Compulsive Sexual Behavior with Non-consensual Urges and Sexual Performance Issues

Compulsive sexual behavior disorder (CSBD), also referred to as sex addiction, hypersexuality, or problematic sexual behavior, is characterized by repetitive and intense preoccupations with sexual fantasies, urges, and behaviors that cause significant distress or lead to psychosocial impairment. ¹ CSBD is still much debated with respect to classification and whether it should be classified as an addictive behavior or rather as an impulse control disorder, an obsessive-compulsive spectrum-related condition, or a sexual dysfunction. Recently added to the International Classification of Diseases, 11th Revision (ICD-11), CSBD is defined by recurrent difficulties in regulating intense sexual urges and behaviors (often leading to considerable psychological and functional distress, guilt, and/or shame), with problematic use of pornography seen in more than 80% of those seeking treatment. ² Elements of diagnosis also consist of persistent loss of control, sexual activities becoming a dominant focus in the individual’s life, repeated unsuccessful efforts to limit them despite knowing better, and harm to general functioning. These disorders continue to be less recognized and diagnosed, particularly in the Indian setting, where work on comorbid sexual dysfunctions and CSBD is scant.

We present a case of a 32-year-old married male, BTech graduate, working as a Chief Officer (CO) in Raipur, who was caught trying to take a video of his sister-in-law while bathing. He was brought to the psychiatry Out patient department (OPD) with a history of persistent sexual fantasies for 15 years, watching pornographic material and masturbation for 14 years, repeated inclination toward clicking non-consensual images of women in the vicinity for 7–8 years, and erectile failure since the last three years.

The reason this case with such a long history came to the psychiatry OPD was that the patient was caught taking non-consensual photographs and videos of women in public and within his family. On detailed exploration, he reported a 15-year history of persistent sexual fantasies, beginning in adolescence after exposure to pornography by peers, followed by escalating urges to secretly photograph unsuspecting women and derive gratification through repeated masturbation. Over the years, he consumed up to 10–12 hours of pornography daily with three to five episodes of masturbation, experienced recurrent relapses despite temporary abstinence (for about two months), and faced multiple incidents of being caught, in public and by his family. His marriage initially was satisfactory, but later became strained due to his sexual preferences and the onset of erectile dysfunction, which improved only after prolonged abstinence and contributed to marital conflict. The patient also disclosed childhood sexual trauma at age 12, alongside growing up in a conflicted household marked by parental disputes and allegations of his mother’s affair with his grandfather, which led him to seek refuge with his grandmother.

More recently, he reported sleep disturbance, reduced concentration, increased appetite, and significant distress related to loss of reputation following repeated episodes of being caught. There was no history suggestive of schizophrenia, other psychotic disorders, bipolar affective disorder, major depressive disorder, obsessive-compulsive disorder, or substance use or dependence. No history of neurological illness, head injury, or endocrine abnormality was reported.

The patient initially sought medical help due to erectile dysfunction, and his behavior being discovered led his family to believe he required intervention. In many mental health settings, such cases are often diagnosed as sexual dysfunction or paraphilic disorders, while the newer diagnosis of CSBD remains under-recognized among professionals. Hypersexuality is at times even misinterpreted as psychosis, leading to inappropriate treatment approaches. In this case, the patient’s history revealed prolonged childhood trauma, marked by exposure to violent parental conflicts that drove him to hide, as well as witnessing his mother’s sexual relationships with his grandfather and others. From a psychoanalytic perspective, CSBD can be understood as arising from disturbances in the psyche and maladaptive attachment patterns formed in early development, where insecure attachment contributes to poor affect regulation and reliance on CSBs as a way of managing distress. ³ Additionally, childhood sexual abuse and traumatic experiences have been shown to foster problematic sexual scripts, emotional dysregulation, and impaired interpersonal connectedness, all of which are evident in this presentation. ⁴

Due to frequent misdiagnosis, cases of CSBD often remain underreported, highlighting the need for greater clinician awareness and training not only in recognizing this condition but also in providing appropriate treatment. Research in this area is still vastly limited, with only four randomized controlled trials conducted to date, emphasizing the necessity for more methodologically rigorous investigations. ⁵ Critical concerns persist, including the risk of pathologizing non-heteronormative sexual expressions and the overall lack of clinician expertise in sexual medicine. ² Future efforts must therefore focus on enhancing diagnostic accuracy, developing evidence-based therapeutic strategies, and integrating sexual medicine knowledge into psychiatric and psychological practice. ²