The New Era for the Treatment of Sexual Compulsivity

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Sexual compulsivity has been debated by clinicians and the public for decades. The field has been grappling with defining what is “too much sex.” What is it? An addiction? A compulsion? Something else? Often, the debates become emotive with much moral and/or religious biases and subjectivity, both amongst clinicians and also with the public and the clickbait headlines in the media.

There are several obstacles that make sexual compulsivity particularly difficult to understand in-depth. Firstly, there is a vast diversity of people’s baseline level of sexual desires and interests, and so many myths on what “healthy sex” should look like, which makes it challenging to discern between shame, moral incongruence, and real sexual compulsivity. Secondly, some mental health professionals have been over-diagnosing sexual compulsivity based on their own ideas of what they deem “too much sex”, “unhealthy”, or “sex addiction” for decades, contributing to the confusion. Thirdly, the field has been held back by poorly conducted research, much pseudo-science, religious biases, and a dominant clinical discourse of “sex/porn addiction” even though the evidence for addiction is poor and has not been clinically endorsed. This dominant discourse of “sex/porn addiction” infiltrated the public’s narrative, making people afraid of sex, particularly sex that is not heteronormative, monogamous, and vanilla.

The history of "sex/porn addiction"

The “sex addiction” clinical discourse became popular in the 80’s, at the time of the AIDS epidemic, so it was a time when people feared sex a lot (for good reasons), when the idea of heterosexual monogamy was highly prized, when Christian values became a central focus, and when strong homophobic narratives were reinforced. It is not a surprise that the concept of “sex addiction” became very popular then, it fitted so well with the public’s perceptions of sex at the time.

Many clinics specialising in “sex/porn addiction” sprung up, treating it with a behavioural addiction model based on abstinence and Christian values, or with prescribing to attend sex addiction 12-step programmes (which are abstinence-based programmes embedded in Christianity). Neither the conceptualisation of “sex/porn addiction” nor its related treatments have been evidenced to be effective, however, there are some reports that they can be iatrogenic. There have always been some clinicians arguing against the concept and treatments of “sex/porn addiction” but the clinical discourse remained for decades, and it is still used by some mental health professionals today.

The idea of “sex addiction” as a mental health disorder did not start in the 80’s, it started in the 60’s with an American psychiatrist treating “homosexuality” as an addiction. I believe it is important to know the history of the term “sex/porn addiction” because this kind of moral and religious subjectivity is still palpable in the modern “sex/porn addiction” texts and clinical training—of course, less overtly queerphobic than in the 60’s and 80’s—but still very much shrouded in heteronormativity, mononormativity, and religiosity.

The new era of therapy for sexual compulsivity

Fortunately, the times are changing, and the profession is catching up with more robust scientific studies on sexual compulsivity. While the Diagnostic and Statistical Manual of Mental Disorders (fifth edition) (DSM-5) is not recognising any disorders related to “too much sex”, the World Health Organisation (WHO) came up with diagnostic criteria for compulsive sexual behaviour disorder (CSBD) in 2019, clearly stating that it is not categorised as an addiction, but as an impulse control disorder. Compulsive sexual behaviours and “sex/porn addiction” are two very different theoretical frameworks that can’t be used interchangeably.

Since then, the quality of the scientific studies has improved and there are many great researchers in this specialist field. The growing profession of clinical sexology has also played a major part in the improvement in both the conceptualisation, assessments, and treatment approaches of sexual compulsivity, strongly opposing the pseudo-science related to “sex addiction” and its abstinence methods, and, instead, recommending a sex-positive and multi-modal approach to treatments.

Some organisations specialised in clinical sexology made statements against the concepts and related treatments of “sex addiction”, including the American Association of Sexuality Educators, Counselors and therapists (AASECT), Center for Positive Sexuality (CPS), The Alternative Sexualities Health Research Alliance (TASHRA), and the National Coalition for Sexual Freedom (NCSF), and more recently, the journal of Sexual and Relationship Therapy in the attempt to develop the field for better and more ethical assessment and treatment methods.

Now, thanks to many specialist clinicians, we are arriving at a new era of understanding sexual compulsivity better, filling the many gaps in the knowledge, and expanding our clinical thinking beyond the reductive frames of heteronormativity, mononormativity, and religiosity. New clinical discourses and innovative thinking are emerging, especially relating to diverse non-Western populations, people of the global majority: women, people with neurodiversity, kinky people, non-monogamous people, digisexual people, queer people, etc.

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The modern body of research is fascinating because the findings keep being replicated that sexual compulsivity may often not be an independent disorder but a symptom of depression and other underlying psychological issues, or a manifestation of moral incongruence, and/or shame.

Of course, we need much more research. Still, the new era of moving away from the reductive concepts of “sex/porn addiction” and into a much larger landscape of understanding diverse sexual behaviours, erotic expressions, psychosexual processes, and overall mental health has come. It is going to be fascinating to see what the research and clinical discourses will reveal in the coming years.