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According to a recent publication, ICD-11 (the International Classification of Disease, used as a coding manual in healthcare) may very well include a diagnosis called “Compulsive Sexual Behavior Disorder.” (Update-as of 6/19/18, it appears this diagnosis was included) So, of course, proponents of sex addiction are rejoicing, claiming final vindication of their beliefs. Not so fast, I say.
If this article is accurate, CSBD will be included in the ICD-11 section on impulsive disorders, not the group of addictive and substance use disorders. Whether these behaviors can or should be described as an addiction is far from supported or accepted.
There has been substantial advocacy regarding the great risk of over diagnosis and pathologizing which is inherent in the concept of sex addiction (and the lucrative sex addiction treatment industry). I, and many brilliant colleagues, have been leading voices of some of this advocacy. And, our advocacy appears to have been quite effective. There are a great number of exclusions built into this diagnosis, which precisely reflect our advocacy:
- CSBD should not be diagnosed when the psychological distress over sexual behaviors are due to moral conflict, or disapproval based on social rejection of these desires. So – the great many bisexual men labelled as sex addicts because their church, wives and therapists view same sex desires as unhealthy, and that man wishes he didn’t have these desires? That man can’t be diagnosed as having CSBD.
- Psychological distress over sexuality alone does not warrant diagnosis of CSBD. So, again, the many sex addiction therapists rendering this diagnosis, based solely upon their patient’s (or their wife’s) feelings about their sexual desires cannot ethically render a diagnosis of CSBD.
- Self-identity as a porn or sex addict is not enough to diagnose CSBD. This is hugely important, in the face of the sex addiction industry, which encourages, and preys upon, people self-identifying as sex or porn addicts. So, those dodgy online sex addiction tests? Yeah. Those are still worthless, as is the treatment related to them. Further - claiming the identity of sex addict, after you've gotten caught in sexual misbehavior won't qualify for CSBD, without a long history of efforts to curtail the behavior BEFORE you got caught...
- Primary mental health disorders must be ruled out, where sexual behaviors are symptomatic of those mental health concerns. So, the research finding that as many as 90% of alleged sex addicts have an underlying diagnosis of anxiety or depression, has won out. Those men who use sexuality as their sole coping mechanism for emotional distress won’t be diagnosed as having CSBD. They should be diagnosed, and treated, as having those mental health conditions. As anxiety and depression resolve, so too do these sexual behaviors.
- CSBD doesn’t indicate a “right” amount or kind, of sex. This has always been a core flaw in the sex addiction concept. You’re a sex addict, if you have or want sex, in a way that that someone else (spouse, pastor or therapist for instance) disapproves of. Efforts to include in DSM-5 the criteria of an orgasm a day on average, failed, on the recognition that it could overdiagnose as many as 40% of men.
- Unfortunately, the CSBD criteria stand great risk of overlapping tremendously with established patterns in paraphilic disorders, which commonly include a high degree of sexual obsession. Aside from a thorough, careful diagnosis by a clinician trained in sexual psychology, there doesn’t currently appear to be an effective way to distinguish the patterns of CSBD from those of a person with, for instance, pedophilia, who is trying not to act on their desires. The CSBD criteria do, appropriately, include an exclusion for paraphilias. This is significant, as multiple studies suggest that over 60% or more of alleged sex addicts may actually have undiagnosed and untreated sexual disorders. Appropriate application of CSBD criteria will require clinicians diagnosing it to rule out paraphilias - many currently don't. Sadly, many individuals with pedophilia, exhibitionism or voyeurism use diagnoses of sex addiction to attempt to avoid criminal responsibility. Unfortunately this also means they never get the treatment they actually need.
- Estimates of people experiencing sex addiction or CSBD have always ranged greatly, usually influenced by how much money the person spouting these statistics makes from treating sex addiction. The more investment they have in the problem, the higher the rates they spout. Objective research consistently finds estimates are very low – less than 1-2%. Proper application of CSBD exclusionary criteria will drive these estimates even lower. How low? We truly don’t know. Allegedly, trials and field studies of these criteria are being scheduled. How these tests will apply the above exclusions should be quite a feat, as parsing through the moral conflicts, primary mental health issues, and the dedicated true believer in self-identification as a sex addict, is not an easy task, and there are no standardized measures to assess these elements.
- I, and many others, have argued that sex isn't compulsive. Compulsion is an anxiety syndrome, part of OCD, and is both theoretically and diagnostically very different. Recent research found that compulsive symptoms actually weren't statistically significant in men reporting these kinds of sexual problems. People with OCD suffer tremendous emotional pain. All day long. People with "sex addiction" typically suffer when they get caught.
It will be extremely interesting to see how this plays out. Inclusion of CSBD in ICD-11 doesn’t necessarily change things very quickly in the United States. For example – the US healthcare system is currently using ICD-10, but only adopted it in 2015. ICD-10 was published in 1992. Will it take 23 years for the US to adopt ICD-11? Current estimates range from ten years, or to as long as 2032. Until this decision is implemented by the federal government, and CMS specifically, health insurance companies in the US won’t accept ICD-11 diagnoses, including CSBD.
Even after ICD-11 is accepted in the US, it STILL doesn’t necessarily change things in mental health diagnoses (and impulse control disorders are a mental health diagnosis). Many state regulations require that licensed clinicians use the DSM to diagnose mental health disorders, particularly in billing to funding streams such as Medicaid. Why? Because the ICD has typically been primarily a coding manual, not a diagnostic one as the DSM is. The ICD was intended to yield consistent sets of billing codes across regions, and has not historically included the level of detail, etiology and guidelines that were included in the DSM. Perhaps a DSM- update will include CSBD. Until then? The only people who can get treatment or diagnosis for CSBD in the United States will be people who can afford to pay cash for their services.
When advocates for sex addiction begin celebrating, and they will, we all need to help them recognize that if they simply rediagnose all of their alleged sex addict patients with CSBD, they are engaging in grossly unethical conduct. CSBD is NOT an endorsement that sex or porn is addictive. The people saying such things are revealing either their financial interests, or deeply held fearful views of their own sexuality.
I, for one, will be quite curious how many of their sex addict patients meet CSBD criteria, accurately applied, when we rule out those: experiencing moral conflicts related to their religious upbringing; people whose sexual behaviors are symptomatic of existing underlying mental health disorders; people who self-identify as a sex addict, because it’s a great way to try out of trouble for sexual misbehaviors; and people who are experiencing distress related to normal, healthy sexual desires.
I’ve always been extremely interested in finding out what is left, when all the above exclusions are applied. Now, we have a chance to find out. I’m quite excited to see.
