What the WHO says about compulsive sexual behaviour

ICD-11 is the WHO's International Classification of Diseases. It was adopted by the World Health Assembly in 2019 and came into effect on 1 January 2022. Compulsive sexual behaviour disorder, code 6C72, sits in its chapter on mental, behavioural or neurodevelopmental disorders, in the group of impulse control disorders.

The WHO's description begins: “Compulsive sexual behaviour disorder is characterised by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour.”

Signs can include sexual activity becoming a central focus of life, to the point of neglecting health, personal care or other responsibilities; “numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour”; and carrying on despite adverse consequences, or while getting little or no satisfaction from it. The pattern lasts “over an extended period of time (e.g., 6 months or more)” and causes marked distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

The WHO notes that the disorder “may be expressed in a variety of behaviours,” and lists use of pornography among them. It is just as specific about what does not count:

• “Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient” for the diagnosis.
• People with “high levels of sexual interest and behaviour (e.g., due to a high sex drive)” who keep control, and are not significantly distressed or impaired, “should not be diagnosed.”
• Brief periods, “up to several months,” of more sexual behaviour during a life change that brings new opportunities, such as moving to a new city or a change in relationship status, are not enough on their own.
• People who judge their own sexual behaviour on religious or moral grounds may describe themselves as “sex addicts.” The WHO says it is important to check carefully whether impaired control is actually present.

In a 2018 article in World Psychiatry, Shane Kraus and colleagues explained the classification. They placed the disorder with impulse control disorders because “we do not yet have definitive information” on whether the processes involved are the same as in substance use disorders. They hoped the diagnosis would help people who seek treatment and “reduce shame and guilt associated with help seeking.”

A 2018 study in JAMA Network Open measured how common this kind of distress is in the United States. Janna Dickenson and colleagues surveyed 2,325 adults aged 18 to 50, randomly sampled from all 50 states in November 2016, using a questionnaire called the Compulsive Sexual Behavior Inventory. 8.6% scored 35 or more out of 65, the cut-off for clinically relevant distress or impairment: 10.3% of men and 7.0% of women. The authors note that the questionnaire is a screening tool, so a high score signals a high probability of meeting the criteria rather than a diagnosis.