Qeae 014

Sexual Medicine Reviews, 2024, 12, 355–370
https://doi.org/10.1093/sxmrev/qeae014
Advance access publication date 25 March 2024
Review
Assessment and treatment of compulsive sexual behavior

disorder: a sexual medicine perspective
Peer Briken, MD1 , Beáta Bőthe, PhD2 ,3 , Joana Carvalho, PhD4 , Eli Coleman, PhD5 ,
Annamaria Giraldi, MD, PhD6 ,7 , Shane W. Kraus, PhD8 , Michał Lew-Starowicz, MD, PhD9 ,
James G. Pfaus, PhD10 ,11 ,*
1 Institute for Sex Research, Sexual Medicine, and Forensic Psychiatry, University Medical Center, Hamburg-Eppendorf, Hamburg 20251,
Downloaded from https://academic.oup.com/smr/article/12/3/355/7634799 by guest on 27 October 2024

Germany
2 Department of Psychology, Université de Montréal, Montréal, QC H3C 3J7, Canada
3 Centre de Recherche Interdisciplinaire Sur Les Problèmes Conjugaux Et Les Agressions Sexuelles, Montréal, QC H3C 3J7, Canada
4 William James Center for Research, Department of Education and Psychology, University of Aveiro, Aveiro 3810-193, Portugal
5 Eli Coleman Institute for Sexual and Gender Health, University of Minnesota, Minneapolis, MN 55454, United States
6 Sexological Clinic, Mental Health Center, Copenhagen University Hospital, Mental Health Services, Copenhagen CPH 2200, Denmark
7 Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen 2200, Denmark
8 Department of Psychology, University of Nevada Las Vegas, Las Vegas, NV 5030, United States
9 Department of Psychiatry, Centre of Postgraduate Medical Education, Warsaw 01-809, Poland
10 Center for Sexual Health and Intervention, Czech National Institute of Mental Health, Klecany 25067, Czech Republic
11 Department of Psychology and Life Sciences, Faculty of Humanities, Charles University, Prague 18200, Czech Republic
*Corresponding author: Department of Psychology and Life Sciences, Faculty of Humanities, Charles University, Pátkova 2137/5, 18200 Praha 8–Libeň, Czech
Republic. Email: [email protected]
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: compulsive sexual behavior; hypersexuality; impulse control disorder; ICD-11; sex/porn “addiction”; comorbidity; paraphilias; assessment; diagnosis;
treatment.
Introduction being labeled an “addiction,” and current social media, peri-

The notion that “out of control,” driven sexual behavior odicals, and online self-help forums have provided a venue for
associated with distress and negative consequences is con- an enormous spread of misinformation regarding its potential
sidered a mental disorder is still quite controversial.1 On causes, severity, and base rates among different populations,
one hand, compulsive sexual behavior (CSB) has a diagnostic especially in North America. This controversy illustrates the
formulation as a CSB disorder (CSBD) that was included as an lack of consensus regarding the definition and diagnosis and
impulse control disorder in the International Classification of is one in which sexual medicine has a unique perspective and
Diseases, Eleventh Revision (ICD-11).2 On the other, it was responsibility to address. Therefore, the International Society
not included as “hypersexual disorder” in the fifth edition of for Sexual Medicine convened an expert scientific panel to
the Diagnostic and Statistical Manual of Mental Disorders provide a comprehensive review of the current understanding
(DSM-5).3 Moreover, treatment centers have profited from it of CSBD as a clinical entity and to what extent empirical data
Received: November 19, 2023. Revised: February 2, 2024. Accepted: February 3, 2024
© The Author(s) 2024. Published by Oxford University Press on behalf of The International Society of Sexual Medicine.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/lice
nses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For
commercial re-use, please contact [email protected]
356 Sexual Medicine Reviews, 2024, Vol 12, Issue 3
support its potential causes, levels of severity, expression in the or sustaining intimate relationships, as well as communication
population, and comorbidity with other disorders. We then and relationship problems.17 Thus, sexual health and well-
consider what might be best practices in potential care and being are hindered among people with CSBD, and given the
treatment. currently known prevalence, this is a serious public health
The history of clinical sexology includes attempts to classify problem for societies.11,17-19
“addiction-like” or compulsive forms of sexual behavior. This Thus, since there is public health relevance for CSBD,
starts in the clinical literature with von Krafft-Ebing’s descrip- the elimination of this category was less in question than a
tion of hyperaesthesia sexualis.4 Since then, various discourses revision of the terminology and its placement as a diagnos-
have ensued to describe this clinical phenomenon, and these tic category. There was quite a debate of whether to place
have been influenced by changing sociopolitical-cultural cli- this syndrome in disorders due to addictive behavior, along
mates. One of the important discourses has been centered with gambling or gaming disorder, or to place it as a type
on the boundary between nonnormative sexual behavior (eg, of impulse control disorder. Other considerations were to
higher sex drive) and a clinical diagnosis of hypersexual place it within obsessive-compulsive disorders (OCDs) or with
disorder or CSB. There is a serious risk of pathologizing sexual sexual dysfunctions, which were moved out of the chapter on
behavior that is outside the norm or subject to moral or mental and behavioral disorders and into a new chapter of

cultural disapproval. Another discourse has dealt with the eti- “conditions related to sexual health.” The final decision was
ologic or classification question: Is the phenomenon a sexual to place this in the subchapter of impulse control disorders
disorder, an “addiction,” an “impulse control disorder,” or an and to name it CSBD. Central to the diagnostic criteria were
“obsessive-compulsive disorder”? Does the phenomenon have difficulties with sexual self-control over a prolonged time that
paraphilic and nonparaphilic modes of expression? How can are associated with distress. In the ICD-11 guidelines,2,20
it be assessed, the differences distinguished, and what are the however, a deliberate attempt was made to prevent the risk of
underlying mechanisms or correlates? overpathologizing. Distress caused by overpathologizing non-
There is not enough space here to go into detail about normative sexual behavior, especially by moral judgments and
the different disputes that marked the consideration of this disapproval, does not qualify for the diagnosis. The descrip-
phenomenon for inclusion in the DSM and ICD historically. tion of CSBD says that it is “characterized by a persistent
Nevertheless, regarding the DSM-5, there was a proposal for pattern of failure to control intense, repetitive sexual impulses
the conception and criteria of a diagnosis of hypersexual or urges resulting in repetitive sexual behavior. Symptoms
disorder for inclusion, as well as careful literature reviews may include repetitive sexual activities becoming a central
from the working group,5 available measurement instruments, focus of the person’s life to the point of neglecting health and
and a completed field trial.6 However, the Board of Trustees personal care or other interests, activities, and responsibilities;
of the American Psychiatric Association decided in the end numerous unsuccessful efforts to significantly reduce repeti-
not to include the diagnostic category in the DSM-5 or tive sexual behavior; and continued repetitive sexual behavior
its 2022 text revision. The 2 overarching reasons involved despite adverse consequences or deriving little or no satisfac-
insufficient scientific evidence that the proposed criteria repre- tion from it. The pattern of failure to control intense sexual
sented a distinct clinical syndrome and concerns about poten- impulses or urges and resulting repetitive sexual behavior is
tial misuse of the hypersexual disorder diagnosis in forensic manifested over an extended period of time (eg, six months
settings.7-9 or more), and causes marked distress or significant impair-
The initial situation for the ICD-11 was considerably dif- ment in personal, family, social, educational, occupational, or
ferent. Although the diagnosis of “excessive sexual drive” had other important areas of functioning. Distress that is entirely
a shadowy existence without empirical research support, it related to moral judgments and disapproval about sexual
had existed in the form of “satyriasis” and “nymphomania” impulses, urges, or behaviors is not sufficient to meet this
in early versions of the ICD and as part of the chapter on requirement.”2
sexual dysfunctions within the ICD-10. However, a more CSBD may be expressed in a variety of behaviors, such as
precise description of the diagnostic prerequisites and detailed sexual behavior with others, masturbation, use of pornogra-
research criteria were absent. The diagnosis was hardly used phy, or cybersex (internet sex). Although precise diagnostic
according to our clinical impression but also according to data requirements for CSBD are an important step, the potential
from published research (eg, no hits if one enters the terms for overpathologizing still exists on the basis of moral judg-
“excessive sexual drive” and “ICD-10” in MEDLINE). This ments or societal disapproval, indeed even in misguided self-
raised the question of whether a new diagnostic category of diagnosis. CSBD must be carefully differentiated from other
the phenomenon should exist and to which chapter it should mental or sexual disorders, such as paraphilic disorder; it must
be assigned. be determined whether it stems from moral guilt; and it must
Aspects associated with the clinical syndrome might affect be distanced from the kind of unscientific information and
various aspects of sexual health and well-being at the indi- misguided beliefs that proliferate on social media, such as the
vidual and cultural levels.10-13 CSBD is often associated with notion that plasma androgens are lost during sexual activ-
negative attitudes about sexuality and excessive guilt about ity21 or that watching pornography results in “pornography-
one’s sexual behavior that can interfere with feelings of plea- induced erectile dysfunction.”22-24
sure and satisfaction and create distress. That guilt may be
due to religious or cultural values, which might stigmatize
certain sexual behaviors (eg, masturbation, use of erotica, What CSBD is and what it is not
same-sex relationships).14 CSBD can also be associated with Despite the proliferation of CSB-related studies in the past 2
coercive sexual behavior involving experiences of being a decades and the inclusion of an official diagnosis for CSBD
victim of sexual violence.12 There can be an increased risk of in the ICD-11,2,25,26 one of the most fundamental ques-
sexually transmitted infections or other health problems.15,16 tions regarding CSBD still pertains to the accurate identifi-
In addition, CSBD can be associated with difficulty developing cation of those experiencing CSBD. This is critical to avoid
Sexual Medicine Reviews, 2024, Vol 12, Issue 3 357
pathologizing normal sexual behaviors or misdiagnosing indi- sexual behavior in response to feelings of depression, anxiety,
viduals and to provide adequate care for everyone seeking boredom, loneliness, or other negative affective states,”2 and
treatment for one’s sexual behaviors.27-29 Persons with CSBD the relationship between emotional regulation and sexual
present themselves clinically and socially with a perception of behavior was described as an important aspect of treatment
out-of-control sexual behavior, extreme guilt over sexual grat- planning.2,36,37
ification, and distress related to the adverse consequences of Several important limitations of CSBD research are per-
repetitive sexual behavior and/or the lack of satisfaction from tinent. First, CSBD research has been conducted mainly in
it. This might include guilt and shame over masturbation, Western countries18 and largely on cisgender heterosexual
online pornography use, intrusive sexual thoughts, and sexual males. Less is known about the specific needs for CSBD assess-
activity with others outside a relationship or established social ment of males in non-Western cultures or in the context of
boundaries. This has been popularized in the media as a “sex women and sexually diverse people.38 Clinical presentations
addiction” or “porn addiction” and therefore as a disorder, of CSBD and therapeutic needs in those populations may
but it is also portrayed in some scientific publications as differ. For example, women more commonly report engaging
being “reminiscent” of addiction and attributed to the kind in sexual fantasies and/or seductive behaviors that lead to
of sensitized brain dopamine function observed in drug addic- multiple affairs, participating in sadomasochistic behavior

