Though the concept of sex addiction has been a subject of debate for some time, there actually hasn’t been an official diagnosis that addresses problematic sexual behavior—until now.
Last month, the World Health Organization (WHO) released the proposal for the 11th edition of the International Classification of Diseases (ICD-11), the first revision of the global standard diagnostic catalogue since 1990. And among the proposed changes is the addition of a mental health condition called compulsive sexual behavior disorder (CSBD), which is a pretty big milestone in the mental health community.
“This is the first time internationally that there is a category for dysregulated or problematic sexual behavior,” Shane W. Kraus, Ph.D., director of the Behavioral Addictions Clinic at the Edith Nourse Rogers Memorial Veterans Hospital in Bedford, Mass., and assistant professor of psychiatry at the University of Massachusetts Medical School, who was part of the WHO work group that developed the diagnostic criteria for CSBD, tells SELF.
CSBD is classified as an impulse control disorder, meaning it appears in the ICD-11 alongside conditions like gambling disorder and kleptomania.
CSBD is characterized by “a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour,” according to its diagnostic description in the ICD-11; this can include both the act of sex and sexual fantasies.
The umbrella term “impulse control disorder” includes a variety of psychiatric disorders “whose essential features are the failure to resist an impulse to perform an act that is harmful to the individual or to others,” according to the ICD. Individuals typically experience an increased sense of tension before the act, but then pleasure or gratification when they do the act, it goes on to explain.
According to the ICD, the hallmark symptoms of CSBD are “repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it.”
For example, someone with CSBD might be over and over again engaging in sexual behavior that they full well know is damaging their relationship with the person they love, like putting their impulse to have sex over their partner’s desires and other aspects of their relationship, or having sex with someone who is not their partner (assuming they’re in a monogamous relationship) in order to satisfy those strong and frequent urges, or engaging in this behavior to the detriment of their job or other responsibilities.
While the official diagnosis may be new, for many mental health professionals, the condition is something they see and discuss often. “A lot of the therapeutic community has been talking about this issue and working with patients seeking help for these kind of sexual problems long before it was canonized in the ICD-11,” Rory Reid, Ph.D., LCSW, assistant professor and research psychologist in the Department of Psychiatry and Biobehavioral Sciences at UCLA, tells SELF.
Reid compares the lag between clinical evidence of a problem and an official diagnosis to the trajectory of PTSD: The disorder was recognized by the APA in the DSM in 1980 after a wave of veterans sought professional help for their similar experiences. “We had all these military personnel coming back from the Vietnam War having these symptoms—flashbacks, anxiety—and they were going in to therapists and psychiatrists to talk about them,” he says. “So therapists started working with it long before it was canonized as a disease or a disorder, and then the scientific community caught up and said, ‘Yeah we’re seeing this, too.’”
It’s worth noting that a CSBD diagnosis is not same thing as having a high sex drive or large number of sexual partners.
Having a lot of sex or sexual desire doesn’t mean you have a condition, similarly to, for instance, how not everyone who drinks what some might consider a lot has alcoholism. “[Their behavior] might cause distress or it might be an issue for them, but it doesn’t mean they have a mental health problem,” Kraus explains.
The ICD criteria also cautions against conflating violating social or cultural norms with having a clinical condition. It explicitly states that “distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours” does not factor into a CSBD diagnosis. For instance, being into kink, having multiple sexual partners, or frequenting sex parties may not be everyone’s cup of tea but it doesn’t qualify you as having CSBD. “Compulsive sexual behavior, when properly diagnosed, is not in any way related to who or what it is that turns a person on,” certified sex addiction therapist (CSAT) Robert Weiss, author of Sex Addiction 101, host of the podcast Sex, Love, and Addiction 101, and CEO of Seeking Integrity, tells SELF.
“People have sexual behaviors that vary across people and cultures and groups, and we want to make sure we’re not overpathologizing people based on specific values,” Kraus explains. The CSBD diagnostic criteria are based on science rather than conjecture, and “very specifically take morality and personal judgement out of the equation,” Weiss says.
In fact, the fear of overpathologizing sexual behavior based on what we view as normal, proper, moral, or socially acceptable is actually one of the controversies that led the American Psychiatric Association (APA) to reject the proposed addition of “hypersexual disorder” to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) back in 2013, Reid points out.
The APA objected that the diagnostic criteria for hypersexual disorder did not clearly differentiate between “normal range high levels of sexual desire and activity” and “pathological levels of sexual desire and activity,” according to a paper that Reid co-authored in 2014. This lack of clarity created a potential for “false positives,” the APA argued, “erroneously diagnosing an individual with a mental disorder that is a normal variant of human behavior.”
