Diagnostic and Statistical Manual of Mental Disorders - Dr. Jen's Recovery Readings

What is Compulsive Sexual Behavior Disorder?

Dr. Jennifer Weeks — Thu, 12 May 2022 12:00:00 +0000

After years in this field, those of us who treat problematic or compulsive sexual behavior still hear from colleagues that they do not believe that sex addiction is real.

Worse yet, those of us who treat it have been accused of simply being in it for the money. I have a good laugh at that one.

However, one of the arguments that some opposed to the concept of sexual addiction make is that a loose diagnosis of the problem can be confounded by religious or personal beliefs.

Moral Incongruence

This has spurred some great research by Perry, Grubbs and others about moral incongruence, whose basic premise is that some people’s distress over their sexual behavior, which they often label pornography addiction, is caused by them sexually acting in a manner that is against either their religious or personal values. Many of these individuals seek treatment for their self-diagnosed addiction.

Are you a Licensed Professional Counselor in need of continuing education? Learn more about Sex Addiction, Erotic Conflict, and Moral Incongruence from Dr. Weeks and Sexual Addiction Treatment Services, an NBCC ACEP™ approved provider!

Sexual Addiction Treatment Services has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 7250. Programs that do not qualify for NBCC credit are clearly identified. Sexual Addiction Treatment Services is solely responsible for all aspects of the programs.

Enter, the World Health Organization

Compulsive Sexual Behavior Disorder (CSBD) is not a name or diagnosis that has made its way into the internet lexicon like sex addiction or pornography addiction. It is, however, the World Health Organization’s recently (2019) approved diagnosis in the International Classification of Diseases-11 (ICD-11) relating to what is commonly referred to as sexual addiction. Reporting on the new system went into effect January 1 of this year.

As a side note, the DSM-V does not recognize sexual addiction or pornography addiction as a valid mental health disorder.

From Reed et al, 2022

Are you a professional looking to stay up-to-date with the latest information on, sex addiction, trauma, and mental health news and research? Or maybe you’re looking for continuing education courses?

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Removing Ambiguity about Compulsive Sexual Behavior

One of the most exciting things about the diagnostic criteria for CSBD is that it removes the confound of moral incongruence from the diagnostic picture. The diagnostic criteria specifically states that any distress that is: “entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviors is not sufficient to meet the requirement of marked distress. If one looks closely, the diagnostic criteria are strictly behavioral, removing the feelings of the actor or any family member of the actor from the picture.”

Why does this make a difference?

Well, for several reasons:

This is global recognition that CSBD is a real and valid issue that many people struggle with.
It allows for a more nuanced diagnosis that can help clinicians provide treatment best suited for their clients.

The treatment paradigm for someone dealing with sexual behavior with moral incongruence is not necessarily the same treatment plan for someone with CSBD.

Concerned that you may be dealing with CSBD? The CSBD-19 is a validated self-report assessment you can take to help you understand your behavior.

Want to take the CSBD-19 right here in your browser with results you can share with your therapist? We’ve made that available for you for free!

Are you looking for more reputable data-backed information on sexual addiction? The Mitigation Aide Research Archive is an excellent source for executive summaries of research studies.

Have you found yourself in legal trouble due to your sexual behavior? Seek assistance before the court mandates it, with Sexual Addiction Treatment Services.

Do you feel your sexual behavior, or that of someone you love, is out of control? Consult with a professional.

The post What is Compulsive Sexual Behavior Disorder? first appeared on Dr. Jen's Recovery Readings.

The Importance of Sex Addiction Research

Dr. Jennifer Weeks — Sat, 20 Mar 2021 14:56:34 +0000

One of the unfortunate, but predictable, outcomes of the horrific Georgia shooting at the massage parlors is the rash of news articles talking about how Sex Addiction isn’t real. Most of what people are saying tends to focus on the lack of inclusion in the DSM-V. It never occurs to many how sex addiction can be confused with moral incongruence. What we need is a thorough discussion of the massive body of sex addiction research.