tion.30 Sex or pornography addiction, in turn, has been used or sex work, and describing themselves as “love addicted.”
in the media as a catch-all physiologic process underlying the Relative to men, women also exhibit higher sexual anxiety
perceived behavior that leads to guilt, shame, or feelings of dis- and depression, external sexual control, and fear of sexual
tress or to perceived conditions in which sexual responses are relationships.39-43 More research is needed to improve clarity
blunted (eg, in pornography-induced erectile dysfunction), in and instrumentation adapted to clinical assessments of these
which people who view pornography and presumably mastur- understudied groups and cultures, especially since the etiology
bate compulsively become unable to gain or sustain erections and expression of CSBD may vary as a function of culture.
to their partners or indeed to previously utilized pornography
vignettes. Instead, they seek out new pornography vignettes
or partners that they find exciting enough to induce erec-
tion and allow masturbation or sexual activity. An industry How much is too much?
based on the principles of Alcoholics Anonymous has grown Two of the important aspects of the CSBD diagnostic criteria
around the treatment of “sex addiction” and “porn addiction” are impulse control problems and moral disapproval. First,
since the 1980s.31,32 This industry is directly related to the we review the scientific evidence on whether the quantity of
increased concept of addiction to describe any excessive, engagement in sexual behaviors might be considered an objec-
out-of-control behavior and to the proliferation of self-help tive, reliable indicator of control problems in CSBD. Then we
groups, which are modeled after 12-step groups and treatment discuss the role of moral disapproval in self-labeling one’s
programs that have been helpful for people with substance use sexual behavior as out of control, compulsive, or addictive-
disorders. like and thus in need of therapy. To explore these issues,
From a diagnostic perspective, CSBD should be recognized we examine the literature on problematic pornography, as
as a distinct and clearly defined clinical disorder2 that is >80% of those seeking treatment for CSBD report problem-
differentiated from other disorders (eg, paraphilias, persistent atic pornography use (PPU),7,44 which is the most commonly
genital arousal disorder33 ). In addition, it must be acknowl- studied CSB in scientific reports.25
edged that feeling a loss of control and the perceived conse- The frequency or amount of a given behavior or activity
quences of uncontrolled sexual behavior represent subjective is a potential objective indicator of control problems (eg,
experiences largely influenced by individual values, beliefs, frequency of alcohol consumption45-47 ). However, when we
cultural norms, environmental expectations, and personal- examine behaviors that derive from natural appetitive drives,
ity characteristics.34 To avoid overpathologizing individually such as sexual behavior, it is more challenging to draw the line
unacceptable, socially unacceptable, or high-frequency sexual between “normal” and “dysregulated” behavior, as people’s
behavior, a restriction was added to the diagnostic require- sexual desires and experiences may vary substantially. This
ments that one’s distress should not be exclusively related variability, even extreme forms, is normal if the behavior
to moral judgment or social disapproval.2,26 However, some does not cause distress, impairment, or other functional prob-
clinicians have argued that feelings of moral incongruence lems.5,48 For example, findings from a recent meta-analysis
toward pornography viewing, masturbation, extramarital sex, of 61 studies suggest that the quantity of pornography use
or other sexual behaviors should not arbitrarily disqualify one has a positive moderate association with PPU,49 indicating
from receiving a diagnosis of CSBD, and its role in the etiology that a higher quantity of pornography use is associated with
and definition of CSBD warrants additional understanding more severe PPU. Yet, the association was only moderate,
and further study.28,29 and the frequency of pornography use was identified as the
Another challenge of the initial clinical assessment is to rule most peripheral symptom of PPU in particular and CSBD in
out “false CSBD presentations,” as a CSBD mental disorder general in network analytical studies of general and treatment-
diagnosis may be used by a patient or partner as a convenient seeking populations.50,51 Thus, the frequency or quantity
excuse for sexual misconduct (eg, when a sexual affair is dis- of pornography use alone might not accurately differentiate
covered by a partner). Therefore, assessing one’s motivation those with and without control problems.
to seek treatment is an important part of the evaluation.35 This notion was supported by large-scale studies in general
Clinicians may be misled by the fact that emotional dysreg- and treatment-seeking populations.52-54 In addition to the
ulation was not included in the ICD-11 diagnostic guidelines groups that rarely used pornography and did not experi-
of CSBD. However, it is recognized as an “additional clinical ence control problems (ie, nonproblematic users, 68%-76%
feature” in which “individuals with CSBD often engage in of users) and those that used pornography frequently and
identified as PPUs (ie, problematic users, 3%-12%),52,54 2 Similarly, high-frequency pornography use without impaired
other groups emerged that might be important for differential control and related adverse consequences should not be diag-
diagnosis. Some used pornography as frequently as prob- nosed as PPU.52 We note that much of the data so far on PPU
lematic users but did not report control problems.53-55 Still have come from the United States, Poland, and China, and it
others used pornography rarely but experienced self-perceived is possible that other cultures exist where pornography use is
PPU. In one study, the high-frequency nonproblematic group not considered a problem.
comprised 19% to 29% of the users52 and may represent
those with high sexual desire whose sexual behaviors align
with their needs and do not cause adverse consequences in
their lives.56,57 Indeed, the number of people with nonprob-
Neurochemical and neuroanatomic
lematic high-frequency use was 3 to 6 times higher than that
mechanisms
with problematic high-frequency use, suggesting that frequent To understand the potential neural bases of CSBD and
pornography use, per se, is not necessarily problematic. especially how moral incongruence could lead to more sexual
The fourth group of pornography users were those who arousal associated with the prospect of engaging in sexual
watched pornography rarely yet were highly distressed about activity, it is necessary to understand how sexual behavior

it (approximately 12% of users54 ). This occurred presumably is organized in the nervous system. Different aspects of
due to moral disapproval of pornography use and perhaps sexual behavior are controlled by excitatory and inhibitory
masturbation.58 According to the early propositions of the neurochemical mechanisms in the brain and the spinal cord72
moral incongruence model of pornography use,59,60 PPU may (Figure 1). These form the biological basis of the dual control
appear due to not only control problems or dysregulation model first proposed by Bancroft and Janssen73 and later
but also high levels of religiosity and/or moral incongruence augmented by Perelman,74 who added the idea of a labile
toward pornography use, making the associations between tipping point between the two. These systems place the
self-perceived PPU and religiosity, moral disapproval, and behavior into a flow from appetitive to consummatory to
incongruence complex. Based on findings of nationally repre- satiety, which overlaps with the 4-stage models proposed
sentative and large-scale cross-sectional and longitudinal stud- by Moll75 and Masters and Johnson,76 as refined by
ies, moral incongruence may be best conceptualized as a mod- Kaplan68 and Georgiadis et al.77 Excitatory systems such
erator of the association between pornography use frequency as mesolimbic dopamine and hypothalamic melanocortin
and moral disapproval of pornography use (“ie, feeling as if activate sexual desire and attention toward external sexual
one’s behaviors and one’s values about those behaviors are cues, while hypothalamic dopamine, noradrenaline, and
misaligned”60 ). The associations between pornography use oxytocin help to switch on the parasympathetic control
frequency and self-perceived PPU can be stronger among those of genital blood flow that creates and augments genital
with higher levels of moral disapproval, resulting in feelings arousal.72 As sympathetic tone ramps up during sexual
of PPU despite the relatively low frequency of pornography interaction, a spinal switch releases it to create sexual climax,
use.61 Similarly, according to a recent systematic review,62 which is registered in the brain as orgasm. The ecstatic
although small to moderate direct positive associations can pleasure of orgasm is likely mediated by endogenous opioid
be seen between religiosity and PPU, the interaction between release (eg, β-endorphin), whereas the longer-lasting state
religiosity and pornography use frequency may be a more of satiety and relaxation is likely mediated by serotonin.72
accurate predictor of self-perceived PPU. Studies including The inhibition induced by satiety is consonant with sexual
adults and adolescents also reported that pornography use refractoriness.
frequency was more strongly related to self-perceived PPU Mesolimbic dopamine activation is a common neurochemi-
at higher levels of religiosity.63,64 Thus, religiosity and moral cal mediator of motivation, desire, and wanting/craving for all
disapproval of pornography use may play crucial roles in self- motivational systems.78,79 It does not mediate sexual reward
perceived PPU, as evidenced by findings suggesting that 1 in 4 per se; rather, it underlies the process of sustained attention
treatment-seeking men may not have objectively dysregulated to and movement toward cues that predict sexual reward,
or high-frequency pornography use but still seek help due to especially those related to pleasure and orgasm.80 Mesolimbic
moral incongruence.53,65 dopamine release can be phasic or tonic in response to cues,
In sum, the frequency and amount of pornography use and these release patterns correspond in sexual behavior to
is not, in itself, a reliable indicator of control problems in appetitive and consummatory processes, respectively.81 Thus,
PPU or CSBD. Using it as an exclusive measure of PPU or in this conceptualization, seeking out stimuli associated with
CSBD could easily result in overestimation of people with a goal would be an appetitive response, whereas acting on the
PPU and associated pathologizing of high sexual desire or goal once it is obtained would be a consummatory response.
passion,56,57,66–68 in addition to the erroneous loss of cases Some cues are prepotent, produce arousal, and are innately
with self-perceived PPU who may not use pornography fre- preferred (eg, visual sexual cues depicting primary and sec-
quently.29,53,54 Therefore, a precise assessment (eg, with well- ondary sex characteristics, beautiful faces/bodies, stimulating
validated scales69-71 and/or clinical interviews adapted cul- or comforting auditory cues, music that gives one “chills,”
turally for diverse populations) and differential diagnosis are certain food- or fluid-related cues, preferred pet animals,
needed to determine whether PPU stems from sexual self- smells). Preference for other cues is learned through their
control problems, moral disapproval of pornography use, or pairing with and thus prediction of arousal and pleasurable
both, as all may trigger treatment seeking but not all be gratification. In all cases, mesolimbic dopamine is a medi-
diagnosed as CSBD. Self-identifying as having PPU purely due ator of cue strength, and its transmission in regions of the
to the distress driven by moral disapproval of pornography brain, such as the amygdala and ventral striatum or nucleus
use is not and should never be sufficient to diagnose PPU.28 accumbens, will be augmented in response to cues that predict
these involve the activation of sympathetic outflow in spinal

circuits that generate climax and open blood vessels so that
blood can move from the periphery back to the core, thus
preventing erection for a time. In the brain, orgasms activate
opioid and serotonin transmission. Both inhibit dopamine
release and cell body activation in the short term, but opioids
in particular sensitize dopamine release in the long term to
unconditioned and conditioned cues that predict reward.72
Refractoriness and satiety occur after natural rewards, but
they do not occur—or they occur differently—from drug
reward or electrical brain stimulation reward. Thus, there
is no withdrawal state after sex. The inability to experience
genital arousal in self-perceived pornography-induced erectile
dysfunction, for example, would be predicted to reverse itself
if the individual allows the refractory state to wear off. This

