Compulsive Sexual Behaviour

Compulsive sexual behaviour is an intense focus on sexual fantasies, urges or behaviours that can’t be controlled, causing distress and problems in relationships, work, health and other areas of life. While debate continues about how to classify it, treatment and self-help approaches can help people manage these behaviours and regain control.

Table of contents

• What is compulsive sexual behaviour?
• Names and classification
• Signs and symptoms
• How common is it and who is affected?
• Types of behaviours involved
• Impact on daily life
• Diagnosis and criteria
• Treatment approaches

What is compulsive sexual behaviour?

hypersexuality, sexual addiction, problematic sexual behaviour, sexual compulsivity, sexual impulsivity, hypersexuality disorder, excessive sexual desire disorder

Compulsive sexual behaviour is characterized by repetitive and intense preoccupations with sexual fantasies, urges, and behaviours that are distressing to the individual and result in problems in important areas of life^[1]. It’s an intense focus on sexual thoughts or activities that can’t be controlled, causing harm to your health, job, relationships or other parts of your life^[1].

The behaviours may involve different kinds of commonly enjoyable sexual experiences. Examples include masturbation, sexual arousal by using a computer to communicate, multiple sexual partners, use of pornography or paying for sex^[1]. However, when these sexual behaviours become a major, constant focus in your life, are difficult to control, cause problems in your life, or are harmful to you or others, that’s likely compulsive sexual behaviour^[1].

Compulsive sexual behaviour is different from having a high sex drive or enjoying sex. A healthy sex drive is about connection, pleasure, and intimacy that adds to your life. Compulsive sexual behaviour is about escape and using sex as a coping mechanism that has started to cause harm^[6]. The behaviour becomes a repetitive, rigid way to numb emotional pain, creating a cycle where you need to engage in the behaviour just to feel normal^[6].

Names and classification

This condition is known by several different names. It is sometimes called hypersexuality or sexual addiction^[1]. Healthcare professionals may refer to it as compulsive sexual behaviour, problematic sexual behaviour, hypersexuality, hypersexuality disorder, sexual compulsivity or sexual impulsivity^[5].

The World Health Organization (WHO) recognizes compulsive sexual behaviour disorder (CSBD) as an impulse control disorder (a condition where a person has difficulty controlling urges or impulses) in the ICD-11 (International Classification of Diseases, 11th Revision)^[2]. However, it is not classified as an addiction^[2].

In contrast, the American Psychiatric Association (APA) does not recognize compulsive sexual behaviour as a standalone diagnosis in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition)^[2]. The condition was proposed for inclusion in the DSM-5 but was ultimately rejected^[2]. Instead, it may sometimes be diagnosed as part of another mental health condition, such as an impulse control disorder or a behavioural addiction^[3].

Debate is ongoing among mental health professionals about whether hypersexuality can be classified as a mental health disorder. The American Psychiatric Association rejected the proposal due to lack of evidence and the potential consequences of calling excessive sexual activity a disease or disorder^[5].

Signs and symptoms

Some signs that you may have compulsive sexual behaviour include the following^[1]:

• You have repeated and intense sexual fantasies, urges, and behaviours that take up a lot of your time and feel as if they’re beyond your control
• You feel driven or have frequent urges to do certain sexual behaviours, feel a release of the tension afterward, but also feel guilt or deep regret
• You’ve tried without success to reduce or control your sexual fantasies, urges or behaviour
• You use compulsive sexual behaviour as an escape from other problems, such as loneliness, depression, anxiety or stress
• You continue to engage in sexual behaviours in spite of them causing serious consequences

You may spend hours each day thinking about sex or fantasies^[6]. You may be obsessed with sex, spending a lot of time fantasizing about your sexual urges and engaging in sexual behaviour^[5]. You might masturbate often (once to several times daily) and frequently view pornography from various sources including videos, adult magazines, or the internet^[5].

People with this condition may experience a range of difficult emotions^[5]:

• Guilt, shame or remorse
• Hopelessness and feeling powerless over the addictive behaviour
• Depression and loneliness
• Fear and anxiety
• Suicidal thoughts

How common is it and who is affected?

Hypersexuality appears to affect about 3% to 10% of the general U.S. population^[5]. A study conducted in 42 countries found that almost 5% of people may be at high risk of compulsive sexual behaviour disorder, but only 14% of them have sought treatment^[2].

It’s more common in men than women. For every two to five males with hypersexuality, one woman is affected^[5]. Sexual addiction begins, on average, at 18 years of age^[5]. Most individuals don’t reach out for professional help until age 37^[5].

Many individuals (88%) have a history of other mental health conditions, including^[5]:

• Mood disorders, including bipolar disorder (a condition causing extreme mood swings)
• Anxiety disorders
• History of suicide attempts
• Personality disorders
• Other addictive disorders
• Impulse control disorders
• Obsessive-compulsive disorder (OCD, a condition causing unwanted thoughts and repetitive behaviours)
• Attention deficit hyperactivity disorder (ADHD, a condition affecting focus and impulse control)

Types of behaviours involved

Compulsive sexual behaviour can generally be divided into two categories: paraphilic and nonparaphilic^[4].

Paraphilias are typically considered to be behaviours that have been deemed socially unacceptable and involve non-human objects, suffering of one’s self or a partner, children or a non-consenting person (for example, fetishism, exhibitionism, and pedophilia)^[4].

