Abstract
This paper comments three recent publications in the Journal of Behavioral Addictions (Brand et al., 2022; Gola et al., 2022; Sassover & Weinstein, 2022). It shortly discusses (1) the role of researcher biases and the significance of the naming of a disorder (here “sexual addiction” and “pornography use disorder”) for stigma and treatment, (2) the development and course of CSBD and its significance for research results, (3) the role of “Sexual” in CSBD. The paper concludes that the guidelines for CSBD give a precise description and the authors plea for an exchange between disciplines and a sex positive treatment approach.
Commentary
The present commentary will deal with three recent publications in the Journal of Behavioral Addictions (Brand et al., 2022; Gola et al., 2022; Sassover & Weinstein, 2022) and their theoretical assumptions regarding Compulsive Sexual Behavior Disorder (CSBD). We will briefly discuss three different aspects that may not have been sufficiently considered so far: (1) The background from which the investigator and the investigated originate and the significance of the naming of the disorder for stigma and treatment, (2) the development and course of CSBD and its significance for research results, (3) The role of “Sexual” in CSBD.
(1) The description of excessive sexual behavior as an addiction has led to an ongoing controversy about terminology and the precise etiological classification since the 1980 (Carnes, 1983). One point that has not been adequately addressed in many previous controversies, nor in the three publications commented on here, is the field of study which the investigators and the clinical populations are drawn from. Patrick Carnes (1983) coined the term “sexual addiction” and referred primarily to the self-descriptions or labeling of those he interviewed (members of self-help groups), who described themselves as “addicts”. It should be considered in what time this phenomenon became dynamic and how this happened (Reay, Attwood, & Gooder, 2013): “sexual addiction” appeared in the period when AIDS and AIDS-associated fears were developing. Since then, the myth of a steadily growing problem (in terms of an increasing prevalence of CSBD) has represented the narrative, however, without empirical evidence. This narrative has been fueled by growing media coverage on the one hand and the digitalization of sexuality and facilitated access to pornography on the other. Alongside this, a self-help system and a privately paid therapy industry – both mainly organized heteronormative and thus also for partners of “sexually addicted” – grew from the 1980s onwards, especially in the United States. There was an attempt at academization through the founding of a professional society (The Society for the Advancement of Sexual Health) and an associated journal in 1994 (since 1994 “Sexual Addiction and Compulsivity”; recently renamed to “Sexual Health and Compulsivity”). In the 2001 edition of „Out of the shadows“ Carnes himself reflected on societal shifts since the book was first published (see also Reay et al., 2013): the ‘‘sexual landscape has changed dramatically. First, there was the AIDS epidemic… Then there was former President Clinton and the intern Monica Lewinsky… Almost simultaneously came the cybersex revolution’’ (Carnes, 2001, p. xiii).
The term “sexual compulsivity” comes from the field of research on men who have sex with men (MSM). Quadland (1985), who as far as we know, first used the term in this context, collected data on 30 gay and bisexual men from New York City who defined themselves as sexually compulsive and who sought treatment for this problem. Later, Eli Coleman was a strong promoter of the term (Coleman, 1991) and Kalichman and Rompa (1995) developed the Sexual Compulsivity Scales to assess HIV risk behavior in MSM. “Sexual impulsivity” seems to have been used firstly by researchers from the field of trauma (Barth & Kinder, 1987). The terms “hypersexuality” and “sexual preoccupation” were often used in the field of forensic-psychiatry and psychology (Briken, 2020). Before Martin Kafka proposed the term “hypersexual disorder” (Kafka, 2010) he presented a diagnostic category he called “paraphilia related disorder” (Kafka, 1994) because his CSBD patients often had a comorbid paraphilic disorder.
It cannot be the task of this commentary to trace the fields from which the actors of the current debates come from. It should only be pointed out that we as researchers might have a bias in the access and selection of the subjects we investigate as well as in the interpretation of data, which might also contribute to the very heterogeneous research results and theoretical assumptions under discussion. CSBD in a person with a pedophilic disorder 1 involving the consumption of abusive images is likely to have very different motives, assessment results, biological correlates than a man who compulsively has sex with other men against a background of CSBD.
Although a diagnostic category for the corresponding phenomenon already existed in the ICD-10 (“excessive sexual drive”), this diagnosis was rarely used for research. Among others, this is probably due to the fact that no precise guidelines for the diagnosis were available. This is different now for the ICD-11 diagnosis and according to the results of a first field trial (Gaebel et al., 2020) clinicians are much more successful and accurate in making a diagnosis when using ICD-11 guidelines compared to ICD-10. It is clear that the CSBD diagnosis currently is an umbrella construct (Briken, 2020). However, it is questionable whether rather precise distinctions as proposed e. g. by Brand et al. 2 are empirically justified and whether they do not bring more disadvantages than advantages at this stage of research. A disadvantage could be the hasty use of addiction-specific therapeutic approaches, e.g., the recommendation of complete abstinence with regard to pornography use or abstinence from masturbation, without an empirical basis for this. Also, it is an open research question whether people with the lay label “pornography addiction” or the proposed diagnosis of “pornography use disorder” will feel more stigmatized or discriminated compared to those with the CSBD label and whether or not this might at the same time even increase the experience of moral incongruence and thus rather worsen the situation for patients 3 . So what therapeutic implications are drawn from using the term “addiction”, especially when it comes to evaluating and refraining from certain sexual behaviors? Would it mean abstinence or controlled consumption? If so, for whom, from what, how, for how long?