will strengthen the dopamine response to erotic cues as one
will no longer be in a state of chronic refractoriness from
compulsive masturbation. Instead, one will seek out more
stimulating erotic material on the internet or elsewhere, which
can then activate excitatory neural systems under residual
refractoriness. This is often interpreted as evidence of “toler-
ance” in behavioral addiction models.30,31,90 Figure 3 shows
psychological and neurobiological processes that conspire to
excite and disinhibit sexual responses in CSBD.
As with autonomic function, arousal states can habituate if
the appetitive behaviors become routine, leading to less potent
Figure 1. Dual control model shows the neurochemical mechanisms of gratification and a dampening of mesolimbic dopamine
excitation and inhibition derived from Bancroft and Janssen73 and
response over time. This also leads to the perception that
Perelman74 and detailed by Pfaus.72 Drugs or psychological states that
activate those mechanisms can shift an individual into general sexual
“normal” sexual stimuli no longer arouse the person because
excitation or inhibition. In cases of compulsive sexual behavior disorder, the individual is “addicted” to abnormally high arousal states
individuals are in states of excitation and/or disinhibition. to function sexually. An analogy here would be to those
who are risk takers vs those who are risk averse.84,91,92
Dishabituation can occur in response to different erotic
reward (Figure 2). This has been observed in brain imaging stimuli that are perceived to be of higher arousing potential.
and functional magnetic resonance imaging studies of self- If people spend inordinate amounts of time seeking out
identified problematic pornography users or “sex addicts” stimuli of ever-higher arousing potential, to the exclusion
relative to controls.82,83 of other need states or rewards, such behavior can resemble
In addition to prepotent cues, a potent driver of mesolim- an OCD or an “addiction.” All of this is driven in large part
bic dopamine transmission is “reward prediction error,”84 by the focused attention and appetitive responses mediated
in which the real reward intensity or occurrence does not by mesolimbic dopamine in states of high transmission due
conform to the prediction based on past experience. When to reward prediction error (Figures 2 and 3). In this case,
this happens, dopamine transmission is augmented, resulting reward prediction error can be produced by guilt, intermittent
in a focus of attention on other details or responses that reinforcement, and seeking more and more arousing stimuli to
might explain the discrepancy and bring the predicted reward overcome the effects of habituation or chronic refractoriness.
back. With respect to CSBD, guilt and forced abstinence are In contrast, in drug addiction, withdrawal typically results
hypothesized to create a reward prediction error (ie, individ- in a hyperaccentuation of physiologic processes that the drug
uals want something that they “should not have” and try to suppresses. For example, opiates induce a state of analgesia.
avoid). The augmented dopamine response to cues that predict Withdrawal from opiates results in hyperalgesia where sim-
reward under such circumstances (eg, fantasy, pornographic ple touch can be experienced as painful.93 Thus, instead of
imagery) contributes to intrusive thoughts and arousal,85,86 pornography-induced erectile dysfunction, the experience of
and sexual rewards experienced on high arousal can become withdrawal from a chronic inhibitory state induced by mastur-
highly preferred and garner preferential attention.35,87,88 This bation should be hyperexcitation that would mitigate against
can feed back to strengthen the feeling of guilt as a preparatory the apparent need for more and more arousing imagery or
state that predicts highly arousing rewards. Thus, although actions. Indeed, withdrawal (abstinence) from pornography
guilt, as a form of frontal lobe–mediated inhibition that is part use by persons who self-identify as PPUs or are diagnosed
of “executive function,” can lead to short-term decreases in with CSBD induces frequent intrusive sexual thoughts, higher
unwanted behaviors, such decreases might create a schedule sexual arousal, and increased out-of-control sexual desire as
of intermittent reinforcement in the long term that strengthens compared with nonabstinent periods.86
the arousal-reward connection.89 Although there are no a priori data predicting who will and
As mentioned earlier, what prevents sexual behavior and will not display CSBD, some neuroanatomic correlates have
pornography use from being an “addiction” are the natural emerged in brain studies of CSBD cases relative to non-CSBD
inhibitory states activated with orgasm and climax that give cases. This goes back to the original findings of hypersexuality
rise to refractoriness.72∗,77 At the level of the spinal cord, in individuals with frontal lobe damage or Kluver-Bucy

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.78,79 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.
syndrome.94 In addition to hyperresponsiveness of Comorbidities and differential diagnoses

mesolimbic dopamine, there is a general finding that the Another concern regarding the accurate assessment of CSBD
regions in the left hemisphere that mediate excitation are stems from the fact that CSB can manifest secondary to
hyperresponsive, whereas regions in the right hemisphere that other mental health or medical conditions. It is well doc-
mediate inhibition are hyporesponsive. This includes greater umented that CSB commonly co-occurs with anxiety dis-
left amygdala volume in CSBDs and other OCDs95 and orders (46%-96%), mood disorders (39%-81%), attention-
greater activation in the left striatum, inferior parietal lobe, deficit/hyperactivity disorder (18.7%), as well as substance
dorsal anterior cingulate gyrus, thalamus, and dorsolateral use disorders (46%-71%).42,98-101 Clinicians should be able
prefrontal cortex in response to visual sexual stimuli in CSBDs to distinguish CSBD from CSB that stems from comorbid
relative to non-CSBDs.96 Conversely, more pornography conditions, especially when the CSB does not meet the diag-
consumption is correlated with lower right striatum volume nostic criteria for CSBD. A differential diagnosis is important
(gray matter) and increased activation of the right striatum by because it leads to different therapeutic approaches.102
visual sexual stimuli, although lower functional connectivity Impaired control over sexual impulses, urges, or behav-
of the right striatum to the left dorsolateral prefrontal iors may occur in patients during manic, hypomanic, or
cortex is observed.97 However, it is not known whether mixed episodes,103-105 as well as in people with neurocogni-
functional differences in these neuroanatomic correlates tive impairment (ie, brain lesions within frontal lobes and tem-
mediate CSBD or hypersexual responses or whether they porolimbic areas, in some cases of Tourette’s syndrome)106-108
are caused by the experiential mechanisms previously or personality disorders (especially borderline)109-112 or while
described. Most important, finding increased activation of under the influence of alcohol, illicit drugs, or some med-
these sites or mesolimbic dopamine (DA) terminal regions, ications.113-118 Dysregulation of emotion has been found
such as the nucleus accumbens, in response to visual as a predisposing factor to CSB, where sexual arousal and
sexual stimuli or fantasies is not by itself evidence of its release through sexual activity may serve as a learned
CSBD. way of coping with negative mood states.102 In fact, CSB

Figure 3. Psychological and neurobiological mechanisms that underlie the maintenance of excitation and disinhibition in compulsive sexual behavior
disorder. After Briken.102
co-occurs with social anxiety and all types of mood disor- substance use if the diagnostic requirements for both disorders
ders, such as major depression, bipolar disorder, and dys- are met.
thymia.99,105,119-122 These cases need additional evaluation Paraphilic disorders represent another diagnostic entity that
to decide whether CSBD should be diagnosed as a separate partially overlaps with CSBD. One diagnosis does not neces-
condition or whether the pattern of behavior should be more sarily exclude the other, as they may be present as comorbid
appropriately diagnosed as a different mental health disorder conditions in up to 30% of cases.126-128 In CSBD, sexual
or medical condition. Despite use of the term compulsive fantasies, urges, or behaviors occur regardless of the focus of
within the diagnostic category, CSBD is not considered a sexual arousal, while in paraphilic disorder they are related
subtype of OCD. Contrary to CSBD, compulsions in OCD to patterns of atypical sexual arousal. According to the ICD-
commonly occur in response to intrusive, unwanted, anxiety- 11, comorbid CSBD would not be diagnosed if an individual
provoking thoughts and are not considered pleasurable.2 is able to exercise some degree of control over the behav-
Nevertheless, OCD and CSBD may be diagnosed as separate ioral expressions of the arousal pattern.2 In those who are
comorbid conditions123 that influence each other. sexually compulsive, craving for more and more differen-
According to the ICD-11, CSBD diagnosis should not be tiated excitement may lead to searching for deviant, even
assigned if (1) there is no evidence of a persistent failure preference-dystonic, paraphilia-related content and penalized
to control sexual impulses, urges, or behaviors and the behavior.31 However, co-occurrence of paraphilias such as
presence of all other diagnostic requirements outside of pedophilia, sexual sadism, or exhibitionism with CSB may
mood episodes; (2) sexual disinhibition due to neurocognitive pose an increased risk for sexual (re)offending.129,130 For
disorder is attributed to primary disease; and (3) impaired these cases, recognition of CSB features may become especially
control over sexual impulses, urges, or behaviors is due to the relevant for the development of successful treatment strategy
direct effect of psychoactive substances, including recreational and reoffense prevention.
drugs or medications, on the central nervous system,
with the onset corresponding to use of the substance or
medication.2 Clinicians should be aware that the use of drugs
CSBD and the forensic context
such as methamphetamine, gamma-hydroxybutyric acid, Evidence of the dynamic risk factors characterizing sexual
gamma-butyrolactone, and alkyl nitrites (“poppers”) to offenders suggests that CSB predicts sexual offending recidi-
facilitate engagement in sexual activity or to enhance pleasure vism in male criminal samples.131-133 CSB or markers of
from it, described as “chemsex,” may also lead to uncon- CSB (eg, excessive pornography use) also predicted sexual
trolled and risky sexual behavior124 given their common violence in the context of domestic violence and intimate
disinhibitory actions on brain dopamine turnover.125 The partner sexual aggression.134,135 Furthermore, community
patterns of substance use (ie, contexts) and their relationship women reporting sexual aggression against men revealed
with sexual behavior (motivation, sequencing, impact) should increased sexual compulsivity as compared with their nonag-
be carefully investigated. As pointed out in the ICD-11, gressive female counterparts.136 Despite the general desire to
diagnosis of CSBD may be assigned with a disorder due to destigmatize and limit overpathologizing, the predictive role
of CSB in sexual offending gives the CSBD diagnosis poten- With regard to etiology or predisposing factors, sexual
tially detrimental implications in the forensic context.137-139 medicine experts have the ability to ask about possible sexual
Indeed, understanding the dynamics of CSBD symptomatol- or other traumatic experiences,12 which are known to create
ogy is of practical interest to establish the mental state of attachment problems commonly observed in patients with
an offender and hence to make inferences about his or her CSBD140 and other mental disorders (eg, borderline person-
criminal responsibility.139 Within that regard, the concept ality disorder, posttraumatic stress disorder).15 In addition, a
of “control” is a fundamental aspect to determine whether differential diagnosis related to comorbidity with paraphilic
the offender was mentally capable of reasoning about and disorders is important. Thus, the expert must also have basic
taking control over his or her actions. The legal concept knowledge of paraphilias and in taking a sexual forensic his-
of guilt or criminal responsibility involves such a capacity. tory. This careful assessment should lead to a comprehensive
However, we must stress that the legal definitions and impli- diagnosis to develop an integrative biopsychosocial treatment
cations associated with the concept of criminal responsibility plan (Figure 4).15,102
vary substantially across countries and legal systems. Accord- Sexual medicine experts are uniquely equipped to provide
ingly, while some legal systems consider sexual compulsivity this type of comprehensive assessment and treatment
a proxy of diminished ability to control, other systems do planning. They are also uniquely trained to perform a detailed,

