Compulsive Sexual Behavior Diagnosis in ICD-11

Notes for Journalists, Healthcare Professionals and General Public. PDF version for printing

“Compulsive Sexual Behaviour” has been classified by World Health Organization as Mental Health Disorder

Despite a few misleading rumors to the contrary, it is untrue that the WHO has rejected  “porn addiction” or “sex addiction”. Compulsive sexual behavior has been called by a variety of names over the years: “hypersexuality”, “porn addiction”, “sex addiction”, “out-of-control sexual behavior” and so forth. In its latest catalogue of diseases the WHO takes a step towards legitimizing the disorder by acknowledging “Compulsive Sexual Behaviour Disorder” (CSBD) as a mental illness. According to WHO expert Geoffrey Reed, the new CSBD diagnosis “lets people know they have “a genuine condition” and can seek treatment.”

  1. On June 18 2018, the WHO’s authors of the International Classification of Diseases, 11thRevision, put out a press release announcing that the implementation version of the upcoming ICD-11 is available online.

SASH, ICD-11, sex addiction, pornography,

  1. Compulsive sexual behavior disorder [6C72] (CSBD) at last offers healthcare professionals a formal, self-evident diagnosis for inability to control sexual behavior3despite negative consequences. Actual implementation of the new codes differs everywhere, but the important thing is that the world’s health experts have agreed that compulsive sexual behavior merits a diagnosis. CSBD can be used for anyone who meets its criteria. “Compulsive sexual behavior” is also “referred to as sexual addiction or hypersexuality” according to diagnostic expert Jon E. Grant, JD, MD, MPH4.

As stated, the new CSBD diagnosis may also be used to diagnose those with severe internet pornography use-related symptoms. More than 80% of people with compulsive sexual behaviour report excessive or problematic pornography use.

“Problematic pornography use may represent a prominent manifestation of hypersexuality (also referred to as sexual compulsivity, sexual addiction or excessive sexual behavior in the literature – Kafka, 2010; Karila et al., 2014; Wéry & Billieux, 2017) because in several studies more than 80% of people with hypersexuality have reported excessive/problematic pornography use (Kafka, 2010; Reid et al., 2012)”. 5

  1. A “compulsive sexual behavior” diagnosis arises from a pattern of failure to control intense, sexual impulses or urges, resulting in repetitive sexual behavior over an extended period of time (e.g., 6 months or more).
  2. Early critics were concerned that any formal diagnosis would be used to pathologize sexual minorities and alternative sexual practices. However, to meet the diagnostic criteria for CSBD, the problematic behavior must cause persistent marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. In other words, the new diagnosis doesn’t diagnose patients based on what sexual behavior they freely engage in. It diagnoses patients based on persistent impairment and distress. If sexual behavior, whatever form it takes, results in neither, the new diagnosis will not apply.

Other critics warned that a CSBD diagnosis might result in mistaken diagnosis by patients whose behavior was not, in fact, compulsive, and whose distress was due to moral judgment by patient or professional. To prevent such outcomes, the new diagnosis provides that, “Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient.” In other words, a patient must actually be unable to control impulses and be engaging in repetitive sexual behavior that has become problematic.

  1. There has been much debate in the lead up to the publication of the new classification in ICD-11. Compulsive sexual behaviour disorder (operationalised as hypersexual disorder) was considered for inclusion in DSM-5 but ultimately excluded. According to leading neuroscientists, “This exclusion has hindered prevention, research, and treatment efforts, and left clinicians without a formal diagnosis for compulsive sexual behaviour disorder.”6

For now, the parent category of the new CSBD diagnosis is Impulse Control Disorders, which includes diagnoses such as Pyromania [6C70], Kleptomania [6C71] and Intermittent Explosive Disorder [6C73]. Yet doubts remain about the ideal category. As Yale neuroscientist Marc Potenza MD PhD and Mateusz Gola PhD, researcher at the Polish Academy of Sciences and the University of California San Diego point out, “The current proposal of classifying CSB disorder as an impulse-control disorder is controversial as alternate models have been proposed …There are data suggesting that CSB shares many features with addictions.” 7

It might be worth noting that ICD-11 includes diagnoses of Gambling Disorder under both Disorders Due to Addictive Behaviors and under Impulse Control Disorders. Thus, categorization of disorders need not always be mutually exclusive.5Classification may also shift with time. Gambling Disorder was originally classified as an impulse disorder in both the DSM-IV and the ICD-10, but based on advances in empirical understanding, Gambling Disorder has been reclassified as a “Substance-Related and Addictive Disorder” (DSM-5) and a “Disorder Due to Addictive Behaviour” (ICD-11). It is possible that this new CSBD diagnosis may follow a similar developmental course as Gambling Disorder has.

