Sexual compulsivity: a new era
The topic of sexual compulsivity has brought strong debates amongst clinicians for decades, some arguing that it is an addiction, some think it is compulsivity, and others think there is no disorders to be found. There are strong opinions amongst the public too, on social media, on television, in newspaper articles, blogs, etc. It is easy for clinicians and the public to be confused about what we should call distress related to sexual behaviours, how we should conceptualise it, and, most importantly, how we can treat it.
Of course, as diligent clinicians, what we decide to call a problem is important because our terminology will determine the treatment pathway. Clinicians who conceptualise sexual compulsivity as an addiction are more likely to offer an addiction-oriented treatment and recommend addiction-based support groups such as 12-step programmes. Clinicians who conceptualise it as sexual compulsivity are more likely to choose a treatment that integrates psychological and sexological knowledge, identifying and treating the underlying causes of the compulsivity. The clinicians who believe there is no disorders – and often, there is no disorders even though patients self-diagnose with one – are more likely to be curious about the patient’s sexual and erotic landscape and help them make sense of their sexual urges and behaviours. Of course, most clinicians will operate within the overlap of those three conceptualisations.
Clinicians have attempted to define what is “too much sex” for decades, with various iterations, and each have been critiqued. Indeed, it is almost impossible to define what constitutes sexual excess or compulsivity. The main critique is that clinicians could be biased with their own moral and/or religious ideas of what is “healthy” sexuality in assessing patients’ sexual behaviours and thus unduly pathologising a large number of patients whose sexuality did not fit with the moral norm of the clinician. As a result, a lot of research, books and training programmes on “sex/porn addiction” have been poorly conducted and plagued the field with much unchecked moral biases. While the DSM-5 TR does not endorse any disorders for sexual compulsivity, the ICD-11 (WHO) settled on compulsive sexual behaviour disorder (CSBD). It was a welcome step forward because it could mitigate some moral biases. The ICD-11 criteria explicitly define CSBD as an impulse control disorder, not addiction. One part of the definition is that sexual compulsivity is about the relationship between strong urges and behaviours, not the number of times someone has sex, how many sexual partners someone has, or how many hours someone watches pornography. Crucially, one of the criteria rules out the disorder if the distress comes from external judgements. The ICD-11 criteria encouraged much better research in the field, and since then, there have been excellent progress in understanding sexual compulsivity, from a less biased position, and with more sexological integration.
Based on more recent research, clinical evidence and ongoing clinical discussions, the field is moving towards a new era in understanding sexual compulsivity in more depth. There will always be different opinions, disagreements and debates on this topic – and disagreements are welcome because it is how we keep developing the field. It is now broadly understood that sexual compulsivity has its roots in three different causes: (1) sexual compulsivity is a symptom of underlying emotional disturbances, primarily depression, anxiety, attachment issues, post-trauma stress; (2) some people struggle with moral incongruence, having sexual behaviours that are pleasurable and/or somewhat helpful in some ways but in conflict with the person’s relational and sexual commitments; (3) some people have high sexual desires, which is not a pathology, but may provoke emotional discomfort if they choose a relationship that does not allow enough room for their sexual desires. Within these three cohorts, there are multiple factors that influence clinical presentations, for example, shame, neurodiversity, some medical conditions, narcissism, psychosexual and relationship issues, only to name a few.
While some root causes of sexual compulsivity are emotional issues and not about sex per se, it is also about sex, because choosing sex for their emotional regulation – as opposed to binge eating food for example, has an erotic and existential meaning. Some of the erotic meaning may be to feel alive, to feel present in the here-and-now, to access sexual pleasure, to feel wanted and desired, etc. So, it is crucial that therapists have an in-depth understanding of human sexuality as well as psychology/ psychotherapy.
The field of sexology recommends a robust knowledge in sexual and erotic diversity to avoid pathologising sexual behaviours that are outside of the norms of heteronormativity and mononormativity, a sex-positive philosophy with a primary sexological lens, and adopting a multi-modal approach to treatment (Bricken et al, 2024), because psychotherapeutic treatments will need to be utilised differently depending on the patient’s clinical presentation. For example, someone with ADHD will need a different integration of therapeutic modalities compared to someone with depression.
It is now clear that CSBD and “sex/porn addiction” are totally different theoretical frameworks and should not be used interchangeably. Some sexological organisations have published statements against the concepts and treatments of “sex/porn addiction” including the American Association of Sexuality Educators, Counselors and therapists (AASECT), Center for Positive Sexuality (CPS), The Alternative Sexualities Health Research Alliance (TASHRA), and the National Coalition for Sexual Freedom (NCSF), and the journal of Sexual and Relationship Therapy to help change the field for better and more ethical assessment and treatment methods.
As the new era in our understanding of sexual compulsivity is emerging, it is time to leave behind the reductive terminology and related treatments of “sex/porn addicton” because those methods, and particularly recommending and promoting abstinence-based programmes such as 12-step programmes, can be iatrogenic, with a high likelihood of harm to the diverse populations that are already sexually marginalised, such as LGBTQ+ people, kinky people, digisexual people, polyamorous people and sex workers.
This new era in understanding and treating sexual compulsivity with better research, based on evidence, with multiple modalities, and with a robust sexological and sex-positive frame is exciting, not only for the field, but mostly for patients, as they will now have more opportunities to choose sexologically-informed clinicians who practice with safer and more ethical methods.
References:
AASECT statement on “sex addiction”: https://www.aasect.org/position-sex-addiction
Briken, P., Bőthe, B., Carvalho, J., Coleman, E., Giraldi, A., Kraus, S. W., Lew-Starowicz, M., & Pfaus, J. G. (2024). Assessment and treatment of compulsive sexual behavior disorder: A sexual medicine perspective. Sexual Medicine Reviews, 12(3), 355-370. doi:10.1093/sxmrev/qeae014
Sprott, R. (2017). Addiction to sex and/or pornography: A position statement from the Center for Positive Sexuality (CPS), The Alternative Sexualities Health Research Alliance (TASHRA), and the National Coalition for Sexual Freedom (NCSF). Journal of Positive Sexuality. https://doi.org/10.51681/1.331
Twist, M. L. C., Neves, S., Vigorito, M. A., Ansara, G., Rudolph, E., Marshall, K., Baydoun, M., Herrero, R. (2025). Statement on behalf of the editorial board from the journal of Sexual and Relationship Therapy: International Perspectives on Theory, Research, and Practice on ‘sex addiction,’ ‘pornography addiction’, out-of-control-sexual-behaviours, and compulsive sexual behaviours. Sexual and Relationship Therapy, 40(4), 721–744. https://doi.org/10.1080/14681994.2025.2578550
Author
Silva Neves is an award-winning, COSRT-accredited and UKCP-registered psychosexual and relationship psychotherapist, and a trauma psychotherapist based in London, UK. Silva is also a COSRT-accredited clinical supervisor.
Silva is a member of the editorial board for the leading international journal Sexual and Relationship Therapy.
Silva is the author of three books: Compulsive Sexual Behaviours, A Psycho-Sexual Treatment Guide for Clinicians (Routledge), Sexology: The Basics (Routledge), Sexual Diversity (Karnac), edited The Routledge International Handbook of Sexual Compulsivity and Clinical Sexology, and co-edited three textbooks: Erotically Queer (Routledge), Relationally Queer (Routledge) and Gender, Sex and Relationship Diversity Therapy (Routledge).
He also contributed chapters and articles in various publications and peer-reviewed journals. He speaks internationally.
Website:
https://www.silvaneves.co.uk