not.102,139 Criminal sentences will likely differ between those thorough, nonjudgmental sexual history, unlike many other
systems. medical practitioners. Learning to separate one’s values
Although a discussion of legal systems is beyond the scope and take a nonjudgmental professional stance in evaluating
of this article, it is worth noting that many health profession- a person’s sexual history, current sexual behaviors, and
als, including professionals in the field of sexual medicine, practices is essential.141 Attitudes toward sexuality-related
could have a role as expert witnesses in sexual offender behaviors, such as the use of pornography and casual sex,
cases. In that regard, understanding the core presentation and must be understood within the patient’s sociocultural but
dynamics of CSBD is paramount. The placement of CSBD also legal context. It is crucial to keep the social dimensions
in the impulsivity disorders section of the ICD-11 highlights of sexuality and sexual disorders in mind. For example,
the capacity to control sexual impulses or urges as a central there are likely to be significant transcultural differences
feature of the disorder. While the DSM-5 task force rejected in CSBD and clinical characteristics (eg, attitudes toward
hypersexual disorder, arguing about the potential misuse of PPU).142 In addition, sexual medicine experts have knowledge
the diagnosis, especially in forensic settings,7 the inclusion and expertise regarding a range of sexual behaviors and
of CSBD in the ICD-11 legitimately opens the discussion sexual disorders, as well as an understanding of sociocultural
again and calls for insights on how the lack of control can be influences, including an appreciation of the effects of minority
conceptualized, assessed, and intervened. Evidence of attempts stress.143 They possess the medical background to understand
to resist and reduce CSB may suggest the willingness but links to a variety of medical conditions, medications, and
incapacity to control. Even when CSB is not accepted as a drugs known to affect sexual functioning and behavior. There
proxy of diminished culpability—possibly the most frequent needs to be knowledge about substances that can be used
scenario—it does have a role in the prevention of criminal to initiate sex or that may support sexual compulsivity or
recidivism. Therefore, discussion of the forensic implications about the practice of taking substances in different social
of CSBD extends to the rehabilitation context of individuals contexts to enhance sex (eg, practices of chemsex).15 Finally,
who have sexually offended, including the danger risk assess- there should be knowledge of, and thorough inquiries about,
ment before parole or release. Despite the fact that CSBD and the potential connections between sexual dysfunctions and
sexual offending behavior may co-occur, the former must not CSBD. Questions about partners and taking a history of
be regarded as a criminal entity or as evidence that criminal the couple’s sexuality should be included in the diagnostic
activity was involved. CSBD cases where criminal activity process, as well as an offer of couples counseling if
is suspected must be handled by clinical forensic experts, necessary.15,102
following their national legislation. After diagnosing CSBD and recognizing the potential
comorbid and contributing factors, the crucial step is to
develop a biopsychosocial case formulation considering all
Role of the sexual medicine expert in the complex factors with the broadest possible understanding
diagnosis and treatment of the specific role that sexuality plays in contributing to or
Making a diagnosis of CSBD requires a careful assessment, maintaining the dysfunctional behavior.144 It is important to
which would include a thorough sexual history and exami- also explore the nonsexual reasons for the sexual behavior
nation of current symptomology. It would also involve taking and why that particular sexual behavior was used for those
a somatic and psychiatric history to exclude somatic causes nonsexual reasons. What is the functionality of the sexual
of CSB (eg, neurologic disease or side effects of drugs or symptom, and where does it become dysfunctional? What
medication). In addition, the examining person must be able is repeated in a dysfunctional way, and what goal is the
to perform a psychiatric assessment to make a differential individual trying to achieve? What are typical triggers,
psychiatric diagnosis and identify mental health comorbidi- emotions, and previous thoughts in connection with and
ties. These include mood and anxiety disorders, substance after sexual behaviors? What roles do guilt and shame
use disorders, posttraumatic stress disorder, and personality play, and do they prevent one from talking about sexual
disorders. Diagnosticians should be able to select and evaluate fantasies, thoughts, and behaviors? What role do early sexual
suitable psychometric assessments of CSBD (eg, the CSBD- experiences play (ie, not only of a traumatic nature)? What
19, currently available in almost 30 languages18 ) and other role do religion, spirituality, and attitudes toward sexuality
appropriate psychometric instruments designed to help diag- play? What role do the couple or family system dynamics
nose common mental health comorbidity. play in the maintenance of the symptomatology? How are the

Figure 4. Considerations for diagnostic and case formulation processes.
symptoms involved in partnered or solo sexual behavior? Are Processes of care and treatment
there typical patterns of the dysfunctional sexual behavior recommendations
here—for example, only brief sexual activity with casual
partners; only routine, or “vanilla,” sex in the relationship; From what has been described so far, we have derived some
masturbation to BDSM sex (ie, bondage, discipline [or basic recommendations for the treatment of people with
domination], sadism, and masochism) but no integration of CSBD with special reference to sexual medicine expertise
BDSM practices in the relationship; and sexual dysfunction (Table 1). The dual control model provides an evidence-based
in partnered sex but no sexual dysfunction with masturbation system that can also be easily communicated with patients.
or when using pornography? Again, these are questions that We assume that in CSBD the relationship between excitatory
can be answered only by clinicians who have the training and and inhibitory factors is imbalanced toward excitation due to
experience of sexual medicine experts. sensitized neurochemical processes that strengthen excitation
With the current state of knowledge, we strongly oppose and produce disinhibition15 (Figure 3). The goal of treatment
therapeutic interventions that increase the experience of is for the patient to achieve a satisfactory balance that sup-
discrimination, stigma, and moral incongruence. This includes ports the control of sexual fantasies and compulsive behaviors
approaches that pathologize sexual behavior of sexually to reduce the risk of self-harm or harm to others and to reduce
diverse individuals, prohibit unilaterally certain sexual distress associated with CSBD.15 The goal is not to renounce
behaviors (eg, viewing pornography, masturbation), apply sexuality. However, omitting certain sexual behaviors, such
an addiction model with notions of abstinence from sexual as problematic use of online pornography to the exclusion of
behavior, or seek to impose the professional’s moral or other sexual behaviors, can be an intermediate goal of treat-
religious values on patients under the guise of evidence-based ment. Treatment for CSBD focuses on the functions (including
treatment. nonsexual functions) that sexual behaviors serve in a person’s
Once all of this is clarified, the clinician can develop a life via a sex-positive approach.147
theory-based formulation based on integrated models of This approach is based on a biopsychosocial understanding
CSBD treatment (Figure 4).15,102 While there is a commonal- of sexuality and sexual disorders, and biopsychosocial factors
ity among these integrative models, they emphasize different should be considered in the individual treatment plan. As
theoretical perspectives and models of sexual and mental already mentioned, knowledge about sexuality, sexual rights
health disorders. A primary perspective is a sexological/sexual and norms, attitudes, behaviors, motives, and motivation is
medicine and sex-positive perspective. Again, to varying crucial for the biopsychosocial understanding of CSBD. CSBD
degrees, they recognize the influence of the dual control73,145 is recognized as an impulse control disorder that manifests
and tipping point models74,146 but incorporate other itself sexually. It deeply affects sexual well-being and the
theories (eg, family systems and social learning, cognitive ability to form and maintain satisfactory emotional and sexual
and behavioral, attachment and interpersonal15,102 ) and relationships; therefore, it should be treated with a trans-
address the importance of sociocultural influences (eg, theoretical and multimodal approach to provide more holis-
moral incongruence,14,59,60 erotic conflicts, and minority tic and individualized therapeutic care.15,102,147,148-150 This
stress143 ). needs specific training since it is not automatically taught in
Table 1. Recommendations regarding intervention trajectories in CSBD: expert opinion.
Area to be approached Recommendations

Assessment of comorbidities • Assess the co-occurrence of other mental health and medical conditions, including medications and
substance use (alcohol, drugs, other)
• Prioritize critical conditions or symptomatology (eg, manic episodes, substance abuse)
Risk assessment • Assess if there is a specific risk posed to partners (eg, sexually aggressive behavior, encounters with
nonconsenting individuals, maltreatment) or a sexually transmitted infection risk to the patient/sexual
partners, a specific risk of self-harm (eg, suicidal ideation, injuries due to intensive masturbation, or patterns
associated with partnered or autoerotic behavior such as smothering)
CSBD and detected criminal • Assign criminal cases to experts with a background in forensic sexology (dependent on countries’ legislation)
sexual activity
CSBD case formulation a • Consider the function of the sexual symptom (eg, does it play a role in individual or couple homeostasis?).
Special attention to emotional regulation difficulties and relationship dynamics is needed
• Consider the context where the symptoms become dysfunctional and what are the consequences of sexually
compulsive behavior

• Identify the symptom’s triggers (emotional, cognitive, or behavioral triggers)
• Identify maintenance factors (eg, lifestyle and routines, rewarding contexts, relationship context)
• Consider how the symptoms evolve in solo and/or partner sex or extramarital sex
• Consider the role of cultural specificities, religion or spirituality, and sexual attitudes
Impact of the intervention • Identify personal and social barriers to improvement or treatment adherence (eg, guilt, shame, social stigma,
partner’s pressure, lack of motivation)
• Identify and incorporate treatment opportunities (eg, social support, partner’s awareness)
• Identify the need for medication
Need of referrals • In the context of critical pathology/psychopathology, a history of sexual abuse (child or otherwise), or
aversive relationship dynamics, consider the referral to other specialties (eg, trauma intervention, couples
therapy) as a first-line intervention
Abbreviation: CSBD, compulsive sexual behavior disorder. a Need of expertise in sexual medicine/clinical sexology.
medical or psychological education (eg, training in psychiatry, • Awareness of thoughts, emotions, and beliefs
psychotherapy, clinical psychology). • Training on self-regulation and urge management
Different psychotherapeutic modalities and techniques can • Skill training: development of problem-solving skills, con-
be used, depending on the patient, resources, possibilities, flict management, time management, and coping strategies
and abilities. Individual therapy, group therapy, and couples • Mindfulness and meditation exercises
therapy are possible modalities. Medical treatment is often • Relapse prevention and maintenance program
utilized. Acceptance and commitment therapy has also been used.151
These treatment choices depend on the following15 : Many of these techniques are especially useful for the initial
treatment phase. However, it is remarkable how treatment
• Motivation and compliance programs to date have paid little attention to the specificity
• Severity of CSBD symptoms with a special focus on failure of the sexual symptom itself,144 the significance of moral
to control sexual impulses and urges incongruence, erotic conflicts, and previous traumatic expe-
• Type of CSBD (autoerotic or partnered) and relationship riences and have neglected to address attachment, intimacy,
status and authenticity.
• Previous medical, psychiatric, sexual, and criminal history A group of experts from the World Federation of Societies
• Comorbid somatic disorders (eg, sexually transmitted of Biological Psychiatry recently proposed an algorithm15 for
infection) and psychiatric disorders (especially the the pharmacologic treatment of CSBD (based on Briken and
association of CSBD with paraphilic disorders or chemsex Turner152 and Thibaut et al153 ). The procedure—and thus the
practices) degree of intervention—depends on the severity of the CSBD
In terms of timing, it makes sense to distinguish an symptoms. Specifically, it focuses on evidence for the use of
initial phase targeting stabilization, motivation, and self- pharmacologic treatment, and it describes 3 levels of CSBD
management15,147,148,149 from later, medium-, and longer- (mild, moderate, severe) that guide the proposals for treat-
term treatment phases that focus on the understanding of ment. Roughly described, psychotherapy alone is used at the
the aforementioned functions of sexual behavior, intimacy level 1 treatment and as a basis of all treatment going forward.
concerns, and relationship issues. At level 2, either selective serotonin reuptake inhibitors (eg,
In a recent systematic review, Antons et al151 identified escitalopram) or the opioid receptor antagonist naltrexone is
24 studies with interventions for CSBD, including 4 ran- considered. At level 3, the combination of these 2 drugs is
domized controlled studies. In the reviewed studies, the most recommended. These medications have shown some efficacy
widely used cognitive behavior therapy components were as in the treatment of CSBD but are prescribed “off-label.” For
follows: the simultaneous presence of CSBD with paraphilic disorders,
there is a separate, longer established algorithm153 that is
• Psychoeducation predominantly oriented toward the risk for other persons
• Stimulation of motivation and motivation for change (eg, and includes testosterone-lowering medications (eg, cypro-
motivational interviewing) terone acetate) or gonadotropin-releasing hormone agonists
• Identification of goals (eg, triptorelin). While these algorithms exist, more evidence
is needed on pharmacologic interventions in CSBD. Until now, Conflicts of interest

