Sex Addiction and Compulsive Sexual Behaviour Disorder (CSBD): Understanding, Assessment and Treatment

By Simon Wilson, psychotherapist and clinical sexologist.

People often come to therapy saying that they think they are “addicted to sex” or “addicted to pornography”. Sometimes they have used those words for years. Sometimes they have only recently started searching online and have found that “sex addiction” is the phrase that most closely resembles what they are experiencing.

It is understandable that people use this language. Sex addiction is still the term most commonly encountered in the media, online searches and self-help material. Clinically, however, the picture is more complicated. Professionals do not all use the same terminology, and they do not necessarily understand the underlying problem in the same way.

The World Health Organization recognises Compulsive Sexual Behaviour Disorder, usually shortened to CSBD, within ICD-11. It describes a persistent pattern in which someone repeatedly struggles to control intense sexual impulses or urges, leading to repetitive sexual behaviour and significant problems in their life.

That sounds relatively straightforward, but in practice assessment requires considerable care. Having a strong sex drive is not a disorder. Neither is frequent masturbation, regular pornography use, multiple sexual partners or an unconventional but consensual sexual life. The difficulty lies in distinguishing sexual behaviour that is frequent or important to somebody from behaviour that has become persistently difficult to control and continues despite consequences.

This distinction is central to how I approach the work. I do not begin with the assumption that somebody is a sex addict simply because they describe themselves that way. Equally, I would not dismiss their concern because sexuality itself is normal. The more useful question is what is actually happening in that person's life and what function their sexual behaviour has come to serve.

What is Compulsive Sexual Behaviour Disorder?

The ICD-11 description of CSBD focuses principally on impaired control. The person repeatedly experiences difficulty controlling sexual impulses or urges and engages in sexual behaviour in ways that become increasingly central to their life. Attempts to reduce or change the behaviour may repeatedly fail. They may continue despite damage to relationships, work, health or other areas of functioning, and in some cases the behaviour continues even when it is no longer particularly satisfying.

The pattern is generally expected to have been present for at least six months and to cause marked distress or significant impairment (World Health Organization, 2024; Kraus et al., 2018).

There is no particular sexual behaviour that defines CSBD. For one person it may involve pornography and masturbation. For another it may involve repeated online sexual activity, sexual encounters, affairs or a combination of behaviours. What matters clinically is not the behaviour in isolation, but the degree of control the person has over it and what happens when they try to change.

This is also why sexual frequency alone tells us very little. Somebody can have a very high level of sexual desire and remain perfectly capable of making choices about their behaviour. Another person may engage less frequently but experience the behaviour as intrusive, compulsive and repeatedly contrary to their own intentions.

Contemporary sexual-medicine specialists have warned against pathologising high sexual desire or consensual sexual behaviour simply because it falls outside conventional expectations (Briken et al., 2024). Sexuality varies enormously between people, and diagnostic language should not become a way of imposing somebody else's moral or cultural expectations on an individual's sexual life.

Is CSBD the same as sex addiction?

The terms sex addiction, compulsive sexual behaviour and CSBD are often used as though they mean exactly the same thing. In everyday conversation they often do. Someone who says “I think I'm a sex addict” may simply be trying to describe the experience of repeatedly doing something sexual that they feel unable to control.

Professionally, there are differences.

CSBD is recognised within ICD-11 and is currently classified as an impulse control disorder rather than as an addictive disorder. It is not included as a formal diagnosis in DSM-5-TR. Some clinicians and researchers nevertheless believe that particular presentations resemble behavioural addictions, particularly where there is craving, impaired control and continued behaviour despite harmful consequences.

Other clinicians understand similar difficulties through the language of compulsivity, impulsivity, emotional regulation, learned behaviour, trauma, attachment, relationship difficulties or combinations of several of these.

I do not think it is especially helpful to correct a client who arrives using the term “sex addiction”. That may be the language that has enabled them to ask for help in the first place. What matters is not winning an argument about terminology but understanding what lies underneath it.

