CSBD/Sex & Porn Addiction in 2025: Is the picture any clearer?

CSBD (Compulsive Sexual Behaviour Disorder) was accepted by WHO into the ICD-11 in 2019 and, since its inclusion, research has proliferated. This is perhaps in part due to the desire to resolve ongoing controversies around nomenclature and classification, but also because academics now have a legitimate condition to research. And with just under 5% of the world’s population meeting the criteria for CSBD ¹, more research is desperately needed. This blog provides an overview of research published over the previous four years, focussing on classification, assessment and treatment.

In 2020, Joshua Grubbs published a systematic 25-year review of “Sexual Addiction”, named as such because the label of CSBD was still in its infancy. Reviewing 330 empirical studies, the paper concluded that there was clear evidence that CSBD is a real phenomenon with clinical implications ². However, he went on to say that in spite of the acceleration in research over the previous 25 years, there was a lack of theoretical integration, deficits in methodological rigour, a paucity of clinical samples and widespread inconsistencies in definitions and measurement of CSBD and a lack of treatment studies. Fortunately, over the past 4 years, these issues are beginning to be addressed.

Assessment

The CSBD-19 is becoming the most popular screening tool being used in research as well as by a growing number of organisations, including the Laurel Centre. Based on the ICD-11 diagnostic criteria, the tool was developed and validated through The International Sex Survey ³ which took place across 42 countries, 5 continents and involved over 80,000 participants. Further research from the survey continues to emerge and has been particularly beneficial for exploring CSBD within non-WEIRD countries and within sexually diverse populations. However, misdiagnosis continues to be a challenge within this field.

Further to Joshua Grubbs seminal work on moral incongruence ⁴, other researchers have gone on to demonstrate the impact of religion ⁵, cultural differences ⁶, minority stress ⁷ and sexual attitudes ⁸. Health professionals can also be prone to misdiagnosis, especially if they have no training in this field and are not using a recognised screening tool ⁹. This really does emphasise the importance of using robust screening tools such as the CSBD-19 and ensuring a detailed assessment, including a sexual assessment, is undertaken. But either way, these sub-clinical populations can still be supported therapeutically to address their concerns with their sexual behaviour.

Classification

While misdiagnosis of CSBD is an area that requires further research and greater training of health professionals, this is a separate issue to that of classification. Whether CSBD is best understood as an impulse control disorder, a compulsive disorder or an addictive disorder, errors in assessment can still occur.

Following 25 years of active research, CSBD was included in the ICD-11 as an impulse control disorder. Previous attempts to categorise the disorder in previous editions of ICD and DSM have included sex addiction, excessive sex drive and hypersexuality. The phenomenon of ‘out of control sexual behaviours’ has been recognised for many years and whilst the ICD-11 Working Group agreed on the relevance of the disorder, it was less clear how to name it, classify it and operationalise it. Although ‘compulsivity’ is in the name, WHO acknowledged that this was not a true compulsion akin to OCD (Obsessive Compulsive Disorder) as the primary goal is seeking pleasure, rather than reducing discomfort. Without evidence of withdrawal and tolerance the classification of an addictive disorder was not appropriate, although the diagnostic criteria include four of Griffith’s six signs of addiction. However, the listing under impulse control disorders is contradicted by the inclusion of ‘deriving little or no satisfaction from the behaviour’, since pleasure seeking is a criterion for all other impulsive disorders.

Another concern raised by researchers is the absence of a criterion relating to emotional regulation in spite of research demonstrating links between CSBD and other mental health disorders ^10,11. These ongoing challenges in determining the most accurate classification can be summarised by comparing the common characteristics of CSBD with other recognised and accepted impulsive, compulsive and addictive disorders within ICD-11.  

Research attempting to secure an accurate classification continues and currently there are significantly more papers supporting behavioural addiction than those challenging it.  Hence the general trend is towards an addition framework and WHO have always made it clear that “the etiology, diagnostic classification, assessment, and treatment of CSBD will continue to evolve as we gain new insights from future research efforts” adding “we anticipate that re­maining controversies will be resolved over the next few years as scholarship on the disorder and related clinical experience con­tinues to grow exponentially” ¹². 

As we will come on to explore in the next section on treatment, there are a variety of treatment approaches for unwanted behaviours, whether impulsive, compulsive or addictive, that have previously been proven effective. Hence the more we are able to understand the underlying mechanisms, the more confident clinicians can be incorporating these evidence-based treatment approaches into their work. Furthermore, an understanding of the different neurological pathways involved may help us to consider appropriate pharmacological interventions that have previously demonstrated efficacy. In spite of the lack of diagnostic criteria regarding emotional regulation, for psychotherapeutic clinicians, treatment will also include exploration of psychological and emotional drivers, many of which may relate to trauma or attachment issues.  

Treatment

Despite the universal call for evidence-based therapeutic interventions for CSBD, the historic and ongoing controversy that surrounds the condition has too often hindered progress. However, that situation is also beginning to change. A number of review papers have been undertaken exploring therapeutic approaches ¹³ and pharmaceutical interventions ¹⁴, and the Laurel Centre have been very pleased to contribute to this body of research through the publication of our peer reviewed efficacy study on the residential recovery course and more recently, the pilot study results from Pivotal Recovery.