WHO’s addition of CSBD has stirred up this existing controversy on the subject of how to define and diagnose disorders related to sexual behavior. “There was never any dispute that healthcare professionals are seeing [the issue of CSBD] all over,” psychologist Eli Coleman, Ph.D., director of the Program in Human Sexuality at the University of Minnesota Medical School and founding editor of the International Journal of Sexual Health, tells SELF. “It’s just been a matter of debate about what we call it.”
The specific language that the medical community (and society in general) uses for a particular condition matters; it shapes our conception of the condition, and in turn, determines how people dealing with those issues are perceived and the treatment they receive. In the case of psychiatric and behavioral disorders, the name experts settle on and the category they file it under (addiction, impulse control disorder, obsessive compulsive disorder) refers to the underlying brain mechanism, or how that particular disorder is thought to be working in the brain. That then tells us how to approach treatment and what treatments are most likely to be effective, Reid explains.
So does this mean that sex addiction is now a formally recognized mental health condition? Well, not exactly.
In regards to CSBD, the largest point of contention is whether or not the disorder should be categorized as an addiction. “There is ongoing scientific debate on whether or not the compulsive sexual behavior disorder constitutes the manifestation of a behavioral addiction,” WHO spokesperson Christian Lindmeier tells SELF. “WHO does not use the term sex addiction because we are not taking a position about whether it is physiologically an addiction or not.”
But unlike the phrase compulsive sexual behavior disorder, most people are familiar with the term sex addiction. It’s also long been used by the mental health professionals that counsel people with these issues.
“I and many others have used multiple terms interchangeably for many years: sex addiction, sexual compulsivity, hypersexuality, compulsive sexual behavior,” says Weiss. “The term I’ve tended to use most often is sex addiction, primarily because that’s the term that the people who are suffering with this disorder will most easily identify with.”
Some experts, including Weiss, feel there is no question whether the sexual behavior patterns associated with CSBD resemble an addiction.
“Anyone who has been to a 12-step sexual recovery meeting can see for themselves the honest pain of the individuals attending,” Weiss says. “They talk about their preoccupation to the point of obsession, their loss of control, and their negative consequences, the same as recovering addicts do in Alcoholics Anonymous and Narcotics Anonymous.”
In some ways, the comparison makes perfect sense. In both cases of substance use disorders and CSBD, the person has difficulty controlling urges to keep engaging in behavior (having sex, using heroin, taking a drink) that is harmful to their own well-being or that of someone they love, negatively impacting their lives, taking priority over all (or almost all) else, and, despite maybe resulting in an instant sense of pleasure, gratification, or relief, definitely not making them feel happy, content, or satisfied in any deep or lasting sense.
And in Weiss’s experience, he sees people struggling with this issue using sex as a coping mechanism, similarly to how a person dealing with alcoholism turns to a drink. “As with other addictions, the ‘substance’ (in this case sexual fantasy and activity) is used to ‘numb out’ and to avoid stress, loneliness, boredom, sadness, and other uncomfortable feelings,” he explains. Oftentimes, “Sex addicts, like [many] other addicts, are not using to feel good, they’re using to feel less.”
There is also some evidence to suggest that the mechanism behind this kind of sexual behavior is addictive.
A 2016 literature review co-authored by Kraus cited neuroimaging studies showing the same systems in the brain may be involved in both compulsive sexual behavior and substance abuse.
But the evidence isn’t definitive, at least not yet. That paper also concluded that the growing body of research is still rife with holes. “Clearly there is not sufficient evidence to say that [compulsive sexual behavior] is an addiction or even a behavioral addiction,” Coleman says.
And Reid points out that despite some overlap, CSBD also lacks key features associated with addiction. “People might argue sexual addiction is similar in nature [to other addictions], and there probably are a lot of similarities with various addictive behaviors,” he notes. “But there are differences too, such as a lack of evidence for symptoms of withdrawal and tolerance in compulsive sexual behavior, whereas these are common symptoms of substance-related addictions.”
There just isn’t enough proof demonstrating CSBD closely mirrors addiction,
whereas with gambling addiction, for example, two of the diagnostic criteria laid out by the APA are a “need to gamble with increasing amount of money to achieve the desired excitement” (e.g. tolerance-building) and being “restless or irritable when trying to cut down or stop gambling” (e.g. withdrawal).
