The World Federation of Societies of Biological Psychiatry guidelines on the assessment and pharmacological treatment of compulsive sexual behaviour disorder

Figures & data

Table 1. Diagnostic criteria for Compulsive Sexual Behaviour Disorder for ICD-11.

Essential (required) features for CSBD • 1. A persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour, must be manifested in one or more of the following:  ^ 1a. Engaging in repetitive sexual activities has become a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities, and responsibilities (yes/no).  ^ 1b. The person has made numerous unsuccessful efforts to control or significantly reduce repetitive sexual behaviour (yes/no)  ^ 1c. The person continues to engage in repetitive sexual behaviour despite adverse consequences (e.g., repeated relationship disruption, occupational consequences, negative impact on health) (yes/no).  ^ 1d. The person continues to engage in repetitive sexual behaviour even when the individual derives little or no satisfaction from it (yes/no). • 2. The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period (e.g., 6 months or more) (Must be met) • 3. The pattern of repetitive sexual behaviour causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning (Must be met). Note for rule out. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not enough to meet this requirement.

Table 2. Treatment studies for naltrexone.

Reference Type of study	Patient characteristics	Previous or concurrent treatments for CSBD	Treatment conditions (dose and duration)	Outcome measures	Efficacy
Double-blind studies
Lew-Starowicz et al. (2022) Poland	N = 73 heterosexual men (mean age 35.74 years; SD 8.09 years) with CSBD according to ICD-11; 87.7% with problematic pornography use and 100% with compulsive masturbation. No significant differences with respect to CSBD symptoms or demographic characteristics. 15 patients were suffering from sexual dysfunctions, mostly erectile dysfunction.	No previous psychiatric treatment	Group A: Paroxetine 20 mg/d Group B: Naltrexone 50 mg/d Group C: Placebo	Primary outcome: Changes in the severity of CSBD symptoms measured with SAST-R, BPS, and HBI. Additionally, craving for sexual activity and pornography vieweing were assessed via smartphone-based Ecological Momentary Assessments.	Significant decrease of self-assessed CSBD symptom severity after 8 and 20 weeks across all three groups, however, no differences between paroxetine, naltrexone and placebo. In clinical interviews paroxetine and naltrexone were found to be more effective than placebo in reducing CSBD symptoms after 8 as well as after 20 weeks. Craving for both sexual encounters and pornography viewing was reduced in the paroxetine condition but not in the other two conditions.
Open studies
Ryback (2004)	N = 21 juvenile, legally-adjudicated sexually-offending patients (in-patients) who met any of the self-reported following criteria: (1) excessive masturbation (>3 times per day); (2) feeling unable to control arousal; (3) spending more than 30% of awake time in sexual fantasies; or (4) having sexual fantasies or behaviour that regularly intruded into and interfered with their functioning in the treatment program (13–17 years of age), high rates of co-occurring ADHD (52%), depressive disorders (24%), and substance use disorders (24%)	Almost all patients were additionally treated with other medication: 52% stimulants, 38% antidepressants, 24% risperidone	Naltrexone was started at 50 mg/d in every patient, with average dose achieved being 170 mg/day (range: 100–200 mg/day)	Outcome measures were self-reported daily sexual fantasies and frequency of masturbation. A positive result was recorded if there was more than a 30% decrease in any self-reported criterion and if this benefit lasted, at least, 4 months.	No clear benefits at doses less than 100 mg/day. At 150–200 mg/day, 15 patients (71.4%) reported benefit. Masturbation frequency decreased from two times a day to two times a week. Also decreases in durations of time fantasising about sex were noted. Those six patients who did not respond to naltrexone were changed to leuprolide (3.5 mg or 7.5 mg/month). In 5 patients, stable benefit was observed at 7.5 mg IM monthly. 13 patients had naltrexone stopped after 2 months, which resulted in reoccurrence of symptoms that began when the tapered dose reached 50 mg per day.
