Should Compulsive Sexual Behavior Disorder Be Considered an Impulse Control Disorder?
With an estimated 3 to 6 percent of the population possibly having compulsive sexual behavior disorder (CSBD), it is now being researched like never before. This is leading to the question whether it should be considered an impulse control disorder, or something else?
Compulsive sexual behavior is more commonly known as sex addiction but covers a broader range of terms such as problematic hypersexuality/hypersexual disorder and sexual compulsivity. The topic of CSB has been discussed for decades under various names such as nymphomania, satyriasis, erotomania, and Don Juanism. In 1987, the American Psychiatric Association first listed CSB as a disorder in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) but later removed it in 2000 with the publication of the fourth edition of the DSM. In the past two decades, there have been thousands of papers published on CSB. Due to the increasing body of research on CSB highlighting health disparities and impaired psychosocial functioning associated with the condition, the World Health Organization recommended classifying CSB as an impulse control disorder in the ICD-11. However, the newly proposed compulsive sexual behavior disorder (CSBD) was not listed as an addictive behavior which some scholars have argued is controversial. CSBD is defined as: difficulties in controlling inappropriate or excessive sexual fantasies, urges/cravings, or behaviors that generate subjective distress or impairment in one's daily functioning. In CSBD, the intensity and repetitiveness of the sexual behavior may increase over time, and this has been linked to health, psychosocial, and interpersonal impairments in many studies.
Research estimates that CSBD ranges from 3-6% of adult males, while a large study of US university students estimated that CSBD to be 3% for men and 1% for women. Among US combat Veterans, CSBD is estimated to be much higher, with one study finding a prevalence rate of 17%. CSBD appears more common in men as compared to women and higher among Western, white individuals compared to other ethnic groups in treatment-seeking patients, university students, and community members. CSBD has also been noted among men who have sex with men and is associated with HIV risk-taking behaviors (e.g., condomless anal intercourse) and sexually transmitted infections among treatment-seeking heterosexual patients. Among men with CSBD, the most reported clinically distressing behaviors are: compulsive masturbation, internet pornography use, casual/anonymous sex with strangers, multiple sex partners, and paid sex. Among women with CSBD, the most reported clinically distressing behaviors are: high masturbation frequency, number of sexual partners, and internet pornography use.
Individuals with CSBD often have other mental health problems as well. Roughly half of CSBD patients report issues with depression, anxiety, substance use, impulse control, or personality disorders. In a study of 103 men with CSBD, 71% met criteria for a mood disorder, 40% for an anxiety disorder, 41% for a substance use disorder, and 24% for an impulse-control disorder. Sexual impulsivity is also associated with social phobia and alcohol use disorder as well as paranoid, schizotypal, antisocial, borderline, narcissistic, avoidant, and obsessive-compulsive personality disorders.
Given the significant challenges of individuals with CSBD, within the last ten years, there has been strong interest in studying the condition and developing treatments for individuals seeking professional help. However, thus far, the reliability, validity, and utility of many of these treatments have not been well-studied, limiting their generalizability for wide-spread clinical practice. More research on pharmacological and psychotherapeutic treatments for CSBD is needed, particularly among diverse populations.
Reasonable concerns have been raised regarding the classification of CSBD as a mental health disorder. Specifically, some critics have argued that labeling CSBD as a mental health disorder will brand normal variants of a healthy sexual behavior as a disorder, or that excessive/problematic sexual behavior may be better explained by other preexisting mental health problems. Others have pointed out that CSBD may merely reflect those with high levels of sexual desire, with suggestions that difficulty controlling sexual urges and high frequencies of sexual behaviors may be better explained as a "high sex drive". Given the high likelihood on the overlap between CSBD and a high sex drive, more research is needed to identify which features are most specifically associated with clinically distressing sexual behaviors and warrant a mental health diagnosis.
With the expected inclusion of CSBD in the ICD-11 as an impulse control disorder, more research will be needed to better understand the diagnostic framework of CSBD. Presently, scholars disagree on whether it should be considered a behavioral addiction, hypersexual disorder, or an impulse control disorder. The one point agreed upon is that individuals with CSBD appear to be suffering and have issues that negatively impact their health and functioning. Future research studies can fill in multiple gaps in knowledge that would more conclusively determine how excessive engagement in sexual behaviors should be classified as a mental health disorder. More research is also needed to fully understand CSBD in order to determine the best treatment approaches (e.g., medication, psychotherapy) for helping those reporting problems controlling their sexual behaviors as well as understand the effectiveness of self-help programs such as Sex Addicts Anonymous, Sexual Compulsives Anonymous, and Sex&Love Addicts. Future treatment research is necessary to inform clinical best practices and directions for training health care professionals on the most effective interventions to help individuals with CSBD to improve their health, functioning, and sense of wellbeing.
Original Article:S. W. Kraus, V. Voon, M. N. Potenza, Should compulsive sexual behavior be considered an addiction? Addiction 111, 2097-2106 (2016)
Massimo Caine , Founder and Director
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