What all this research highlights is that the complexity of CSBD not only hinders accurate classification, but also our ability to develop universal treatment objectives and therefore measures of treatment efficacy. This extends not only to the treatment of the compulsive behaviours but also to how we work with the impact on relationships.

Conclusion

Research in the field of CSBD continues to accelerate, but in the meantime, we are still some way from having a clearly defined picture of how it should be classified, assessed and treated. Furthermore, there is still a considerable shortage of research in some areas, including the impact on partners and how CSBD inter-relates with other conditions, including sexual dysfunctions, ADHD, ASD and sexual offending.

While research continues, clinicians should endeavour to remain open-minded and up-to-date with the latest thinking and maintain a client focus at all times. As we continue to learn from research it is essential that clinical judgement is used to differentiate between the many ways that people present with CSBD including sub-clinical populations with moral incongruence. There are a number of different treatment methods that have demonstrated efficacy and thorough assessment and sensitivity is required to determine which approach is likely to be most beneficial for each individual. 

If you’re interested in training in working with CSBD, why not take a look at our accredited diploma. We ensure we’re always up to date with ongoing research and update our training accordingly. Next month, we’ll be running our next online Tutor Tuesday where you can learn more about this course and ask our tutors any questions with no strings attached. Please use the buttons below to learn more and sign up.

References

1. 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 Addiction, 9 (2): 247-258. ↩︎
2. Grubbs J.B., Hoagland C, Lee B.N., Grant J.T., Davison P.M., Reid R.C., et al. (2020) Sexual addiction 25 years on: a systematic review of empirical literature on compulsive sexual behavior and an agenda for future research. Clinical Psychology Review 82: 1-15. ↩︎
3. Bőthe B, Koós M, Nagy L, Kraus SW, Potenza MN, Demetrovics Z. (2021). International sex survey: study protocol of a large, cross-cultural collaborative study in 45 countries. Journal of Behavioral Addictions, 10(3): 632–45. ↩︎
4. Grubbs, J.B., Perry, S.L., Wilt, J.A., (2019). Pornography problems due to moral incongruence: An integrative model with a systematic review and meta-analysis. Archives of  Sexual  Behaviour, 48: 397-415. ↩︎
5. Coleman, E., Jennings, T., Gleason, N., Danielson, S., Nielsen, K., Milner, M., Ryan, L., Rahm-Knigge. (2023) The relationship between compulsive sexual behavior, religiosity, and moral disapproval. Journal of Sex & Marital Therapy, 49 (3) 314-330. ↩︎
6. Briken, P., Wiessner, C., Stuhlhofer, A., Klein, V., Fuß, J., Reed, G., Dekker, A., (2022). Who feels affected by “out of control” sexual behavior? Prevalence and correlates of indicators for ICD-11 Compulsive Sexual Behavior Disorder in the German Health and Sexuality Survey. Journal of Behavioral Addiction, 11: 900–911. ↩︎
7. Jennings, T.L., Gleason, N., & Kraus, S.W. (2022). Assessment of compulsive sexual behavior disorder among lesbian, gay, bisexual, transgender, and queer clients – commentary to the debate: “Behavioral addictions in the ICD-11”. Journal of Behavioral Addictions, 11(2), 216-221. ↩︎
8. Lewczuk, K., Wizła, M., Gola, M., (2022). The relation of sexual attitudes to hypersexuality and problematic pornography use. Archives of Sexual Behavior (2023) 52: 411–430. ↩︎
9. Fuss, J., Keeley, J. W., Stein, D. J., Rebello, T. J., García, J. Á., Briken, P., Robles, R., Matsumoto, C., Abé, C., Billieux, J., Grant, J. E., Kraus, S. W., Lochner, C., Potenza, M. N., & Reed, G. M. (2024). Mental health professionals’ use of the ICD-11 classification of impulse control disorders and behavioral addictions: An international field study. Journal of Behavioral Addictions, 13(1), 276-292.  ↩︎
10. Coleman, E., Rahm-Knigge, R.L., Danielso,n S., Katja, H., Nielsen K.H., Gleason, N., Jennings, T., Miner, M.H., (2023). The Relationship between Boredom Proneness, Attachment Styles and Compulsive Sexual Behavior. Journal of Sex & Marital Therapy, 49:2, 172-188. ↩︎
11. Ballester-Arnal, R., Castro-Calvo, J., Giménez-García, C., Gil-Juliá, B., & Gil-Llario, M. D. (2020). Psychiatric comorbidity in compulsive sexual behavior disorder (CSBD). Addictive Behaviors, 107, 106384. ↩︎
12. Reed, G.M., First, M.B., Bilieux, J., Cloitre, M., Briken, P., Archab, S., Brewin, C.R., King, D.L., Kraus, S.W., Bryant, R. A. (2022). Emerging experience with selected new categories in the ICD-11: complex PTSD, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder. World Psychiatry, 21: 189-213. ↩︎
13. Antons, S., Brand, M., (2021). Diagnostic and Classification Considerations Related to Compulsive Sexual Behavior Disorder and Problematic Pornography Use. Current Addiction Reports, 8, 452–457. ↩︎
14. Borgogna, N.C., Owen, T., Johnson, D., Kraus, S.W., (2023). No Magic Pill: A Systematic Review of the Pharmacological Treatments for Compulsive Sexual Behavior Disorder. The Journal of Sex Research, 61:9, 1328-1341. ↩︎