Raymond et al. (2010) USA	N = 19 patients with paraphilic and non-paraphilic CSB Mean age 44.1 years (SD = 9.4 years, range 28–62 years). Co-occurring disorders (n): Major depression (13), dysthymia (1), depression not otherwise specified (1), Bipolar II disorder (2), cyclothymic disorder (1), generalised anxiety disorder (5), alcohol abuse (2), cannabis abuse (1), adjustment disorder (1).	Concomitant CBT in all patients; 17 patients with concomitant antidepressant treatment	Naltrexone, dosage range 50–200 mg/d. 15 Patients concurrent use of SSRI or SNRI, two patients additionally bupropion, three patients additionally bupropion and SSRI. 15 Patients were on the same medication regime for at least 6 months at the time naltrexone was initiated. 1 patient started sertraline 1 month before naltrexone. 3 patients had stopped taking dextroamphetamine, lamotrigine, and nefazodone the day naltrexone was started.	CSB rated based on the Clinical Global Impression (CGI) score	17 patients reported that CSB symptoms improved either very much or much after naltrexone treatment was started. Mean effective dose was 104 mg/d (SD = 41 mg/d). Mean treatment duration in participants who responded to treatment was 1 year (SD = 1.0 year).
Savard et al. (2020) Sweden	N = 20 men (mean age 38.8; SD = 10.3) with CSBD according to ICD-11; 95% with excessive masturbation. Exclusion criteria: 1.) alcohol dependence, use of illicit drugs in the past month, ongoing opioid or benzodiazepine medication, 2.) Severe psychiatric disorder, 3.) Change of concurrent medication or dosage in the last 3 months, 4.) Sexual behaviours with high risk to offend, 5.) Ongoing psychotherapeutic treatment. Co-occurring psychiatric disorders (n): Anxiety disorder (5), ADHD (5),	Antidepressants (2 patients) Stimulants (1 patient)	Starting dose 25 mg for 3–5 days, then increase to 50 mg/d Naltrexone 50 mg/day for 4 weeks (25 mg/day in 1 case due to fatigue)	Hypersexual disorder: Current assessment scale (HD:CAS) Hypersexual Behaviour Inventory (HBI) Sexual compulsivity scale	Significant reduction in HD:CAS scores after 2 and 4 weeks and HBI scores after 2 weeks and after 4 weeks. Increase of scores after 4 weeks without naltrexone; however, scores were below baseline scores.
Case studies
Grant and Kim (2002) USA	N = 1 man (58 years) Insatiable demand for multiple sexual partners and co-occurring kleptomania	Cognitive-behavioural therapy for 10 years Fluoxetine 80 mg/day for 16 weeks, both without change	Naltrexone 150 mg/day	Self-report	After 2 weeks with naltrexone at 150 mg/day, cessation of compulsive sexual behaviour reported. 3 days after treatment discontinuation, return of sexual urges reported. 4 days after restarting medication, remission of symptoms reported.
Raymond et al. (2002) USA	a.) N = 1 woman (42-years) frequent sexual activity with multiple partners outside her marriage; co-occurring depression b.) N = 1 man (62 years) extramarital affairs with work associates and prostitutes, preoccupation with masochistic fantasies	a.) 20–60 mg fluoxetine with lowering depressive symptoms b.) 40 mg/day fluoxetine	a.) Additionally 50–150 mg naltrexone/day b.) Additionally 50–100 mg naltrexone/day	Self-report	a.) With 100 mg /day naltrexone, almost complete remission of sexual urges; after 8 months, change from fluoxetine to citalopram at 60 mg/day; with increases in sexual urges, increased to 150 mg naltrexone, with subsequent decrease in sexual urges b.) With 40 mg/day fluoxetine, improvement in CSB, depressive symptoms and sexual preoccupation; due to difficulties in sexual functioning, fluoxetine switch to nefazodone. After stopping all medications, sexual preoccupation reoccurred; trials with fluoxetine, buproprion, citalopram and buspirone were ineffective. With 50 mg naltrexone, improvement in all symptoms; after 2 months, loss of efficacy; with naltrexone increase to 100 mg/day, improvement of symptoms for the next 8 months reported.
Bostwick and Bucci (2008) USA	N = 1 man (24 years) Preoccupation with internet pornography, multiple hours each day with sexual chats, consumption of pornography and meeting cyber-contacts for spontaneous sex.	Sertraline 100 mg/day for 1 year, group and individual psychotherapy, Sexual Addicts Anonymous, pastoral counselling	100 mg/day Sertraline + 150 mg/day naltrexone for 3 years	Self-report	After adding naltrexone, complete control over sexual impulses reported. Later, 50 mg/day achieved similar positive results.
Kraus et al. (2015) USA	N = 1 man (in his 30s) with problematic internet pornography viewing	Cognitive-behavioural therapy (CBT)	After 10 weeks of CBT, 50 mg/day naltrexone added given persistent/increased urges for viewing pornography	Self-report	After 2 weeks of naltrexone treatment, decreases in urges to masturbate to pornography reported.
Camacho et al. (2018) Portugal	N = 1 (27 years) with distressing sexual urge to have sex with transvestite men and excessive viewing of pornography (3–10 h/d)	Psychotherapy fluoxetine 20–40 mg/d, aripiprazole 10 mg/d, other antidepressants, mood stabilisers, and antipsychotics	Naltrexone 50 mg/d was added to fluoxetine 40 mg/d and aripiprazole 10 mg/d. Naltrexone was increased after several weeks to 100 mg/d.	Self-report Y-BOCS-II compulsions score	After 2 months of naltrexone treatment, significant improvement in the reduction of sexual fantasies and control of sexual impulses. No more visits of prostitutes reported. Y-BOCS-II score decreased from 14 to 0 after 2 months. After about 10 months, spontaneous stopping of naltrexone treatment and sexual compulsions returned within 2 days.

