WHO Classifies Compulsive Sexual Behavior as a Mental Health Disorder

In a first for a sexual disorder, the World Health Organization (WHO) recently classified compulsive sexual behavior disorder (CSBD) as a mental health disorder.

The designation was made last month in the WHO’s International Classification of Diseases, the ICD-11, “which provides a common language that allows health professionals to share health information across the globe,” according to the WHO.

Rather than classify the condition as a sexual disorder, the WHO lists it in the ICD-11 under “impulse control disorders.”

The concept isn’t new, says Rory Reid, PhD, a research psychologist and assistant professor of psychiatry at the Semel Institute for Neuroscience and Human Behavior at UCLA in Los Angeles, who specializes in impulse control disorders, such as gambling and hypersexuality.

What is new about the WHO’s decision, says Dr. Reid, is that for the first time we have a governing body of disorders and diseases recognizing compulsive sexual behavior in an official way.

“In essence, the WHO is stepping up and saying we’re going to officially classify this in our canonized system of disorders and diseases; and they are saying this is a legitimate phenomenon,” he says.

How It Is Defined

The WHO was very specific in what constitutes compulsive sexual behavior disorder, saying that it is “characterized by a persistent pattern of failure to control intense, repetitive sexual impulses or urges, resulting in repetitive sexual behavior.”

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
  • Multiple unsuccessful efforts to significantly reduce repetitive sexual behavior
  • Continued repetitive sexual behavior despite adverse consequences or deriving little or no satisfaction from it
  • Having this pattern of behavior for six months or more
  • Behavior causing distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning

Decision May Help Patients

Many experts on compulsive sexual behavior say the WHO classification can be life-changing for people struggling with their sexual behavior.

“If you ask 100 experts what it is, you will get 200 responses,” says Timothy Fong, MD, clinical professor of psychiatry at the Semel Institute for Neuroscience and Human Behavior at UCLA.

“We need a universal language to understand human behavior, both conventional and unconventional,” says Dr. Fong. “When the human brain doesn’t function the way it is supposed to, we need to be able to describe, measure, and treat. We need that with compulsive sexual behavior disorder just as we do other conditions, such as heart disease.”

“This designation will make peoples’ lives better.”

Fong says that when people come into his office and say that their sexual behavior is causing problems, his job as a doctor is to find a solution, but it’s not always a single cause.

“In some people, their brain is not working properly. In others it may be a result of another mental health disorder, such as depression, which causes them to use sex to deal with sadness or loneliness,” he says. “The WHO designation allows us to have a discussion and guideposts that clinicians, legislators, patients, families, and researchers can all use as a way to describe behavior for research, documentation, and treatment. That’s the power of classification.”

According to Ashley Hampton, PhD, a psychologist in private practice in Birmingham, Alabama, sexual behavior is usually a “hush-hush” topic. Designating it as a mental health disorder could open the doors for patients to talk to healthcare providers about the impact the behavior may be having on their daily activities and quality of life.

The WHO classification also gives physicians a code to use to request insurance reimbursement for treating the condition, though it is up to insurers to determine if they will. (While the ICD-11 was released in June 2018, it does not take effect until 2022, according to WHO.)

Past Controversy

The new classification is not without controversy.

The American Psychiatric Association (APA) turned down a proposal to classify hypersexuality as a mental health disorder when it last updated its Diagnostic and Statistical Manual of Mental Disorders (the current version is known as the DSM-5) several years ago. The APA reached its decision even though field trials by UCLA researchers “suggested the criteria were valid and reliable,” according to an article published in December 2014 in the journal Current Sexual Health Reports.

Issues that kept the APA from adding in the designation included concern over diagnosing someone with a mental health disorder when what they had was a normal variation of sexual behavior, says Reid, who was the lead researcher for the field trial for hypersexuality research and the first author of the journal article.

“The APA didn’t think the evidence was strong enough to classify hypersexuality as a mental health disorder last time. But looking at the research that has evolved in the last five years could make the association change their minds the next time they update the DSM,” says Fong.

Sex Addiction in the News

Hypersexuality has been in the news recently following actress Jada Pinkett Smith’s comments that she believes she had a sex addiction when she was younger.

Pinkett Smith made the disclosure last week on her Facebook Watch series but did not say that she had actually been diagnosed.

Other celebrities, such as Charlie Sheen and David Duchovny, have spoken about their sex addiction in the past.

Risk of Misuse

Kenneth Rosenberg, MD, a clinical associate professor of psychiatry at Weill Cornell Medical College in New York City, who specializes in addiction medicine, agrees it’s likely that the disorder could make it into the next DSM. But he respects the APA’s decision “because the threshold for sexual compulsion has to be higher because of how the information might be misused.”

Dr. Rosenberg cites the example of classifying someone’s sexual orientation as a mental health disorder, as homosexuality was until recently.

“The American Psychiatric Association erred terribly and with serious consequences for gay and lesbian people in the last century by classifying homosexuality as a mental health disorder,” he says. “Fortunately, they corrected the error by the end of the century, but it had a negative impact for many people.”

Rosenberg stresses the need to be “very careful and thoughtful today around nonconformist sexual behaviors. While compulsive sexual behavior disorder is a bona fide medical condition, the parameters, clinical criteria, and the nature of the behavior need to be carefully considered to prevent any further errors,” he says.

According to Reid, as many as 3 to 4 percent of U.S. adults may have compulsive sexual behavior disorder. That is not a surprising rate, he says, considering 1 to 3 percent of adults have a gambling disorder.

What the Classification Does Not Cover

Reid and other experts are quick to clarify this is not about a high sex drive or a lot of sexual activity.

“This disorder is describing the person who feels driven to engage in sexual behaviors at the expense of other important aspects of their lives, despite the consequences they may experience, despite multiple unsuccessful efforts to stop the behavior,” Reid says.

He stresses that “it involves other consenting adults. Lack of consent is critical when it comes to the ‘Me Too’ movement that shed light on men and women sexually harassing others, or coercing others to have sex. 'Me Too' is all about people who have preyed on vulnerable populations in ways where that person did not consent or felt coerced to consent — and coerced consent is not consent at all,” Reid adds.

“People don’t get a free pass because they have a sexual diagnosis,” says Rosenberg.

The new designation should not give cover to anyone to explain poor sexual activity choices or infidelity, Dr. Hampton adds.

How Can It Be Treated?

While there are no drugs approved by the Food and Drug Administration (FDA) specifically to treat compulsive sexual behavior disorder, a range of therapies are available that are tailored to individual patients Reid says, including cognitive behavioral therapy. Medication can be helpful to treat a co-occurring condition, such as depression.

Experts disagree on whether compulsive sexual behavior disorder is, in fact an addiction, though addiction treatments can often be effective for the disorder, notes Rosenberg, including 12-step groups, which have the added advantage of usually being free.

“There are some elements of addiction,” says Reid, “but there are also similarities with other disorders, such as an eating disorder. The distinction is that with addictions the goal is often abstinence, but here we want to help people to reorganize their relationship with sexuality in a way that doesn’t cause them distress. The goal is not to extinguish their sexuality. It’s to help them manage.”

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