Regardless of how this discussion evolves over time, the current inclusion of CSBD in the ICD-11 provides a welcome and necessary recognition that there are people who are in need of effective clinical intervention to help them better negotiate their sexual behavior and its consequences. It will also facilitate much needed future research on problematic sexual behavior. (See additional quotation in footnotes).

  1. In the wake of the World Health Organization(WHO) classifying gaming disorder and CSBD as mental health conditions, a report in the Guardian newspaper9stated that a London hospital is preparing to launch the first ever National Health Service-funded internet addiction center for young people and adults.
  2. According to Mateusz Gola PhD, researcher at the Polish Academy of Sciences and at University of California San Diego, the new CSBD diagnosis has other benefits as well. “It sets out clear diagnostic criteria. Moreover, clinical psychologists and psychiatrists in training will now study the disorder. Without the formal CSBD diagnosis, many clinicians were uninformed about compulsive sexual behavior issues. Eventually, this diagnosis could also give more patients access to insurance-covered treatment.” Gola added that, the new diagnosis, “doesn’t solve the problem of how to treat CSBD effectively, but it allows for more consistent studies, potentially leading to standardized, reliable approaches.”
  1. Shane W. Kraus, Ph.D. Assistant Professor of Psychiatry and Director of the Behavioral Addictions Clinic at Edith Nourse Rogers Memorial Veterans Hospital, University of Massachusetts Medical School said in regard to the new diagnostic category: “This is a positive first step. The inclusion of CSBD in ICD-11 would likely increase access to care for patients (internationally and within the US).In addition, inclusion would also increase research funding which has been historically focused on diagnosable mental health disorders. In addition, I think it would reduce stigma for affected persons and increase more provider education on the issue.”
  1. Diagnostic manuals like the ICD and the DSM do not label mental health conditions as “Addictions” per se. They prefer “Disorder.”
  1. An express purpose of the recent ICD-11 release is to allow countries to train health professionals on the manual’s diagnoses. Researchers have also urged7that clinicians and counselors become trained and to better understand compulsive sexual behaviours:

 “It is also important that care providers (i.e., clinicians and counselors) from whom individuals may seek help are familiar with CSBs. During our studies involving over 3,000 subjects seeking treatment for CSB, we have frequently heard that individuals suffering from CSB encounter multiple barriers during their seeking of help or in contact with clinicians (Dhuffar & Griffiths, 2016). Patients report that clinicians may avoid the topic, state that such problems do not exist, or suggest that one has a high sexual drive, and should accept it instead of treating (despite that for these individuals, the CSBs may feel ego-dystonicand lead to multiple negative consequences). We believe that well-defined criteria for CSB disorder will promote educational efforts including development of training programs on how to assess and treat individuals with symptoms of CSB disorder. We hope that such programs will become a part of clinical training for psychologists, psychiatrists, and other providers of mental health care services, as well as other care providers including primary care providers, such as generalist physicians.”

11. The Society for the Advancement of Sexual Health (SASH) is a nonprofit organization dedicated to promoting an integrative approach to sexual health research, education and intervention that addresses the full spectrum, from problematic attitudes and behaviors to the pursuit of fulfillment, freedom and pleasure. Members of SASH include practitioners who treat CSBD, as well as educational, legal, policy, and research professionals.

SASH offers a premier training curriculum to professionals in the mental health and medical fields. The Advanced Training in Problematic Sexual Behaviors (ATPSB) program is dedicated to addressing and treating harmful sexual behavior.  The ATPSB program accomplishes this mission by establishing standards of knowledge for entry‐level practitioners, creating standards of care inclusive of various descriptions of problematic sexual behaviors (PSB), and by providing course content addressing current trends in the assessment and treatment of PSB. Finally, the ATPSB program, in conjunction with SASH, provides national leadership in addressing the varied needs of those suffering from problematic sexual behavior and the professionals treating them. (See

https://www.sash.net/advanced-training-problematic-sexual-behaviors-certificate-program/)

  • SASH does not pathologize any consensual sexual behaviors or identities (fetishes, sexual orientation, gender identity, etc.). The focus is not about particular sexual behaviors or urges, but rather it is about individuals’ inability to exercise control when they choose.
  • SASH does not encourage therapists to be moralistic or judgmental about what is sex positive or negative for clients. Clients personally make the decision about what is sexually healthy for them. That is part of the treatment process.
  • SASH does not advocate for any particular model of treatment. It encourages the application and use of research-based therapies and interventions that are outcome driven.  SASH also encourages multi-faceted treatment approaches, including trauma, psychodynamic, attachment, addiction, gestalt, narrative, and behavioral treatment models. Many members of SASH are sex therapists; others are sex addiction therapists. Some are both.

