# 175 - 6C72 Compulsive sexual behaviour disorder # 6C72 Compulsive sexual behaviour disorder Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Boundary with the effects of psychoactive substances, including medications Episodes of stealing may occur during substance intoxication. Individuals taking prescribed dopamine agonists – for example, for Parkinson disease or restless legs syndrome – may exhibit repetitive stealing behaviour with onset corresponding to use of the medication. Kleptomania should not be diagnosed if stealing is better accounted for by intoxication or the disinhibiting effects of alcohol, drugs or medication. However, among individuals with kleptomania, alcohol and substance use may be associated with acts of theft or attempted theft. The presence of features of kleptomania outside of episodes of intoxication is helpful in making this distinction. Boundary with disinhibition in dementia and secondary personality change Some individuals with dementia or secondary personality change may steal objects as a part of a more general pattern of disinhibition of impulse control due to brain damage. A separate diagnosis of kleptomania should not be assigned in such cases. Boundary with disorders associated with impairment of cognitive or intellectual functioning Some individuals with dementia, disorders of intellectual development, or cognitive or intellectual impairment associated with other conditions may steal objects due to their impaired judgement without exhibiting the other features of kleptomania. Compulsive sexual behaviour disorder Essential (required) features • The presentation is characterized by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour, manifested in one or more of the following. • Engaging in repetitive sexual behaviour has become a central focus of the individual’s life to the point of neglecting health and personal care or other interests, activities and responsibilities. • The individual has made numerous unsuccessful efforts to control or significantly reduce repetitive sexual behaviour. • The individual continues to engage in repetitive sexual behaviour despite adverse consequences (e.g. marital conflict due to sexual behaviour, financial or legal consequences, negative impact on health). • The individual continues to engage in repetitive sexual behaviour even when they derive little or no satisfaction from it. • The pattern of failure to control intense, repetitive sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g. 6 months or more). • The pattern of failure to control intense, repetitive sexual impulses or urges and resulting repetitive sexual behaviour is not better accounted for by another mental disorder (e.g. a manic episode) or other medical condition, and is not due to the effects of a substance or medication. 6C72 Impulse control disorders | Compulsive sexual behaviour disorder 527 Impulse control disorders • The pattern of repetitive sexual behaviour results in marked distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. If functioning is maintained, it is only through significant additional effort. Distress that is entirely related to moral judgements and disapproval about sexual impulses, urges or behaviours is not sufficient to meet this requirement. Additional clinical features • Compulsive sexual behaviour disorder may be expressed in a variety of behaviours, including sexual behaviour with others, masturbation, use of pornography, cybersex (internet sex), telephone sex and other forms of repetitive sexual behaviour. • Individuals with compulsive sexual behaviour disorder often engage in sexual behaviour in response to feelings of depression, anxiety, boredom, loneliness or other negative affective states. Although not diagnostically determinative, consideration of the relationship between emotional and behavioural cues and sexual behaviour may be an important aspect of treatment planning. • Individuals who make religious or moral judgements about their own sexual behaviour or view it with disapproval, or who are concerned about the judgements and disapproval of others or about other potential consequences of their sexual behaviour, may describe themselves as “sex addicts” or describe their sexual behaviour as “compulsive” or similar terms. In such cases, it is important to examine carefully whether such perceptions are only a result of internal or external judgements or potential consequences, or whether there is evidence that impaired control over sexual impulses, urges or behaviours and the other diagnostic requirements of compulsive sexual behaviour disorder are actually present. Boundary with normality (threshold) • There is wide variation in the nature and frequency of individuals’ sexual thoughts, fantasies, impulses and behaviours. This diagnosis is only appropriate when the individual experiences intense, repetitive sexual impulses or urges that are experienced as irresistible or uncontrollable, leading to repetitive sexual behaviour, and when the pattern of repetitive sexual behaviour results in marked distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. Individuals with high levels of sexual interest and behaviour (e.g. due to a high sex drive) who do not exhibit impaired control over their sexual behaviour and significant distress or impairment in functioning should not be diagnosed with compulsive sexual behaviour disorder. The diagnosis should also not be assigned to describe high levels of sexual interest and behaviour (e.g. masturbation) that are common among adolescents, even when this is associated with distress. • Compulsive sexual behaviour disorder should not be diagnosed based on distress related to moral