only 1 randomized controlled trial for paroxetine, naltrexone, J.G.P. is a consultant for FirmTech, Kanna Health, Ovoca Bio/IVIX,
and placebo154 ; 1 prospective open open-label trial with nal- Reunion Neuroscience, SmartBod/Lioness, and Vella Bioscience and
trexone155 ; and some retrospective analyses and case studies15 serves as editor in chief of Current Sexual Health Reports. E.C. serves
have been published. on the Sexual Health Advisory Committee for Ro, Inc. A.G. has
received honoraria for lectures or participation in advisory boards
or being a consultant for Viatris, Eli Lilly, Pfizer, Sandoz, Futura
Medical/Exeron, Astellas, Novo Nordic, Freya, and Lundbeck. S.W.K.
Conclusion is a board member for the Nevada Advisory Committee on Problem
With this article, we have attempted to clarify the role of sex- Gambling and the Society for the Advancement of Sexual Health and
ual medicine experts in the diagnosis and treatment of CSBD. serves as editor in chief of Sexual Health & Compulsivity. M.L.-S.
has received honoraria as a consultant for AbbVie, Angelini, Apotex,
We are convinced that the expertise from sexual medicine
Bayer, Berlin Chemie, Biogen, Bristol Myers Squibb, Eli Lilly, European
is essential in adequately assessing and treating those with House Ambrosetti, European Foundation of Art Therapy, Lundbeck,
CSBD. At the same time, we express our concern about Novo Nordisk, OCInfo, Pfizer, Polpharma, Servier, Stada, and Verco.
treatment approaches that reinforce sex-negative moralizing

P.B. was a consultant to the World Health Organization regarding the
attitudes about sexuality and are not informed from sexol- development of the ICD-11 classification of sexual disorders and sexual
ogy and sexual medicine training. Without this training and health.
expertise supported by multicultural perspectives, we see a
risk of overdiagnosing conditions that do not actually meet
the criteria for CSBD, thus increasing moral incongruence and
distress. In addition, we strongly recommend that patients References
with CSBD receive integrated, comprehensive, biopsychoso- 1. Fuss J, Lemay K, Stein DJ, et al. Public stakeholders’ com-
cial, and sexologically informed treatment that goes beyond ments on ICD-11 chapters related to mental and sexual health.
control over sexual behavior and reduction of sexually dys- World Psychiatry. 2019;18(2):233–235. https://doi.org/10.1002/
functional behavior but assists patients to achieve sexually wps.20635.
healthy and satisfied lives. To accomplish this, the expertise 2. World Health Organization. International Classification of Dis-
of sexual medicine specialists is indispensable. eases, Eleventh Revision. WHO Press; 2019/2021.
3. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders. 5th ed. American Psychiatric Pub-
lishing; 2013.
Acknowledgments 4. von Krafft-Ebing R. Psychopathia Sexualis. Rebman FJ, trans.
J.G.P. is chair of the ISSM Subcommittee on Compulsive Sexual Behav- Physicians and Surgeons Book Company; 1886/1929.
ior Disorder and Hypersexuality. 5. Kafka MP. Hypersexual disorder: a proposed diagnosis for
The views expressed in this article are those of the authors and do DSM-V. Arch Sex Behav. 2010;39(2):377–400. https://doi.o
not represent the official policies or positions of the World Health rg/10.1007/s10508-009-9574-7.
Organization. 6. Reid RC, Carpenter BN, Hook JN, Garos S, Manning JC.
Report of findings in a DSM-5 field trial for hypersexual disor-
der. J Sex Med. 2012;9(11):2868–2877. https://doi.org/10.1111/
j.1743-6109.2012.02936.x.
Author contributions
7. Kafka MP. What happened to hypersexual disorder? Arch
Conception and design: P.B., J.C., M.L.-S., J.G.P. Acquisition of data: Sex Behav. 2014;43(7):1259–1261. https://doi.org/10.1007/
P.B., B.B., J.C., E.C., A.G., S.W.K., M.L.-S., J.G.P. Analysis and inter- s10508-014-0326-y.
pretation of data: P.B., B.B., J.C., E.C., A.G., S.W.K., M.L.-S., J.G.P. 8. Halpern AL. The proposed diagnosis of hypersexual dis-
Drafting the manuscript: P.B., B.B., J.C., E.C., A.G., S.W.K., M.L.-S., order for inclusion in DSM-5: unnecessary and harmful.
J.G.P. Revising it for intellectual content: P.B., B.B., J.C., E.C., A.G., Arch Sex Behav. 2011;40(3):487–488. https://doi.org/10.1007/
S.W.K., M.L.-S., J.G.P. Final approval of the completed manuscript: P.B., s10508-011-9727-3.
B.B., J.C., E.C., A.G., S.W.K., M.L.-S., J.G.P. 9. Moser C. Hypersexual disorder: just more muddled thinking.
Arch Sex Behav. 2011;40(2):227–229. https://doi.org/10.1007/
s10508-010-9690-4.
10. Bőthe B, Vaillancourt-Morel MP, Bergeron S. Hypersexuality
Funding in mixed-sex couples: a dyadic longitudinal study. Arch
Research from J.G.P.’s laboratory was supported in part by the Cana- Sex Behav. 2021;50(5):2139–2150. https://doi.org/10.1007/
dian Institutes of Health Research (project grant 162264) and by s10508-021-01959-0.
the Grantová agentura České republiky (GA23-06662S). M.L.-S. was 11. Grubbs JB, Floyd CG, Kraus SW. Pornography use and public
supported by the Centre of Postgraduate Medical Education statutory health: examining the importance of online sexual behavior in
research funding (project 501-1-065-38-22) and receives funding for the health sciences. Am J Pub Health. 2023;113(1):22–26. https://
noncommercial research on pharmacologic interventions in compulsive doi.org/10.2105/AJPH.2022.307146.
sexual behavior disorder from the Polish Medical Research Agency 12. Slavin MN, Scoglio AA, Blycker GR, Potenza MN, Kraus SW.
(grant 2022/ABM/03/00039). B.B. was supported by a postdoctoral Child sexual abuse and compulsive sexual behavior: a systematic
fellowship from the SCOUP Team–Sexuality and Couples–Fonds de literature review. Curr Addict Rep. 2020;7(1):76–88. https://doi.o
recherche du Québec, Société et Culture, and by the Banting Postdoc- rg/10.1007/s40429-020-00298-9.
toral Fellowship from the Social Sciences and Humanities Research 13. Slavin MN, Blycker GR, Potenza MN, Bőthe B, Demetrovics Z,
Council of Canada. S.W.K. has been supported by grants from the Inter- Kraus SW. Gender-related differences in associations between
national Center for Responsible Gaming, MGM Resorts International, sexual abuse and hypersexuality. J Sex Med. 2020;17(10):2029–
Center for the Application of Substance Abuse Technologies (University 2038. https://doi.org/10.1016/j.jsxm.2020.07.008.
of Nevada, Reno), Massachusetts General Hospital, and Kindbridge 14. Coleman E, Jennings T, Gleason N, et al. The relationship
Research Institute (GR15685). between compulsive sexual behavior, religiosity, and moral
disapproval. J Sex Marital Ther. 2023;49(3):314–330. https:// 32. Coleman E. Evolution of the field of impulsive/compulsive sexual
doi.org/10.1080/0092623X.2022.2117746. behavior and sexual addiction: a lost opportunity for dialogue. In:
15. Turner D, Briken P, Grubbs J, et al. The World Federation of Schneider JP, Kaplan D, Lasser M eds. Reflections on the History
Societies of Biological Psychiatry guidelines on the assessment of the Sex Addiction Field. CreateSpace Independent Publishing
and pharmacological treatment of compulsive sexual behaviour Platform; 2017: 23–43.
disorder. Dialogues Clin Neurosci. 2022;24(1):10–69. https:// 33. Goldstein I, Komisaruk BR, Pukall CF, et al. International
doi.org/10.1080/19585969.2022.2134739. Society for the Study of Women’s Sexual Health (ISSWSH)
16. Gleason N, Smith G, Canning JR, et al. The relationship between review of epidemiology and pathophysiology, and a consen-
alcohol and drug use, compulsive sexual behavior, and con- sus nomenclature and process of care for the management
domless anal sex in men who have sex with men: analysis of persistent genital arousal disorder/genito-pelvic dysesthesia
of retrospectively-reported sexual behavior. AIDS Behav. 2023; (PGAD/GPD). J Sex Med. 2021;18(4):665–697. https://doi.o
27(7):2317–2327. https://doi.org/10.1007/s10461-022-03961-6. rg/10.1016/j.jsxm.2021.01.172.
17. Dickenson JA, Gleason N, Coleman E, Miner MH. Preva- 34. Grubbs JB, Tahk R, Fernandez DP, Fernandez EF, Ley D.
lence of distress associated with difficulty controlling sexual Pornography and pride: antagonism drives links between nar-
urges, feelings, and behaviors in the United States. JAMA cissism and perceived addiction to pornography. J Res Pers.
Netw Open. 2018;1(7):e184468. https://doi.org/10.1001/jamane 2023;107:104419. https://doi.org/10.1016/j.jrp.2023.104419.

