The World Health Organization’s International Classification of Diseases (ICD) list is meant to to keep the world updated on global health trends by both recognizing and defining mental and physical illnesses.
There have been newsworthy additions — gaming disorder being one — to the latest version of the list known as ICD-11. And, with around 55,000 descriptions for injuries, diseases and causes of death on the list, that is to be expected.
But one recognition in particular has cast a spotlight on a long-brewing controversy in the professional mental health world. In ICD-11, WHO filed “compulsive sexual behavior disorder” — often commonly referred to as sex addiction — as an impulse-control disorder. Previously, it had not.
Mental health professionals tell Salon that the recognition of compulsive sexual behavior disorder is a key step toward progress for mental health across the globe — in part due to the controversial debate that has surrounded it throughout history.
“This is, without doubt, a watershed moment for the mental health and addiction communities,” Robert Weiss, a sexologist and addiction therapist told Salon. “It's similar to when alcoholism and drug addiction were finally officially recognized in the 1970s. This really is a big deal.”
Official recognition from WHO is important, because it could in turn empower data collection specialists, health insurers and national health program managers to properly diagnose and treat the disorder. WHO's new list will not take effect until Jan. 1, 2022, as revisions still need to be made.
The road to recognizing compulsive sexual behavior disorder as a mental health disorder has been a rocky one. In 2012, the American Psychiatric Association did not include it in an updated version of "The Diagnostic and Statistical Manual of Mental Disorders" (DSM-%), which is known as the “bible” of diagnostic categories in mental health. "Sexual addiction” was previously in the DSM-III in 1980, although it was later removed in the 1994 edition.
As noted in a study in "The Journal of Treatment & Prevention," part of the controversy has surrounded the question of whether or not to use the label “addiction” — and thus to treat compulsive sexual behavior disorder as one. Weiss said there have been concerns regarding the semantics of the word “addiction,” too.
“First and foremost, some people think the word ‘addiction’ is shaming,” he said. “Addicts themselves don’t tend to feel that way, but the people around them sometimes do. So, among some clinicians, there is backlash about all things addiction.”
There has also been a fear that recognizing compulsive sexual behavior disorder would pathologize normal sexual behavior, Dr. Stefanie Carnes, a certified sex addiction therapist and president of the International Institute for Trauma and Addiction Professionals (IITAP), told Salon.
“One of the things WHO did in their description of the criteria is say specifically, 'You can’t make the diagnosis of the compulsive disorder just due to shame or moralistic thoughts and feelings,'” Carnes said.
As explained in a paper published in "World Psychiatry," a peer-reviewed medical journal, the WHO’s proposed guidelines “emphasize that compulsive sexual behavior disorder should not be diagnosed based on psychological distress related to moral judgments or disapproval about sexual impulses, urges or behaviors that would otherwise not be considered indicative of psychopathology.”
In other words, a diagnosis cannot be made for someone with conservative religious views who frequents pornography sites a few times a month and thus believes that is a problem.
The study explained that WHO’s proposed inclusion characterizes the disorder as “a persistent pattern of failure to control intense, repetitive sexual impulses or urges, resulting in repetitive sexual behavior over an extended period (e.g., six months or more) that causes marked distress or impairment in personal, family, social, educational, occupational or other important areas of functioning.”
Carnes, who helps rehabilitate those with compulsive sexual behavior disorder, said their compulsive desire for sex has often completely destroyed their lives.
“I have patients who have completely destroyed their lives as a result [of sex addiction] – health consequences, financial consequences – over an excessive amount of time,” she said. “Patients who have anonymous hookups every night or spend $300,000 on a prostitute.”
Carnes added someone who has the disorder is not someone with a high sex drive. The person must demonstrate the behavior is out of control and compulsive.
“Often times, their behavior gets out of control, and there are huge ramifications in their lives that create mood disorders such as depression and anxiety,” she explained. “The families are devastated, their partners are devastated and traumatized by their behavior."
According to some, perhaps the most important part of WHO's recognition is that the disorder can at long last be destigmatized.
“The best part about this new diagnosis is that the people who are struggling with sexual addiction/compulsivity finally have an official diagnosis they can point to,” Weiss said. “This seemingly simple thing may help a great deal with the shame they typically feel.”
And this was exactly part of the reason for including the disorder in the ICD-11, according to the Christian Lindmeier, a spokesperson for WHO.
“Evidence suggests that the disorder is a real clinical problem with potential significant consequences,” Lindmeier wrote in an email. “Inclusion in ICD-11 is believed to help with addressing needs for treatment seeking individuals.”
However, Lindmeier noted that “the terminology ‘sex addiction’ is not being used, because WHO is not taking a position about whether it is physiologically an addiction or not.”
Lawrence Siegel, a clinical sexologist, told Salon in an email that he does not believe the recognition is a win for mental health awareness, because the associated behavior is a symptom – not a disease.
“When sexual behavior becomes difficult to manage for an individual, it is important that the perspective taken is not one of being victim to some unexplainable or biological forces, but rather to honesty examine one's own values, desires and relationships,” he told Salon. “The behavior is a symptom – not a disease – and the diagnosis should be what underlies or drives the behavior – not the behavior itself.”
This recognition does come at an interesting time, as some high-profile sexual misconduct cases – the disgraced Hollywood mogul Harvey Weinstein included – are said to be receiving treatment for "sex addiction."
This is one example of how WHO's recognition could be abused. According to Weiss, there is a very fine line between being a sex offender and someone who actually suffers from compulsive sexual behavior disorder.
“Sex addiction/compulsivity is not in any way related to illegal or sexually violent behavior,” Weiss explained to Salon. “Sex addiction/compulsivity is defined by three things: preoccupation to the point of obsession with sexual fantasies and behavior; loss of control over sexual fantasies and behavior, typically evidenced by multiple failed attempts to quit or cut back; and negative life consequences directly related to a person’s out of control sexual behaviors.”
“Things like illegality and violence do not factor into the diagnosis at all,” he added. “Moreover, the vast majority of sex addicts never engage in illegal or violent sexual behavior.”
As for what treatment looks like for those who truly have the disorder, Carnes used the analogy of recovering from an eating disorder.
“You just don’t say, 'I’m going to abstain from sex,' Like you wouldn’t say, 'I’m not going to eat,'" she said. “They design a sex plan that is healthy for them."