World Health Organization’s ICD-11: Compulsive Sexual Behavior Disorder

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This page describes the process which saw Compulsive Sexual Behaviour Disorder accepted by the World Health Organization in ICD-11. See bottom of page for papers debating the classification of CSBD.

Porn Addicts Are Diagnosable Using the WHO’s Diagnostic Manual (ICD-11)

As you may have heard, in 2013 the editors of the Diagnostic and Statistical Manual (DSM-5), which lists mental health diagnoses, declined to add a disorder called “Hypersexual Disorder.” Such a diagnosis could have been used to diagnose sexual behavior addictions. Experts say that this has caused major problems for those suffering:

This exclusion has hindered prevention, research, and treatment efforts, and left clinicians without a formal diagnosis for compulsive sexual behaviour disorder.

World Health Organization to the rescue

The World Health Organization publishes its own diagnostic manual, known as the International Classification of Diseases (ICD), which includes diagnostic codes for all known diseases, including mental health disorders. It is used worldwide, and it is published under an open copyright.

So why is the DSM used widely in the United States? The APA promotes the use of the DSM instead of the ICD because the APA earns millions of dollars selling its copyrighted materials relating to the DSM. Elsewhere in the world, however, most practitioners rely on the free ICD. In fact, the code numbers in both manuals conform to the ICD.

The next edition of the ICD, the ICD-11, was adopted in May, 2019, an will gradually be rolled out nation by nation. Here’s the final language.

Here’s the text of the diagnosis:

6C72 Compulsive sexual behaviour disorder is characterised 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.

Essential (Required) Features:

The new “Compulsive sexual behaviour disorder” (CSBD) diagnosis is helping people get treatment and assisting researchers in investigating compulsive porn use. However, this field is so political that some sexologists have continued their campaign to deny that the diagnosis covers compulsive porn use. This is but the latest skirmish in a very long campaign. For more details about recent efforts, see Propagandists misrepresent peer-reviewed papers and ICD-11 search features to fuel false claim that WHO’s ICD-11 “rejected porn addiction and sex addiction”.

In 2022, the ICD-11 endeavored to put an end to the agenda-driven sexologists’ propaganda efforts by revising the “Additional Clinical Features” section to mention “the use of pornography” specifically.

Compulsive Sexual Behaviour Disorder may be expressed in a variety of behaviours, including sexual behaviour with others, masturbation, use of pornography, cybersex (internet sex), telephone sex, and other forms of repetitive sexual behaviour.

For now, the ICD-11 has adopted a conservative, wait-and-see approach and has placed CSBD in the “Impulse control disorders” category (which is where gambling started out before it was moved to the category called “Disorders due to substance use or addictive behaviours.” Further research will determine its final resting place. (Meanwhile, the sexology-dominated DSM has been updated without including CSBD at all! Shocking.

The academic debate is in full swing, as you can see at the bottom of this page. The neuroscientists and addiction experts continue their basic science based on the brain changes common to all addictions (behavioral and substance). The sexologists continue to defend their superficial, often agenda-driven (“porn can never be a problem”) research and propaganda efforts.

Fundamental mechanisms

Mountains of research reveal that behavioral addictions (food addiction, pathological gambling, video gaming, Internet addiction and porn addiction) and substance addictions share many of the same fundamental mechanisms leading to a collection of shared alterations in brain anatomy and chemistry.

In light of the latest scientific advances, the criticisms of the sexual-behavior addiction model are increasingly unfounded and outdated (and no studies have yet falsified the porn addiction model). Supporting the addiction model, there are now more than 60 neurological studies on porn users/sex addicts. With only one exception, they reveal brain changes that mirror those occurring in substance addicts (and dozens of neuroscience-based reviews of the literature). In addition, multiple studies report findings consistent with escalation of porn use (tolerance), habituation to porn, and even withdrawal symptoms – which are all key indicators of addiction.

Mission matters

The ICD is sponsored by the World Health Organization. According to the ICD’s Purpose, “It allows the world to compare and share health information using a common language. The ICD defines the universe of diseases, disorders, injuries and other related health conditions. These entities are listed in a comprehensive way so that everything is covered.” (World Health Organization, 2018). The goal, then, is to cover every legitimate health problem, so it can be tracked and studied around the world.

All clinicians (psychiatrists, mental health professionals, clinical psychologists, addiction treatment providers and those who work in prevention) strongly favor the ICD diagnosis of CSBD.

However, keep in mind that there are other disciplines. Many non-clinicians, for example, have their own agenda. They may even have motivations that conflict with getting patients the help they need, and they sometimes have very loud voices in the press. Groups that sometimes fall into this non-clinician category can be found in mainstream psychology media, the gaming and porn industries (and their researchers), sociologists, some sexologists, and media researchers.

It is not uncommon for large industries to pay “thought leaders” substantial retainers to speak out in favor of positions that such industries would like to see become/remain policy. So, as you read articles in the mainstream press, keep in mind that different disciplines maybe have very different motives. It is wise to question whether any particular spokespersons’ motives further humanity’s wellbeing, or impair wellbeing.

The Classification Debate: Papers about how best to classify CSBD in the ICD-11 (with excerpts from some):

Consistent with contemporary approaches to the conceptualization of addictive behaviors (e.g., Brand et al., 2019; Perales et al., 2020), we argue that considering a process-based perspective will help elucidate whether or not CSBD may be best conceptualized within an addiction framework.

In this commentary paper, it is discussed if Compulsive Sexual Behavior Disorder (CSBD) is best categorized as an Impulse Control Disorder, an Obsessive-Compulsive Disorder or in light of the overlap of characteristics with both Gaming and Gambling Disorder as an addictive behavior. The overlapping features are: loss of control over the respective excessive behavior, giving increasing priority to the excessive behavior under investigation and upholding such a behavior despite negative consequences. Besides empirical evidence regarding underlying mechanisms, phenomenology also plays an important role to correctly classify CSBD. The phenomenological aspects of CSBD clearly speak in favor of classifying CSBD under the umbrella of addictive behaviors.

in addition to the role of negative reinforcement motivations that Gola et al. (2022) describe as the main pathway in the development of CSBD, clinically, at least at the beginning of the developmental process similar to substance use positive reinforcement motivations are often of high importance. This changes in the course of development4. Figure 1 illustrates how this might lead to an “addictive like” symptomatology with aspects of impulsivity, compulsivity, and addiction.

While Brand and colleagues’ focus on whether theories of and mechanisms underlying addictive behaviors are applicable to proposed behavioral addictions is entirely sensible, we can expect and should encourage debate on the precise nature of addictive traits and mechanisms…

..the value of an overlapping public mental health approach to substance use and related addictive conditions is paramount for harm reduction. Where lessons from work on public mental health approaches to substance use disorder and to gambling disorder, are relevant to other proposed behavioral addictions, this may be a particular important justification for their inclusion under this rubric.

This commentary examines the proposal made by Brand et al. (2022) regarding a framework outlining relevant criteria for considering possible behavioural addictions within the current World Health Organisation’s International Classification of Diseases (ICD-11) category of ‘other specified disorders due to addictive behaviours’. We agree with the framework as it highlights the clinical perspective requiring agreed-upon classifications and criteria to produce effective diagnostic procedures and efficacious treatments. Additionally, we propose to add the need of recognising potential addictive behaviour through the inclusion of a fourth meta-level criterion: ‘grey literature evidence’.

Update. See these 2 articles for more: