Compulsive Sexual Behavior

Why should we be concerned about compulsive sexual behavior?

Pornography, which is just one part of compulsive sexual behavior, is a huge business, and as such, it is here to stay. Some estimates claim that the pornography business (online, video, and magazines) makes $10 billion to $14 billion in annual sales globally and that it is a bigger industry than all the major league sports and possibly even bigger than the Hollywood movie industry. Companies earn revenue by making adult movies available in people’s homes and hotel rooms. There are many debates about the social and personal aspects of pornography, but what we know is that most people who use it can control their behavior. As with many of the behaviors we discuss on this blog, however, a portion of people cannot control their use of pornography. These individuals might have a problem referred to as compulsive sexual behavior.

Compulsive sexual behavior (CSB) is a term that characterizes 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. They act out impulsively (act on impulses and lack impulse control) or compulsively (are plagued by intrusive obsessive thoughts and driven behaviors). CSB can involve fantasies and urges in addition to or in place of the behavior, but it must rise to a level of clinically significant distress and interference in one’s daily life to qualify as a disorder.

Over the centuries, compulsive sexual behavior has gone by many names, such as hypersexuality, hyperphilia, erotomania, satyriasis, promiscuity, Don Juanism, Don Juanitaism, and more recently sexual addiction, impulsive-compulsive sexual behavior, and paraphilia-related disorder. The terminology has often implied different values, attitudes, and theoretical orientations.

Compulsive sexual behavior can generally be divided into two categories: paraphilic and nonparaphilic. Paraphilias (for example, fetishism, exhibitionism, sexual sadism, and pedophilia) are typically behaviors that have been deemed socially unacceptable. They may involve non-human objects, the suffering of one’s self or a partner, or sex with children or a nonconsenting person. Nonparaphilic CSB, which is characterized by more typical sexual desires, includes compulsive sexual acts with multiple partners, constant fixation on a partner who may be considered unobtainable, compulsive masturbation, compulsive use of pornography, and compulsive sex and sexual acts within a consensual relationship. In this chapter, when we refer to compulsive sexual behavior, we are referring only to nonparaphilic behaviors.

Unlike some of the other behaviors in this book, nonparaphilic CSB is not currently recognized by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). Although CSB was considered for inclusion, its inclusion was not approved. In fact, there was considerable debate about the disorder, whether it was a “real” problem, and what, if anything, it was similar to. Although DSM-5 did not ultimately acknowledge CSB as an independent disorder, the World Health Organization (WHO) has recommended it be included in the forthcoming eleventh edition of the International Classification of Diseases as an impulse control disorder.

The WHO believes that diagnoses, such as CSB, that affect public health should be recognized. CSB is associated with sexually transmitted infections, including HIV infection, unintended pregnancies, viewing of pornography at home and in the workplace, and extensive cybersex users who use the Internet to seek partners. Thus, the WHO believes that it is clinically useful to view CSB as being related to other disorders that are also characterized by repeated failures to resist impulses, drives, or urges despite long-term harm.

Jon E. Grant, JD, MD, MPH, Brian L. Odlaug, PhD, MPH, and Samuel R. Chamberlain, MD, PhD are the co-authors of "Why Can't I Stop?: Reclaiming Your Life from a Behavioral Addiction"