposing a classification for the most important international diagnostic manuals.

In 1998, Goodman suggested a checklist of seven criteria, where the presence of at least three of them would diagnose the SA, which was defined by himself as a maladaptive pattern of sexual behaviours, which put an individual either under a significant clinical stress or marked impairments in various aspects of life, during a time span of at least 12 months. The criteria were:

Tolerance, as defined by either of the following: (a) A need for markedly increased amount or intensity of the sexual behaviour to achieve the desired effect. (b) Markedly diminished effect with continued involvement in the sexual behaviour at the same level of intensity.

Withdrawal, as manifested by either of the following: (a) Characteristic psychophysiological withdrawal syndrome of physiologically described changes and/or psychologically described changes upon discontinuation of the sexual behaviour. (b) The same (or a closely related) sexual behaviour is engaged in to relieve or avoid withdrawal symptoms.

The sexual behaviour is often engaged in over a longer period, in greater quantity, or at a higher level of intensity than was intended.

There is a persistent desire or unsuccessful efforts to cut down or control the sexual behaviour.

A great deal of time is spent in activities necessary to prepare for the sexual behaviour, to engage in the behaviour or to recover from its effects.

Important social, occupational or recreational activities are given up or reduced because of the sexual behaviour.

The sexual behaviour continues despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the behaviour.

The criteria presented by Goodman for the SA diagnosis widely trace those necessary in defining the ‘addiction’. ¹⁵

A few years later, Patrick Carnes, after gathering data on over 1,600 patients, proposed a set of diagnostic criteria for the formulation of the SA diagnosis, mostly expanding on Goodman’s work; some of them are:

A minimum of three criteria met during a 12-month period: (a) Recurrent failure to resist impulses to engage in specific sexual behaviour. (b) Frequent engaging in these behaviours to a greater extent or longer duration than intended. (c) Persistent desire or unsuccessful efforts to stop, to reduce or to control behaviours. (d) Inordinate amount of time spent in obtaining sex, being sexual or recovering from sexual experiences. (e) Preoccupation with the behaviour or preparatory activities. (f) Frequently engaging in the behaviour when expected to fulfil occupational, academic, domestic or social obligations. (g) Continuation of the behaviour despite knowledge of having a persistent or recurrent social, financial, psychological or physical problem that is caused or exacerbated by the behaviour. (h) Need to increase intensity, frequency, number or risk of behaviours to achieve the desired effect or diminished effect with continued behaviours at the same level of intensity, frequency, number or risk. (i) Giving up or limiting social, occupational or recreational activities because of behaviour. (j) Distress, anxiety, restlessness or irritability if unable to engage in the behaviours.

Has significant personal and social consequences (such as loss of partner, occupation or legal implications).

As shown it presents a significant overlap between Goodman’s and Carnes’ criteria to develop a diagnosis. On the other hand to Carnes, it is essential in defining an SA the presence of B criteria: an impairment on significant personal matter in the life of a subject. Moreover, a much greater significance is given to the loss/reduction of control in sexual activity, while tolerance and abstinence are not mentioned, even though criteria ‘8’ and ‘10’ seem to describe those clinical conditions by using a different terminology. ¹⁶

Carnes’ contribution is even more significant in the development in 2011 of one of the first screening tools for SA: the Sexual Addiction Screening Test, a self-administered test composed by 25 items. ¹¹

An other significant contribution in the history of SA diagnosis is Kafka’s (2010), who suggested a specific classification integrable in DSM-5, refused later on by the authors. Kafka amends the denomination from SA to hypersexual disorder. The diagnosis of this clinical condition does not require the criteria of addiction, tolerance and abstinence anymore, but merges other peculiar aspects of the field of addictions, such as the ineffective efforts of controlling sexual urges.

Kafka himself points out four criteria at the basis of the pathology:

Over a period of at least six consecutive months, recurrent and intense sexual fantasies, sexual urges or sexual behaviours in association with four or more of the following five criteria: (a) Excessive time consumed by sexual fantasies and urges, and by planning for and engaging in sexual behaviour. (b) Repetitively engaging in these sexual fantasies, urges and behaviour in response to dysphoric mood states (e.g., anxiety, depression, boredom and irritability). (c) Repetitively engaging in sexual fantasies, urges or behaviours in response to stressful life events. (d) Repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges and behaviour. (e) Repetitively engaging in sexual behaviours while disregarding the risk for physical or emotional harm to self or others.

There is clinically significant personal distress or impairment in social occupational or other important areas of functioning associated with the frequency and intensity of the sexual fantasies, urges and behaviours.

These sexual fantasies urges, and behaviour are not due to direct physiological effects of exogenous substances (e.g., drugs of abuse or medications) or to manic episodes.

The person is at least 18 years of age.

These authors are considered milestones for those who work and analyse hypersexuality and particularly by those who consider SA as a psychopathological condition of its own, inscribed within the greater field of addictions. ¹⁷

Conclusions

The diagnosis of SA is a complex topic that can present difficulties both diagnostically and therapeutically. Some consider SA to be a form of compulsive behaviour, while other schools of thought believe it should not be labelled as addiction. This makes the diagnosis often controversial and non-standardised.

One more difficulty lies in distinguishing between healthy sexuality and sexual behaviours that become problematic. The difference often lies in the controllability and the negative impact on well-being.

Furthermore, SA can coexist in comorbidity with other psychological disorders, such as OCD and substance abuse. The presence of multiple disorders can complicate the diagnosis, as clinical manifestations overlap, and symptoms may be confused with those of other disorders. Diagnosing SA requires an in-depth evaluation by an experienced professional, as there are no specific tests or biomarkers to identify it. Future research should focus on clarifying these differences as best as possible, so as to provide the clinician with accurate tools for an appropriate differential diagnosis.