A New Avenue to Pathologize Sexual Minority Populations? Internalized Sexual Stigma and Endorsement of Compulsive Sexual Behaviour Disorder Criteria

Background: While the term sex addiction has long been used colloquially, it is controversial and not recognized diagnostically. This debate has received renewed focus with the World Health Organization (WHO) adopting compulsive sexual behaviour disorder (CSBD) in the ICD-11, the first diagnosis of its kind. Of particular concern is how this diagnosis might impact sexual minority populations—including lesbian, gay, and bisexual (LGB) persons—whose identities have historically been pathologized by medical bodies. Given sexual behaviors vary across time and culture, the CSBD diagnosis does not include specific behavioral criteria but relies on client self-perception. Relatedly, recent literature suggests that people may misinterpret their sexual behaviors, mistaking moral qualms (i.e., feeling bad about behavior) for “compulsivity.” Given this, it seems possible that LGB persons with internalized sexual stigma, who experience angst about a central facet of their personhood, might be especially likely to feel that their sexual behaviors are dysregulated. Our primary hypothesis was that internalized sexual stigma would predict endorsement of compulsive sexual behavior among LGB respondents.

Methods: Data were derived from a cross-sectional survey administered via Qualtrics survey panels. Participants included LGB adults matched to U.S. nationally representative norms for race/ethnicity, sex, and age (n =496). We conducted our analyses in two steps. We first constructed an OLS regression model wherein a recently developed CSBD screening measure (α=.96) served as the outcome variable. Our focal predictor, internalized sexual stigma, was assessed via the Revised Internalized Homophobia Scale (α=.89). Control variables included various behaviors assumed common to CSBD—e.g., pornography viewing, masturbation, casual sex, cybersex—as well as demographic indicators. We next assessed endorsement of the WHO’s diagnostic criteria more directly by constructing a binary logistic regression model (where 0 = no endorsement of symptoms, 1 = endorsement of one or more of four major criteria). We dichotomized this variable given WHO requires one or more of these items for diagnosis. The same variables as in the first model were entered as predictors.

Results: Our hypothesis was supported in both models. In the first model, internalized sexual stigma was significantly associated with the CSBD screening measure and was the largest predictor in the model (β =.42, p <.001). The overall model accounted for 50% of the variance in the outcome variable. In the second model, internalized sexual stigma was a robust predictor of endorsement of CSBD diagnostic criteria (aOR =1.15, p <.001). The pseudo R² (Nagelkerke) suggested that the overall model accounted for approximately 43% of the variance in the outcome variable.

Implications: Our findings suggest that the WHO’s new CSBD diagnosis might conflate internalized sexual stigma with “compulsive” sexual behavior. For LGB individuals who haven’t embraced their sexual orientation, any sexual urges or behaviors might feel distressing and dysregulated. This has significant implications for social work practice in that diagnosing practitioners might mistake normative behaviors as pathological and formulate a course of treatment that is damaging. Given this, the new CSBD diagnosis might confer iatrogenic harms and even act as a new covert avenue of reparative therapy.