ICD-11 Classification: Compulsive Sexual Behaviour Disorder.
My analysis: information for clinicians and the public:
How to diagnose and its implication for treatment change.
Many patients report negative consequences as a result of repetitive consensual sexual behaviours. In their initial consultation, they often use a ‘sex addiction’ language as it is the most known language: their behaviour feels like an addiction because they can’t stop it.
For years, clinicians have been in strong disagreement between those believing in ‘sex addiction’ and offering an addiction treatment to such problematic sexual behaviours and those who refused the theory that sex can be addictive and therefore offering a non-addiction treatment. There has been much debate on how to call this condition: ‘sex addiction’?, compulsive sexual behaviour? Hypersexual behaviour? Out-of-control sexual behaviour?
From this month, June 2018, the ICD-11 (International Classification of Disease), included Compulsive Sexual Behaviour as a disorder.
The description of the disorder is:
‘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.’
It is an interesting set of criteria which brings forth important clinical considerations for both therapists and patients.
The purpose of my analysis is two-fold: to understand the diagnosis and its exclusions, and its implication on treatment change. I will highlight the therapeutic methods that are traditionally practiced under the umbrella of ‘sex addiction’ and my recommendations on how treatment may now develop and change.
Firstly, one of the good outcome of such classification is that the psychotherapeutic community can now stop fighting over what terms to use. We can use Compulsive Sexual Behaviour Disorder, not ‘sex addiction’. WHO (World Health Organisation) clearly states that there is no clinical evidence of an addictive component to sex therefore the disorder is classified under Impulse Control Disorder, which is very different from addiction. From now on, we can confidently put the term ‘sex addiction’ in inverted comas, as it is not a clinical term. In fact, it never was a clinical term: the words ‘sex addiction’ were coined in the late 70’s. The diagnosis classification makes ‘sex addiction’ an outdated and old fashion term. Just the same as we used to call female anxiety ‘hysteria’ or people suffering from bipolar disorder ‘manic depressive’: there are thousands of examples of old fashioned terms that disappear when we acquire more knowledge on the problems. This is good, because it means that the field of sexual health behaviours can finally be updated to fit with 2018.
Secondly, it is important that a disorder is diligently diagnosed. For example, most people have heard the term PTSD (Post-Traumatic Stress Disorder), however only a few people use this diagnosis accurately. For the disorder to be diagnosed, the symptoms have to be so elevated that the patient cannot function in normal life. Most patients who experience terrible flashbacks as a result of a trauma who can also go to work and turn up to therapy with good hygiene are less likely to fit the criteria for the disorder. Such people would be classified as PTS (Post-Traumatic Stress), which is also a condition that can be treated with therapy, but is not a disorder. A patient not meeting the criteria for PTSD does not negate their suffering with flashback symptoms, which are very distressing. Therapy helps treating the symptoms for PTS for a better quality of life, without calling it a disorder. It is the clinician’s duty to inform the patient about how severe a condition is based on diagnostic criteria. Patients can then agree or disagree, they can be free to go to another clinician for a second opinion, or they can agree on their treatment plan.
If a patient comes to a doctor’s office with stomach pain and fearing it is cancer. It is the doctor’s responsibility to do all the tests required and diligently diagnose or undiagnose conditions and inform the patient what condition they will be treated for. This is the expectations of all patients when seeing a medical doctor. We, psychotherapists, have to be as diligent with diagnosis.
So let’s see how we can diagnose Compulsive Sexual Behaviour Disorder:
1- ‘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.’ Under ICD-11, the sexual behaviour that is problematic has to be evaluated by the patients themselves. A client may say that their repetitive visits to sex workers is a problem but their pornography use is not. We, clinicians, are not to tell patients what is problematic or not.