judgements and disapproval about sexual impulses, urges or behaviours that would otherwise not be considered to be indicative of psychopathology (e.g. a woman who believes that she should not have sexual impulses at all; a religious young man who believes Impulse control disorders | Compulsive sexual behaviour disorder Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders that he should never masturbate; a person who is distressed about their homosexual attraction or behaviour). Similarly, compulsive sexual behaviour disorder cannot be diagnosed based solely on distress related to real or feared social disapproval of sexual impulses or behaviours. • Compulsive sexual behaviour disorder should not be diagnosed based solely on relatively brief periods (e.g. up to several months) of increased sexual impulses, urges and behaviours during transitions to contexts that involve increased availability of sexual outlets that previously did not exist (e.g. moving to a new city, a change in relationship status). Course features • Many individuals with compulsive sexual behaviour disorder report a history of sexually acting out during pre-adolescence or adolescence (e.g. risky sexual behaviour, masturbation to modulate negative affect, extensive use of pornography). Developmental presentations • Compulsive sexual behaviour disorder in adulthood has been associated with high rates of childhood traumas, including sexual abuse, with women reporting higher rates and severity of abuse. • Adolescents and adults with compulsive sexual behaviour disorder commonly experience high rates of co-occurring mental, behavioural and neurodevelopmental disorders, including disorders due to substance use. • Assessing the presence of compulsive sexual behaviour disorder may be particularly challenging during adolescence due to divergent views regarding the appropriateness of sexual behaviour during this life stage. Increased frequency of sexual behaviour or uncontrolled sexual urges associated with rapidly changing hormonal levels during this developmental stage may be considered to reflect normal adolescent experiences. Conversely, frequent or risky sexual behaviour among adolescents may be considered abnormal due to the potential for the behaviour to interfere with social and emotional development. Culture-related features • Cultural and subcultural variation may exist for compulsive sexual behaviour. Norms for what is considered appropriate sexual behaviour, activities judged unacceptable, and perceptions regarding gender roles influence sexual activity. These factors may affect norms regarding masturbation, use of pornography, having multiple sexual partners concurrently and the number of lifetime sexual partners. Impulse control disorders | Compulsive sexual behaviour disorder 529 Impulse control disorders • Culture shapes the distress caused by engaging in sexual behaviour and whether sexual activity is viewed as disordered. For example, in cultures where masculine ideals are associated with sexual conquest, higher rates of sexual behaviour may be considered normative, and should not be the primary basis for assigning a diagnosis. Sex- and/or gender-related features • Men are more likely to be diagnosed with compulsive sexual behaviour disorder. • Women with compulsive sexual behaviour disorder are more likely than men to report a history of childhood sexual abuse. Boundaries with other disorders and conditions (differential diagnosis) Boundary with bipolar and related disorders Increased sexual impulses, urges or behaviours and impaired ability to control them can occur during manic, mixed or hypomanic episodes. A diagnosis of compulsive sexual behaviour disorder should only be assigned if there is evidence of persistent failure to control intense, repetitive sexual impulses, urges or behaviours and the presence of all other diagnostic requirements outside of mood episodes. Boundary with obsessive-compulsive disorder Although the word “compulsive” is included in the name of this condition, sexual behaviour in compulsive sexual behaviour disorder is not considered to be a true compulsion. Compulsions in obsessive-compulsive disorder are almost never experienced as inherently pleasurable; they commonly occur in response to intrusive, unwanted and typically anxiety-provoking thoughts, which is not the case with sexual behaviour in compulsive sexual behaviour disorder. Boundary with personality disorder Some individuals with personality disorder may engage in repetitive sexual behaviour as a maladaptive regulation strategy (e.g. to prevent or reduce emotional distress or to stabilize their sense of self). Although both diagnoses can be assigned together, if the sexual behaviour is entirely accounted for by emotion dysregulation or other core features of personality disorder, an additional diagnosis of compulsive sexual behaviour disorder is not warranted. Boundary with paraphilic disorders The core feature of compulsive sexual behavioural disorder is a persistent pattern of failure to control intense repetitive sexual impulses or urges resulting in repetitive sexual behaviour that results in marked distress or impairment in functioning. Paraphilic disorders, on the other hand, are characterized by persistent and intense patterns of atypical sexual arousal manifested in sexual thoughts, fantasies, urges or behaviours, and have resulted in actions towards individuals whose age or status renders them unwilling or unable to consent, or are associated with marked distress or significant risk of injury or death. If an individual with a paraphilic disorder is able to exercise Impulse control disorders | Compulsive sexual behaviour disorder