Nonparaphilic compulsive sexual behaviour is characterized by more typical sexual desires. These include compulsive sexual acts with multiple partners, constant fixation on a partner that may be considered unobtainable, compulsive masturbation, compulsive use of pornography, and compulsive sex and sexual acts within a consensual relationship^[4].

Often, the sexual behaviours and urges that individuals with compulsive sexual behaviour experience are not problematic in and of themselves. For example, patients may engage in common sexual behaviours such as masturbation, viewing pornography, having multiple partners, or cybersex^[8]. The issue arises from the patient’s inability to control their impulses, even when the behaviours are having a negative effect on their life^[8].

Impact on daily life

Untreated compulsive sexual behaviour can damage your self-esteem, relationships, career, health and other people^[1]. The condition can lead to a loss of time, productivity, and self-esteem, as well as potential damage to relationships, career, and overall health^[8].

Compulsive sexual behaviour can affect a person’s mental health, relationships, and ability to function in many ways^[6]:

• Loss of interest in activities: Instead of going out with friends, you might choose to stay home and watch pornography^[6]
• Feelings of guilt and shame: When you can’t seem to get your behaviour under control, you start to feel ashamed and struggle with low self-esteem^[6]
• Legal troubles: If your sexual behaviour violates the law or rights of others, you may face legal consequences^[6]
• Financial problems: Spending large amounts of money on things like sex workers or purchasing pornography can compromise your financial stability^[6]
• Co-occurring health problems: Compulsive sexual behaviour can increase your risk of depression, anxiety, sexually transmitted infections (STIs), and unhealthy substance use^[6]
• Relationship issues: People may attempt to conceal their behaviour from loved ones to avoid scrutiny. This can lead to conflict and a loss of trust^[6]
• Employment problems: If your compulsive sexual behaviour affects your ability to focus on your responsibilities at work, you could risk losing your job^[6]

Repetitive sexual activities may become a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities, and responsibilities^[2].

Diagnosis and criteria

There’s an ongoing debate among mental health professionals about exactly how to define compulsive sexual behaviour. It’s not always easy to figure out when sexual behaviour becomes a problem^[3].

You can ask your healthcare provider to refer you to a mental health provider with experience in diagnosing and treating compulsive sexual behaviour. A mental health exam may include talking about your physical and mental health, as well as your overall emotional well-being, sexual thoughts, behaviours and urges that are hard to control, use of recreational drugs and alcohol, family, relationships and social life, and concerns and problems caused by your sexual behaviour^[3].

The ICD-11 includes specific criteria for diagnosing compulsive sexual behaviour disorder^[2]:

• Pattern of failure to control intense sexual impulses or urges and resulting repetitive sexual behaviour
• Manifested over an extended period of time (for example, 6 months or more)
• Causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning

Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement^[2]. Mental distress entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to diagnose compulsive sexual behaviour disorder^[2].

The proposed criteria also include that repetitive sexual activities have become a central focus of the person’s life to the point of neglecting health and personal care or other interests^[8], numerous unsuccessful efforts to control or significantly reduce sexual behaviours^[8], continued engagement in repetitive sexual behaviour despite adverse consequences^[8], and continued repetitive sexual behaviour even when the individual derives little or no satisfaction from it^[8].

Treatment approaches

With treatment and self-help, you can learn to manage compulsive sexual behaviour^[1]. Treatment for compulsive sexual behaviour typically involves psychotherapy (a type of counseling that helps address mental health issues), medications, and self-help groups^[3].

A primary goal of treatment is to help you manage urges and reduce excessive behaviours while maintaining healthy sexual activities^[3]. If you have compulsive sexual behaviour, you may also need treatment for another mental health condition. People with compulsive sexual behaviour often have alcohol or drug abuse problems or other mental health problems, such as anxiety or depression, which need treatment^[3].

Psychotherapy

Several types of psychotherapy can help^[3]:

Cognitive behavioural therapy (CBT) helps you identify unhealthy, negative beliefs and behaviours and replace them with more adaptive ways of coping^[3]. You learn strategies to make these behaviours less private and interfere with being able to access sexual content so easily^[3].

Acceptance and commitment therapy is a form of CBT that emphasizes acceptance of thoughts and urges and a commitment to strategies to choose actions that are more consistent with important values^[3].

Psychodynamic psychotherapy focuses on increasing your awareness of unconscious thoughts and behaviours, developing new insights into your motivations, and resolving conflicts^[3].

Some treatment guides suggest shame is at the core of compulsive sexual behaviour disorder. The shame is associated with feelings of self-defectiveness, social pain and isolation, and functions in two ways^[2]. First, chronic shame from social stigma or early traumatic experiences increases the soothing function of sexual behaviour, making it compulsive. Second, excessive or inappropriate sexual behaviour causes extra shame and forms a self-sustaining cycle. Therefore, treatment is primarily aimed at shame reduction and social reintegration^[2].

Medications

As of the end of 2019, the U.S. Food and Drug Administration (FDA) had approved no medications specifically for compulsive sexual behaviour disorder^[2]. However, medications that affect the brain’s chemistry, such as antidepressants, naltrexone, mood stabilizers, and anti-androgens, may improve symptoms^[8].

Support and ongoing care

Self-help support groups can provide accountability, connection and encouragement from others who understand your experience^[5]. Treatment may be intense at first, and you may find periodic, ongoing treatment through the years helpful to prevent relapses^[3].

People with other addictions or severe mental health problems or who pose a danger to others may benefit from inpatient treatment initially. Whether inpatient or outpatient, treatment may be intense at first^[3].