Table 3. Treatment studies for SSRIs.

Reference Type of study	Patient characteristics	Previous or concurrent treatments for CSBD	Treatment conditions (dose and duration)	Outcome measures	Efficacy
Double-blind studies
Wainberg et al. (2006) USA	N = 28 homosexual men (mean age 36.8 years) with CSBD	23% psychotherapy, 3.8% medication, 19.2% self-help groups	13 Participants citalopram (20–60 mg/d) vs. 15 participants placebo for 12 weeks. Mean daily citalopram dose at week 4 was 25.5 mg and 43.36 mg at week 12.	Clinical Global Impressions scale-Compulsive Sexual Behaviour (CGI-CBS), Compulsive Sexual Behaviour Inventory (CSBI), Yale-Brown Obsessive Compulsive Scale-Compulsive Sexual Behaviour (YBOCS-CSB)	Decreases were observed in CSB symptoms in both groups after 12 weeks. However, stronger decreases in desire for sex, frequency of masturbation, and hours of pornography use per week were observed in the citalopram group. Although there was a significant decrease in CSB symptoms measured with the YBOCS-CSB, the Compulsive Sexual Behaviour Inventory or the CGI-CSB in the whole group, no differences were observable between the two groups. Furthermore, although there was a significant decrease in the number of partners per month and in the frequency of oral and anal sex per month across the whole study population, again no differences occurred between the two groups. The same pattern was found concerning frequency of risky sexual contacts per month.
Lew-Starowicz et al. (2022) Poland	N = 73 heterosexual men (mean age 35.74 years; SD 8.09 years) with CSBD according to ICD-11; 87.7% with problematic pornography use and 100% with compulsive masturbation. No significant differences with respect to CSBD symptoms or demographic characteristics. 15 patients were suffering from sexual dysfunctions, mostly erectile dysfunction.	No previous psychiatric treatment	Group A: Paroxetine 20 mg/d Group B: Naltrexone 50 mg/d Group C: Placebo	Primary outcome: Changes in the severity of CSBD symptoms measured with SAST-R, BPS, and HBI. Additionally, cravings for sexual activity and pornography vieweing were assessed via smartphone-based Ecological Momentary Assessments.	Significant decrease of self-assessed CSBD symptom severity after eight and 20 weeks across all three groups, however, no differences between paroxetine, naltrexone and placebo. In clinical interviews paroxetine and naltrexone were found to be more effective than placebo in reducing CSBD symptoms after eight as well as after 20 weeks. Craving for sexual encounters and pornography viewing was reduced in the paroxetine condition but not in the other two conditions.
Open studies
Kafka (1991) USA	N = 10 men with nonparaphilic sexual addictions (5 men with additional paraphilic disorders) (age range 27–50 years)	Supportive psychotherapy	6 Patients fluoxetine 20–60 mg/day, 1 patient imipramine 225 mg/day, 1 patient lithium 1500 mg/day, 1 patient imipramine 125 mg/day + lithium 600 mg/day, 1 patient fluoxetine 60 mg/day + trazodone 150 mg/day for 12 weeks	Sexual Outlet Inventory	All but one patient (fluoxetine monotherapy) experienced substantial improvement in symptomatology.