And many experts argue that unless scientific evidence can prove that this issue is actually an addiction, we should refrain from calling it one, as WHO opted to do.
Outside the strictly scientific argument about whether this qualifies as an addiction, there are other rationales for taking this more conservative stance and avoiding the term sex addiction.
What we call something in public discourse shapes our understanding of what the issue is. Coleman fears that the term sex addiction is so overused and imprecise that it has lost significance. “One of the problems is the term sex addiction is used so casually that the scientific meaning is lost in really understanding the underlying mechanisms,” he says. “It has a lot of connotations that don’t really reflect what the condition is about.”
Even more importantly, the label we give the condition also has ramifications for how we treat it. “The term [sex addiction] implies that it is like alcohol or heroin addiction, and that’s a completely different mechanism, so you could apply inappropriate treatment to this condition,” Coleman explains. For example, addiction treatment typically involves abstaining from the thing the person is addicted to. “And sex is a basic appetitive drive, so abstinence doesn’t work…Counting the days of going without sex? It doesn’t make any sense.”
From Coleman’s perspective, the optimal approach is more akin to the treatment of an eating disorder, which involves refraining from dysregulated behavioral patterns and relearning to engage in the behavior in healthy ways.
Experts agree that we need more research on compulsive sexual behavior, and that this research will reveal more about what exactly the disorder is and how to treat it.
“The jury’s still out on trying to really tease out these nuances both clinically and scientifically so that we can have clarity about what this phenomenon is exactly,” Reid says.
It’s also entirely possible that there are multiple disorders underpinning these displays of behavior. “The problem is that for people with out-of-control sexual behavior, it could be driven by a number of different mechanisms,” Coleman explains. “I think that [WHO] recognizes that it’s still uncertain if this is where it should be, as an impulse control disorder, but there is quite a bit of literature that supports that for many of these people that it is like an impulse control disorder.” Either way, “I think what we call it and how we describe it is very much going to evolve with good research over time,” Kraus says.
Kraus and Reid both note as an example how the understanding of pathological gambling as a behavioral issue has changed over time. It was initially categorized as an impulse control disorder, because that’s what the limited evidence pointed to. But a cadre of subsequent research produced enough scientific evidence to re-categorize it as an addictive disorder in the DSM-5, Reid explains. “We could see a similar trajectory for compulsive sexual behavior disorder. It’s too early to tell at this point.”
WHO’s inclusion of CSBD in the ICD-11 isn’t putting an end to this debate; it establishes that it’s one worth having, and a debate worth putting research dollars towards.
“Settling on this term will help us open up the conversation and do the research that may enable us to come up with more accurate frameworks and better terminology to talk about it,” Reid explains. “Now let’s continue to press forward scientifically and clinically learn more about it in terms of what’s causing this, what brain mechanisms or other biological factors might be linked to this, and how we best treat it.” Kraus thinks it’s likely that WHO’s designation will influence both future research in the U.S. and discussions about adding CSBD, or something similar, to future versions of the DSM.
And in the meantime, the immediate benefit of the classification is that it will hopefully help people suffering feel destigmatized and seek treatment.
“I think the broader goal of this classification is that it will open access to healthcare, hopefully reduce stigma, and increase people seeking help,” Kraus says. (Providers will be able to use the ICD diagnostic code to bill insurance, for instance.)
Weiss adds, “People who are struggling with [this] finally have an official diagnosis they can point to…This seemingly simple thing may help a great deal with the shame they typically feel.”
And as Kraus puts it, “This is definitely not the final solution, but it’s a good starting place for more research and treatment for people.”
You could argue that for now, it’s less important what we call CBSD, and more important that we have a way to talk about and diagnose the issue, even if it’s not a perfect process.
While Weiss, for example, has long been comfortable with the term sex addiction, he doesn’t especially care what term we agree to officially use. He thinks giving therapists accurate guidelines to identify the issue is more important. “Compulsive sexual behavior disorder is fine by me. As long as we have accurate, research-based criteria we can use to identify and diagnose the issue, I’m happy,” he says. “And the WHO has just provided us with exactly that.”
Reid points out that many patients, too, are probably less interested in the technical diagnostic term their health care providers use than in actually having their problems recognized and treated. “There are some of these scientific nuances, but I think for the person out there who’s struggling. they’re not going to really differentiate between what we label it,” he says. “They’re going to say ‘You can call it impulsive sexual behavior, you can call it hypersexual disorder, you can call it sex addiction—this is what describes me.’”