What is compulsive sexual behaviour?
Many clients report negative consequences as a result of unwanted, repetitive, consensual sexual behaviours. In their initial consultation, they often use a ‘sex addiction’ language as it is the most known language: their behaviours feel like an addiction because they think they can’t stop it.
For years, clinicians have been in strong disagreement between those believing in ‘sex addiction’ and offering an addiction treatment to such problematic sexual behaviours and those who refused the theory that sex can be addictive and therefore offering a non-addiction treatment. There has been much debate on how to call this condition: ‘sex addiction’ or compulsive sexual behaviour?
In June 2018, the ICD-11 (International Classification of Disease) included Compulsive Sexual Behaviour as a disorder, sparking more confusion between clinicians, some feeling that ‘sex addiction’ has finally been validated and others thinking that the ‘sex addiction’ diagnosis has been formally rejected.
My aim in writing this blog is to bring some clarity on the diagnosis of compulsive sexual behaviour disorder.
The diagnosis: compulsive sexual behaviour disorder.
The ICD-11 has identified the diagnostic criteria for the disorder as follows:
‘Compulsive sexual behaviour disorder is characterized by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it. The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g. 6 months or more), and causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement.’
It is an interesting set of criteria which brings forth important clinical considerations for both therapists and clients. One of the good outcomes of such classification is that the psychotherapeutic community can now have an answer to the question: ‘what shall we call it?’ WHO (World Health Organisation) clearly states that there is no clinical evidence of an addictive component to sex therefore the disorder is classified under Impulse Control Disorder, which is different from addiction.
Dr Geoffrey M. Reed (Department of mental health and substance abuse) at WHO asserts in a personal communication on 12th June 2018:
‘”Sex addiction” has been listed as a synonym, only to indicate that this was terminology that sometimes might be used, not that we were endorsing it. However, the presence of the index term seemed to be interpreted by some as indicating that it was okay to refer to it that way. This was not our intention and classification and professional coders would know that, but obviously there was a risk of misinterpretation. This was not a message we wanted to be sending. We do not consider that there is sufficient evidence to conceptualize this as an addiction, as I have said (e.g., per the Kraus et al article, which you know). So after some internal discussion, I asked that the index term to be removed, which it subsequently was’.
This should be enough clarity for clinicians. From now on, we can confidently put the term ‘sex addiction’ in inverted comas, as it is not a clinical term nor a diagnosis. The science simply does not support the addiction model. It is time to understand the term ‘sex addiction’ as an old fashion term that needs to disappear from our mental health language, just as much as ‘hysteria’ or ‘manic depressive’ as disappeared from our diagnostic language.
I have seen good clinicians prematurely assessing clients with ‘sex addiction’ or ‘compulsive sexual behaviours’ either because of a lack of knowledge or out of their own sexual morality. As clinicians, we must be diligent in formulating a robust conceptualization of clients’ presentations. Failure to do so can cause harm.
The diagnosis of Compulsive Sexual Behaviour Disorder:
1. ‘A persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities.’
The sexual behaviour that is problematic has to be evaluated by the clients themselves. A client may say that their repetitive visits to sex workers is a problem but their pornography use is not. We, clinicians, are not to tell clients what is problematic and what is not.
This criteria focuses on the link between the intense impulses and urges and the repetitive behaviours. It does not include intense urges and impulses that do not result in repetitive unwanted behaviours, nor wanted repetitive behaviours. Also, the symptoms have to be significant enough for the person to struggle with looking after their health, personal care or other interests. This is when we need to be diligent: if a client presents in our consulting room with good hygiene, able to hold a job with responsibilities, feed themselves, and get on with life, the criteria for the disorder cannot be formulated. Most clients seek treatment after their behaviours have been discovered by their partner, they come to therapy in great distress, but it is the distress of the possibility of losing their relationship rather than the distress of their sexual behaviours. When the behaviours are successfully hidden, people tend to continue the behaviours, firstly because they think they can get away with it but also because there is an element of pleasure. Moreover, feeling shame after doing a pleasurable behaviour is not the same as doing an unwanted behaviour from which no pleasure is derived.
2. ‘Numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it’
This is a crucial part of the disorder diagnosis which is usually overlooked in assessments. Many people do not attempt to reduce their repetitive sexual behaviours until after they are caught by their partner or at high risk of being caught. For these people, if there was no risk of getting caught they would continue their sexual behaviours, indicating that they derive enough satisfaction from such behaviours. They may think ‘I shouldn’t be doing this’ but they do it anyway because the motivation to meet their sexual needs trumps the motivation to keep to their agreed relationship boundaries with their partner. If this is the case, it is not a disorder, it is a sexual health conflict between what they want sexually and what is permissible or not within their relationship.
