Searching for clarity in muddy water: future considerations for classifying compulsive sexual behavior as an addiction (2016)

We recently considered evidence for classifying compulsive sexual behavior (CSB) as a non-substance (behavioral) addiction [1]. Our review found that CSB shared clinical, neurobiological and phenomenological parallels with substance-use disorders; however, we concluded that more research is needed in order to address current shortcomings.

The responding commentaries highlight important issues regarding classification efforts including the lack of a consensus definition for CSB and disagreement about proposed criteria central to defining CSB [2]. More research should examine which proposed criteria – whether those relating more closely to sexual addiction [3] or hypersexual disorder [4] – accurately reflect CSB in clinical contexts. Although the two diagnostic categories may conceptually differentiate between addiction and excessive drive, the criteria overlap and stress and negative emotionality as triggers apply to both [5]. More research is needed to better understand in CSB how central features of addiction (e.g. tolerance, withdrawal) relate to CSB and its treatment. Additional concerns included improving research methodologies and minimizing possible confounds that may limit generalizability of studies [2]. Although data suggest that other behavioral addictions are comorbid with other psychiatric disorders [6, 7], additional research is needed to determine the prevalence of co-occurring disorders with CSB [8]. Co-occurring behavioral addictions with CSB should be considered, particularly if the behaviors are intertwined (e.g. traveling to resort casinos to engage in sex and gamble). Further, additional research is needed to better understand the prevalence of CSB among the general population.

Additional points were raised regarding the language used to describe CSB, with ‘risky’ or ‘excessive’ terminology being potentially misleading. ‘Excessive’ sex may not be problematic [8]. Instead, sexual behavior leading to significant functional impairment or psychological distress may more likely reflect important clinical hallmarks of CSB. Applying a more objective approach to developing a diagnostic framework for CSB may promote advancement. Objective indicators of distress (e.g. repeated attempts to quit, craving, etc.) rather than frequency of sexual behaviors should be a focus [9], particularly as frequency of sexual behaviors may not be a strong predictor of CSB [10].

The pathologizing of sexual behaviors falling outside normative standards or ranges and the evolution of sexual practices and societal values over time were also discussed [11]. Notably, changes in usage of digital technologies have altered sexual behaviors, particularly amongst youth and young adults. Internet pornography is thriving, casual sex (‘hook-up’) websites are widely popular, and social media may act as a sexual conduit for many individuals. These developments are accompanied by many unanswered questions [12]. Future longitudinal research is needed to examine how digital technologies are related to the development and maintenance of CSB over the lifespan.

Although the American Psychiatric Association rejected hypersexual disorder [4] from DSM-5, a diagnosis of CSB (excessive sex drive) can be made using ICD-10 [13]. CSB is also being considered by ICD-11 [14], although its ultimate inclusion is not certain. Future research should continue to build knowledge and strengthen a framework for better understanding CSB and translating this information into improved policy, prevention, diagnosis, and treatment efforts to minimize the negative impacts of CSB.