Different people can use the same phrase while describing quite different psychological problems.

One person may have become increasingly dependent on pornography and masturbation as a way of switching off from anxiety or loneliness. Another may describe powerful sexual urges followed by repeated impulsive behaviour. Another may be involved in a pattern of secrecy and sexual encounters that has seriously damaged a relationship. Somebody else may be deeply distressed about relatively ordinary sexual behaviour because it conflicts with their religious or moral beliefs.

These presentations require different formulations, even though every one of those people might initially type “sex addiction treatment” into Google.

Porn addiction, problematic pornography use and moral conflict

Pornography is one of the areas where this distinction becomes particularly important.

There are people whose pornography use is genuinely difficult to control. They may spend increasing amounts of time viewing pornography, repeatedly attempt to stop and continue despite consequences for relationships, work or sexual functioning. For some, problematic pornography use forms part of a broader pattern of CSBD.

But frequent pornography use is not, on its own, evidence of a disorder.

Research into moral incongruence has helped clarify why this matters. Grubbs and colleagues have shown that some people's distress about pornography is influenced not only by how they use it but also by conflict between their behaviour and their moral, cultural or religious beliefs (Grubbs et al., 2019).

The ICD-11 criteria explicitly state that distress based entirely on moral judgement or disapproval is not enough to diagnose CSBD.

That does not mean the distress is unimportant. It means that the source of the distress needs to be understood properly.

A person who is unable to control their behaviour despite repeated attempts may need one form of intervention. Someone whose distress is primarily driven by guilt, shame or moral conflict may need something rather different.

Why does compulsive sexual behaviour develop?

There is no single established cause of CSBD.

That may sound unsatisfactory, but it is clinically useful. It means we should resist simplistic explanations. Claims that sex addiction is always caused by trauma, or that pornography inevitably rewires the brain into addiction, are not supported by the evidence.

I find it more useful to think in biopsychosocial terms and to ask how the pattern has developed for the individual in front of me.

Emotional regulation is one important area. Sexual arousal and sexual behaviour can alter emotional states very quickly. For some people, pornography, masturbation or sexual encounters become ways of responding to anxiety, loneliness, boredom, shame, anger or emotional distress.

Lew-Starowicz and colleagues reviewed the relationship between compulsive sexual behaviour and difficulties with emotional regulation and found meaningful associations, while also noting that the evidence remains developing (Lew-Starowicz et al., 2020).

For some clients, a recognisable pattern emerges in which distress is followed by sexual behaviour, the sexual behaviour produces short-term relief, and the consequences then generate further distress. That can become a self-reinforcing cycle. It is a useful formulation when it fits, but it should not be treated as an explanation for everybody.

Trauma is another area where caution is needed.

Research has found associations between childhood sexual abuse and later compulsive sexual behaviour (Slavin et al., 2020). However, association does not mean that trauma causes CSBD in any simple or inevitable way. Most people who experience childhood sexual abuse do not develop compulsive sexual behaviour, and some people with CSBD report no significant history of sexual trauma.

A trauma-informed therapist should be prepared to explore trauma where it is relevant without assuming in advance that trauma must be the explanation.

The same applies to attachment, shame, impulsivity and neurodivergence. These may be important parts of somebody's psychological history and may help us understand why a particular pattern has developed, but they should emerge from assessment rather than being imposed as a ready-made theory.

Assessment of compulsive sexual behaviour

A specialist psychosexual assessment needs to do more than count how often somebody watches pornography or has sex.

I would want to understand when the behaviour began, how it has changed over time, what happens before and afterwards, whether the person has tried to stop, what consequences have occurred and what makes control easier or more difficult.

I would also want to understand the wider context of their life: relationships, intimacy, mood, anxiety, impulsivity, alcohol or substance use, ADHD or other neurodevelopmental factors, trauma where relevant, medication, physical health, sexual interests, cultural or religious beliefs, and any safeguarding or sexual risk concerns.

It is important to be clear about the distinction between assessment and diagnosis. In my role as a psychotherapist, I do not provide a formal medical or psychiatric diagnosis. Psychosexual assessment is used to understand and formulate the person's difficulties, consider whether their presentation is consistent with recognised clinical descriptions such as CSBD, and identify when medical or psychiatric assessment by another appropriately qualified professional may be needed.

That broader assessment matters because not every apparent case of compulsive sexual behaviour is best understood as CSBD.

Changes in sexual behaviour can sometimes occur in association with mania or hypomania, substance use, neurological conditions or medication effects. In those circumstances, a psychosexual formulation on its own would be insufficient and medical or psychiatric assessment may be necessary.

Questionnaires can be helpful as part of this process. The Compulsive Sexual Behavior Disorder Scale, the CSBD-19, was developed specifically around the ICD-11 criteria and has been tested across large international samples (Bőthe et al., 2020). It can help identify patterns that deserve further exploration, but it does not replace clinical judgement.

A score on a questionnaire is not the same thing as understanding a person.

Treatment for CSBD and sex addiction

The treatment evidence for CSBD is promising but still relatively young.

A systematic review published by Antons and colleagues in 2022 identified 24 studies examining treatment for CSBD and problematic pornography use. Only four were randomised controlled trials. The review found encouraging evidence, particularly for interventions that contained cognitive behavioural components, but the authors were appropriately cautious because of methodological weaknesses in the research.

A later meta-analysis of psychotherapy for problematic pornography use also found evidence of benefit, particularly from cognitive behavioural therapy (CBT) and Acceptance and Commitment Therapy, although problematic pornography use is not identical to CSBD and the authors again noted limitations in the available studies (López-Pinar et al., 2025).

This means that we have reason to believe therapy can help, but we should not pretend that one model has been conclusively established as the treatment for every presentation.

Where impaired control is central, therapy may focus initially on recognising triggers, understanding behavioural patterns, developing strategies for managing urges and creating more space between impulse and action.

For some people that work is relatively behavioural.

For others it quickly becomes clear that the sexual behaviour is connected with wider psychological difficulties. If somebody is using sexual behaviour to regulate distress, then emotional regulation may need attention. If trauma is genuinely involved, trauma-focused work may become appropriate. If shame is prominent, it may need to be addressed carefully so that responsibility can be developed without reinforcing the belief that the person is fundamentally defective.

These broader psychotherapeutic approaches should not be represented as though they have the same direct research evidence for treating CSBD as CBT-based interventions currently have. They may nevertheless be entirely appropriate when they arise from a thoughtful individual formulation.

That distinction matters to me. Evidence should guide treatment, but treatment should still be of a person rather than merely of a diagnostic label.

CSBD, sex addiction and relationships

Compulsive sexual behaviour often has a relational dimension, particularly when there has been secrecy, deception or sexual activity outside agreed relationship boundaries.

At that point there may be two therapeutic tasks rather than one.

The individual may need help understanding and changing their sexual behaviour. Their partner may be dealing with shock, anger, mistrust, questions about sexual health, uncertainty about what is true and profound doubt about the future of the relationship.

Couple therapy can be valuable in those circumstances, but it is useful to be precise about what it is doing. Couple therapy is not necessarily treating CSBD itself. It may be treating the relational consequences of the behaviour: betrayal, damaged trust, communication breakdown and loss of intimacy.

Sometimes a couple will decide to rebuild. Sometimes therapy helps them establish that the relationship cannot continue. Either way, the work should not be reduced to simply getting the person with the sexual behaviour problem to stop.

Responsibility, risk and safeguarding

Being sex-positive does not mean being uncritical about sexual behaviour.

There are situations in which behaviour is illegal, non-consensual, unsafe or presents a risk to another person. Those circumstances require direct attention to safeguarding, risk and responsibility.

Similarly, understanding why somebody behaves as they do does not remove accountability.

I see a clear difference between shame and responsibility. Shame tells somebody that they are fundamentally bad. Responsibility asks them to understand what they have done, recognise its impact and make different choices.

