World Health Organization's ICD-11: Compulsive Sexual Behavior Disorder

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Porn Addicts Will Soon Be Diagnosable Using the WHO’s Diagnostic Manual (ICD-11)

As you may have heard, in 2013 the editors of the Diagnostic and Statistical Manual (DSM-5), which lists mental health diagnoses, declined to add a disorder called “Hypersexual Disorder.” Such a diagnosis could have been used to diagnose sexual behavior addictions. Experts say that this has caused major problems for those suffering:

This exclusion has hindered prevention, research, and treatment efforts, and left clinicians without a formal diagnosis for compulsive sexual behaviour disorder.

World Health Organization to the rescue

The World Health Organization publishes its own diagnostic manual, known as the International Classification of Diseases (ICD), which includes diagnostic codes for all known diseases, including mental health disorders. It is used worldwide, and it is published under an open copyright.

So why is the DSM used widely in the United States? The APA promotes the use of the DSM instead of the ICD because the APA earns millions of dollars selling its copyrighted materials relating to the DSM. Elsewhere in the world, however, most practitioners rely on the free ICD. In fact, the code numbers in both manuals conform to the ICD.

The next edition of the ICD, the ICD-11, is due out sometime in 2018 (although the mental-health portion may be delayed and published separately). Unlike the DSM-5 editors, the editors of the ICD-11 propose to add a new mental-health diagnosis that would encompass those with disorders relating to sexual addictive behaviors. Here’s the current proposed language:

6C92 Compulsive sexual behaviour disorder is characterized by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. Symptoms may include 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. The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g., 6 months or more), and 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.

This new “Compulsive sexual behaviour disorder” (CSBD) diagnosis is critically important. First, it will help those suffering get the treatment they need. Second, the existence of a formal diagnosis in the world’s premier medical manual will facilitate future research. Without a formal diagnosis, some sexology journals and professional magazines (including popular Psychology Today) have been refusing to publish related research and commentary. (Shared via private correspondence with a current PT blogger.) The absence of a formal diagnosis has hindered the publication of critically important research and slowed mainstream understanding of the risks of this disorder.

What do the pro-porn activists say?

Some pro-porn, anti-addiction sexologists have mischaracterized the new CSBD diagnosis as a “rejection” of the concept of sexual behavior addictions. The anti-addiction sexologists may fool members of the lay public and sympathetic bloggers, but their claim is hollow, as neither the DSM-5 nor ICD-11 uses the word “addiction” to describe recognized addictions. Whether it’s meth, heroin, smoking, gambling, or internet gaming, the two diagnostic manuals make use of the term "disorder" instead of “addiction.” On one hand the naysayers are right - you won't find “porn addiction,” “sex addiction,” or “cybersex addiction,” listed in the ICD-11 or DSM-5. But neither will you find “methamphetamine addiction,” “cocaine addiction,” or “gambling addiction,” even though these are DSM-5 recognized disorders. The so-called “rejection” of sex and porn addiction is a misleading claim by the naysayers.

In addition, a recent piece in World Psychiatry (the world’s top-ranked psychiatry journal) further undercuts the empty claim. Here’s an excerpt from the World Psychiatry piece, co-authored by experts who serve on the ICD-11. Indeed author Geoffrey Reed is in charge of all of the mental disorder diagnoses for the ICD-11. The authors make it clear that the ICD-11 has not ruled out that compulsive sexual behaviors may indeed be addictions. Instead, the ICD-11 has adopted a conservative, wait-and-see approach while further research is published.

… Currently, there is an active scientific discussion about whether compulsive sexual behaviour disorder can constitute the manifestation of a behavioural addiction. For ICD-11, a relatively conservative position has been recommended, recognizing that we do not yet have definitive information on whether the processes involved in the development and maintenance of the disorder are equivalent to those observed in substance use disorders, gambling and gaming. For this reason, compulsive sexual behaviour disorder is not included in the ICD-11 grouping of disorders due to substance use and addictive behaviours, but rather in that of impulse control disorders. The understanding of compulsive sexual behaviour disorder will evolve as research elucidates the phenomenology and neurobiological underpinnings of the condition.

