The World Health Organization (WHO) released the current revision (11th) of the International Classification of Diseases on June 18, 2018 with plans to revise it annually. The ICD-11 contains some 55,000 diagnoses of injuries, diseases, and causes of death. One of the more significant changes in the area of sexuality was with the addition of “Compulsive sexual behavior disorder”. 

Previously, hypersexuality, or excessive sexual drive was identified under “Other sexual dysfunction not due to a substance or known physiological condition” (F52.8). For ICD-11, disorders like “hypoactive sexual desire disorder (HA00)” remain under the sexual dysfunctions category, but compulsive sexual behavior disorder is listed as an Impulse Control Disorder. Impulse Control Disorders includes a variety of psychiatric disorders “whose essential features are the failure to resist an impulse to perform an act that is harmful to the individual or to others”(1)World Health Organization. (2018). ICD-11 for Mortality and Morbidity Statistics. https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/826065555.

In a WPA article proposing the change(2)Kraus, S. W., Krueger, R. B., Briken, P., First, M. B., Stein, D. J., Kaplan, M. S., … Reed, G. M. (2018). Compulsive sexual behaviour disorder in the ICD‐11. World Psychiatry, 17(1), 109–110. http://doi.org/10.1002/wps.20499, the authors stated (references in original article replaced with “*”):

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*.(3)Kraus, S. W., Krueger, R. B., Briken, P., First, M. B., Stein, D. J., Kaplan, M. S., … Reed, G. M. (2018). Compulsive sexual behaviour disorder in the ICD‐11. World Psychiatry, 17(1), 109–110. http://doi.org/10.1002/wps.20499

As pointed out in the article, specific attention was given to concerns of “overpathologizing sexual behaviours”. High frequency sexual behavior is not sufficient criteria for diagnosis. Nor is client self diagnosis of “porn addict” or “sex addict”. Additionally,

The proposed diagnostic guidelines also emphasize that compulsive sexual behaviour disorder should not be diagnosed based on psychological distress related to moral judgments or disapproval about sexual impulses, urges or behaviours that would otherwise not be considered indicative of psychopathology. Sexual behaviours that are egodystonic can cause psychological distress; however, psychological distress due to sexual behaviour by itself does not warrant a diagnosis of compulsive sexual behaviour disorder.(4)Kraus, S. W., Krueger, R. B., Briken, P., First, M. B., Stein, D. J., Kaplan, M. S., … Reed, G. M. (2018). Compulsive sexual behaviour disorder in the ICD‐11. World Psychiatry, 17(1), 109–110. http://doi.org/10.1002/wps.20499

After an extensive review of the literature in 2015, Kraus concluded: “Despite the growing body of research linking compulsive sexual behavior (CSB) to substance addictions, significant gaps in understanding continue to complicate classification of CSB as an addiction.”(5)Kraus, S. W., Voon, V., and Potenza, M. N. (2016) Should compulsive sexual behavior be considered an addiction?. Addiction, 111: 2097–2106. doi: 10.1111/add.13297. While there have been a number of additional articles and theories since 2015, no definitive studies have quelled the debate.

This leaves both pros and cons to the move. To quote an opinion piece in The Lancelot psychiatry journal:

There are both pros and cons regarding the classification of compulsive sexual behaviour disorder as an impulse-control disorder. On one hand, inclusion of compulsive sexual behaviour disorder in ICD-11 could improve consistency in diagnosis, treatment, and study of individuals with this disorder. On the other hand, classification of compulsive sexual behaviour disorder as an impulse-control disorder as opposed to an addictive disorder might negatively influence treatment and study by limiting treatment availability, treatment training, and research efforts. Compulsive sexual behaviour disorder seems to fit well with non-substance addictive disorders proposed for ICD-11, consistent with the narrower term of sex addiction currently proposed for compulsive sexual behaviour disorder on the ICD-11 draft website.* 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. (6)Potenza, M. N., Gola, M., Voon, V., Kor, A., & Kraus, S. W. (2017). Is excessive sexual behaviour an addictive disorder?. The Lancet Psychiatry, 4(9), 663-664.

And, the disagreement continues.

But… For today, a diagnosis of “sexual addition” still isn’t official. Nor is “hypersexuality” or “excessive sexual desire” under ICD-11. But, the “nod and wink” to the problem therapists have been addressing for decades at least gives an additional step in supporting research and academic work on the subject … like the one released in March this year on Treating Compulsive Sexual Behavior(7)Efrati, Yaniv & Gola, Mateusz. (2018). Treating Compulsive Sexual Behavior. Current Sexual Health Reports. 10.1007/s11930-018-0143-8..

Description from ICD-11
6C72 Compulsive sexual behaviour disorder(8)https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1630268048

Parent

Impulse control disorders

Description

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.

Exclusions

So what do you think? Is this a step in the right direction or backwards? Is WHO being too conservative or do you agree the literature isn’t there for identifying a true sexual addiction yet?

References   [ + ]

1. World Health Organization. (2018). ICD-11 for Mortality and Morbidity Statistics. https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/826065555
2, 3, 4. Kraus, S. W., Krueger, R. B., Briken, P., First, M. B., Stein, D. J., Kaplan, M. S., … Reed, G. M. (2018). Compulsive sexual behaviour disorder in the ICD‐11. World Psychiatry, 17(1), 109–110. http://doi.org/10.1002/wps.20499
5. Kraus, S. W., Voon, V., and Potenza, M. N. (2016) Should compulsive sexual behavior be considered an addiction?. Addiction, 111: 2097–2106. doi: 10.1111/add.13297.
6. Potenza, M. N., Gola, M., Voon, V., Kor, A., & Kraus, S. W. (2017). Is excessive sexual behaviour an addictive disorder?. The Lancet Psychiatry, 4(9), 663-664.
7. Efrati, Yaniv & Gola, Mateusz. (2018). Treating Compulsive Sexual Behavior. Current Sexual Health Reports. 10.1007/s11930-018-0143-8.
8. https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1630268048