Half of Therapists May Misdiagnose Sex Addiction

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In 2017, the World Health Organization adopted a controversial diagnosis as part of the 11th Edition of its International Classification of Disease (ICD-11). Compulsive Sexual Behavior Disorder (CSBD) was established as an Impulse Control Disorder, with the following criteria:

1. Pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour
2. Manifested over an extended period of time (e.g., 6 months or more)
3. Causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning (distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement)

Many of us found it a bit conflicted that a “compulsive” disorder was being classed in an “impulse-control” category, but were generally pleased that the criteria included an explicit exclusion for individuals who were experiencing distress due to moral incongruence. So, individuals who feel shame and distress because they engage in once-weekly masturbation wouldn’t meet the criteria, if their distress is solely due to the fact that their religion tells them that masturbation is sinful.

However, many of us, myself included, expressed concern that therapists would simply diagnose CSBD in any individual who self-identified as a sex addict, as opposed to giving an adequate clinical examination of the behaviors, motivations, environment, and context. We were frankly concerned that the CSBD diagnosis would be used as a rubber stamp, applied to anyone who said "I think I'm a sex addict!"

There are many reasons why individuals may self-identify as being "addicted" to sex, even when they are not actually engaging in more frequent sexual behaviors than other people. Moral incongruence is a key factor: The higher levels of shame a person feels about their sexual desires and behaviors, the more difficulty they have reporting or experiencing self-control over those behaviors. However, as my colleague Marty Klein has noted, “Feeling out of control is different than being out of control.”

Just because some people self-report (after a sexual behavior) that they didn’t feel like they could stop, doesn’t mean they couldn’t stop. Indeed, in my experience, most of these people are actually experiencing regret and remorse for their behaviors, which they reinterpret as a feeling of loss of control. Calling oneself a sex addict is an effective way to externalize the responsibility for one’s choices, as opposed to acknowledging “I made choices that I later wished I hadn’t, because they conflicted with my values, relationship agreements, and religion.”

Now, an international field study of the ICD-11 CSBD diagnostic criteria reveals that such concerns were likely valid. Over 1,000 licensed mental health professionals participated in research examining the consistency and accuracy of their diagnostic decisions, utilizing case vignettes and applying criteria from the ICD-11. The research looked at Compulsive Sexual Behavior Disorder, but also examined criteria and accuracy for gaming disorder, pyromania, kleptomania, and intermittent explosive disorder.

Results for these other disorders were quite positive: Although gaming disorder was controversial and contested, results found that clinicians were largely accurate (79%) when not diagnosing gaming disorder in individuals who gamed frequently but demonstrated no pathological involvement in gaming. Unfortunately, this was far from true when it came to Compulsive Sexual Behavior Disorder. There, when the vignette described a person who self-identified as a “sex addict,” but demonstrated no evidence of loss of control over their sexual behaviors, fully 50 percent of therapists still diagnosed CSBD, contrary to diagnostic guidelines.

The researchers did not include vignettes that explored the moral-exclusion quandary. Other research has suggested that failing to consider the moral distress can also lead to dramatic over-diagnosis of CSBD.

The researchers note the very high levels of incorrect over-diagnosis of CSBD based solely on self-report, and recommend that there is a clear need for careful training programs on this topic, and that validated testing measures should be used, rather than reliance on self-identification.

ICD-11 is still not used in the United States. It took the U.S. 23 years to adopt ICD-10, and that literally required multiple acts of Congress. At this time, there appears no rush in Washington, DC to amend our healthcare system and implement ICD-11. However, when it is finally implemented in the U.S., there are many sex-addiction therapists who will look forward to diagnosing all their patients with CSBD, despite the fact that they display no actual signs of loss of control. This risk of over-diagnosis was a primary reason why a similar diagnosis was excluded from DSM-5 by the American Psychiatric Association.

Hopefully, this current research helps to highlight the risks of over-diagnosis, and leads to better training and diagnostic criteria to prevent misdiagnosis.

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