The ‘sex addiction’ practice: In the traditional ‘sex addiction’ model as well as in 12-steps programmes (such as SLAA and SAA), patients are commonly told to stop all forms of sexual behaviours, including those which the client hasn’t mentioned as problematic. There is no clinical evidence that this intervention has any benefits. However there is evidence that it exponentially increases sexual shame. I often hear some people say: ‘it is a way to ‘re-boot’ the brain. Our brain is an organ that is intelligent and alive, not a computer. There is no such thing as ‘re-booting’ a brain. Doing this unnecessary intervention also makes the therapist’s ideas and opinions the standard of ‘success’ rather that the client’s goal of what they want to achieve. It creates a power imbalance so great that it impairs the therapeutic collaboration.
The new diagnosis: This criteria focuses on the link between the intense impulses and urges and the repetitive behaviours. It does not include intense urges and impulses that do not result to repetitive unwanted behaviours nor wanted repetitive behaviours nor behaviours that are not the effect of uncontrolled intense sexual urges and impulses. It is quite specific. Also, the symptoms have to be significant enough for the person to struggle with looking after their health, personal care or other interests. This is when we need to be diligent as much as we are with making the difference between PTSD and PTS. If a patient presents in our consulting room with good hygiene, able to hold a job with responsibilities, feed themselves, and get on with life, the criteria for the disorder cannot be formulated. I work in private practice: most of my clients can hold their job and meet their needs for health and personal care. Although, I frequently hear clients say that they are so preoccupied by their sexual urges that they don’t have a hobby. It is something that can be addressed in therapy, for sure, but not having a hobby or having a lot of sexual preoccupation is not sufficient for a disorder if they can manage other areas of their life.
2- ‘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’ This is a crucial part of the disorder diagnosis which is usually overlooked in the traditional ‘sex addiction’ assessment. Many people do not attempt to reduce their repetitive sexual behaviours until after they are caught by their partner or at high risk of being caught. For these people, if there were no risk of getting caught they would continue their sexual behaviour, indicating that they derive enough satisfaction from such behaviour. They may think ‘I shouldn’t be doing this’ but they do it anyway because the motivation to meet their sexual needs trumps the motivation to keep to their agreed relationship boundaries with their partner. If this is the case, it is not a disorder, it is a sexual health conflict between what they want sexually and what is permissible or not within their relationship. However, some people do try very hard to stop their repetitive sexual behaviours without success before they are at high risk of being caught: for these people, important questions need to be asked before we prematurely assume that it is part of the disorder: for example, do they want to stop because they perceive that others (society, religious groups, etc.) would disapprove? If so, it is not a disorder (I explain more about that below). Most people would stop behaviours that do not produce any satisfaction, any pleasure or do not interest or arouse them in any way. The diagnostic criteria for the disorder would only apply to people who do a repetitive sexual behaviour for which they derive almost no pleasure and cannot stop that behaviour. For example, the most common story is a problematic sexual behaviour that provides a sense of feeling connected and loved. Although such behaviour can be destructive if it is outside of their committed relationship, it also provides the satisfaction of connection: this means that the disorder diagnosis must be ruled out. Instead, the patient’s problem can be understood, and treated, as a sexual health behaviour problem. Let’s think about this: meeting this diagnostic criteria is very rare.
3- ‘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’. This is another important criteria to explore. People’s sexual behaviour is usually different before and after they get caught by their partner. In fact, it is very rare for patients to come to therapy before they get caught. There is a question over inability to control those urges resulting in repetitive sexual behaviours and choosing not to control them because they produce much pleasure. I think that ‘the pattern of failure to control’ refers to an inability to control sexual impulses and urges (as the disorder is under Impulse Control Disorder). If people can have continued repetitive sexual behaviours over an extended period of six months or more and not get caught, it means they are highly functioning and very much in control: it takes much planning and organization to hide such behaviours from your partner. After they get caught, it is often when patients report marked distress and significant impairment in personal areas: they have to deal with the consequences of being caught, the intense emotions that their partner feels faced with the discovery of the enormous betrayal, chaos in all areas of their life trying to deal with the fall out of the discovery. People who have not been caught, or those who are single and do not breach any relationship agreements usually do not report marked distress or impairment in their life functioning. The exception is if patients have strong moralistic or religious views over some sexual activities, which is excluded from the diagnosis criteria (see below). Just like the last diagnostic criteria, meeting this criteria for the disorder is very rare.
