CSBD, Shame and the Cycle of Compulsive Sexual Behaviour
Updated: Oct 25
By Simon Wilson, Psychotherapist and Clinical Sexologist
It can be difficult to talk about sexual behaviour when you are afraid of what another person will think of you. You might have rehearsed the conversation, decided how much to disclose, or wondered whether you could explain the problem without describing the parts that trouble you most. Even the prospect of seeking help can bring an uncomfortable question: what will this say about me?
For someone concerned about compulsive sexual behaviour, shame deserves careful attention. It may concern the behaviour itself, its consequences, the secrecy surrounding it, or what the person believes their sexuality means about them. Those are different experiences, and understanding the difference is part of the therapeutic work.
I would want to understand what somebody feels ashamed of before deciding what that shame tells us. It may accompany behaviour that has caused considerable harm. It may also surround consensual sexual interests or behaviour that do not constitute a disorder. The intensity of the feeling cannot settle that question on its own.
What shame can do to our understanding of ourselves
Psychological research commonly distinguishes shame, which involves a negative evaluation of the whole self, from guilt, which is more focused on a particular action. Someone experiencing guilt might regret having lied to their partner. Shame can turn that regret into a broader conviction that they are fundamentally dishonest, defective or beyond help. In practice, the two feelings often overlap. Tangney and colleagues’ review describes how shame can be associated with concealment and withdrawal, while guilt can support efforts to make amends.
This distinction is useful, although it should not become a rigid division into good and bad emotions. Guilt can also be excessive or misplaced. A person may feel guilty about sexual desire, masturbation or their sexual orientation without having harmed anyone.
In therapy, I would be interested in whether somebody can describe what happened with enough precision to consider what needs to change. A sweeping judgement about being a terrible person tells us relatively little about the circumstances of a particular episode, the decisions involved, or the consequences that now need attention.
How shame may become part of a repeating pattern
One possible pattern involves using sexual behaviour to find temporary relief from distress. Someone feels lonely, unsettled or inadequate, turns to pornography or another sexual activity, and experiences a brief change in how they feel. Afterwards, they may be distressed by having broken an agreement, lost time, concealed something or acted against their own intentions.
If that distress becomes an overwhelming attack on themselves, they may struggle to examine the episode. They might make an absolute promise never to repeat it, avoid thinking about it, and then find themselves poorly prepared when similar circumstances arise again.
This is a possible clinical formulation, rather than a sequence that should be assumed to explain everyone. Lew-Starowicz and colleagues’ review describes links between compulsive sexual behaviour and difficulties regulating emotion. It supports exploring the emotional function of behaviour, but does not establish that shame causes CSBD or that everybody follows the same cycle.
The order of events needs investigating. Shame might precede the behaviour, follow it, or become particularly prominent after discovery. Other factors may be more important for a particular person. A useful assessment leaves room for those differences.
For somebody who recognises this pattern, examining an episode means slowing it down. What was happening beforehand? What did the person expect the behaviour to provide? At what point did it become difficult to change direction? What happened afterwards? These questions give us something more specific to work with than another promise to exercise greater willpower.
Feeling ashamed does not establish that you have CSBD
Compulsive Sexual Behaviour Disorder concerns a persistent pattern of impaired control over repetitive sexual behaviour, with significant distress or impairment. Shame and guilt are not reliable indicators of the disorder by themselves. ICD-11 also excludes distress arising entirely from moral judgements or disapproval as a sufficient basis for diagnosis. Kraus and colleagues explain these distinctions in their account of CSBD.
Research on pornography illustrates why this matters. Some people experience distress because their behaviour conflicts with deeply held beliefs. Researchers describe this conflict as moral incongruence. Grubbs and colleagues’ systematic review and meta-analysis examined how this can contribute to feeling addicted to pornography.
That does not mean a person’s concern is imaginary, or that religious and moral beliefs should be dismissed. It means that the source of the distress needs to be understood respectfully. Therapy should allow someone to examine their values and make considered choices without imposing the therapist’s beliefs.
Moral conflict and impaired control can also coexist. Research by Lewczuk and colleagues found that difficulties with regulation, patterns of pornography use and moral incongruence each contributed to reported pornography problems. It would therefore be too simple to divide people into those with a behavioural problem and those who merely feel ashamed.
