Q&A: Compulsive sexual behavior disorder added to ICD-11 as mental disorder

Judy Silverstein

WHO has added compulsive sexual behavior disorder as an impulse control disorder to the International Classification of Diseases, Eleventh Revision.

According to the ICD-11, compulsive sexual behavior disorder is characterized by a persistent inability to control intense, repetitive sexual impulses or urges resulting in recurring sexual behavior. This pattern manifests over an extended period (6 months or more), negatively affecting familial, social, educational and/or occupational areas of functioning.

In individuals with symptoms of compulsive sexual behavior disorder, repetitive sexual activities may become an essential focus of their life to the point that they neglect their health and personal care or other interests, activities and responsibilities, according to the ICD-11 classification. Other symptoms may include continued repetitive sexual behavior despite negative consequences or receiving little or no satisfaction from the behavior.

Healio Psychiatry spoke with Judy Silverstein, PhD, American Association of Sexuality Educators, Counselors and Therapists certified sex therapist, supervisor for the American Board of Sexology and clinical psychologist, to learn more about what the addition of compulsive sexual behavior to the ICD-11 will mean to the field of psychiatry. – by Savannah Demko

Why wasn't compulsive sexual behavior disorder considered a mental health disorder before?

The diagnosis of sexual addiction is still somewhat controversial. Some sexologists claim that high sex drive or sexual acting out should not be pathologized. Some addiction specialists view only chemical addictions as true addiction; only recently have scientists recognized the chemicals released during orgasm (eg, oxytocin). However, the withdrawal and tolerance of chemical addictions both occur with sex addiction, and the behavior of sex addicts creates more and more shame and remorse over time.

There is no doubt that sexual behavior can be compulsive, as sexual thoughts and fantasies can be obsessive. Compulsivity may interfere with healthy sexual functioning, even with work, school and social interaction. It can create medical problems, such as STDs, as well.

How prevalent is the condition in the U.S.?

I believe that with the availability of internet pornography, compulsive masturbation — causing interference in life — has become extremely prevalent. The problem with much of the pornography is that it distorts and/or idealizes sexual behavior.

Many people addicted to porn have difficulty with real intimacy and sexuality. I’ve seen a significant increase in sexual dysfunction in younger men in recent years. Women tend to be far less visual but can also masturbate compulsively to the point of interference in daily life (less often than male compulsive masturbation). What is more common among women is “love addiction” — self destructive relationships which become obsessions.

PAGE BREAK

I don’t know the exact frequency of sexual addiction, but I would guess about 5% to 10% of the population uses sex as a way of attempting to treat or avoid other life problems such as fear of intimacy, depression, social anxiety and other relationship problems.

What behaviors/actions associated with sex addiction should psychiatrists be aware of when dealing with patients?

People who compulsively act out while married or in a committed relationship obviously endanger that relationship. Deception is extremely destructive to both partners. The prevalence of obsessive/compulsive masturbation, with or without the use of pornography, is most likely greater in young men, and a few women. The compulsive use of pornography can lead to desensitization to erotic stimulation in a human (non-screen) relationship, unrealistic expectations with real intimacy, and even sexual dysfunctions.

Will the new ICD-11 classification help more people get help/treatment?

I believe the new diagnosis will increase the number of physicians who recommend treatment, but people with sexual addiction often do not want to give up their “drug of choice” as it is so inherently reinforcing — orgasm is an intense reward. Shame also keeps sex addicts from facing treatment.

What is the take-home message for psychiatrists regarding sex addiction?

Psychiatrists should inquire about whether sexual obsessions and compulsions interfere in people’s lives. They need to be aware of underlying anxiety, depression and intimacy disorders. Sexual acting out may be a way of masking or avoiding deeper emptiness and loneliness. As with other addictions, denial is prevalent.

When I suspect an addiction, inventories can be useful. I often ask people to refrain from their “drug” for a couple of weeks. If they can manage this easily I am less likely to see the acting out as addictive, but if temporary abstinence is too difficult, most likely sexual acting out is compulsive. I use words like obsession or compulsion when discussing with clients, rather than addiction, as people are less likely to be defensive.

Psychiatrists should also be aware of Sexaholics Anonymous and Sex and Love Addicts Anonymous, two of the 12-step programs for sex addiction, and sex and love addiction, which can be frightening initially but very helpful and free to many addicts. There are also therapy groups specifically for sexual addiction.

References:

WHO. ICD-11 for Mortality and Morbidity Statistics. https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1630268048. Accessed on July 16, 2018.

Disclosure: Silverstein reports no relevant financial disclosures.