A full blown narrative of the research on sexual addiction conducted since the publication of the DSM-V in 2013 would be beyond the scope of this blog. I will, however, leave you with a few paragraphs regarding the topic that I recently included in a sentence mitigation report.

Diagnostic and Statistical Manual of Mental Disorders– V: (DSM-V)

In the current edition of the DSM, there is no stated mental disorder that encompasses the concept of sexual addiction. Be that sexual addiction, sexual compulsivity, hypersexual disorder, etc. To simply negate a mental health phenomenon because it is not in a version of the DSM that is currently almost 8 years old is to negate both the history of the disorder with the DSM and the body of research that has been conducted since the DSM-V work group decided against including Hypersexual Disorder.

Prior to the publication of the newest edition of the DSM-V in 2013, the Sexual and Gender Identity Disorders Workgroup (Kafka, 2014) considered the inclusion of Hypersexual Disorder into the upcoming edition of the DSM. The suggested diagnostic criteria were as follows:

The “Almost Officially” a Disorder

Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges, and sexual behavior in association with four or more of the following criteria:
1. Excessive time is consumed by sexual fantasies and urges and by planning for and engaging sexual behavior.
2. Repetitively engaging in these sexual fantasies, urges and behaviors in response to dysphoric mood states (e.g., anxiety, depression, boredom, and irritability).
3. Engaging repetitively in these sexual fantasies, urges and behavior in response to stressful life events.
4. Repetitive and unsuccessful attempts to control or significantly reduce the sexual urges, fantasies, and behavior.
5. Repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others.
There is clinically significant personal distress or impairment in social, occupational, or other important areas of functioning associated with the frequency and intensity of sexual fantasies, urges or behavior.
These sexual fantasies, urges and behavior are not due to the direct physiological effects of exogenous substances (e.g., drugs of abuse or medication), a co-occurring general medical condition or to a manic episode.
The person is at least 18 years of age.

Specify if masturbation, pornography, sexual behavior with consenting adults, cybersex, telephone sex and strip clubs.

It was ultimately decided that Hypersexual Disorder would not be included into the DSM-V. The main reasons cited for the lack of inclusion were concerns around diagnostic accuracy, moral and cultural confounds and a lack of research supporting the concept (Kafka, 2014).

Do you believe you have an online pornography addiction? Take the free Cyber Pornography Addiction Test (CYPAT) and have the results to speak with your therapist.

What’s changed in Sex Addiction Research since 2013?

In the nearly 8 years since the publication of the DSM-V, a vast body of scientific research in peer reviewed journals has been published seeking to understand the concept of sexual addiction and compulsivity which has also been termed hypersexuality.

A recent metanalysis was published by Grubbs et. al. (2020) that systematically reviewed the scientific research on the topic. Research on the topic, alternatively called sexual addiction, sexual compulsivity, hypersexuality, and compulsive sexual behavior began in the mid 1990’s. Research increased during the time that the DSM-V was in development. Knowledge on the topic continues to expand. The Grubbs et. al. (2020) metanalysis included 371 papers published in peer reviewed scientific journals documenting the results of 471 individual scientific studies.

The Grubbs et. al. (2020) meta-analysis yielded several findings. On the negative side, the study found that there was a lack of rigorous outcomes studies for the treatment of Compulsive Sexual Behavior. Therefore, to date, there is no gold standard approach to treating the issue. The study did reveal that the Hypersexual Behavior Inventory (Reid et. al., 2011) is a well validated and clinically useful tool to assess Compulsive Sexual Behavior. The main finding pertinent to this case is that there is “clear evidence that CSB is a real phenomenon with clinical implications.” (Grubbs et. al., 2020, p 11)

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International Classification of Diseases – 11 (ICD-11) and Sex Addiction Research

The ICD-11 is the international equivalent of the DSM-V in the United States. The International Statistical Classification of Diseases is published by the World Health Organization and its most recent version was published in 2019 (WHO, 2019). Like the DSM, prior to any condition being accepted into the ICD there is a process of extensive debate and consideration. The ICD-11 does include a diagnosis of Compulsive Sexual Behavior Disorder (CSBD) which is classified under impulse control disorders. The diagnostic criteria share some traits with the proposed DSM-V diagnostic criteria for Hypersexual Disorder.

The Diagnostic criteria for Compulsive Sexual Behavior Disorder (ICD-11)

Essential (required) features for compulsive sexual behavior disorder:

A persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behavior, must be manifested by one or more of the following:
1. Engaging in repetitive sexual activities has become a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities, or responsibilities.
2. Person has made numerous unsuccessful efforts to control or significantly reduce the repetitive sexual behavior.
3. The person continues to engage in repetitive sexual behavior despite adverse consequences (repeated relationship disruption, occupational consequences, negative impact on health, etc.).
4. Person continues to engage in repetitive sexual behavior even when the individual derives little or no satisfaction from it.
The pattern of failure to control intense sexual impulses or urges and resulting repetitive sexual behavior is manifested over an extended period of time (e.g., 6 months or more.)
The pattern of repetitive sexual behavior causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning NOTE: Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges or behaviors is not enough to meet this criterion.

The inclusion of the rule out relating to erotic conflict or moral incongruence is a necessary criterion to address historical concerns about pathologizing sex with a label of addiction or compulsivity. Simply engaging in a sexual behavior that is non-normative or outside of a person’s religious or moral belief is not sufficient to diagnose Compulsive Sexual Behavior Disorder according to the ICD-11.

Check out my more recent article about Compulsive Sexual Behavior Disorder for more information about CSBD and its classification.

Do you believe your sexual behaviors are compulsive or harmful to you or others? Then you should take the CSBD-19 free, validated self-assessment tool.

References

Bothe, B., Potenza, M.N., Griffiths, M.D., Kraus, S.W., Klein, V., Fuss, J., & Demetrovics, Z. (2020). Journal of Behavioral Addictions 9(2), 247-258.

Gola, M., Lewczuk, K., Potenza, M.N., Kingston, D.A., Grubbs, J.B., Stark, R. & Reid, R. (2020). What should be included in the criteria for compulsive sexual behavior disorder. Journal of Behavioral Addictions published online November 25, 2020.

Grubbs, J.A., Hoagland, K.C., Lee, B.N., Grant, J.T., Davison, P, Reid, R.C. & Kraus, S.W. (2020). Sexual Addiction 25 years on: A systematic and methodological review of empirical literature and an agenda for future research. Clinical Psychology Review (82), 1-15.

Kafka, M.P. (2014). What happened to hypersexual disorder? Archives of Sexual Behavior, 43(7), 1259-1261.

Reid, R.C., Garos, S. & Carpenter, B.N. Reliability, validity, and psychometric development of the hypersexual behavior inventory in an outpatient sample of men. Sexual Addiction and Compulsivity, 18(1), 30-51.

Are you looking for more reputable data-backed information on sexual addiction? The Mitigation Aide Research Archive is an excellent source for executive summaries of research studies.

Do you feel your sexual behavior, or that of someone you love, is out of control? Then you should consult with a professional.

Have you found yourself in legal trouble due to your sexual behavior? Seek assistance before the court mandates it, with Sexual Addiction Treatment Services.

The post The Importance of Sex Addiction Research first appeared on Dr. Jen's Recovery Readings.

Pornography Problem: Erotic Conflict or Addiction?

Dr. Jennifer Weeks — Thu, 17 May 2018 16:53:49 +0000

As a therapist, how do we determine whether a pornography problem is erotic conflict or an addiction?

When I started in this field, sex addiction was not a common term. Therapists who treated sex addiction were not that prevalent, therefore you never heard about sex addiction on the news.

Today, it’s a different story.

You hear the term sex addiction all the time, bandied about every time there’s a celebrity sex scandal. Therapists who treat sex addiction, whether specifically trained to do so or not, are much more common now too.