4- ‘Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement’. This is a crucial component of the diagnosis. It is not possible to diagnose Compulsive Sexual Behaviour Disorder if the patient feels much sexual shame, moral judgement or disapproval from society, families, religious groups, etc. about their sexual impulse, urges or behaviour. It is very common for people to feel distress at their behaviour after they get caught by their partner, the distress coming from their partner disapproving with their illicit sexual activities. For example, a man repetitively seeing a Dominatrix sex worker because he derives much pleasure from BDSM practice is found out by partner who doesn’t practice BDSM: she may feel disgusted by what he had been doing and highly disapproving: the patient then feels great distress at his behaviour and wants to stop: this patient cannot be diagnosed with the disorder. Or a gay man having frequent anonymous sex in sex clubs and feeling his behaviour is ‘wrong’ because of the societal judgement that frequent anonymous sex is undesirable or that his thinking about the behaviour is homonegative cannot be diagnosed with the disorder. If somebody feels bad about their sexual behaviour because they have read a book or a website that is sex-shaming or sex-negative: the diagnosis for the disorder is ruled out.
Why this last diagnostic component is essential:At the time when the ‘sex addiction’ theories flourished, it was also the time of the AIDS epidemic. Many people were afraid of sex, and the public latched onto the notion that there was much darkness in human sexuality and that the safest way to be was the heterosexual, monogamous way: there was much fear that too much lust can cause harm and disease. I’m not surprised that it was a popular notion then. However, the ‘sex addiction’ model emerged without knowledge or specific training in human sexuality. The people who coined the term ‘sex addiction’ based their understanding of the problem on what they already knew: the 12-step programme which had great success with people suffering from alcoholism. Because compulsive sexual behaviours can feel like an addiction, they assumed it was an addiction and didn’t pay attention to the human sexuality part of the equation: the erotic works in very different ways from alcohol.
Changing the term is important because the diagnosis informs the treatment. If clinicians continue to call the problem ‘sex addiction’, they are likely to treat their patients with an addiction treatment, which is now clinically unfit as the proper clinical diagnosis refute the addiction element. It is not the faults of clinicians. Most ‘sex addiction’ therapists are well-meaning. But they have been trained in a model that is outdated.
Now that the notion of addiction is refuted, we can finally open our understanding to other ways of looking at the problem. It means new, updated training that is psycho-sexologically based rather than addiction based, as well as incorporating the impulse control element to it, rather than the addiction methods. It will take some time for clinicians to have their skills upgraded, but we can now have hope that the field is going to move on.
The process of change:When Carl Rogers promoted a radically different way to approach human psychology which was quite different from the traditional psychoanalysis, it wasn’t accepted with open arms. There was much resistance. Psychoanalysts feared that their knowledge was being attacked and their livelihood at risk. It took years for a change in psychology to be upgraded. Now, we can appreciate the great contribution of Freud, and at the same time not offering a purist Freudian method because there is so much other knowledge. Many psychoanalysts updated their skills and incorporated many other forms of treatment: psychology became enhanced, not threatened. My hope is that the same process can happen in the field of ‘sex addiction’: there will be much protest from the strong addiction believers, but, over time, I am sure many clinicians will update their skills for the benefits of our patients and for the development of our profession.
As explained above, the diagnostic criteria for Compulsive Sexual Behaviour Disorder are very specific: many people will not meet the criteria. It doesn’t mean they don’t have a problem, but it means they don’t have a disorder. We can stop the fear-mongering rhetoric that ‘sex addiction’ is a terrible chronic disease on the rise causing chaos in our neighbourhoods. It is not. And 12-step meetings are not recommended now that we know the problem is not an addiction.