In clinical work, reducing shame and increasing responsibility can happen at the same time.

Does recovery from sex addiction or CSBD mean abstinence?

Usually, no.

This is one area where the language of addiction can sometimes be misleading. Sexuality is not something that most people need to eliminate from their lives.

For many clients, the aim is not to become less sexual. It is to become more able to choose how they express their sexuality.

That may mean reducing or stopping particular behaviours. Where behaviour is illegal, non-consensual, unsafe or seriously damaging, stopping it may be essential. But that is different from treating sexuality itself as the problem.

Contemporary sexual-medicine guidance argues for an approach that supports positive, safe and pleasurable sexuality rather than reinforcing sexual shame (Briken et al., 2024).

For me, a useful measure of progress is not simply how many times somebody has masturbated or watched pornography. I would also want to know whether they feel more in control, whether secrecy has reduced, whether relationships are healthier, whether sexual behaviour is less driven by distress and whether the choices they make increasingly feel like actual choices.

When might specialist help be useful?

It may be worth seeking assessment if sexual behaviour repeatedly feels outside your control; if you have tried to change it several times without success; if it is beginning to interfere with relationships, work or wellbeing; if secrecy has become a significant part of your life; or if you continue despite consequences that you genuinely want to avoid.

It can also be useful simply because you are unsure what is happening.

You may believe that you have a sex addiction and discover that CSBD is a useful framework for understanding your difficulties. You may discover that pornography has become problematic without your difficulties fitting that framework. You may realise that shame or moral conflict is playing a much larger role than you had appreciated.

A good assessment does not need to end with a diagnosis in order to be useful.

Many people begin therapy asking, “Why can't I just stop?”

I tend to think a better question is: “What happens when this becomes difficult for me to control?”

That question leaves room for the complexity of sexuality. It allows us to understand what the behaviour means, how it developed, what keeps it going and what would genuinely need to change.

It also avoids two equally unhelpful extremes: treating every difficult sexual behaviour as addiction, and dismissing genuine suffering because sexuality itself is normal.

The work lies somewhere more thoughtful in between.

You can read more about therapy for compulsive sexual behaviour and what happens in therapy, or request an initial consultation.

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. https://doi.org/10.1556/2006.2022.00061

Bőthe, B., Potenza, M. N., Griffiths, M. D., Kraus, S. W., Klein, V., Fuss, J., & Demetrovics, Z. (2020). The development of the Compulsive Sexual Behavior Disorder Scale (CSBD-19): An ICD-11 based screening measure across three languages. Journal of Behavioral Addictions, 9(2), 247–258. https://doi.org/10.1556/2006.2020.00034

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. https://doi.org/10.1093/sxmrev/qeae014

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. https://doi.org/10.1007/s10508-018-1248-x

Kraus, S. W., Krueger, R. B., Briken, P., First, M. B., Stein, D. J., Kaplan, M. S., Voon, V., Abdo, C. H. N., Grant, J. E., Atalla, E., & Reed, G. M. (2018). Compulsive sexual behaviour disorder in the ICD-11. World Psychiatry, 17(1), 109–110. https://doi.org/10.1002/wps.20499

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. https://doi.org/10.1016/j.sxmr.2019.10.003

López-Pinar, C., Esparza-Reig, J., & Bőthe, B. (2025). Psychotherapy for problematic pornography use: A comprehensive meta-analysis. Journal of Behavioral Addictions, 14(2), 630–643. https://doi.org/10.1556/2006.2025.00018

Slavin, M. N., Scoglio, A. A. J., Blycker, G. R., Potenza, M. N., & Kraus, S. W. (2020). Child sexual abuse and compulsive sexual behavior: A systematic literature review. Current Addiction Reports, 7(1), 76–88. https://doi.org/10.1007/s40429-020-00298-9

World Health Organization. (2024). Clinical descriptions and diagnostic requirements for ICD-11 mental, behavioural and neurodevelopmental disorders. World Health Organization.