 

For interviews or more information including full copies of the sources cited, please contact [email protected]

 

 

FOOTNOTES:

  1. http://www.who.int/news-room/detail/18-06-2018-who-releases-new-international-classification-of-diseases-(icd-11)

ICD-11 Press Release

WHO releases new International Classification of Diseases (ICD 11) 18 June 2018 News Release Geneva

The World Health Organization (WHO) is today releasing its new International Classification of Diseases (ICD-11).

The ICD is the foundation for identifying health trends and statistics worldwide, and contains around 55 000 unique codes for injuries, diseases and causes of death. It provides a common language that allows health professionals to share health information across the globe.

“The ICD is a product that WHO is truly proud of,” says Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “It enables us to understand so much about what makes people get sick and die, and to take action to prevent suffering and save lives.”

ICD-11, which has been over a decade in the making, provides significant improvements on previous versions. For the first time, it is completely electronic and has a much more user-friendly format. And there has been unprecedented involvement of health care workers who have joined collaborative meetings and submitted proposals. The ICD team in WHO headquarters has received over 10 000 proposals for revisions.

ICD-11 will be presented at the World Health Assembly in May 2019 for adoption by Member States, and will come into effect on 1 January 2022. This release is an advance preview that will allow countries to plan how to use the new version, prepare translations, and train health professionals all over the country.

The ICD is also used by health insurers whose reimbursements depend on ICD coding; national health programme managers; data collection specialists; and others who track progress in global health and determine the allocation of health resources.

The new ICD-11 also reflects progress in medicine and advances in scientific understanding. For example, the codes relating to antimicrobial resistance are more closely in line with the Global Antimicrobial Resistance Surveillance System (GLASS). ICD-11 is also able to better capture data regarding safety in healthcare, which means that unnecessary events that may harm health – such as unsafe workflows in hospitals – can be identified and reduced.

The new ICD also includes new chapters, one on traditional medicine: although millions of people use traditional medicine worldwide, it has never been classified in this system. Another new chapter on sexual health brings together conditions that were previously categorized in other ways (e.g. gender incongruence was listed under mental health conditions) or described differently. Gaming disorder has been added to the section on addictive disorders.

“A key principle in this revision was to simplify the coding structure and electronic tooling – this will allow health care professionals to more easily and completely record conditions,” says Dr Robert Jakob, Team Leader, Classifications Terminologies and Standards, WHO.

Dr Lubna Alansari, WHO’s Assistant Director-General for Health Metrics and Measurement, says: “ICD is a cornerstone of health information and ICD-11 will deliver an up-to-date view of the patterns of disease.”

 

  1. CSBD description: https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1630268048
  2. The ICD-11 official publication spells “behaviour” the European way.
  3. Current Psychiatry, February 2018” p.34
  4. Revisiting the Role of Impulsivity and Compulsivity in Problematic Sexual Behaviours (Bőthe et al. 2018) P2
  5. “Is excessive sexual behavior an addictive disorder?” (Potenza et al. 2017) https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366%2817%2930316-4/fulltext
  6. Promoting educational, classification, treatment, and policy initiatives Commentary on: Compulsive sexual behaviour disorder in the ICD-11 (Kraus et al., 2018)13 June 2018
  7. The Proof of the Pudding Is in the Tasting: Data Are Needed to Test Models and Hypotheses Related to Compulsive Sexual Behaviors (Gola & Potenza, 2018)

“It would be relevant to consider how the DSM and the International Classification of Diseases (ICD) operate with respect to definition and classification processes. In doing so, we think it is relevant to focus on gambling disorder (also known as pathological gambling) and how it was considered in DSM-IV and DSM-5 (as well as in ICD-10 and the forthcoming ICD-11). In DSM-IV, pathological gambling was categorized as an “Impulse-Control Disorder Not Elsewhere Classified.” In DSM-5, it was reclassified as a “Substance-Related and Addictive Disorder.”…. A similar approach should be applied to CSB, which is currently being considered for inclusion as an impulse-control disorder in ICD-11 (Grant et al., 2014; Kraus et al., 2018)”

  1. https://www.theguardian.com/society/2018/jun/22/nhs-internet-addiction-clinic-london-gaming-mental-health