Sex and everything that revolves around it can no doubt be stressful and confusing, at least some of the time. But for a decent chunk of Americans, a new survey suggests, their sexual hangups might be causing them a significant amount of mental anguish.
According to the survey, published Friday in JAMA Network Open, 8.6 percent of people report experiencing distress or feeling unable to function normally due to what they perceive as problems controlling their sexual urges, feelings, and behaviors. But the study authors and experts elsewhere bring up problems with interpreting the survey results that are representative of issues that plague the entire field of this research; for example, that what can be perceived as distress caused by sexual urges could actually be distress due to persecutory societal norms and beliefs.
The concept of sex addiction has been roundly criticized, even by researchers and clinicians who study and treat sex-related problems. In 2016, for instance, the American Association of Sexuality Educators, Counselors and Therapists (AASECT) issued a position statement blankly asserting that sex and porn addiction shouldn’t be classified as mental health disorders, and that sex addiction training and treatment was inadequately “informed by accurate human sexuality knowledge.”
At the same time, mental health professionals don’t deny that people can feel pain over trying to control their sexual urges and feelings, or that people’s sexual compulsions can be harmful to themselves and others. Earlier this year, with some controversy, the World Health Organization introduced a new diagnosis to its 11th edition of the International Classification of Disease, a codebook widely used by hospitals and doctors: compulsive sexual behavior disorder (CSBD). CSBD, according to the WHO, is classified by a “persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behavior.”
The diagnosis has been proposed for inclusion in the ICD for a few years, while a similar diagnosis was also considered by the American Psychiatric Association for inclusion in its 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), but they ultimately balked. The latter was a decision that erred on the side of caution, according to Russell Stambaugh, a sex therapist and AASECT member.
“WHO agreed to list Compulsive Sexual Behavior… because WHO wanted to reduce barriers to treatment for the fraction of screenees who really need professional help,” he told Gizmodo. But the DSM committee chose otherwise because it feared that labeling compulsive sexual behavior a mental disorder would only contribute to more stigma around sex and create false positives (people who might have some sex-related problems, but not to a degree that require treatment).
The question of how many people with unhealthy sexual compulsions need help is still up in the air, as is who exactly is at greater risk of CSBD and why. So the researchers behind this study, led by Janna Dickerson, a postdoctoral fellow at the University of Minnesota’s Program in Human Sexuality, decided to take a stab at it.
In the fall of 2016, they recruited more than 2,300 adults between the ages of 18 and 50 to take an online survey. Hoping to get a nationally representative sample, they asked people who once took part in a similar survey, the National Survey of Sexual Health and Behavior, to participate, as well as a random slice of Americans.
With answers on a one to five scale—ranging from never to very frequently—the volunteers were asked questions like “How often have you had sex or masturbated more than you wanted to?” and “How often have your sexual thoughts or behaviors interfered with relationships?” Those who had a total score of 35 or more on the scale, called the Compulsive Sexual Behavior Inventory (CSBI), were considered to have distress or impairment associated with difficulty controlling their sexual urges, feelings and behaviors.
Overall, 8.6 percent of the group met that criteria, breaking down to 10.3 percent of men and 7 percent of women.
The numbers are roughly in line with previous, smaller surveys, according to David J. Ley, a clinical psychologist and author who has often been critical of the concept of sex addiction. But Ley, who was not involved in the current study, noted these numbers don’t necessarily represent all serious cases of CSBD, or mean that everyone whose score is high will need treatment.
“The critical point is that there is extensive research showing that feeling as though it is difficult to control your sexual desires doesn’t actually predict sexual behaviors or behavior problems,” he told Gizmodo.
Douglas Braun-Harvey, a San Diego-based sex educator and AASECT member, also points out the scale used in the study doesn’t take into account other important aspects of diagnosing CSBD. For one, people generally aren’t diagnosed with the disorder if they have moral or religious conflicts that might be causing them to feel distraught about their sexual thoughts, but the scale doesn’t ask about this.
“Nor can a survey study distinguish between medical conditions related to distress about sexual control,” he added.
Dickerson and her colleagues admit these caveats in the paper, and that these numbers are only meant to be an early, imperfect estimate of how common CSBD could be.
“But we don’t yet have a clear estimate of this new disorder, so this screening tool is the best we have to date,” she told Gizmodo.
There’s a wide variety of problems that could be considered CSBD. For some, they might personally feel as though they’re masturbating too much; for others, it could be that they feel their sexual urges are somehow ruining their close relationships. But CSBD, Dickerson said, isn’t meant to legitimatize the idea of someone “objectively” being too sexual.
“One of the debates [in the field] has typically been, ‘Well, what is too much sexual behavior?’ But there really is no quantifiable amount of ‘healthy sexuality,’” she said. “This isn’t about having too much of any one behavior, it’s about whether you’re having difficulty controlling your behaviors or feelings, and whether that difficulty enters your social and personal life.”
Dickerson and her team were surprised by some of their findings, particularly that women were almost as likely as men to report these problems.
“Sexual compulsivity has typically thought to be a syndrome of men. But what our study found is that this isn’t the case at all,” Dickerson said. “What we now know that women are experiencing difficulty, but we don’t really know this means.”
Past efforts to study CSBD among women might have fallen short because the researchers’ own biases, for instance, leading to an underestimate of the problem. The disorder might also be expressed differently among women, or happen for different reasons than it does in men, perhaps due to societal pressures.
“Women face different consequences for not conforming to sexual standards. And currently, we don’t have a good gender-informed model of CSBD in women. So that’s an important direction to move into,” Dickerson said.
At the same time, Dickerson doesn’t want the public to come away with the wrong impression and assume that CSBD is becoming more common in women. “Given that CSBD is new, we really don’t have an understanding of what this would be like in women. There’s lot of factors at play,” she said.
The same caution applies to figuring out why racial and sexual minorities seem to be greater risk of of CSBD, such as “gay lesbian, bi and other” people (when compared to heterosexuals), or black and Hispanic people (compared to whites). We don’t know for sure if these patterns are genuine or a fluke of the data collection, or why they might be true. Past theories about this might be barking up the wrong tree.
Some researchers, for example, have previously speculated that gay men are more likely to develop a sexual compulsion, in part, because they have more sexual partners and have more or are more accepting of casual sex. But more recent research, the authors point out, has found that the stress and marginalization of being a minority itself can raise the risk of compulsive behaviors and other mental health problems.
There’s just not much we know about CSBD right now, including the best way to help people through it. But clinicians and researchers like Dickerson are trying to figure it out.
“The way we approach it at our clinic is to get people to come up with their boundaries about sexual behavior, hold to them, and begin to work on the underlying factors that led them to engage in the behaviors in the first place,” she said.
And despite their criticisms, Ley and the other experts we reached out to do think this research is valuable, so long as we’re careful about interpreting it.
“The hopeful news is that research like this helps us to help the people who are struggling, not by suppressing their sexual behaviors, but by exploring and resolving these moral conflicts,” Ley said.[JAMA Network Open]