The same goes for pornography addiction.

For some reason, this feels less stigmatizing to many. There are now large numbers of therapists who treat pornography addiction. There are also many new programs popping up to help men deal with their pornography addictions. These programs are often not run by a therapist or affiliated with a 12-step program, but instead created and run by independent agents or religious institutions.

Updates:

The Impact of Media Discussion of Addiction

As the visibility of pornography addiction grows, the type of clients we have coming to the office have changed. In the beginning, over 8 years ago, the (predominantly) men who were coming in to address problems with pornography were men who had struggled for most of their lives with pornography use.

They were:

Watching more than they wanted to
Couldn’t stop
Were experiencing serious repercussions in
- Their work
- Their relationships
- The legal system

I would diagnose these men as pornography or, more broadly, sex addicts.

The Changing Face of Sex and Pornography Addicts: The Pornography Problem

Today, many of the men who are coming in with self-diagnosed addictions are men who look at some pornography.

They don’t:

Look at it a lot; once or twice a week, sometimes less
Look at it for hours and hours on end
Look at anything illegal
Often look at any pornography that is more “hardcore”

Their pornography use is usually causing a conflict in their relationship. These are not men that I would diagnose with a pornography addiction, but they call themselves pornography addicts.

So, are these men who come in pornography addicts? Or are they men who are experiencing an erotic conflict?

What is an Erotic Conflict?

And how do we know what type of pornography problem it is

An erotic conflict is experienced by a person who is engaging in, or fantasizing about, a sexual behavior that conflicts with his or her moral values or religious values.

For example, a person who is attracted to sex with the same sex might experience an erotic conflict because their religious beliefs tell them that same sex attraction is wrong. Therefore, their behavior conflicts with their religious beliefs.

A person who uses escorts might be experiencing an erotic conflict because breaking the law is against their personal moral values.

A man who is watching pornography occasionally, a few times a month, might feel as though he has a sexual addiction or pornography addiction because his religious beliefs tell him that lust and pornography are bad. Therefore, he equates any use of pornography with addiction.

What does the DSM-V say about the Pornography Problem?

There is no DSM-V definition of sexual addiction or pornography addiction but we can extrapolate the criteria from drug and alcohol and gambling addictions. These are all use disorders in the DSM-V. This means that someone who is a pornography addict would experience at least two of the following issues:

Watching pornography more often than they intended and for longer periods of time than intended
An inability to stop watching pornography
Spending a lot of time creating opportunities to watch pornography
Craving pornography use
Failure to fulfill obligations at work, home or school due to using pornography
Continuing to use pornography even after interpersonal problems resulting from use
Social isolation due to pornography use
The need for more pornography or more intense pornography to get the same feeling and difficulties when they try to stop using pornography or can’t access it

Here is my plea to clinicians and to society as well:

Can we please be more discerning in diagnosing sexual and pornography addiction?

What happens when we over diagnose pornography addiction?

We never get to the underlying issue. If someone is actually experiencing an erotic conflict, they may never get to the root of the issue. They may work a 12-step abstinence model and therefore condemn any experiences of lust as bad or problematic. This can place moral good or bad judgements on sexual behavior, in other words more psychological harm if the client continues to engage in the behavior. It can shame the normal biological process of attraction by labeling it as lust. It may prevent the client from learning about healthy sexuality and what truly arouses and attracts them. Ultimately, they may never work through the conflict between their body and their beliefs to a healthy resolution.
We cause more shame. Though being a pornography addict is less shameful than it used to be, being named an addict will create very shameful thoughts for most people. This shame must be worked through when the person actually has an addiction. When the person is mislabeled, it can cause more shame and isolation than necessary. This adds to the “I’m a bad person” thoughts the pornography consumer might have for looking at pornography.
We trivialize sexual addiction. The therapeutic community and, often, the media hotly debate whether sexual or pornography addictions are “real.” The con side often uses the argument that those who support the idea of sexual addiction are religious conservatives who are condemning normal sexual practices. When someone with an erotic conflict, often based on religious beliefs, is diagnosed with an addiction, this reinforces the argument that we are trying to morally dictate sexual practices and label them addictions

Do you believe you have an online pornography addiction? Then take this free Cyber Pornography Addiction Test (CYPAT) and have the results to speak with your therapist.