Most patients that we are likely to see in our consulting room will not have the disorder. They will struggle with competing motivations between sexual urges, needs and gratifications and honouring their relationship agreements. Much like many people have competing motivations between eating a chocolate cake and not wanting to put on weight.
Now that the ICD-11 has formulated strict diagnostic criteria, the window for clinicians to prematurely and inadequately pathologise sexual behaviours has become much narrower, thankfully. I’m hoping there will be less opportunity for clinician’s own bias and personal opinions about human sexuality poluting their clinical judgements.
Whilst clinicians have to upgrade their skills from the old-fashioned ‘sex addiction’ model, patients may feel confused about how to select their therapist.
Here is my recommendations:
1- I believe that a therapist treating compulsive sexual behaviours and other sexual health behaviour problems need to have had a robust prost-graduate training in psychosexual and relationship therapy. If your therapist is trained in addiction and NOT in psychosexual therapy, you will most likely receive the old-fashioned ‘sex addiction’ treatment.
2- If your therapist administers a ‘sex addiction’ test, you may likely be treated with ‘sex addiction’. If your therapist administers tests, they should be clinically appropriate ones such as: The Sexual Symptom Assessment Scale, the ACE test (Adverse Childhood Experiences) or a test on attachment styles which is available for free online.
3- Ask your therapist how they will assess and diagnose you: you can go through the Compulsive Sexual Behaviour Disorder criteria with your therapist very carefully and being sure whether you qualify for the disorder diagnosis or not. Remember, meeting the diagnosis is very specific and rare: if your therapist seems too quick or too keen to diagnose you: you have the right to disagree and you have the right not to give consent for your treatment.
4- If your therapist says that one of the first things to do is to do 90 days of ‘sobriety’ and encourages you to go to 12-step SLAA or SAA meetings: you are in a ‘sex addiction’ treatment, not the modern sexual health behaviour treatment. There is no clinical evidence that 90 days of ‘sobriety’ has any efficiency anyway, because we cannot ‘reboot’ a brain. This process can actually exponentially increase sexual shame.
5- If your therapist says that you need to ‘break through denial’ or that you have to ‘admit being powerless over your illness’: this is an addiction- language which means that your therapist is likely using an addiction model. Under the modern non-addiction model, denial is considered a protection rather than a resistance: we seek to understand how and why the protection is in place and heal the disturbance underneath rather than ‘breaking through’ denial which can increase distress.
6- You have a therapist delivering a modern, updated treatment if you hear that impulse control is not activity-specific but it is affect regulation focused. Impulse control is not a chronic disease to manage forever. It is a set of emotional regulation tools to learn along with a deep understanding of the erotic, which can create permanent change. Impulse control is not about admitting powerlessness over the illness. It is the opposite: being conscious of your own agency and how you can make decisions now.
Given the strict criteria to diagnose Compulsive Sexual Behaviour as a disorder, the clinician’s role is more about undiagnosing than diagnosing: reassuring the public that they do not have a disorder. The sexual health behaviour problem can feel out of control, and it can feel like an addiction which can be treated appropriately with the right therapy. Patients are likely to come in their initial consultation with a ‘sex addiction’ language: it is ok. It is not their job to be educated with the right language and their suffering needs to be validated. But it is our job, as clinicians, to explain to them that they do not suffer a disorder. Just the same way that a doctor might explain that your worrying stomach pain feel frightening but it is not stomach cancer, after a proper assessment and carefully ruling out diagnostic criteria.
For clinicians wanting to upgrade their knowledge, I recommend the books:
Treating Out of Control Sexual Behavior, Rethinking Sex Addiction, by Douglas Braun-Harvey and Michael A. Vigorito.
Ethical Porn for Dicks by David J. Ley.
The Myth of Sex Addiction by David J. Ley
The Biology of Desire by Marc Lewis.
Silva Neves
Psychosexual and relationship Psychotherapist
