Why "Compulsive Sexual Behavior Disorder" Isn't the Same as "Sex Addiction"

A decade-long debate seemed settled in June when the World Health Organization officially added “compulsive sexual behavior disorder” to the newest edition of the International Classification of Diseases. Unfortunately, in the aftermath, many publications declared “sex addiction” was officially a mental health disorder. Technically, that’s wrong, but the blunder sheds light on the controversy surrounding the diagnosis. Even now, scientists are still trying to figure out the best way to think about people with very strong sexual urges.

It was a calculated choice by the WHO to replace the existing ICD-10 category of “excessive sexual drive” with “compulsive sexual behavior disorder” — not “sex addiction” or “hypersexuality.” It’s also very purposefully classified as an “impulse control disorder” instead of a disorder related to addiction. Impulse disorders, wrote members of the WHO ICD-11 Working Group in a 2014 paper, are defined by the repeated failure to resist a craving despite knowing the action can cause long-term harm.

The reason for this linguistic and categorical change is to make clear there’s no “right amount of sexuality” and to acknowledge that “it is important that the classification does not pathologize normal behavior.” Ultimately, the goal is to help identify repetitive behavior that can shut down a person’s life, though the language we use about it continues to be controversial. Despite the vagaries, Marc Potenza, Ph.D., M.D., a professor of psychiatry at the Yale School of Medicine, says the WHO’s move is a good thing.

“I believe that the inclusion of compulsive sexual behavior disorder within the ICD-11 is a positive step,” Potenza tells Inverse. “My experience as a clinician indicates that there are many people who experience difficulties controlling their sexual urges and then engage in sex compulsively and problematically. Having a defined set of diagnostic criteria should help significantly with respect to advancing prevention, treatment, research, education, and other efforts.”

Why Some Think It’s an “Addiction”

Potenza co-authored a 2016 paper questioning whether compulsive sexual behavior should be considered an addiction, concluding that significant gaps in the understanding of the disorder mean that it can’t technically be called an addiction yet. Today, however, the disorder continues to be described as “sex addiction” by universities, medical centers, and researchers. It’s unclear whether the word addiction here is colloquial or clinical.

For his part, Potenza suspects compulsive sexual behavior disorder may eventually be reclassified as an addictive disorder in future editions of the ICD. It’s not currently in the Diagnostic and Statistical Manual of Mental Disorders (DSM), but he predicts it might likewise be introduced and classified as an addictive order there once more data is gathered.

The central elements of addictions, he explains, include continued engagement in a behavior despite adverse consequences, appetitive urges or cravings that often immediately precede engagement, compulsive or habitual engagement, and difficulties controlling the extent of engagement in the behavior.

“From this perspective,” Potenza says, “compulsive sexual behavior disorder demonstrates the core features of addictions.”

Why Some Think It’s Not an Addiction

But Nicole Prause, Ph.D., a neuroscientist and sexual psychophysiologist who founded the sexual biotechnology company Liberos LLC, argues that sex is not addictive and that “compulsive sexual behavior” shouldn’t have been included in the ICD-11. In 2017, Prause and her colleagues published a paper in The Lancet in response to Potenza’s study, arguing that while “sex has components of liking and wanting that share neural systems with many other motivated behaviors,” experimental studies don’t actually demonstrate that excessive sexual behavior can be classified as addiction.

“Scientists generally were glad to see ‘sex addiction’ was kept out of the ICD-11,” Prause tells Inverse. “Therapists created ‘sex addiction’ training 40 years ago and were pushing to get it in with no good evidence.”

Prause generally doesn’t believe “compulsive sexual behavior” needs a name at all. Creating a means for diagnosis, she says, can increase “shame on sexual behaviors,” and people conditioned to think that sex is bad are more likely to think they have a problem. She argues that the population most likely to be classified as sexually compulsive are gay men, noting that there are even “examples of ‘sex addiction’ therapists offering to help gay men stop being gay,” which is “reparative, anti-gay therapy all over again.”

“The diagnosis has never been tested,” Prause says. “We have no idea if these patients even exist. The committee invented a new diagnosis and added it without ever seeing if anyone would meet the criteria.”

She argues that the grounds for such a diagnosis haven’t been backed up by research on actual sex in a lab. So far, estimates of how many people who identify as having a compulsive sexual behavior disorder vary and are predominantly based on self-reports. Epidemiological estimates have the number at three to six percent of adults, writes the WHO ICD-11 Working Group in a paper released this year, but more recent studies have suggested that range is closer to one to three percent of adults. Researchers at the University of Cambridge, meanwhile, reported in 2014 that compulsive sexual behavior can affect as many as one in 25 adults.

Now that it’s in the ICD-11, researchers are waiting to see how that will affect the official rates of identification.

“Growing evidence suggests that compulsive sexual behavior disorder is an important clinical problem with potentially serious consequences if left untreated,” writes the ICD-11 Working Group. “We believe that including the disorder in the ICD-11 will improve the consistency with which health professionals approach the diagnosis, and treatment of persons with this condition, including consistency regarding when a disorder should be diagnosed.”

Potenza says that it can be hard for a specialist to diagnose a person with compulsive sexual behavior disorder because, like alcoholism or a gambling addiction, it probably doesn’t have visible signs. But Potenza says the disorder can seep into and negatively impact other parts of a person’s life.

Scientists Are Still Figuring It Out

A good place for a psychiatrist to start helping a patient, he says, is to ask them about their sexual behaviors in a clinical setting and to see whether the patient has any concerns. There’s not a lot of research out there on actually treating people with the disorder, and the few that exist seem to suggest that people who are concerned they have excessive sexual behavior tend to feel better about it with time and acceptance, not therapy.

Meanwhile, there’s a fair amount of time before Americans will see any of this play out. The ICD-11 won’t be presented at the World Health Assembly until May 2019 and, if it’s accepted, it won’t become official until 2022 and likely won’t be used in the United States until 2032.

A lot can change in the interim. Prause says that her team just completed a large laboratory study evaluating the validity of the sexual compulsivity diagnosis, in which people stroke their genitals in a lab while scientists monitor their brain — so it’s likely that the science surrounding the controversy will shift before the ICD-11 is officially in use.