The book had a range of influences – from punk rock to earlier fashion iconoclasts like Guy Bourdin and his surrealism, and Helmut Newton, in its stylized, sado-masochistic look. Sex has photographs that feature adult content and softcore pornographic as well as simulations of sexual acts, including sadomasochism and analingus. Madonna wrote the book as a character named "Mistress Dita", inspired by 1930s film actress Dita Parlo. It also includes cameos by actress Isabella Rossellini, rappers Big Daddy Kane and Vanilla Ice, model Naomi Campbell, gay porn star Joey Stefano, actor Udo Kier, socialite Tatiana von Fürstenberg, and nightclub owner Ingrid Casares.
The packaging for the book is made of aluminium, which was Madonna's idea, and is spiral bound and enclosed in a Mylar sheet. Due to the scandalous nature of the photographs and the media mayhem surrounding it from the initial preview of the book, Madonna did not have to promote Sex, except for a pre-release party and some television specials. Her publishers were extremely apprehensive about the release as well as its commercial potential. Sex was released alongside her fifth studio album Erotica, which was released a day earlier.
The extremely controversial book was received negatively by both critics and fans of the singer, who felt she had gone too far. Despite this it was a commercial success, managing to sell over 150,000