Porn Addiction or Compulsive Sexual Behaviour Disorder? A Guide

"Doctor, am I addicted to porn?" This question comes from many directions. Some people watch for hours a day until their work suffers. Some watch once a week but feel intense guilt because it conflicts with their religion or a promise to their partner. Some have been told "you're addicted" by a partner who found their browsing history. All of these involve real distress, but they are not always the same thing. This article explains, in an academic and non-judgemental way, how medicine currently sees this issue, how to tell the patterns apart, and how help works.

Is "porn addiction" a disorder?

"Porn addiction" is a term people use every day, but it is still debated among researchers.

• DSM-5-TR (2022) from the American Psychiatric Association does not include a diagnosis of "porn addiction" or "sex addiction". A proposed hypersexual disorder was considered during the development of DSM-5 but was not included.
• ICD-11 from the World Health Organization (adopted in 2019, in use since 2022) includes compulsive sexual behaviour disorder (CSBD), code 6C72, in the impulse control disorders chapter. It is not classified as an "addiction" in the same way as substance addictions.

CSBD covers any kind of sexual behaviour that has become uncontrolled; watching porn while masturbating is one of the most common patterns. In this article I use "problematic porn use" when speaking broadly, and CSBD when talking about the diagnosis.

A US national survey (Dickenson and colleagues, 2018) using the CSBI-13 screening tool found that about 10.3% of men and 7.0% of women scored at a level reflecting distress or impairment from difficulty controlling sexual urges. That is a screening figure, not a diagnosis, but it tells you that you are not alone with this.

What CSBD looks like under ICD-11 (6C72)

At the heart of CSBD is a persistent pattern of failing to control intense, repetitive sexual impulses or urges, leading to repetitive sexual behaviour over an extended period (around 6 months or more), together with these features:

• Sexual activity becomes the centre of life, to the point of neglecting health, self-care or other responsibilities.
• Repeated unsuccessful attempts to cut down.
• Continuing despite harm, or getting little or no satisfaction from it any more.
• Marked distress or significant impairment in family, social, educational, occupational or other important areas of life.

A crucial point is that ICD-11 states that distress arising only from moral judgements or disapproval of sexual impulses or behaviours is not enough for the diagnosis. CSBD is also separate from paraphilic disorders, which are about "what you are aroused by" rather than "control".

Loss of control ≥ 6 months

Centre of life

• Neglecting health and self-care
• Neglecting other responsibilities

Can't cut down

• Many attempts
• Little real reduction

Continues despite harm

• Negative consequences
• Or little satisfaction left

Distress or impairment

• Family, social, work, study
• Moral distress alone doesn't count

WHO ICD-11 (2019/2022) classifies it as an impulse control disorder. It is not in DSM-5-TR.

Moral incongruence versus loss of control

Joshua Grubbs and colleagues (2019) reviewed the research and found that feeling "addicted" is strongly associated with religiosity and moral disapproval of porn, more than with how much someone actually watches. They called this moral incongruence: the behaviour clashes with your own values, so you suffer a great deal, even if you are reasonably in control.

The two can occur together, and both deserve care. Telling them apart is not about saying "there's nothing wrong with you"; it's about choosing help that fits. Telling someone who suffers mainly from shame that they are "severely addicted" can make the shame, and the cycle, worse.

Effects on relationships and erections: what the evidence says

Relationships. The problems I see most often are not caused by porn itself, but by secrecy, lying, feeling betrayed and feeling compared. Couples with different agreements about porn suffer in different ways. Some couples watch together without any problem; for others it's a deal-breaker. There is no single right answer for every couple. What matters is an agreement that both people genuinely accept.

Erections ("porn-induced ED"). The evidence is mixed.

• Landripet and Štulhofer (2015) studied young men in several countries and found no clear association between the amount of porn watched and ED.
• Jacobs and colleagues (2021) surveyed more than 3,400 men aged 18–35 and found that problematic use (measured with an online porn addiction scale) was associated with ED, but this was a cross-sectional study that cannot show cause and effect.
• Possible mechanisms include unrealistic expectations, an idiosyncratic masturbation style and performance anxiety. Read more in Death grip and masturbation style.

In short, there is no evidence that watching porn by itself directly causes ED, but in some people problematic use may be a contributing factor. Men with ED should always have physical causes checked, rather than assuming "it's because of porn".

A first self-assessment

Ask yourself honestly, thinking about the past 6 months:

1. Have I tried to cut down or stop many times without success?
2. Am I spending so much time on this that it affects my sleep, work, studies or finances?
3. Do I keep going even though I know it's causing harm, or even though I barely enjoy it any more?
4. Do I mainly use it to escape when I'm stressed, lonely, bored or sad?
5. Does my distress come mainly from "I can't control it", or mainly from "it's wrong in my eyes"?

Researchers use screening tools such as the CSBD-19, built on the ICD-11 criteria, and the short Brief Pornography Screen. These can help open a conversation with a professional, but they are not a diagnosis. A real assessment looks at your whole life context, including conditions that often occur alongside, such as depression, anxiety, ADHD and substance use.

Treatment

Guidelines from the World Federation of Societies of Biological Psychiatry (WFSBP, Turner and colleagues, 2022) state that psychoeducation and psychotherapy are the first-choice treatments and should always be provided, with medication as an add-on in some cases.

• Cognitive behavioural therapy (CBT) identifies triggers, such as stress, loneliness or late nights, and builds realistic coping plans.
• Acceptance and commitment therapy (ACT) teaches you to sit with urges without acting on them, and to choose behaviour based on your own values. A small trial by Crosby and Twohig (2016) of 28 men found large reductions in viewing after therapy, but almost all participants came from one religious group, so more research is needed.
• Couple work. When trust has been damaged, couple therapy helps rebuild communication and create new agreements.
• Treating co-occurring conditions, such as depression, anxiety, ADHD and substance use, which are often important drivers.
• Medication. No medicine is approved specifically for CSBD. The most studied options are SSRIs and naltrexone. A small randomised trial by Lew-Starowicz and colleagues (2022) found that both paroxetine and naltrexone were reasonably safe and outperformed placebo on some, but not all, measures, and the placebo group also improved a lot. The evidence is therefore still limited. Medication should only be used as assessed and prescribed by a doctor.

1. 1Self-reflectionLoss of control, or mainly a clash with values?
2. 2Confidential talkAssess co-occurring depression, ADHD, substance use
3. 3Therapy firstEducation, CBT, ACT and couple work
4. 4Medicine if neededSSRI or naltrexone, limited evidence, as assessed by your doctor

WFSBP guidelines (Turner and colleagues 2022): psychoeducation and psychotherapy should always be provided.

Where to start on your own

1. Set a goal that matches your values. Some people want to stop completely; others want to watch less and stop it affecting their life. Both are valid goals.
2. Notice your triggers. Write down when urges come and what you were feeling just before.
3. Change your environment. Keep your phone out of the bedroom, use filters or screen-time limits, and reduce late-night time alone with a screen.
4. Have alternatives ready when an urge hits, such as going for a walk, taking a shower, calling a friend or doing a breathing exercise. Urges usually peak and then fade within a few minutes.
5. Reduce shame. Harsh self-criticism after a slip often sends you back to porn to escape the bad feeling. Treat a slip as information, not failure.
6. Look after the rest of your life. Sleep, exercise, relationships and hobbies all reduce the need to use porn as an escape.

For partners

If you are a partner who has just found out, anger, hurt and feeling not good enough are all understandable. Try to separate "the behaviour" from "your worth". Your partner's porn use usually doesn't mean you are unattractive. Talk about agreements and trust when you are both ready. If this relates to your partner's work or content production, read When your partner is a sex content creator. And if your conversations keep going in circles, couple counselling can help a great deal.

When to seek help

Talk to a professional when:

• You have tried to cut down on your own without success, and it's affecting your work, finances, sleep or relationships.
• Shame or guilt is so heavy that you feel depressed, or have thoughts of harming yourself. Call 1323, Thailand's free 24-hour mental health hotline (Thai language; ask for English support), or 1669 for medical emergencies.
• Your sexual behaviour has started to involve drugs or other substances. Read Chemsex and harm reduction.
• You find yourself drawn to material involving children or people who haven't consented. Please stop and seek help now, before anyone is harmed. Possessing or distributing child sexual abuse material is a criminal offence under Thai law. You can get confidential help from 1323, the social assistance hotline 1300, or the online self-help programme Troubled Desire.

If you're not sure who to talk to, read When to see a clinical sexologist. At Dr. Kris Clinic I listen to this confidentially and without judgement. I help work out where the distress is coming from, assess co-occurring conditions and effects on sexual health, plan therapy for individuals and couples, and refer to a psychiatrist when needed. Consultations are available in person at the clinic in Surat Thani and online, in English or Thai.