therapy sessionA Hopeful Outlook

In the April 2016 edition of Addiction, Dr. Richard B. Krueger of Columbia University and the New York State Psychiatric Institute provided a short commentary on the ways in which psychotherapeutic clinicians, if and when it’s appropriate, can make a DSM-5 and/or an ICD-10-CM diagnosis of sexual addiction. This is important primarily as it relates to insurance companies, who don’t especially like to pay for the treatment of any issue that can’t be identified with a numeric or an alphanumeric code.

In addition to his other impressive academic and professional credentials, Dr. Krueger served as a member of the American Psychiatric Association’s Sexual and Gender Identity Disorders Workgroup, tasked with making recommendations to the APA regarding the latest version of its diagnostic manual, the DSM-5, published in 2013. Furthermore, Dr. Krueger is a member of the World Health Organization’s Sexual Health and Disorders Committee, charged with making recommendations for changes to the next version of that group’s diagnostic manual, the ICD-11, scheduled for publication in 2018.

Although the APA ultimately rejected, with little explanation, its own Workgroup’s rather strong recommendation—eloquently presented in a position paper by Harvard’s Martin Kafka—to include Hypersexual Disorder (aka, sexual addiction) in the DSM-5, Dr. Krueger believes there are ways to work around this rejection. I will discuss his suggestions momentarily, after a brief look at the history of sexual compulsivity as defined in these dueling diagnostic manuals.

A Short History of Sexual Addiction Diagnoses

In the United States it has been possible to diagnose sexual addiction, albeit indirectly, since the DSM-III was published in 1980 with a brief mention of hypersexual behaviors. In the next versions, the DSM-IV and the DSM-IV-TR, the APA backtracked but still included a diagnosis of Sexual Disorders Not Otherwise Specified, which specifically allowed for diagnoses with hypersexual behavior as an element. The DSM-5 is another story entirely, but I’ll address that issue momentarily.

In Europe and most of the rest of the world, where the ICD is generally utilized when making diagnoses, Pathological Sexuality appeared in the ICD-6 and ICD-7. In the ICD-8, the diagnosis Unspecified Sexual Deviation appeared, with pathological sexuality not otherwise specified as a possible manifestation. In the ICD-9, published in 1975, the diagnosis became Sexual Deviation and Disorders, Unspecified. In 1989, in the ICD-9-CM (a version of the ICD created specifically for use in the United States), the diagnosis of Unspecified Psychosexual Disorder was listed. In the ICD-10, released in 1992, the diagnosis of Excessive Sexual Drive appeared.

About this diagnosis, the ICD-10 stated:

Both men and women may occasionally complain of excessive sexual drive as a problem in its own right, usually during late teenage or early adulthood. When the excessive sexual drive is secondary to an affective disorder (F30-F39), or when it occurs during the early stages of dementia (F00-F03), the underlying disorder should be coded. Includes: nymphomania, satyriasis.

Needless to say, this statement used dated, shaming, and inaccurate language that has little to do with sexual addiction as we now understand it.

The Current Approach to a Sex Addiction Diagnosis

Earlier this year, the ICD-10-CM was published, and Excessive Sexual Drive was decommissioned as a diagnosis. The new recommendation, using the diagnostic code F52.8, is Other Sexual Dysfunction Not Due to Substance or Known Physiological Condition. Unfortunately, this diagnosis still includes the dated terminology of its predecessor, listing excessive sexual drive, nymphomania, and satyriasis as possible manifestations.

Meanwhile, the DSM-5 lists a pair of equally unwieldy options: Other Specified Sexual Dysfunction and Unspecified Sexual Dysfunction.

Other Specified Sexual Dysfunction, diagnostic code 302.79, is defined as follows:

This category applies to presentations in which symptoms characteristic of a sexual dysfunction that cause clinically significant distress in the individual predominate but do not meet the full criteria for any of the disorders in the sexual dysfunctions diagnostic class. The other specified sexual dysfunction category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific sexual dysfunction. This is done by recording “other specified sexual dysfunction” followed by the specific reason (e.g. “sexual aversion”).