The Takeaways

My goal here and in my practice is not to condemn or judge. We all have our own set of values that we would like to live by.

My plea is that we, both clinicians and consumers, really look at the behavior: Is the client presenting in your office who uses pornography an addict or someone with an erotic conflict? The treatment is different.

If they have an erotic conflict, the work is to process through the beliefs, sexuality and the conflict to come to a resolution that fits the client’s moral and personal compass.

If the client is an addict, the treatment will likely follow a more traditional addiction model with 12-step attendance, abstinence from certain behaviors and recovery work.

I leave you with my plea again: CAN WE PLEASE BE MORE DISCERNING IN DIAGNOSING SEXUAL AND PORNOGRAPHY ADDICTION?

Do you feel your sexual behavior, or that of someone you love, is out of control? Consult with a professional.

Have you found yourself in legal trouble due to your sexual behavior? Seek assistance before the court mandates it, with Sexual Addiction Treatment Services.

Are you looking for more reputable data-backed information on sexual addiction? The Mitigation Aide Research Archive is an excellent source for executive summaries of research studies.

The post Pornography Problem: Erotic Conflict or Addiction? first appeared on Dr. Jen's Recovery Readings.

It’s not all sex addiction: A clinical look at BDSM fetish

Dr. Jennifer Weeks — Wed, 30 Jul 2014 19:48:23 +0000

BDSM play. Hands in manacle

When I started working nearly exclusively in the sex addiction field, it was not very widely known and even less widely accepted.

Update: Pornography and BDSM: What Americans are Really Doing

Those 7 years have brought a great deal of recognition to the addiction. The increased attention to sex addiction is, in part, a great thing.

However, there is a down side as well.

The moniker sex addict now seems to be tossed around rather lightly. It’s used as an excuse for sexual behavior when celebrities are caught engaging in behind someone’s back. In my opinion, this is a detrimental development.

First, it minimizes the pain and suffering experienced by someone who truly has a sex addiction.

Secondly, it has the potential to demonize aspects of sexuality because they are “outside the box.”

Why we don’t just say “It’s Sex Addiction”

As a clinician, supervisor, and trainer, I try to emphasize the importance of correctly diagnosing a client’s behavior.

I do not throw the label sex addict around lightly.

I also understand there are things people do that are outside of the comfort zone of societal norms. This does not necessarily make a person a sex addict. I struggle with the idea that one can sometimes hear espoused that anything that is outside the norm of traditional heterosexual sex stereotypes is addiction. In this, and a series of writings to follow, I will take a look at behaviors that are often labeled addictive even when they may not be so.

Just because it may make someone uncomfortable, does not make it addictive.

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Fetish and Kink Play versus Sex Addiction

The inspiration for this first article comes from my brother, Christopher Weeks, who is a professional photographer (http://black-cat-studios.tumblr.com/) in Tampa, Florida.

He recently posted photography work he had done at an event called Fetish Divine (www.fetishdivine.com). Fetish Divine is an organization that hosts pan-sexual play parties at a club in Tampa.

When my brother photographs these events (as an invited professional) he often gets complaints from others about the photographs being lewd or pornographic.

The famous Supreme Court opinion by Justice Potter Stewart on obscene material has been quoted by the masses for years:

“I know it when I see it.”

However, isn’t that dependent on the viewer?

This discussion with my brother started me thinking about how we view S&M in the sex addiction treatment community. There are some that would always categorize this type of behavior as addictive. The DSM-V (the diagnostic bible for mental health practitioners) places sadomasochism in the paraphilia section of disorders.

Sexual Masochism disorder is defined by a person:

For at least 6 months, obtaining recurrent and intense sexual arousal from the act of being humiliated, beaten, bound or otherwise made to suffer, as manifested by fantasies, urges or behaviors.

Sexual Sadism Disorder is defined by a person:

For at least 6 months, obtaining recurrent and intense sexual arousal from the physical or psychological suffering of another person, as manifested by fantasies, urges or behaviors.

The key to both of these diagnoses is the B section.

For Sexual Masochism, the fantasies, urges or behaviors must cause significant distress or impairment in social, occupational, or other important areas of functioning.

For Sexual Sadism, the individual has to have acted on these urges with a non-consenting person, or the sexual urges or fantasies must cause clinically significant distress or impairment in the same categories listed above.

From a purely clinical point of view, engaging in BDSM only becomes an issue if it impairs a person’s functioning or if it is with a non-consensual partner.

Do you have a problem or just an interest?

From the perspective of Sexual Addiction (a diagnosis that does not exist in the DSM-V), we look at BDSM as behavioral categories or scales according to one instrument (the Sexual Dependency Inventory). This means that someone who is a sex addict may engage in behaviors involving pain exchange or humiliation and/or domination. In addiction treatment, as in the DSM criteria for SMD or SSD, we look at the effects of engaging in this behavior on the person:

Does it cause distress on any level?
Has the person ever tried to stop engaging in the behavior?
Do we see an escalation of the behavior in order to get the same feeling or high?

If the answer to these and similar questions is no, then we cannot unequivocally say that the person who is engaging in the BSDM is a sex addict.

Check out the latest research on fetishes and criminality:

Criminal Histories and Recidivism Rates for Juveniles Convicted of Child Pornography Possession

Does everyone consent?

When discussing any fetish with a client, I don’t approach it as right or wrong, or addictive or not. We try to frame the fetish with the question “is it healthy or not.” Is the engagement in the fetish consensual for all parties?

Consent is critical. Consent is different from coercion or compliance.

Learn more about consent, compliance, and coercion from Dr. Weeks.

If a person is consenting, they fully wish to participate in the behavior. They are not doing so because they are pressured by a partner or feel they are obligated to do so for some reason. If I engage in the behavior because I fear my partner will leave me, then this is not true consent.

Psychological Distress

Another aspect we look at when discussing fetishes is psychological distress.

Does engaging in the behavior cause any type of psychological distress to the person?
Is it creating strain on relationships?
Is it interrupting normal life functioning?
Does the person feel ashamed of the behavior they are engaging in or aroused by?

Again, if the answer to these questions is no, then it is not my place as a therapist to label the behavior as dysfunctional, addictive, or wrong.

Struggling with excessive sexual thoughts, urges, or activities that are causing you distress? Take the free, online Sexual Symptom Assessment Scale (SSAS) and get a link to share with your therapist.

Take Aways

As I move into my 8th^th year of working nearly exclusively with sexual addiction, I fear that our community, as well as the public, has a tendency to pathologize non-traditional sexuality. I also have a fear that well-meaning therapists will impose their own sexual beliefs and views onto others, particularly clients, and end up doing more harm to a person than good.

As therapists who deal with sex on a daily basis, it behooves us to know our own boundaries with sex but also be open to other forms of sexuality that others enjoy. Can we work to re-frame sexuality, sexual addiction, and “deviance,” moving away from right and wrong, good and bad to “is it healthy for you?”

If it is, then perhaps we don’t need to pathologize it. If it is not, then we can help our client to work through their issue.

Do you feel your sexual behavior, or that of someone you love, is out of control? Consult with a professional.

Are you looking for more reputable, data-backed information on sexual addiction? The Mitigation Aide Research Archive is an excellent source for executive summaries of research studies.

Have you found yourself in legal trouble due to your sexual behavior? Seek assistance before the court mandates it, with Sexual Addiction Treatment Services.

Stay up-to-date with all of Dr. Jen’s work through her practice’s newsletter!

The post It’s not all sex addiction: A clinical look at BDSM fetish first appeared on Dr. Jen's Recovery Readings.