However, some people do try very hard to stop their repetitive sexual behaviours without success before they are at high risk of being caught: for these people, important questions need to be asked before we prematurely assume that it is part of the disorder: for example, do they want to stop because they perceive that others (society, religious groups, etc.) would disapprove? If so, it is not a disorder (I explain more about that below). Most people would stop behaviours that do not produce any satisfaction or any pleasure in any way. The diagnostic criteria for the disorder would only apply to people who do a repetitive sexual behaviour for which they derive almost no pleasure and cannot stop that behaviour. For example, the most common story is a problematic sexual behaviour that provides a sense of feeling connected and loved. Although such behaviour can be destructive if it is outside of their committed relationship, it also provides the satisfaction of connection: this means that the disorder diagnosis must be ruled out. Instead, the patient’s problem can be understood, and treated, as a sexual health behaviour problem driven by a longing for connection and intimacy. People meeting this diagnostic criteria are rare.
3. ‘The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g. 6 months or more), and causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning’.
This is another important criteria to explore. People’s sexual behaviour is usually different before and after they get caught by their partner. There is a question over inability to control those urges resulting in repetitive sexual behaviours and choosing not to control them because they produce much pleasure. I think that ‘the pattern of failure to control’ refers to an inability to control sexual impulses and urges (as the disorder is under Impulse Control Disorder). If people can have continued repetitive sexual behaviours over an extended period of six months or more and not get caught, it means they are highly functioning and very much in control: it takes much planning and organization to hide such behaviours from a partner. After they get caught, it is often when clients report marked distress and significant impairment in personal areas: they have to deal with the consequences of being caught, the intense emotions of their partner faced with the discovery of the enormous betrayal, chaos in all areas of their life trying to deal with the fall out of the discovery. People who have not been caught, or those who are single and do not breach any relationship agreements usually do not report marked distress or impairment in their life functioning. The exception is if clients have strong moralistic or religious views over some sexual activities, which is excluded from the diagnosic criteria (see below). Meeting this criteria for the disorder is also rare.
4. ‘Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement’.
This is a central component of the diagnosis. It is not possible to diagnose Compulsive Sexual Behaviour Disorder if the client feels much sexual shame, moral judgement or disapproval from society, families, religious groups, and so on about their sexual impulse, urges or behaviours. For example, a man repetitively seeing a Dominatrix sex worker because he derives much pleasure from BDSM practice is found out by partner who doesn’t practice BDSM: she may feel disgusted by what he had been doing and highly disapproving: the client then feels great distress at his behaviour and wants to stop: this client cannot be diagnosed with the disorder. Or a gay man having frequent anonymous sex in sex clubs and feeling his behaviour is ‘wrong’ because of the societal judgement that frequent anonymous sex is undesirable cannot be diagnosed with the disorder. If somebody feels bad about their sexual behaviour because they have read a book or a website that is sex-shaming or sex-negative: the diagnosis for the disorder is ruled out.
Fortunately, the diagnostic criteria for the disorder are very specific and most clients would not meet those criteria. It means that it is important not to pathologise clients with mental health labels without doing a thorough assessment and considering very carefully all the diagnostic criteria. However many clients present with problematic sexual behaviours that feel compulsive without it being a disorder. How can we help the clients meeting the disorder diagnosis and those with a sexual health behaviour problem?
The psycho-sexological assessment
An effective treatment is underpinned by a robust psycho-sexological assessment which is framed by a sex-positive philosophy. A psycho-sexological assessment includes the following understanding:
- A compulsive sexual behaviour is not an addiction.
- It is not an illness nor a character defect.
- It seeks to resolve unmet needs, emotionally and sexually.
- It seeks to resolve an attachment problem.
- It can be treated with permanent change.
- An exploration of the client’s erotic mind is necessary.
- Focusing on sexual health principles rather than behaviours is important to avoid shaming and pathologising.
- Treating the underlying causes of the behaviours rather than the behaviour itself (which is only a symptom) is more appropriate than focusing on stopping the behaviour.
- The underlying causes are often traumas, acute sexual shame, psychosexual dysfunctions, poor self-esteem, negative core beliefs.
- A 12-step fellowship programme is not recommended.
- Abstinence is not recommended as it can increase sexual shame exponentially.
The treatment for compulsive sexual behaviours varies depending on the unique clinical picture of the client’s presentations. Effective and ethical treatments need to move beyond the old-fashion conceptualisation of ‘sex addiction’ and needs to focus on a sex-positive and sexology-informed framework. To learn more about the treatment pathways, you can register on the three-day advanced clinical training offered by The Contemporary Institute of Clinical Sexology in August 2019.