In my role as a psychotherapist, I do not provide a formal medical or psychiatric diagnosis. Psychosexual assessment and formulation help us understand the difficulty and identify when medical or psychiatric assessment may be needed. My broader article on sex addiction and CSBD explains this assessment process in more detail.
Taking responsibility when someone else has been hurt
Working with shame requires particular care when there has been deception, broken relationship agreements or harm to another person. Someone may worry that becoming less self-critical would mean letting themselves off. Their partner may understandably be concerned that psychological explanations will become excuses.
My view is that therapeutic work should keep the consequences clearly in sight. Understanding the circumstances of a behaviour does not remove responsibility for it. Where conduct is unsafe, non-consensual or illegal, addressing safety and preventing further harm must take priority.
Responsibility needs to become specific: acknowledging what happened, recognising its impact, changing harmful behaviour and accepting that another person has choices about the relationship. Expressions of self-hatred cannot substitute for those tasks.
I would also want to notice whether a conversation repeatedly moves away from the affected partner’s experience and towards reassuring the person who feels ashamed. That can happen without being deliberate, but the effect still deserves attention. A partner should not be expected to provide reassurance, forgive, resume sexual intimacy or remain in a relationship to support someone else’s treatment.
There may be separate therapeutic needs here. The person concerned about their behaviour may need help understanding and changing it, while their partner needs space to consider what has happened and what they want. I discuss that perspective further in Supporting Partners Following Sexual Betrayal.
What working with shame in therapy can involve
The starting point is an assessment in which difficult material can be discussed without humiliation. Contemporary sexual-medicine guidance recommends a respectful, sexologically informed approach and cautions against treatment that reinforces moralising or negative attitudes towards sexuality. Briken and colleagues also emphasise that treatment should support a satisfying sexual life alongside addressing impaired control and harmful consequences.
From there, the work depends on the individual formulation. I might explore how someone speaks to themselves after an episode, what they fear would happen if they were more open in therapy, or whether they can acknowledge a problem without turning it into a judgement about their entire identity. Where distress appears to contribute to the behaviour, we would consider other ways of responding to it. Practical work on routines, triggers and opportunities to make different choices may also be necessary.
These are possible elements of treatment, not evidence that reducing shame alone will resolve CSBD. A systematic review by Antons and colleagues found encouraging treatment evidence, particularly for approaches containing cognitive behavioural components, while identifying substantial limitations in the research. A thoughtful clinical rationale should not be presented as a proven cure.
Progress would need to be considered in everyday life. Is the person becoming more able to discuss difficulties honestly? Can they recognise a developing pattern and respond differently? Are they following through on changes, respecting boundaries and taking account of other people? Feeling less ashamed may be valuable, but it is only one part of that picture.
You do not need to resolve all of this before seeking help. It is enough to say that something about your sexual behaviour, or your feelings about it, has become difficult to manage. An initial conversation can begin with that uncertainty and work towards a clearer understanding of what needs attention.
References
Antons, S., Engel, J., Briken, P., Krüger, T. H. C., Brand, M., & Stark, R. (2022). Treatments and interventions for compulsive sexual behavior disorder with a focus on problematic pornography use: A preregistered systematic review. Journal of Behavioral Addictions, 11(3), 643–666. Article.
Briken, P., et al. (2024). Assessment and treatment of compulsive sexual behavior disorder: A sexual medicine perspective. Sexual Medicine Reviews, 12(3), 355–370. Article.
Grubbs, J. B., Perry, S. L., Wilt, J. A., & Reid, R. C. (2019). Pornography problems due to moral incongruence: An integrative model with a systematic review and meta-analysis. Archives of Sexual Behavior, 48(2), 397–415. Article.
Kraus, S. W., et al. (2018). Compulsive sexual behaviour disorder in the ICD-11. World Psychiatry, 17(1), 109–110. Article.
Lewczuk, K., Glica, A., Nowakowska, I., Gola, M., & Grubbs, J. B. (2020). Evaluating pornography problems due to moral incongruence model. The Journal of Sexual Medicine, 17(2), 300–311. Article.
Lew-Starowicz, M., Lewczuk, K., Nowakowska, I., Kraus, S. W., & Gola, M. (2020). Compulsive sexual behavior and dysregulation of emotion. Sexual Medicine Reviews, 8(2), 191–205. Article.
Tangney, J. P., Stuewig, J., & Mashek, D. J. (2007). Moral emotions and moral behavior. Annual Review of Psychology, 58, 345–372. Article.
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