tworkopen.2018.4468. 35. Lew-Starowicz M, Gola M. Compulsive- and other out-of-control
18. Bőthe B, Koós M, Nagy L, et al. Compulsive sexual behav- sexual behaviors. In: Lew-Starowicz M, Giraldi A, Krüger THC
ior disorder in 42 countries: insights from the Interna- eds. Psychiatry and Sexual Medicine: A Comprehensive Guide for
tional Sex Survey and introduction of standardized assess- Clinical Practitioners. Springer; 2020: 457–469.
ment tools. J Behav Addict. 2023;12(2):393–407. https://doi.o 36. Lew-Starowicz M, Lewczuk K, Nowakowska I, Kraus S, Gola
rg/10.1556/2006.2023.00028. M. Compulsive sexual behavior and dysregulation of emo-
19. Briken P, Wiessner C, Štulhofer A, et al. Who feels affected by tion. Sex Med Rev. 2020;8(2):191–205. https://doi.org/10.1016/
“out of control” sexual behavior? Prevalence and correlates of j.sxmr.2019.10.003.
indicators for ICD-11 compulsive sexual behavior disorder in the 37. Miner MH, Dickenson J, Coleman E. Effects of emotions
German Health and Sexuality Survey (GeSiD). J Behav Addict. on sexual behavior in men with and without hypersexual-
2022;11(3):900–911. https://doi.org/10.1556/2006.2022.00060. ity. Sex Addict Compulsivity. 2019;26(1-2):24–41. https://doi.o
20. Reed GM, Drescher J, Krueger RB, et al. Disorders related to rg/10.1080/10720162.2018.1564408.
sexuality and gender identity in the ICD-11: revising the ICD- 38. Kowalewska E, Gola M, Kraus SW, Lew-Starowicz M. Spotlight
10 classification based on current scientific evidence, best clinical on compulsive sexual behavior disorder: a systematic review of
practices, and human rights considerations. World Psychiatry. research on women. Neuropsychiatr Dis Treat. 2020;16:2025–
2016;15(3):205–221. https://doi.org/10.1002/wps.20354. 2043. https://doi.org/10.2147/NDT.S221540.
21. Prause N. Dhāt syndrome emerges in the United States from 39. Kürbitz LI, Briken P. Is compulsive sexual behavior different in
anti-masturbation semen retention/NoFap groups. Int J Impot women compared to men? J Clin Med. 2021;10(15):3205. https://
Res. Published online July 8, 2023. https://doi.org/10.1038/ doi.org/10.3390/jcm10153205.
s41443-023-00732-2. 40. Ferree MC. Females and sex addiction: myths and diagnostic
22. Landripet I, Štulhofer A. Is pornography use associated with implications. Sex Addict Compulsivity. 2001;8(3-4):287–300.
sexual difficulties and dysfunctions among younger hetero- https://doi.org/10.1080/107201601753459973.
sexual men? J Sex Med. 2015;12(5):1136–1139. https://doi.o 41. Kowalewska E, Kraus SW, Lew-Starowicz M, Gustavsson K,
rg/10.1111/jsm.12853. Gola M. Which dimensions of human sexuality are related to
23. Ley DJ. The Myth of Sex Addiction. Rowman & Littlefield; 2012. compulsive sexual behavior disorder (CSBD)? Study using a mul-
24. Park BY, Wilson G, Berger J, et al. Is internet pornography causing tidimensional sexuality questionnaire on a sample of Polish males.
sexual dysfunctions? A review with clinical reports. Behav Sci J Sex Med. 2019;16(8):1264–1273. https://doi.org/10.1016/j.
(Basel). 2016;6(3):17. https://doi.org/10.3390/bs6030017. jsxm.2019.05.006.
25. Grubbs JB, Hoagland C, Lee B, et al. Sexual addiction 25 42. Kuzma JM, Black DW. Epidemiology, prevalence, and natural
years on: a systematic and methodological review of empirical history of compulsive sexual behavior. Psychiatr Clin N Am.
literature and an agenda for future research. Clin Psychol Rev. 2008;31(4):603–611. https://doi.org/10.1016/j.psc.2008.06.005.
2020;82:101925. https://doi.org/10.1016/j.cpr.2020.101925. 43. Sussman S. Love addiction: definition, etiology, treatment.
26. Kraus SW, Krueger RB, Briken P, et al. Compulsive sex- Sex Addict Compulsivity. 2010;17(1):31–45. https://doi.o
ual behaviour disorder in the ICD-11. World Psychiatry. rg/10.1080/10720161003604095.
2018;17(1):109–110. https://doi.org/10.1002/wps.20499. 44. Wordecha M, Wilk M, Kowalewska E, et al. “Pornographic
27. Billieux J, Schimmenti A, Khazaal Y, Maurage P, Heeren A. binges” as a key characteristic of males seeking treatment for
Are we overpathologizing everyday life? A tenable blueprint for compulsive sexual behaviors: qualitative and quantitative 10-
behavioral addiction research. J Behav Addict. 2015;4(3):119– week-long diary assessment. J Behav Addict. 2018;7(2):433–444.
123. https://doi.org/10.1556/2006.4.2015.009. https://doi.org/10.1556/2006.7.2018.33.
28. Gola M, Lewczuk K, Potenza MN, et al. What should 45. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG.
be included in the criteria for compulsive sexual behavior AUDIT: The Alcohol Use Disorders Identification Test: Guide-
disorder. J Behav Addict. 2020;11(2):160–165. https://doi.o lines for Use in Primary Care. 2nd ed. World Health Organiza-
rg/10.1556/2006.2020.00090. tion; 2001.
29. Kraus SW, Sweeney PI. Hitting the target: considerations for dif- 46. Di Castelnuovo A, Costanzo S, Bagnardi V, et al. Alco-
ferential diagnosis when treating individuals for problematic use hol dosing and total mortality in men and women. Arch
of pornography. Arch Sex Behav. 2019;48(2):431–435. https:// Int Med. 2006;166(22):2437–2445. https://doi.org/10.1001/a
doi.org/10.1007/s10508-018-1301-9. rchinte.166.22.2437.
30. Toates F. A motivation model of sex addiction—relevance 47. Doll R, Peto R, Boreham J, Sutherland I. Mortality in
to the controversy over the concept. Neurosci Biobehav relation to smoking: 50 years’ observations on male British
Rev. 2022;142:104872. https://doi.org/10.1016/j.neubiore doctors. BMJ. 2004;328(7455):1519–1528. https://doi.o
v.2022.104872. rg/10.1136/bmj.38142.554479.AE.
31. Carnes P. Out of the Shadows: Understanding Sexual Addiction. 48. Reid RC. How should severity be determined for the DSM-
3rd ed. Hazeldon; 2001. 5 proposed classification of hypersexual disorder? J Behav
Addict. 2015;4(4):221–225. https://doi.org/10.1556/2006.4. adolescents: latent profile and network analysis. J Behav Addict.
2015.041. 2022;11(3):912–927. https://doi.org/10.1556/2006.2022.00065.
49. Chen L, Jiang X, Wang Q, Bőthe B, Potenza M, Wu H. The 66. Leonhardt ND, Busby DM, Willoughby BJ. Do you feel in con-
association between the quantity and severity of pornography trol? Sexual desire, sexual passion expression, and associations
use: a meta-analysis. J Sex Res. 2022;59(6):704–719. https://doi.o with perceived compulsivity to pornography and pornography
rg/10.1080/00224499.2021.1988500. use frequency. Sex Res Social Pol. 2020;18(2):377–389. https://
50. Bőthe B, Lonza A, Štulhofer A, Demetrovics Z. Symptoms of doi.org/10.1007/s13178-020-00465-7.
problematic pornography use in a sample of treatment consid- 67. Rosenberg H, Kraus SW. The relationship of “passion-
ering and treatment non-considering men: a network approach. ate attachment” for pornography with sexual compulsiv-
J Sex Med. 2020;17(10):2016–2028. https://doi.org/10.1016/j. ity, frequency of use, and craving for pornography. Addict
jsxm.2020.05.030. Behav. 2014;39(5):1012–1017. https://doi.org/10.1016/j.addbe
51. Werner M, Štulhofer A, Waldorp L, Jurin T. A network h.2014.02.010.
approach to hypersexuality: insights and clinical implica- 68. Kaplan HS. The Sexual Desire Disorders. Brunner-Routledge;
tions. J Sex Med. 2018;15(3):373–386. https://doi.org/10.1016/ 1995.
j.jsxm.2018.01.009. 69. Bőthe B, Potenza MN, Griffiths MD, et al. The devel-
52. Bőthe B, Tóth-Király I, Potenza MN, Orosz G, Demetrovics Z. opment of the Compulsive Sexual Behavior Disorder Scale