In short, the ICD-11 has adopted the same strategy once used with respect to “gambling disorder.” When gambling was first given a medical diagnosis it, too, was characterized as an “impulse control disorder” while it was further investigated. Many hundreds of studies later, gambling disorder has now been characterized as a behavioral-addiction disorder. As explained in “The Proof of the Pudding Is in the Tasting: Data Are Needed to Test Models and Hypotheses Related to Compulsive Sexual Behaviors” (2018):

As described elsewhere (Kraus, Voon, & Potenza, 2016a), there is an increasing number of publications on CSB, reaching over 11,400 in 2015. Nonetheless, fundamental questions on the conceptualization of CSB remain unanswered (Potenza, Gola, Voon, Kor, & Kraus, 2017). 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).

That said, some of the authors of the above piece have already publicly stated that sufficient evidence exists to characterize CSBD as a disorder due to addictive behavior (which is how gambling and gaming will be characterized in the upcoming ICD-11). Thus, some experts expect that CSBD will ultimately migrate there as well. Here’s what these experts said in a recent piece:

Research into the neurobiology of compulsive sexual behaviour disorder has generated findings relating to attentional biases, incentive salience attributions, and brain-based cue reactivity that suggest substantial similarities with addictions. … We believe that classification of compulsive sexual behaviour disorder as an addictive disorder is consistent with recent data and might benefit clinicians, researchers, and individuals suffering from and personally affected by this disorder.

Obviously, other experts are still undecided and want to see more research and commentary before committing the ICD to this position. This is not unusual in the case of new diagnoses. Already, however, DSM insider Jon E. Grant, JD, MD, MPH, Professor - Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Pritzker School of Medicine, published a 2018 article in Current Psychiatry, making it clear that CSBD "can be accurately diagnosed and successfully treated." He notes that CSBD is "also referred to as sexual addiction or hypersexuality." This means that in his expert opinion, the ICD-11 has not "rejected" sexual behavior addiction; it merely chose the umbrella term of CSBD.

In addition, mountains of research reveal that behavioral addictions (food addiction, pathological gambling, video gaming, Internet addiction and porn addiction) and substance addictions share many of the same fundamental mechanisms leading to a collection of shared alterations in brain anatomy and chemistry.

In light of the latest scientific advances, the criticisms of the sexual-behavior addiction model are unfounded and outdated (and no studies have yet falsified the porn addiction model). Supporting the addiction model, there are now 38 neurological studies on porn users/sex addicts, revealing brain changes that mirror those occurring in substance addicts (and 14 neuroscience-based reviews of the literature). In addition, 22 studies report findings consistent with escalation of porn use (tolerance), habituation to porn, and even withdrawal symptoms - which are all key indicators of addiction.

The important point is that when the new ICD-11 is published those with porn addiction will be diagnosable using the new CSBD diagnosis – while the dust continues to settle in the medical field.

Mission matters

The ICD is sponsored by the World Health Organization. According to the ICD's Purpose, "It allows the world to compare and share health information using a common language. The ICD defines the universe of diseases, disorders, injuries and other related health conditions. These entitites are listed in a comprehensive way so that everything is covered." (World Health Organization, 2018). The goal, then, is to cover every legitimate health problem, so it can be tracked and studied around the world.

Such uniformity is critical for clear diagnoses, appropriate treatment and prevention. Thus almost all clinicians (psychiatrists, mental health professionals, clinical psychologists, addiction treatment providers and those who work in prevention) strongly favor the publication of the proposed ICD diagnosis of CSBD.

However, keep in mind that there are other disciplines. Many non-clinicians, for example, have their own agenda. They typically don't treat those suffering. In fact, they may even have motivations that conflict with getting patients the help they need, and they sometimes have very loud voices in the press. Groups that sometimes fall into this non-clinician category can be found in mainstream psychology media, the gaming and porn industries (and their researchers), sociologists, some sexologists, and media researchers. It is not uncommon for large industries to pay "thought leaders" substantial retainers to speak out in favor of positions that such industries would like to see become/remain policy.

In any event, it is well to understand that different disciplines can have very different motives. It is wise to question whether any particular spokespersons' motives further humanity's wellbeing, or impair wellbeing.

Update. See these 2 articles for more: