For those unaware, one of the most hotly contested issues in sex therapy is whether or not sex addiction is a useful diagnosis and whether it even actually exists as a distinct addictive process in the first place. This controversy receives lots of coverage in the media and I am often contacted by journalists for expert opinions (check out this recent article in Prevention Magazine, for example, it’s pretty good).

I don’t think that anyone argues that sexual behavior can be problematic or feel “out of control.” Indeed, the Out of Control Sexual Behavior (OCSB) model is gaining a lot of traction in therapist circles. The main concern with the sex addiction model, however, is that by placing sexuality alongside toxic and dangerous substances such as alcohol and hard drugs, it unduly stigmatizes sexual expression as inherently dangerous, taking us back to the Victorian dark ages of sexual repression. For this reason, one of the common criticisms of the sex addiction field is that clinicians untrained in human sexuality diagnose and pathologize individuals who stray from heteronormative and mononormative sexual expressions as struggling with mental pathology. Of course, there must be a middle ground between unquestioning validation and trigger-happy pathologization.  Earlier this summer, the World Health Organization (WHO) sought to find this median by releasing their latest International Classification of Diseases (ICD) 11.

There’s a lot that’s positive in the new ICD 11 classification, and also consistent with the American Association of Sex Educators, Counselors, and Therapist’s (AASECT) ‘s position statement on sex addiction (and I should know, I was one of four co-authors of the position statement). Let’s go through it in more thorough detail (you can reach the synopsis here).

First, WHO uses the terminology “compulsive” rather than “addiction” and classifies it as an impulse control disorder. This is significant because sex addiction proponents for years have tried unsuccessfully to point to some kind of biological basis for sex addiction, similar to substance dependence. The WHO classification makes it clear that this is not the case. The terms addiction and compulsion are often conflated, but the difference is important since addictionologists often advocate for an abstinence-only approach to treatment to get the “brain chemicals balanced” or some other pseudoscientific explanation. To this point, there has been no evidence of a chemically dependent sexual response akin to substance dependence. Proponents of the addiction model will argue that dopamine and endorphins are released during pleasure, but these same chemicals are released during pleasurable things such as eating cake or watching a beautiful sunset. It is unclear how the process is radically different in terms of the neurochemicals involved in sex and riding roller coasters.

Second, WHO makes explicit that the diagnosis is not related to moral judgments and disapproval. This is significant because a large segment of individuals who show up for sex addiction treatment are individuals who are morally upset with their fetishes or use of porn, or their partner is. Indeed, paraphilias (fetishes) have been specifically excluded from the criteria. Recent research shows that those who have moral difficulty with their sexual behavior (mostly, but not exclusively for religious reasons, for example) are more likely to identify as sex addicts, irrespective of the frequency of the problematic sexual behavior.

In addition, the ICD description eliminates people who identify as sex addicts simply because they were caught cheating or having an affair because they would have needed to persistently fail in controlling their impulses. Many folks who have made bad decisions may be drawn to a mental health diagnosis such as sex addiction as a means of taking away personal responsibility from destructive behaviors such as infidelity. Rather than seeing oneself as the victimizer, sex addiction provides these individuals with a useful label of victimhood. Instead of taking personal responsibility, they can now find fault in their childhood and any other myriad of historical difficulties, even if they are historically accurate and true. I certainly don’t want to insinuate that a history of childhood abuse could not influence individuals to misbehave, but I am providing a reason why the sex addiction diagnosis has gained social currency and popularity that goes well beyond grounded science.

Indeed, much of the criticism of the sex addiction model is that it employs junk science to lump a bunch of disparate behaviors (foot fetishists, adulterers, and people uncomfortable with porn) all under one label while prescribing a one-size fits all approach to treatment. The experience of many former sex addiction patients I have worked with is that everyone who goes into a sex addiction clinic gets a diagnosis. The ICD classification makes it clear we are dealing with compulsivity, not a biological addiction, and adds specific criteria to exclude individuals who should not be diagnosed, which is most of them.

Which then leads to the question of how should we approach working with individuals who have wreaked havoc on their lives and the lives of others due to their sexual behaviors? I have written much on this topic, which you can access here and here and here, but fundamentally I want to start with a mindset of exploration and curiosity rather than all-knowing labeling. Sexuality is very complex and the same behaviors could have radically different meanings for the individuals involved. You can have ten people engaged in the same sexual behavior, but for ten drastically different reasons. So, it is important to stay open-minded and curious and proceed from a sexologically informed perspective. Often those struggling with out of control sexual behavior qualify for a dual diagnosis, meaning they are primarily struggling with another mental health issue such as depression, anxiety, or OCD, and the sexual behavior is a symptom, not the disease.

If we get too stuck on the labeling and judging the behavior, we may miss the big picture, and leave the individual actually feeling more shamed and compulsive than when he or she first came in. Tons of research suggests that compulsivity is highly linked to shame. Think about it, if I told you to never think of a pink elephant because that would be terrible, are you more or less likely to find yourself thinking of the pink elephant? You need to think of it just to think about what you are trying to avoid! And the more you resist, the more you become hyperfocused and obsessed about it, leading to an intensifying obsessive-compulsive cycle. Rather, good sex therapy involves placing the sexual behavior within an accurate contextual and systemic framework and understanding its deeper, underlying meaning to the individual. Once we rush to place labels, we’ve already shut down the conversation. For this reason, sex addiction is often a case of too much certainty clouding the mental health field’s pursuit of knowledge.