«Sex has become a source of pain and suffering for me. So many years compulsively searching for something that should be good and pleasurable, and that has already lost all its value… I started with pornography, but it wasn’t enough. … Then came prostitution, sexual webcams and saunas. Today, luckily, I am here asking you for help and wanting to get out of this forever. “Sex has destroyed my life, my marriage and my professional career.”
Luis, 35 years old.
Luis is among the 8% of men in the world population who suffer from a lack of control in their sexual life. The percentage of women affected by these difficulties is lower and is around 2% of the general population.
For sexual health professionals, this is an increasingly common demand in sexology consultations. Despite advances in knowledge of this pathology, it continues to be a topic of study and debate with many aspects.
The official name: compulsive sexual behavior disorder
It is common to hear, colloquially, the label “sexual addiction.” However, from a scientific point of view it is an obsolete term. The way to refer to the problem presented by patients like Luis has evolved a lot in the last decade. Terms such as hypersexual disorder, compulsive sexual behavior, sex addiction, cybersex addiction or problematic pornography use, among others, have been used. Many times they referred to the same problem, while other times they tried to explain nuances of very heterogeneous patients.
After much dispute, an agreement was finally reached in 2019. The World Health Organization decided to include the diagnosis of compulsive sexual behavior disorder (CBD) in the eleventh edition of the International Classification of Diseases (ICD-11) as a disorder characterized as “a persistent pattern of inability to control intense sexual urges, resulting in repetitive sexual behaviors.
To reach this diagnosis, several criteria must be met:
– Repetitive sexual behaviors that become the main focus of the person’s life, to the point of being negligent with their health or with the attention of other interests, activities or responsibilities.
– That the patient acknowledges having made numerous unsuccessful efforts to control or significantly reduce his sexual behavior.
– That they continue to engage in sexual behavior despite the adverse consequences (rupture of relationships, negative impact on health, work, occupation, etc.).
– Maintaining sexual behavior even when little or no pleasure is derived from it.
Additionally, these symptoms must cause significant distress or impairment over a prolonged period of at least six months. If this discomfort is solely related to moral judgments and moral disapproval about sexual impulses or behaviors, it would not be sufficient to make a diagnosis of TCSC.
Is the problem sex or pornography?
Within the TCSC there are numerous behaviors that can cause discomfort to the person: compulsive masturbation, consumption of pornography, consensual sexual relations with adults, cybersex, webcams, sexual chats and attendance at prostitution clubs, among others. However, approximately 80% of patients seeking help through TCSC have a problem controlling their pornography consumption, which makes us suspect that this is the main problem we should focus on.
For this reason, the term “problematic use of pornography” (UPP) is on the rise and is a recognized entity in research and with great scientific support. Some experts have proposed the UPP as an independent entity from the TCSC, even with specific evaluation criteria and instruments.
Consuming porn has consequences, but it is not always problematic use
About 97% of teenage boys have consumed pornography in the past year, and about 80% of girls have also viewed it. However, not all adolescents end up developing a UPP. International studies that have conducted surveys with more than 15,000 participants identified that only 3-8% of them had problematic use.
UPP is characterized by highly frequent and compulsive consumption of pornography, uncontrolled and persistent, despite the discomfort it causes or the associated negative consequences.
Furthermore, the description and evaluation of problematic pornography use is based on criteria related to behavioral addiction:
– Salience: pornography has great importance or prominence in a person’s life.
– Mood regulation: pornography serves as a source of regulation of unpleasant emotions or as an emotional refuge.
– Relapse: the person tries to quit repeatedly and fails.
– Abstinence: irritability or mood swings when pornography is not around.
– Tolerance: increasing amounts are needed to experience the same effects.
– Conflict: produces consequences in different areas of the person’s life.
What does neuroscience say about this pathology?
Scientific evidence increasingly supports the consideration of TCSC as a behavioral addiction, with neurobiological abnormalities similar to other addictions.
Specifically, in 2014 the first study was carried out that compared a control group with a group of subjects who compulsively consumed pornography. The authors concluded that pornography affected the brain in a similar way to cocaine or heroin.
Furthermore, they presented the first image (fMRI) of structural alterations in the reward system and related areas in subjects with compulsive pornography consumption, compared to healthy subjects.
As if that were not enough, a 2022 systematic review showed that there are different neurobiological alterations associated with TCSC such as increased functional connectivity between the left inferior frontal gyrus and the right temporal and polar plane, the right and left insula, the supplementary motor cortex right and the right parietal operculum. And they confirm the similarities at a neurobiological level between compulsive sexual behavior disorder and drug and alcohol addiction.
Systematic review of alterations in the functional connectivity of the TCSC. PreSMA: Supplementary motor area; VStr: Ventral striatum; vmPFC: Ventral-medial prefrontal cortex; IFG: Inferior Frontal Gyrus; dACC: Dorsal anterior cingulate cortex; STG: Superior temporal gyrus; dlPFC: Dorsolateral prefrontal cortex.
Some of the criticisms of the addictive model point out that certain characteristic elements of substance addictions, such as tolerance and withdrawal, have not been consistently demonstrated in the case of TCSC.
However, the latest research shows that about 70% of UPP patients show withdrawal symptoms such as hard-to-stop thoughts, sleep problems, and irritability. A recent study also shows that tolerance is a factor present in UPP in adolescents, mainly in boys.
Without a doubt, there are many questions that the scientific community needs to resolve about TCSC. What seems indisputable is that it is a labyrinth with an exit: many people have already left these problem behaviors behind thanks to psychotherapeutic help.
This article, in which Alejandro Villena Moya, Researcher in the consequences of pornography consumption, UNIR – Universidad Internacional de La Rioja and Carlos Chiclana Actis, Associate professor, Universidad CEU San Pablo, have also participated, has been published in ‘The conversation ‘.