High-frequency pornography use may not always be problem- (CSBD-19): an ICD-11 based screening measure across three
atic. J Sex Med. 2020;17(4):793–811. https://doi.org/10.1016/j. languages. J Behav Addict. 2020;9(2):247–258. https://doi.o
jsxm.2020.01.007. rg/10.1556/2006.2020.00034.
53. Chen L, Jiang X, Luo X, Kraus SW, Bőthe B. The role of impaired 70. Bőthe B, Tóth-Király I, Zsila Á, Griffiths MD, Demetrovics Z,
control in screening problematic pornography use: evidence from Orosz G. The development of the Problematic Pornography Con-
cross-sectional and longitudinal studies in a large help-seeking sumption Scale (PPCS). J Sex Res. 2018;55(3):395–406. https://
male sample. Psychol Addict Behav. 2022;36(5):537–546. https:// doi.org/10.1080/00224499.2017.1291798.
doi.org/10.1037/adb0000714. 71. Kraus SW, Gola M, Grubbs JB, et al. Validation of a brief
54. Vaillancourt-Morel M-P, Blais-Lecours S, Labadie C, Bergeron S, pornography screen across multiple samples. J Behav Addict.
Sabourin S, Godbout N. Profiles of cyberpornography use and 2020;9(2):259–271. https://doi.org/10.1556/2006.2020.00038.
sexual well-being in adults. J Sex Med. 2017;14(1):78–85. https:// 72. Pfaus JG. Pathways of sexual desire. J Sex Med. 2009;6(6):1506–
doi.org/10.1016/j.jsxm.2016.10.016. 1533. https://doi.org/10.1111/j.1743-6109.2009.01309.x.
55. Prause N, Pfaus JG. Viewing sexual stimuli associated with 73. Bancroft J, Janssen E. The dual control model of male sexual
greater sexual responsiveness, not erectile dysfunction. Sex Med. response: a theoretical approach to centrally mediated erec-
2015;3(2):90–98. https://doi.org/10.1002/sm2.58. tile dysfunction. Neurosci Biobehav Rev. 2000;24(5):571–579.
56. Štulhofer A, Bergeron S, Jurin T. Is high sexual desire a https://doi.org/10.1016/S0149-7634(00)00024-5.
risk for women’s relationship and sexual well-being? J Sex 74. Perelman MA. The sexual tipping point: a mind/body model
Res. 2016;53(7):882–891. https://doi.org/10.1080/00224499. for sexual medicine. Sex Med. 2009;6(3):629–632. https://doi.o
2015.1084984. rg/10.1111/j.1743-6109.2008.01177.x.
57. Štulhofer A, Jurin T, Briken P. Is high sexual desire a facet of 75. Moll A. The Sexual Life of the Child. Macmillan; 1908.
male hypersexuality? Results from an online study. J Sex Mari- 76. Masters WH, Johnson V. Human Sexual Response. Little Brown;
tal Ther. 2016;42(8):665–680. https://doi.org/10.1080/0092623 1966.
X.2015.1113585. 77. Georgiadis JR, Kringelbach ML, Pfaus JG. Sex for fun: a
58. Prause N. Porn is for masturbation. Arch Sex Behav. synthesis of human and animal neurobiology. Nat Rev Urol.
2019;48(8):2271–2277. https://doi.org/10.1007/s10508-019- 2012;9(9):486–498. https://doi.org/10.1038/nrurol.2012.151.
1397-6. 78. Berridge KC, Robinson TE. What is the role of dopamine in
59. Grubbs JB, Perry SL, Wilt JA, Reid RC. Pornography problems reward: hedonic impact, reward learning, or incentive salience?
due to moral incongruence: an integrative model with a system- Brain Res Brain Res Rev. 1998;28(3):309–369. https://doi.o
atic review and meta-analysis. Arch Sex Behav. 2019;48(2):397– rg/10.1016/S0165-0173(98)00019-8.
415. https://doi.org/10.1007/s10508-018-1248-x. 79. Koob GF. Hedonic valence, dopamine and motivation. Mol Psy-
60. Grubbs JB, Perry SL. Moral incongruence and pornography use: chiatry. 1996;1(3):186–189.
a critical review and integration. J Sex Res. 2019;56(1):29–37. 80. Pfaus JG, Kippin TE, Coria-Avila GA, et al. Who, what, where,
https://doi.org/10.1080/00224499.2018.1427204. when (and maybe even why)? How the experience of sexual
61. Grubbs JB, Kraus SW, Perry SL, Lewczuk K, Gola M. Moral reward connects sexual desire, preference, and performance.
incongruence and compulsive sexual behavior: results from Arch Sex Behav. 2012;41(1):31–62. https://doi.org/10.1007/
cross-sectional interactions and parallel growth curve anal- s10508-012-9935-5.
yses. J Abnorm Psychol. 2020;129(3):266–278. https://doi.o 81. Blackburn JR, Pfaus JG, Phillips AG. Dopamine functions
rg/10.1037/abn0000501. in appetitive and defensive behaviours. Prog Neurobiol.
62. Jennings TL, Lyng T, Gleason N, Finotelli I, Coleman E. Com- 1992;39(3):247–279. https://doi.org/10.1016/0301-0082(92
pulsive sexual behavior, religiosity, and spirituality: a system- )90018-A.
atic review. J Behav Addict. 2021;10(4):854–878. https://doi.o 82. Golec K, Draps M, Stark R, Pluta A, Gola M. Aberrant
rg/10.1556/2006.2021.00084. orbitofrontal cortex reactivity to erotic cues in compulsive sexual
63. Grubbs JB, Lee BN, Hoagland KC, Kraus SW, Perry SL. behavior disorder. J Behav Addict. 2021;10(3):646–656. https://
Addiction or transgression? Moral incongruence and self- doi.org/10.1556/2006.2021.00051.
reported problematic pornography use in a nationally represen- 83. Voon V, Mole TB, Banca P, et al. Neural correlates of sex-
tative sample. Clin Psychol Sci. 2020;8(5):936–946. https://doi.o ual cue reactivity in individuals with and without compulsive
rg/10.1177/2167702620922966. sexual behaviours. PLoS One. 2014;9(7):e102419. https://doi.o
64. Rousseau A, Bőthe B, Štulhofer A. Theoretical antecedents of rg/10.1371/journal.pone.0102419.
male adolescents’ problematic pornography use: a longitudinal 84. Schultz W. Multiple functions of dopamine neurons. F1000 Biol
assessment. J Sex Res. 2021;58(3):331–341. https://doi.o Rep. 2010;2:2. https://doi.org/10.3410/B2-2.
rg/10.1080/00224499.2020.1815637. 85. Lewczuk K, Wizła M, Glica A, Potenza MN, Lew-Starowicz
65. Jiang X, Wu Y, Zhang K, Bőthe B, Hong Y, Chen L. Symp- M, Kraus SW. Withdrawal and tolerance as related to com-
toms of problematic pornography use among help-seeking male pulsive sexual behavior disorder and problematic pornography
use—preregistered study based on a nationally representative 104. Kopeykina I, Kim H-J, Khatun T, et al. Hypersexuality and couple
sample in Poland. J Behav Addict. 2022;11(4):979–993. https:// relationships in bipolar disorder: a review. J Affective Disord.
doi.org/10.1556/2006.2022.00076. 2016;195:1–14. https://doi.org/10.1016/j.jad.2016.01.035.
86. Zimmer F, Imhoff R. Abstinence from masturbation and hyper- 105. Kowatch RA, Youngstrom EA, Danielyan A, Findling RL.
sexuality. Arch Sex Behav. 2020;49(4):1333–1343. https://doi.o Review and meta-analysis of the phenomenology and clin-
rg/10.1007/s10508-019-01623-8. ical characteristics of mania in children and adolescents.
87. Ismail N, Gelez H, Lachapelle I, Pfaus JG. Pacing conditions Bipolar Disord. 2005;7(6):483–496. https://doi.org/10.1111/
contribute to the conditioned ejaculatory preference j.1399-5618.2005.00261.x.
for a familiar female in the male rat. Physiol Behav. 106. Baird AD, Wilson SJ, Bladin PF, Saling MM, Reutens DC. Neu-
2009;96(2):201–208. https://doi.org/10.1016/j.physbeh.2008. rological control of human sexual behavior: insights from lesion
09.013. studies. J Neurol Neurosurg Psychiatry. 2007;78(10):1042–1049.
88. Kilimnik CD, Meston CM. Sexual shame in the sexual excitation https://doi.org/10.1136/jnnp.2006.107193.
and inhibition propensities of men with and without nonconsen- 107. Freeman RD, Tourette Syndrome International Database Con-
sual sexual experiences. J Sex Res. 2021;58(2):261–272. https:// sortium. Tic disorders and ADHD: answers from a world-
doi.org/10.1080/00224499.2020.1718585. wide clinical dataset on Tourette syndrome. Eur Child Ados-
89. Ferster CB, Skinner BF. Schedules of Reinforcement. Appleton- esc Psychiatry. 2007;16(suppl 1):15–23. https://doi.org/10.1007/

Century-Crofts; 1957. s00787-007-1003-7.
90. Blinka L, Ševčíková A, Dreier M, Škařupová K, Wölfling 108. Mendez MF, Shapira JS. Hypersexual behavior in frontotemporal
K. Online sex addiction: a qualitative analysis of symptoms dementia: a comparison with early-onset Alzheimer’s disease.
in treatment-seeking men. Front Psychiatry. 2022;13:907549. Arch Sex Behav. 2013;42(3):501–509. https://doi.org/10.1007/
https://doi.org/10.3389/fpsyt.2022.907549. s10508-012-0042-4.
91. Kahneman D, Tversky A. Prospect theory: an analysis of deci- 109. Schulte-Herbruggen O, Ahlers CJ, Kronsbein JM, et al.
sion under risk. Econometrica. 1979;47(2):263–292. https://doi.o Impaired sexual function in patients with borderline per-
rg/10.2307/1914185. sonality disorder is determined by history of sexual abuse.
92. Mukherjee K. A dual system model of preferences under J Sex Med. 2009;6(12):3356–3363. https://doi.org/10.1111/
risk. Psychol Rev. 2010;117(1):243–255. https://doi.o j.1743-6109.2009.01422.x.
rg/10.1037/a0017884. 110. Hull JW, Clarkin JF, Yeomans F. Borderline personality
93. Leng C, Chen L, Gong X, et al. Upregulation of P2X2 disorder and impulsive sexual behavior. Hospital Community
and P2X3 receptors in rats with hyperalgesia induced by Psychiatry. 1993;44(10):1000–1002. https://doi.org/10.1176/
heroin withdrawal. Neuroreport. 2018;29(8):678–684. https:// ps.44.10.1000.
doi.org/10.1097/WNR.0000000000001018. 111. Jardin C, Sharp C, Garey L, et al. Compelled to risk: does
94. Klüver H, Bucy P. Preliminary analysis of functions of the sexual compulsivity explain the connection between borderline
temporal lobes in monkeys. Arch Neurol Psychiatr. 1939; personality disorder features and number of sexual partners? J
42(6):979–1000. https://doi.org/10.1001/archneurpsyc.1939. Personal Disord. 2017;31(6):738–752. https://doi.org/10.1521/
02270240017001. pedi_2017_31_277.
95. Schmidt C, Morris LS, Kvamme TL, Hall P, Birchard T, Voon V. 112. Elmquist J, Shorey RC, Anderson S, Stuart GL. Are borderline
Compulsive sexual behavior: prefrontal and limbic volume and personality symptoms associated with compulsive sexual behav-
interactions. Hum Brain Mapp. 2017;38(3):1182–1190. https:// iors among women in treatment for substance use disorders?
doi.org/10.1002/hbm.23447. An exploratory study. J Clin Psychol. 2016;72(10):1077–1087.
96. Seok JW, Sohn JH. Gray matter deficits and altered resting- https://doi.org/10.1002/jclp.22310.
state connectivity in the superior temporal gyrus among 113. Rawson RA, Washton A, Domier CP, Reiber C. Drugs and
individuals with problematic hypersexual behavior. Brain sexual effects: role of drug type and gender. J Subst Abuse Treat-
Res. 2018;1684:30–39. https://doi.org/10.1016/j.brainre ment. 2002;22(2):103–108. https://doi.org/10.1016/S0740-5472
s.2018.01.035. (01)00215-X.
97. Kühn S, Gallinat J. Neurobiological basis of hypersexuality. Int 114. Abernathy K, Chandler LJ, Woodward JJ. Alcohol and the pre-
Rev Neurobiol. 2016;129:67–83. frontal cortex. Int Rev Neurobiol. 2010;91:289–320.
98. Black DW, Kehrberg LLD, Flumerfelt DL, Schlosser SS. Charac- 115. Heatherton TF, Wagner DD. Cognitive neuroscience of self-
teristics of 36 subjects reporting compulsive sexual behavior. Am regulation failure. Trends Cogn Sci. 2011;15(3):132–139. https://
J Psychiatry. 1997;154(2):243–249. https://doi.org/10.1176/a doi.org/10.1016/j.tics.2010.12.005.
jp.154.2.243. 116. O’Sullivan SS, Evans AH, Lees AJ. Dopamine dysregulation
99. Kafka MP, Prentky RA. Preliminary observations of DSM-III-R syndrome: an overview of its epidemiology, machanisms and
Axis I comorbidity in men with paraphilias and paraphilia-related management. CNS Drugs. 2009;23(2):157–170. https://doi.o
disorders. J Clin Psychiat. 1994;55:481–487. rg/10.2165/00023210-200923020-00005.
100. Raymond NC, Coleman E, Miner MH. Psychiatric comor- 117. Moore TJ, Glenmullen J, Mattison DR. Reports of patho-
bidity and compulsive/impulsive traits in compulsive sexual logical gambling, hypersexuality, and compulsive shopping
behavior. Compr Psychiatry. 2003;44(5):370–380. https://doi.o associated with dopamine receptor agonist drugs. JAMA Int
rg/10.1016/S0010-440X(03)00110-X. Med. 2014;174(12):1930–1933. https://doi.org/10.1001/jamai
101. Ballester-Arnal R, Castro-Calvo J, Gimenez-Garcia C, Gil-Julia nternmed.2014.5262.
B, Gil-Llario MD. Psychiatric comorbidity in compulsive sex- 118. Corvol J-C, Artaud F, Cormier-Dequaire F, et al. Longitudi-
ual behavior disorder (CSBD). Addict Behav. 2020;107:106384. nal analysis of impulse control disorders in Parkinson dis-
https://doi.org/10.1016/j.addbeh.2020.106384. ease. Neurology. 2018;91(3):e189–e201. https://doi.org/10.1212/
102. Briken P. An integrated model to assess and treat compulsive WNL.0000000000005816.
sexual behaviour disorder. Nat Rev Urol. 2020;17(7):391–406. 119. Zlot Y, Goldstein M, Cohen K, Weinstein A. Online dating is
https://doi.org/10.1038/s41585-020-0343-7. associated with sex addiction and social anxiety. J Behav Addict.
103. Dvorak RD, Wray TB, Kuvaas NJ, Kilwein TM. Mania 2018;7(3):821–826. https://doi.org/10.1556/2006.7.2018.66.
and sexual risk: associations with behavioral self-regulation. J 120. Weiss D. The prevalence of depression in male sex addicts residing
Affect Disord. 2013;150(3):1076–1081. https://doi.org/10.1016/ in the United States. Sex Addict Compuls. 2004;11(1-2):57–69.
j.jad.2013.04.023. https://doi.org/10.1080/10720160490458247.
121. Kalra G. The depressive façade in a case of compulsive sex 137. Abdalla-Filho E, de Jesus MJ, Diehl A, et al. Forensic implications
behavior with frottage. Indian J Psychiatr. 2013;55(2):183–185. of the new classification of ICD-11 paraphilic disorders in Brazil.
https://doi.org/10.4103/0019-5545.111460. J Sex Med. 2019;16(11):1814–1819. https://doi.org/10.1016/j.
122. Di Nicola M, Tedeschi D, Mazza M, et al. Behavioural addictions jsxm.2019.07.025.
in bipolar disorder patients: role of impulsivity and personality 138. Martínez-López JNI, Robles R, Fresán A, et al. Legal and
dimensions. J Affect Disord. 2010;125(1-3):82–88. https://doi.o policy implications in Mexico of changes in ICD-11 para-
rg/10.1016/j.jad.2009.12.016. philic disorders. J Sex Med. 2019;16(10):1623–1637. https://
123. Fuss J, Briken P, Stein DJ, Lochner C. Compulsive sexual behavior doi.org/10.1016/j.jsxm.2019.07.022.
disorder in obsessive-compulsive disorder: prevalence and asso- 139. Briken P, Boetticher A, Krueger RB, Kismödi E, Reed GM.
ciated comorbidity. J Behav Addict. 2019;8(2):242–248. https:// Current legal situation for patients with paraphilic disorders and
doi.org/10.1556/2006.8.2019.23. implications of the ICD-11 for paraphilic disorders for Germany.
124. Lafortune D, Blais M, Miller G, Dion L, Lalonde F, Dargis L. Psy- J Sex Med. 2019;16(10):1615–1622. https://doi.org/10.1016/j.
chological and interpersonal factors associated with sexualized jsxm.2019.07.011.
drug use among men who have sex with men: a mixed-methods 140. Coleman E, Jennings T, Gleason N, et al. The relationship
systematic review. Arch Sex Behav. 2021;50(2):427–460. https:// between boredom proneness, attachment styles and compulsive
doi.org/10.1007/s10508-020-01741-8. sexual behavior. J Sex Marital Ther. 2023;49(2):172–188. https://

125. Pfaus JG, Wilkins MF, DiPietro N, et al. Inhibitory and doi.org/10.1080/0092623X.2022.2086511.
disinhibitory effects of psychomotor stimulants and depres- 141. Althof SE, Rosen RC, Perelman MA, Rubio-Aurioles E.
sants on the sexual behavior of male and female rats. Standard operating procedures for taking a sexual history.
Horm Behav. 2010;58(1):163–176. https://doi.org/10.1016/j. J Sex Med. 2013;10(1):26–35. https://doi.org/10.1111/
yhbeh.2009.10.004. j.1743-6109.2012.02823.x.
126. Kafka MP, Hennen J. A DSM-IV Axis I comorbidity study 142. Ahorsu D, Adjorlolo S, Nurmala I, Ruckwongpatr K, Strong C,
of males (n=120) with paraphilias and paraphilia related Lin C-Y. Problematic porn use and cross-cultural differences: a
disorders. Sex Abus. 2002;14(4):349–366. https://doi.o brief review. Current Addiction Reports. 2023;10(3):572–580.
rg/10.1177/107906320201400405. https://doi.org/10.1007/s40429-023-00505-3.
127. Kafka MP, Hennen J. Hypersexual desire in males: are 143. Jennings TL, Gleason N, Kraus SW. Assessment of compulsive
males with paraphilias different from males with paraphilia- sexual behavior disorder among lesbian, gay, bisexual, transgen-
related disorders? Sex Abus. 2003;15(4):307–321. https://doi.o der, and queer clients: commentary to the debate: “Behavioral
rg/10.1177/107906320301500407. addictions in the ICD-11.”. J Behav Addict. 2022;11(2):216–221.
128. Briken P, Habermann N, Kafka MP, Berner W, Hill A. The https://doi.org/10.1556/2006.2022.00028.
paraphilia-related disorders: an investigation of the relevance of 144. Briken P, Turner D. What does “sexual” mean in compulsive
the concept in sexual murderers. J Forensic Sci. 2006;51(3):683– sexual behavior disorder? J Behav Addict. 2022;11(2):222–225.
688. https://doi.org/10.1111/j.1556-4029.2006.00105.x. https://doi.org/10.1556/2006.2022.00026.
129. Klein V, Schmidt AF, Turner D, Briken P. Are sex drive 145. Janssen E, Bancroft J. The dual control model of sexual response:
and hypersexuality associated with pedophilic interest and a scoping review, 2009-2022. J Sex Res. 2023;60(7):948–968.
child sexual abuse in a male community sample? PLoS https://doi.org/10.1080/00224499.2023.2219247.
One. 2015;10(7):e0129730. https://doi.org/10.1371/journal.po 146. Perelman MA. Sex coaching for non-sexologist physicians:
ne.0129730. how to use the sexual tipping point model. J Sex
130. Hertz PG, Rettenberger M, Turner D, Briken P, Eher R. Hypersex- Med. 2018;15(12):1667–1672. https://doi.org/10.1016/j.
ual disorder and recidivism risk in individuals convicted of sexual jsxm.2018.10.010.
offenses. J Forens Psychiatry Psychol. 33:572–591. 147. Coleman E, Dickenson JA, Girard A, et al. An integra-
131. Kingston DA, Bradford JM. Hypersexuality and recidivism tive biopsychosocial and sex positive model of understand-
among sexual offenders. Sex Addict Compulsivity. 2013; ing and treatment of impulsive/compulsive sexual behav-
20(1-2):91–105. ior. Sex Addict Compuls. 2018;25(2-3):125–152. https://doi.o
132. Langevin S, Proulx J, Lacourse E. Sexual aggressors against rg/10.1080/10720162.2018.1515050.
women’s sexual lives: a latent class analysis. Int J Offender 148. Munns R, Dickenson J, Candelario-Perez L, et al. Psychotherapies
Ther Comp Criminol. 2018;62(6):1430–1451. https://doi.o in the treatment of compulsive sexual behavior disorder. In:
rg/10.1177/0306624X17694374. Balon R, Briken P eds. Compulsive Sexual Behavior Disorder:
133. Marshall LE, Marshall WL, Moulden HM, Serran GA. Understanding, Assessment, and Treatment. American Psychiatric
The prevalence of sexual addiction in incarcerated sexual Association; 2021: 109–128.
offenders and matched community nonoffenders. Sex 149. Braun-Harvey D, Vigorito D. Treating out of Control
Addict Compulsivity. 2008;15(4):271–283. https://doi.o Sexual Behavior: Rethinking Sexual Addiction: Springer;
rg/10.1080/10720160802516328. 2016.
134. Simmons CA, Lehmann P, Collier-Tenison S. Linking 150. Lew-Starowicz M, Coleman E. Mental and sexual health
male use of the sex industry to controlling behaviors in perspectives of the International Classification of Diseases
violent relationships: an exploratory analysis. Violence (ICD-11) compulsive sexual behavior disorder. J Behav
Against Women. 2008;14(4):406–417. https://doi.org/10.1177/ Addict. 2022;11(2):226–229. https://doi.org/10.1556/2006.2022.
1077801208315066. 00032.
135. Gardner AR, Grigorian H, Florimbio AR, Brem MJ, 151. Antons S, Engel J, Briken P, Krüger THC, Brand M,
Wolford-Clevenger C, Stuart GL. The association between Stark R. Treatments and interventions for compulsive
compulsive sexual behavior and sexual aggression sexual behavior disorder with a focus on problematic
perpetration among men arrested for domestic violence. pornography use: a preregistered systematic review. J Behav
Sex Addict Compulsivity. 2018;25(2-3):226–240. https://doi.o Addict. 2022;11(3):643–666. https://doi.org/10.1556/2006.2022.
rg/10.1080/10720162.2018.1532361. 00061.
136. Carvalho J, Nobre PJ. Psychosexual characteristics of 152. Briken P, Turner D. Pharmacotherapy for patients with CSBD.
women reporting sexual aggression against men. J In: Balon R, Briken P eds. Compulsive Sexual Behavior Disorder:
Interpers Violence. 2016;31(15):2539–2555. https://doi.o Understanding, Assessment, and Treatment. American Psychiatric
rg/10.1177/0886260515579504. Association; 2021: 109–128.
153. Thibaut F, Cosyns P, Fedoroff JP, et al. The World Federa- naltrexone for treatment of compulsive sexual behaviour disorder.
tion of Societies of Biological Psychiatry (WFSBP) 2020 guide- World Psychiatry. 2022;21(3):468–469. https://doi.org/10.1002/
lines for the pharmacological treatment of paraphilic disor- wps.21026.
ders. World J Biol Psychiatry. 2020;21(6):412–490. https://doi.o 155. Savard J, Oberg KG, Chatzittofis A, Dhejne C, Arver S, Joki-
rg/10.1080/15622975.2020.1744723. nen J. Naltrexone in compulsive sexual behavior disorder: a
154. Lew-Starowicz M, Draps M, Kowalewska E, Obarska K, Kraus feasibility study of twenty men. J Sex Med. 2020, 2020;17(8):
SW, Gola M. Tolerability and efficacy of paroxetine and 1544–1552.

Qeae 014

Uploaded by

Copyright:

Available Formats

Qeae 014

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Qeae 014

Uploaded by

Copyright:

Available Formats

Sexual Medicine Reviews, 2024, 12, 355–370

Assessment and treatment of compulsive sexual behavior

Downloaded from https://academic.oup.com/smr/article/12/3/355/7634799 by guest on 27 October 2024

Introduction being labeled an “addiction,” and current social media, peri-

Downloaded from https://academic.oup.com/smr/article/12/3/355/7634799 by guest on 27 October 2024

Downloaded from https://academic.oup.com/smr/article/12/3/355/7634799 by guest on 27 October 2024

Downloaded from https://academic.oup.com/smr/article/12/3/355/7634799 by guest on 27 October 2024

these involve the activation of sympathetic outflow in spinal

Downloaded from https://academic.oup.com/smr/article/12/3/355/7634799 by guest on 27 October 2024

Downloaded from https://academic.oup.com/smr/article/12/3/355/7634799 by guest on 27 October 2024

syndrome.94 In addition to hyperresponsiveness of Comorbidities and differential diagnoses

Downloaded from https://academic.oup.com/smr/article/12/3/355/7634799 by guest on 27 October 2024

Downloaded from https://academic.oup.com/smr/article/12/3/355/7634799 by guest on 27 October 2024

Downloaded from https://academic.oup.com/smr/article/12/3/355/7634799 by guest on 27 October 2024

Table 1. Recommendations regarding intervention trajectories in CSBD: expert opinion.

Area to be approached Recommendations

Downloaded from https://academic.oup.com/smr/article/12/3/355/7634799 by guest on 27 October 2024

is needed on pharmacologic interventions in CSBD. Until now, Conﬂicts of interest

Downloaded from https://academic.oup.com/smr/article/12/3/355/7634799 by guest on 27 October 2024

Downloaded from https://academic.oup.com/smr/article/12/3/355/7634799 by guest on 27 October 2024

Downloaded from https://academic.oup.com/smr/article/12/3/355/7634799 by guest on 27 October 2024

Downloaded from https://academic.oup.com/smr/article/12/3/355/7634799 by guest on 27 October 2024

Downloaded from https://academic.oup.com/smr/article/12/3/355/7634799 by guest on 27 October 2024

Downloaded from https://academic.oup.com/smr/article/12/3/355/7634799 by guest on 27 October 2024

You might also like