(2) To our knowledge, there have been no prospective cohort studies on the development and course of CSBD. However, according to clinical experience (Briken & Basdekis-Jozsa, 2010), affected individuals may present at different stages of CSBD. For example, 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 development 4 . Figure 1 illustrates how this might lead to an “addictive like” symptomatology with aspects of impulsivity, compulsivity, and addiction.
Illustration of the relationship between impulsivity, compulsivity, positive and negative reinforcement in the development of an addictive like symptomatology in persons with CSBD
Citation: Journal of Behavioral Addictions 11, 2; 10.1556/2006.2022.00026
Illustration of the relationship between impulsivity, compulsivity, positive and negative reinforcement in the development of an addictive like symptomatology in persons with CSBD
Citation: Journal of Behavioral Addictions 11, 2; 10.1556/2006.2022.00026
Illustration of the relationship between impulsivity, compulsivity, positive and negative reinforcement in the development of an addictive like symptomatology in persons with CSBD
Citation: Journal of Behavioral Addictions 11, 2; 10.1556/2006.2022.00026
The so far different conceptions and research findings could therefore also be strongly influenced by the precise timepoint during the course of CSBD at which someone is investigated or assessed. Especially, Sassover and Weinstein's paper (2022) also points out that up to date the core criteria of tolerance development and withdrawal symptoms are far from being investigated systematically or rigorously in studies on CSBD. The role and the importance of positive and negative reinforcement, tolerance and withdrawal symptoms also for therapy and outcome should be studied in the future, if the question of impulsivity, compulsivity or addiction is to be further clarified.
(3) What is probably most striking to sex researchers and sexual health professionals with their typical bias (see under 1) is that no specific role is assigned to “Sexual” at all regarding CSBD in the three papers under debate. Sexual behavior is different from substance use and gambling for many reasons. It takes place under different moral and cultural conditions and other forms of shame are relevant. Many aspects of sexuality are therefore particularly difficult to assess for the investigator. When we realize that many individuals with CSBD have had sexual abuse experiences in the past (e.g. Slavin et al., 2020), it raises the question of what it will mean for these persons to be labeled as “sexually addicted” . If sexuality serves as a coping mechanism on the one hand but perhaps also as self-harm on the other, how do we do justice to this heterogeneous aspect of symptomatology in research? How do forms of solo sex in CSBD, e.g. collecting pornography with or also without masturbation, differ from sexual behaviors with others? When is a behavior “sexual” at all? 5
We also need the perspective of sexual health experts, and we must consider that the World Health Organization and the ICD-11 have a global perspective on public and sexual health relevant problems and therefore the diagnostic categories should also be suitable for countries beyond Europe or North America.
From the perspective of sex research - and the table in the paper of Sassover and Weinstein points this out particularly well - the Dual Control Model offers the most theoretically sound starting point, which can also be used particularly well empirically and clinically in work with patients. Briken (2020) makes a proposal for this in his integrative approach on the assessment and treatment of CSBD. Treatment should help patients to develop intimacy, healthy and positive sexuality (Munns et al., 2020).
The guidelines for CSBD are very detailed and precise 6 . Most aspects mentioned critically are considered if one looks at the detailed description of the guidelines (https://gcp.network/). They offer an opportunity for research and patient care that goes far beyond previous conceptions. This is probably the main reason explaining the significant increase in research efforts by working groups that were previously less or not active in the field. That's great. At this point, this commentary should be seen as a plea for continued fruitful exchange between disciplines, which is entering a new phase in the process of scientific debate with the new diagnostic category.
Funding sources
This work has not been supported by any funding.
Authors' contribution
PB developed the first draft of the manuscript, DT provided significant input for the subsequent versions. Both authors agreed on the final version.
Conflict of interest
Peer Briken was an advisor to the WHO with regard to the classification of sexual disorders in ICD-11. All views expressed in this article represent the view of its authors and do not represent the official policy or position of the WHO. Daniel Turner declares that no conflict of interest exists.
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contrary to what Gola et al. (2022) stated, a paraphilic disorder is not an exclusion criterion for a CSBD diagnosis; if the diagnostic requirements of both CSBD and a paraphilic disorder are met, both diagnoses may be assigned.
Brand et al. (2022) “The diagnosis of compulsive sexual behavior disorder may fit for individuals who not only use pornography addictively, but who also suffer from other non-pornography-related compulsive sexual behaviors. The diagnosis of pornography-use disorder as other specified disorder due to addictive behaviors may be more adequate for individuals who exclusively suffer from poorly controlled pornography viewing (in most cases accompanied by masturbation).”
The theoretical model of moral incongruence should not (Gola et al., 2022) be equated with the guidelines that say: “Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviors is not sufficient to meet this requirement.” This follows the idea that a sole sex negative or pornography rejecting (e.g. moral or religious) attitude alone cannot qualify for a psychiatric diagnosis.
The sexual behavior is also rewarding to the person in the short-term, despite longer-term harm either to the individual or to others.
Contrary to the statement by Gola et al. (2022) please note that under Additional Clinical Features the ICD-11 guidelines say that CSBD may be expressed in a variety of behaviors, including sexual behavior with others, masturbation, use of pornography, cybersex (Internet sex), telephone sex, and other forms.
It is not correct that the guidelines for CSBD do not consider factors like substance use or mania (Gola et al. 2022). The guidelines state that CSBD symptomatology is not better accounted for by another mental disorder (e.g., Manic Episode) or other medical condition and is not due to the effects of a substance or medication.
