Diagnosis of hypersexual or compulsive sexual behavior can be made using ICD-10 and DSM-5 despite rejection of this diagnosis by the American Psychiatric Association (2016)

Diagnoses that could refer to compulsive sexual behavior have been included in the DSM and ICD for years and can now be diagnosed legitimately in the United States using both DSM-5 and the recently mandated ICD-10 diagnostic coding. Compulsive sexual behavior disorder is being considered for ICD-11.

Kraus et al. wrote that the diagnosis of compulsive sexual behavior was being considered for inclusion in ICD-11 and observed that the diagnosis of hypersexual disorder was rejected by the American Psychiatric Association (APA) for inclusion in DSM-5 [1]. It should be noted that diagnoses that could refer to compulsive sexual behavior have been included in the DSM since DSM-III was published in 1980 [2], and in the ICD since it first added a classification that included mental disorders with ICD-6 in 1948 [3]. In DSM-IV and DSM-IV-TR, the diagnosis of ‘sexual disorders not otherwise specified [NOS]’ (302.9) was included; this allowed for a diagnosis that included hypersexual behavior [4]. In ICD-6 and -7 the term ‘pathological sexuality’ was included [5, 6]; in ICD-8, the term ‘unspecified sexual deviation’, which included ‘pathological sexuality NOS’ was included [7]. In ICD-9, published in 1975, and used by most countries aside from the United States, this category was continued as ‘sexual deviation and disorders, unspecified’ [8]. In ICD-9-CM (clinical modification), an edition published specifically for the United States that came into use in 1989, ‘unspecified psychosexual disorder’ [9], was included. Both these diagnoses had had the diagnostic code of 302.9.

Paradoxically, although hypersexual disorder was rejected by the American Psychiatric Association for DSM-5 [10], on 1 October 2015 the use of the diagnostic codes of ICD-10 became obligatory in the United States, enabling its diagnosis. These codes are included in parentheses and gray text in DSM-5 next to the DSM-9-CM codes presented in bold type [11]. In ICD-10, the category ‘excessive sexual drive’ was included as F52.7; this category, which reflects dated and pejorative terminology, is: ([12], p. 194):

‘Both men and women may occasionally complain of excessive sexual drive as a problem in its own right, usually during late teenage or early adulthood. When the excessive sexual drive is secondary to an affective disorder (F30-F39), or when it occurs during the early stages of dementia (F00-F03), the underlying disorder should be coded. Includes: nymphomania satyriasis.’

A ‘clinical modification’ of the WHO ICD-10 was published in the United States as ICD-10-CM [13] in 2016. The diagnostic code for excessive sexual drive, F52.7, was ‘decommissioned’ for use in the United States when ICD-10-CM was prepared initially in the late 1990s [14]. The recommended code, according to the ICD-10-CM index, is F52.8, which is the code for ‘other sexual dysfunction not due to substance or known physiological condition’; the inclusion terms of ‘excessive sexual drive’, ‘nymphomania’ and ‘satyriasis’ are listed under F52.8. DSM-5 also lists ‘other specified sexual dysfunction’ as F52.8 [13]. This diagnosis may thus be used for hypersexual disorder.

Although ICD-11 is not scheduled to be published until 2018, the diagnosis of Compulsive Sexual Behavior Disorder is being considered [15]and the suggested definition has been posted on the ICD-11 Beta Draft website [16], the text of which is:

‘Compulsive sexual behaviour disorder is characterized by persistent and repetitive sexual impulses or urges that are experienced as irresistible or uncontrollable, leading to repetitive sexual behaviours, along with additional indicators such as sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other activities, unsuccessful efforts to control or reduce sexual behaviours, or continuing to engage in repetitive sexual behaviour despite adverse consequences (e.g., relationship disruption, occupational consequences, negative impact on health). The individual experiences increased tension or affective arousal immediately before the sexual activity, and relief or dissipation of tension afterwards. The pattern of sexual impulses and behaviour causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning.’

Furthermore, it should be noted that, although hypersexual behavior was rejected by the APA, in fact the ICD is by far the most widely used classification of mental disorders world-wide, and its diagnostic codes are mandated for use in the United States and other countries by international treaty [17, 18] as opposed to DSM-5 diagnoses, which have no such mandate. It thus seems that diagnostic entities involving hypersexual or compulsive sexual behavior can still be made and will continue to provide a framework that will lead to refinement of diagnostic nomenclature and criteria and stimulate further research into the nature and causes of such behavior.