Kafka and Prentky (1992) USA	N = 10 men with paraphilic disorder and non-paraphilic sexual addictions vs. N = 10 men with non-paraphilic sexual addictions only 11 men (6 paraphilic and 5 non-paraphilic) met criteria for current major depression using DSM-III-R criteria	10 Men concurrent psychotherapy	Fluoxetine starting at 20 mg/day to a maximum of 60 mg/day. Mean dose at 12 weeks was 39.37 mg/day (SD = 14.81)	Sexual Outlet Inventory	4 men dropped out during the study (1 paraphilic and 3 non-paraphilic) Significant reductions were observed in total sexual outlet, masturbation frequency, frequency of sexual activities, intensity of sexual desire after 12 weeks of treatment. Greater decreases were observed in the paraphilic group in total sexual outlet; however, higher baseline total sexual outlet was observed in the paraphilic group. Overall average reduction of total sexual outlet was 65.2%
Stein et al. (1992) USA	N = 13 men (5 with paraphilic disorder, 5 with non-paraphilic sexual addictions, 3 with sexual thoughts or rituals that met DSM-III-R criteria for obsessive compulsive disorder (OCD); ages between 18–58 years)	Not reported	Fluoxetine up to 80 mg/d; clomipramine up to 400 mg/d Fluvoxamine up to 300 mg/d; Fenfluramine up to 40 mg/d	Clinical Global Impression change score	No change was reported in paraphilic fantasies or behaviours or improvement in non-sexual OCD symptoms; in 2 of 5 patients, decreases reported in non-paraphilic sexual addiction; in 2 of 5 improvement noted in sexual obsessions or compulsions
Kafka (1994) USA	N = 12 men with paraphilia-related disorders (mean age 39.6 years; SD = 7.5 years)	Not reported	Sertraline mean dose 99.0 mg, SD = 62.8 mg/day (range 25–250 mg/day) for 4–64 weeks	Sexual Outlet Inventory	Statistically significant reduction in unconventional total sexual outlet and average time spent per day without adversely affecting conventional total sexual outlet.
Case studies
Elmore (2000) USA	a.) N = 1 man (24 years) with excessive use of telephone sex, excessive masturbation and co-occurring depression b.) N = 1 woman (30 years) with excessive masturbation and compulsive sex with multiple partners, co-occurring mixed personality disorder and PTSD	Not reported	In a.) Paroxetine 20 mg/day for 4 months In b.) Sertraline 200 mg/day for 20 months, partly with trazodone augmentation 150 mg/day for 6 months, amitriptyline augmentation 50 mg/day for 1 year	Self-reported intensity and frequency of CSBs	In a.) Decreases in CSBs after 2 weeks In b.) Decreases in sexual desire, arousal, and sexual activity.
Gola and Potenza (2016) Poland	N = 3 men (24, 32, and 35 years) Problematic pornography use and compulsive masturbation	Cognitive-behavioural therapy (on-going)	Paroxetine 20 mg/day Treatment duration between 14.5 and 20.5 weeks Follow-up 3-month	Self-reported time spent with pornography consumption (daily)	Decreased libido and delayed ejaculation during first 2–4 weeks. Within 10 weeks, normalisation of libido and sexual functioning. After 12 weeks, occurrence of new sexual behaviours (e.g., engaging in paid sexual relationships, extra-marital affair); however, no increase in pornography consumption. Still no increase in pornography consumption after 3-month follow-up

Table 4. Treatment studies with other drugs.

