Assessment and treatment of compulsive sexual behavior disorder: a sexual medicine perspective

Abstract

Introduction: The addition of compulsive sexual behavior disorder (CSBD) into the ICD-11 chapter on mental, behavioral, or neurodevelopmental disorders has greatly stimulated research and controversy around compulsive sexual behavior, or what has been termed "hypersexual disorder," "sexual addiction," "porn addiction," "sexual compulsivity," and "out-of-control sexual behavior."

Objectives: To identify where concerns exist from the perspective of sexual medicine and what can be done to resolve them.

Methods: A scientific review committee convened by the International Society for Sexual Medicine reviewed pertinent literature and discussed clinical research and experience related to CSBD diagnoses and misdiagnoses, pathologizing nonheteronormative sexual behavior, basic research on potential underlying causes of CSBD, its relationship to paraphilic disorder, and its potential sexual health consequences. The panel used a modified Delphi method to reach consensus on these issues.

Results: CSBD was differentiated from other sexual activity on the basis of the ICD-11 diagnostic criteria, and issues regarding sexual medicine and sexual health were identified. Concerns were raised about self-labeling processes, attitudes hostile to sexual pleasure, pathologizing of nonheteronormative sexual behavior and high sexual desire, mixing of normative attitudes with clinical distress, and the belief that masturbation and pornography use represent "unhealthy" sexual behavior. A guide to CSBD case formulation and care/treatment recommendations was proposed.

Conclusions: Clinical sexologic and sexual medicine expertise for the diagnosis and treatment of CSBD in the psychiatric-psychotherapeutic context is imperative to differentiate and understand the determinants and impact of CSBD and related "out-of-control sexual behaviors" on mental and sexual well-being, to detect forensically relevant and nonrelevant forms, and to refine best practices in care and treatment. Evidence-based, sexual medicine-informed therapies should be offered to achieve a positive and respectful approach to sexuality and the possibility of having pleasurable and safe sexual experiences.

Keywords: ICD-11; assessment; comorbidity; compulsive sexual behavior; diagnosis; hypersexuality; impulse control disorder; paraphilias; sex/porn “addiction”; treatment.

Figure 1

Dual control model shows the neurochemical mechanisms of excitation and inhibition derived from Bancroft and Janssen and Perelman and detailed by Pfaus. Drugs or psychological states that activate those mechanisms can shift an individual into general sexual excitation or inhibition. In cases of compulsive sexual behavior disorder, individuals are in states of excitation and/or disinhibition.

Figure 2

Modified inverted optimality curve. (A) Response competence as a function of reward strength. (B) Mesolimbic/mesocortical dopamine transmission intensity (straight line and arrow) overlaid on panel A. Dopamine release mediates goal and cue seeking, with the conscious interpretation of “wanting,” “liking,” and “needing,” depending on the intensity of the dopamine response.^, Thus, dopamine mediates normal reactivity and hyperreactivity to cues that generate sexual arousal and anticipate sexual reward. But as this moves from attentional balance to attentional bias and lock, the dopamine response mediates the compulsivity observed in compulsive sexual behavior disorder, leading ultimately to the kind of attentional lock reminiscent of drug addiction. The shaded area is where the dopamine response mediates the type of hyperattention to sexual stimuli observed in compulsive sexual behavior disorder.

Figure 3

Psychological and neurobiological mechanisms that underlie the maintenance of excitation and disinhibition in compulsive sexual behavior disorder. After Briken.

Figure 4

Considerations for diagnostic and case formulation processes.