Unspecified Sexual Dysfunction, diagnostic code 302.70, is defined as follows:

This category applies to presentations in which symptoms characteristic of a sexual dysfunction that cause clinically significant distress in the individual predominate but do not meet the full criteria for any of the disorders in the sexual dysfunctions diagnostic class. The unspecified sexual dysfunction category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific sexual dysfunction, and include presentations for which there is insufficient information to make a more specific diagnosis.

Dr. Krueger suggests these as viable options when clinicians must officially diagnose sex addicts. And for insurance purposes these alternatives may work. However, the criteria are largely unrelated to the benchmarks used by certified sex addiction treatment specialists (CSATs) when identifying sexual addiction.

Typically, CSATs identify sexual addiction based on three measures:

  • Sexual preoccupation to the point of obsession
  • Loss of control over sexual urges, fantasies, and behaviors (typically evidenced by failed attempts to quit or cut back)
  • Negative life consequences related to compulsive sexual behaviors, such as ruined relationships, trouble at work or school, loss of interest in nonsexual activities, financial problems, loss of community standing, shame, depression, anxiety, legal issues, and more

It would be nice to work with an official diagnosis that reflects the reality of sexual addiction as described above. For the time being, however, 302.79 and 302.70 in the DSM-5 and F52.8 in the ICD-10-CM provide the language we must work with if and when we need an official diagnosis (for whatever reason).

What Does the Future Hold?

As of now, Compulsive Sexual Behavior Disorder is being considered as a possible diagnosis in the ICD-11, scheduled for publication in 2018. The suggested definition of this disorder is posted on the ICD-11 beta draft website. It reads, in part:

Compulsive sexual behavior disorder is characterized by persistent and repetitive sexual impulses or urges that are experienced as irresistible or uncontrollable, leading to repetitive sexual behaviors, along with additional indicators such as sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other activities, unsuccessful efforts to control or reduce sexual behaviors, or continuing to engage in repetitive sexual behaviors despite adverse consequences (e.g., relationship disruption, occupational consequences, negative impact on health). … The pattern of sexual impulses and behavior causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning.

If you compare this to the diagnostic criteria currently used (unofficially, of course) by certified sex addiction treatment specialists, you’ll find that the ICD-11’s suggested language is an almost exact match. Furthermore, the dated, potentially shaming, and not exactly accurate language of the past has been eliminated.

Importantly, in my opinion, this suggested language is very much in line with wording suggested in Kafka’s APA commissioned position paper, proposing the following diagnostic criteria for Hypersexual Disorder:

A. Over a period of at least 6 months, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors in association with 3 or more of the following 5 criteria:

  • Time consumed by sexual fantasies, urges or behaviors repetitively interferes with other important (non-sexual) goals, activities and obligations.
  • Repetitively engaging in sexual fantasies, urges or behaviors in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability).
  • Repetitively engaging in sexual fantasies, urges or behaviors in response to stressful life events.
  • Repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges or behaviors.
  • Repetitively engaging in sexual behaviors while disregarding the risk for physical or emotional harm to self or others.

B. There is clinically significant personal distress or impairment in social, occupational or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges or behaviors.

C. These sexual fantasies, urges or behaviors are not due to the direct physiological effect of an exogenous substance (e.g., a drug of abuse or a medication).

Specify if:

  • Masturbation
  • Pornography
  • Sexual Behavior with Consenting Adults
  • Cybersex
  • Telephone Sex
  • Strip Clubs
  • Other:

So it appears that scholars and clinicians in the both the United States and the remainder of the world agree on the basics of what sexual addiction is and how it should be diagnosed. The only remaining question is whether the World Health Organization (and eventually the APA) will finally hop on board the reality train, officially and accurately recognizing sexual addiction, whatever we choose to call it, as the debilitating yet treatable disorder that it is.