Reference Type of study	Patient characteristics	Previous or concurrent treatments for CSBD	Treatment conditions (dose and duration)	Outcome measures	Efficacy
Open studies
Coleman et al. (2000) USA	N = 14 men (age range 26–67 years) with CSBD diagnoses; 5 patients with co-occurring paraphilias	2 or more SSRIs	11 Men treated with nefazodone long-term treatment (13.4 months on average) with mean dose of 200 mg/d (range 50–400 mg/d)	Self-report	In six patients, good control over recurrent, intrusive sexual thoughts. In five patients, remission of CSBD symptoms.
Kafka and Hennen (2000) USA	N = 26 men with paraphilias (n = 14) and non-paraphilic hypersexuality (n = 12) 17 men with an additional retrospective diagnosis of ADHD and symptoms of ADHD persisting into adulthood Mean age 37.7 years	T1: Before SSRI treatment; T2: after SSRI treatment but immediately prior to the prescription of a psychostimulant; T3 follow-up of combined SSRI and psychostimulant treatment. At T1: 19 men treated with fluoxetine at a mean dose of 49 mg/day, 3 men treated with sertraline at a mean dose of 110 mg/day, 2 men treated with paroxetine at a mean dose of 35 mg/day, 2 men treated with fluvoxamine at a mean dose of 100 mg/day; SSRI treatment on average 8.8 months.	At T2: 25 men treated with methylphenidate sustained release with mean dose of 40 mg/day (range 20–100 mg/day) and 1 participant dextroamphetamine for at least 8 weeks	Sexual Outlet Inventory	21 Men completed the trial. At T2: Significant reduction in total sexual outlet and median time per day spent in sexual behaviours. At T3: Significant reduction in total sexual outlet and time spent with sexual behaviours per day. No difference between paraphilic and non-paraphilic hypersexual patients on outcome measures. After 8 weeks both the total sexual outlet and the median time per day spent with sexual behaviours were substantially decreased. Total sexual outlet decreased more than 63% from 9 to 3.
Case studies
Rubey et al. (1993) USA	N = 2 men a.) 25 years; daily masturbation, prostitutes several times a week, preoccupation with pornographic material b.) 19 years; borderline mentally retarded, intrusive sexual thoughts	Not reported	a.) Clomipramine 125 mg/day b.) clomipramine 150 mg/day	Self-report	a.) After 1 week, decline in sexual ruminations and almost no urge to visit prostitutes or pornographic bookstores, decline in masturbation frequency b.) Decrease in sexual thoughts
Fong et al. (2005) USA	N = 1 man (32 years) Obsessive use of strip clubs and massage parlours	Cognitive-behavioural therapy and fluoxetine 80 mg/d for 6 months, no change in sexual symptoms, naltrexone 25 mg was added to fluoxetine; however, this was stopped after 10 days due to nausea.	Topiramate 200 mg/d monotherapy	Self-report	After 6 weeks, stopped engaging in sexual behaviours.
Khazaal and Zullino (2006) Switzerland	N = 1 man (33 years of age) Excessive sex with prostitutes (spending nearly one-third of monthly income) No history of other psychiatric disorder Co-occurring obesity	Simultaneously three sessions of cognitive-behavioural therapy for obesity	50 mg/day topiramate monotherapy for 4 months	Self-report	Reduction in sex with prostitutes; reductions in urges, cravings and attractions of environmental cues after two weeks of treatment. 2 weeks after discontinuation of treatment, relapse in compulsive visits with prostitutes
Gulsun et al. (2007) Turkey	N = 1 woman (21 years of age) Compulsive telephone sex accompanied by masturbation (15–16 times a day) No history of any other medical condition	None	First 3 months: clomipramine 150 mg/day; after 3 months, additional treatment with valproic acid 1000 mg/day	Self-reported masturbation frequency	2 weeks after treatment started with valproic acid. decrease in masturbation frequency was noted. One month later, no more masturbation reported.
Blum and Grant (2022) USA	N = 2? or 8 men (age range 21–56 years) with CSBD diagnosis; 4 patients with co-occuring anxiety disorders, 4 patients with co-occuring depression, and 2 patients with co-occuring substance use disorder	Additional treatment: 4 patients had an SSRI, 1 patient had naltrexone, 1 patient had phenelzine, and 1 patient had bupropion.	All patients started with 600 mg NAC twice a day, increase of dose to 1200 mg NAC twice a day after 1 week. Four patients stayed on 2400 mg daily and four patients increased the dose to 3600 mg daily. Treatment duration: 2–6 months	CSB-Yale-Brown Obsessive Compulsive Scale (YBOCS)	CSB-YBOCS scores were assessed before NAC treatment was started and 4–6 weeks into treatment. Five patients reported an improvement of more than 35% on the YBOCS. Three patients did not show an improvement.

Table 5. Treatment studies for hormonal agents.

Reference Type of study	Patient characteristics	Previous treatments	Treatment conditions	Outcome measures	Efficacy
Open studies
Winder et al. (2014,2018) UK	N = 127 men convicted for sexual offences currently imprisoned with hyper-arousal, intrusive sexual fantasies or urges, or dangerous paraphilias	83% in sex offender treatment program	Cyproterone acetate (CPA) at 50–100 mg/d (16 patients) Fluoxetine or paroxetine 20–60 mg/day (75 patients) SSRI + CPA (7 patients) GnRH-agonists (two patients) No medication (20 patients)	Sexual Compulsivity Scale (SCS); self-reported measures of sexual thoughts, feelings, and behaviours	Only participants that took medication for 6 months were included (n = 33): Significant reductions in SCS scores noted after 3 months and after 6 months. Significant reductions in masturbation frequency, time spent thinking about sex, and strength of sexual urges reported. Ability to distract from sexual thoughts already after 1 month (stronger decrease during SSRI than during CPA treatment).
Case studies
Davies (1974)	a.) N = 2 men with distressing vivid sexual fantasies 1 Man (22 years) with additional sadistic fantasies 1 Man (33 years) with excessive masturbation b.) N = 10 homosexual men with CSB	Not reported	Cyproterone acetate 50–200 mg/day; Treatment duration not reported	Masturbation frequency	In a.) reductions in masturbation frequency and disappearance of sadistic fantasies. In b.) reduction in masturbation frequency.

Table 6. A proposed algorithm for pharmacological treatment of CSBD without any chemsex practice and without any paraphilic disorder, based on Briken and Turner (2021) and Thibaut et al. (2020).

Level of severity	Treatment
LEVEL 1 – mild and mild to moderate
Aim: support the control of sexual fantasies, compulsions, and behaviours without risk of self-harm or harm to others	Psychoeducation (prevention of unwanted pregnancies, STIs; education about the risks associated with CSB) Motivational interviewing Psychotherapy, preferentially CBT or ACT (level C of evidence) Treatment of co-occurring depressive or anxiety disorders or addictive or other psychiatric disorders if any Reduce levels of stress and impulsivity and improve self-esteem
LEVEL 2a – moderate
Aims: support the control of sexual fantasies, compulsions, and behaviours Specifiers: Presence of co-occurring depression or anxiety disorder No satisfactory results at level 1	Psychotherapy, preferentially CBT or ACT SSRI^a: dosage gradually increased at the same level as prescribed in OCD (e.g., sertraline 50–200 mg/day or fluoxetine 20–80 mg/day or paroxetine 20–60 mg/day) (level B of evidence)
LEVEL 2b – moderate
Aim: support the control of sexual fantasies, compulsions, and behaviours Specifiers: Presence of co-occurring alcohol or substance misuse, other addictive behaviours No satisfactory results at level 1	Psychotherapy, preferentially CBT or ACT Naltrexone^b 50–200 mg/day (level B of evidence)
LEVEL 3 – severe
Aim: support the of control severe CSBD symptoms Specifiers: No satisfactory results at level 2a and 2b	Psychotherapy, preferentially CBT or ACT Add naltrexone^b (50–200 mg/day) to SSRI^a or SSRI^a to naltrexone^b (e.g. sertraline 50–200 mg/day or fluoxetine 20–80 mg/day or paroxetine 20–60 mg/day) (level C of evidence)

^aBe careful in case of adolescents; there is an increased risk of suicide for SSRIs noted across age groups. National guidelines on antidepressant use monitoring may apply.

^bContraindications of naltrexone: acute hepatitis or severe hepatocellular insufficiency; concomitant use of opioids; pregnancy, lactation; suicidal risk; severe kidney failure; hypersensitivity to naltrexone or one of its components; individuals under 18 or over 65 years of age (French Health Authority 2015).

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