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An integrated model to assess and treat compulsive sexual behaviour disorder

Nature Reviews Urology volume 17, pages 391–406 (2020)Cite this article

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Abstract

Contrary to common belief, hypersexual or compulsive sexual behaviour disorder is not a current fashion diagnosis. Nevertheless, the introduction of dedicated diagnostic guidelines for International Classification of Diseases 11th Revision (ICD-11) brings an opportunity for more accurate diagnosis and, therefore, improved research into the disorder’s aetiology, assessment and therapy. A considerable proportion of both men and women consider themselves to have a problem with pornography and an even greater proportion experience their sexual behaviour as insufficiently controllable. For these people, the interplay between excitatory and inhibitory factors could be in dysbalance. In this context, biological correlates are important, but social factors, such as negative attitudes towards pornography or hostile attitudes to sexuality, also have a role. In patients with compulsive sexual behaviour disorder, excessive pornography consumption, masturbation and/or promiscuity that are out of control and lead to distress and impairment are usually present. Differential diagnoses, such as neuropsychiatric syndromes that can exhibit hypersexuality as a symptom, such as frontal lobe lesions, should be investigated and treated, as should comorbid disorders such as depression. Therapeutic approaches can be based on the Dual-Control Model and the Sexual Tipping Point Model. In each patient, an individualized therapeutic approach is multimodal and includes psychopharmaceuticals such as selective serotonin reuptake inhibitors and naltrexone as well as specific psychotherapeutic approaches. The efficacy of some therapeutic approaches has now also been supported by initial randomized controlled trials in this patient population.

Key points

  • Compulsive sexual behaviour disorder (CSBD) is characterized by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour accompanied by distress or significant impairment.

  • New, precise guidelines for CSBD have been developed for the International Classification of Diseases 11th Revision (ICD-11), which will facilitate the differentiation from normal variants of sexual behaviour and differential diagnostic disorders, such as increased libido in manic episodes or hypersexuality in frontal brain syndrome.

  • The current concept of CSBD can be well supported by common theoretical assumptions on sexual behaviour such as the Dual Control Model and the Sexual Tipping Point Model.

  • These theoretical models, as well as the knowledge of comorbidities and functionality of CSBD, can be used to derive an integrated model for assessment and treatment approaches, which include cognitive behavioural therapy, other psychotherapies and medications such as selective serotonin reuptake inhibitors or naltrexone.

  • Therapy addresses the balance between sexual self-control and excitation as well as underlying motivation and functionality with both psychosocial and drug-related approaches in three stages depending on the urgency and severity of the underlying mental health problems.

  • In the future, examining certain subgroups of patients with CSBD, such as those with personality disorders, will be especially valuable, but, above all, therapeutic approaches must be studied in further randomized controlled trials.

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Fig. 1: CSBD versus disorders with compulsive sexual behaviour as a symptom.
Fig. 2: Overlap between CSBD and paraphilic disorders.
Fig. 3: An integrated model of CSBD based on the Dual Control Model and the Sexual Tipping Point Model.
Fig. 4: An integrated model of CSBD therapy.
Fig. 5: Using structured diaries as an aid for patients.

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  1. Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

    Peer Briken

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Acknowledgements

P.B. was consultant for the World Health Organization (WHO) regarding the development of the ICD-11 classification of sexual disorders and sexual health. The views expressed in this article are those of the author and do not represent the official policies or positions of the WHO.

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Nature Reviews Urology thanks M. Gola, S. Kraus and E. Coleman for their contribution to the peer review of this work.

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Related links

The twelve steps (SAA): https://saa-recovery.org/our-program/the-twelve-steps/

Glossary

Hypersexuality

Level of sex drive, the frequency of sexual activity and/or the need to have sex frequently.

Sexual compulsivity

Perceived lack of control over sexual behaviour and the perception that sexual behaviour is driven.

Frontal brain syndrome

A brain disorder that is usually caused by physical damage to the frontal lobe of the brain.

Normophilic

Mainstream and socially accepted sexual interests (for example, sexual interest in adults) as distinguished from paraphilic interests (for example, sexual interest in children).

Klüver–Bucy syndrome

A brain disorder resulting from bilateral lesions of the medial temporal lobe of the brain.

Sexual preoccupation

Frequency of sexual thoughts, daydreams or dreams.

Cognitive behavioural therapy

(CBT). A form of psychotherapy that focuses on changing unhelpful thoughts and behaviours, improving emotional regulation and developing personal coping strategies.

Urge surfing

A technique that can be used to avoid acting on any behaviour that you want to reduce or stop by practicing mindfulness.

Acceptance and commitment therapy

(ACT). A form of psychotherapy that uses acceptance, mindfulness and behaviour-change strategies to increase psychological flexibility.

Mindfulness

Process of bringing one’s attention to experiences occurring in the present moment without judgement.

Sex-positive

Positive attitudes towards sex.

Transference

The concept of transference stems from psychoanalysis and describes the process by which a person unconsciously transfers and reactivates old feelings, affects, desires and fears from childhood to new relationships — for example, to the psychotherapist.

Eye Movement Desensitization and Reprocessing

A psychotherapeutic treatment method for traumatized persons.

Conflict constellations

Conflicting internal demands within the subject.

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Briken, P. An integrated model to assess and treat compulsive sexual behaviour disorder. Nat Rev Urol 17, 391–406 (2020). https://doi.org/10.1038/s41585-020-0343-7

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