פּראַמאָוטינג בילדונג, קלאַסאַפאַקיישאַן, באַהאַנדלונג, און פּאָליטיק ינישאַטיווז קאָמענטאַר אויף: קאָמפּולסיווע געשלעכט נאַטור דיסאָרדער אין די יקד-קסנומקס (קרוס עט על., קסנומקס)

לינק צו פּאַפּיר

Gola Mateusz

In an era of unfettered Internet access on mobile devices, such behaviors as pornography use, searching for paid sexual services, and casual sexual encounters (so called hook-ups) appear to have become more prevalent. Everyday common and clinical observations indicate that for some individuals, these new forms of sexual behaviors have become problematic and prompted treatment seeking (גאָלאַ, לעווקזוק, & סקאָרקאָ, 2016). Given such cases, terms such as “sex addiction” exist in the mass media and public discussion. However, despite the high social importance and interest in this phenomenon, compulsive sexual behaviors (CSBs) for years have arguably remained at the margin of systematic scientific investigation and psychiatric classification (קאַפקאַ, קסנומקס; Kraus, Voon, & Potenza, 2016; Potenza, Gola, Voon, Kor, & Kraus, 2017).

Decades of scientific and clinical discussions regarding CSBs, hypersexsuality, and sex addiction have generated multiple ideas, but in comparison to other psychiatric behaviors and disorders, relatively little data exist to test them (גאָלאַ & פּאָטענזאַ, 2018). On one hand, insufficient data may have hindered the inclusion of CSB disorder or related constructs [i.e., hypersexual disorder (קאַפקאַ, קסנומקס)] in the fifth edition of דיאַגנאָסטיק און סטאַטיסטיקאַל מאַנואַל פון גייַסטיק דיסאָרדערס (דסם-קסנומקס; American Psychiatric Association, 2013), despite the results of a DSM-5-related field trial of hypersexual disorder (ריד עט על., 2012). On the other hand, the absence of an official diagnostic entity with specified criteria may have hindered research, data collection, and educational efforts relating to CSBs. Fortunately, important recent advances in understanding significant facets of CSBs have occurred.

Kraus et al. (2018) described criteria for CSB disorder as proposed for inclusion in ICD-11. In our opinion, the World Health Organization’s decision for proposing CSB disorder for inclusion in the upcoming ICD-11 is a very important step from the perspective of individuals seeking treatment for CSBs; clinicians providing such treatment; researchers interested in studying this topic; and society raising questions and receiving answers, which should ultimately inform policy efforts. We would like to briefly present perspectives on these four areas and voice most important issues that we believe are worth future investigation.

For many individuals who experience persistent patterns of difficulty or failures in controlling intense, repetitive sexual impulses or urges that result in sexual behavior associated with marked distress or impairment in personal, family, social, educational, occupational, or other important areas of functioning, it is very important to be able to name and identify their problem. It is also important that care providers (i.e., clinicians and counselors) from whom individuals may seek help are familiar with CSBs. During our studies involving over 3,000 subjects seeking treatment for CSB, we have frequently heard that individuals suffering from CSB encounter multiple barriers during their seeking of help or in contact with clinicians (Dhuffar & Griffiths, 2016). Patients report that clinicians may avoid the topic, state that such problems do not exist, or suggest that one has a high sexual drive, and should accept it instead of treating (despite that for these individuals, the CSBs may feel ego-dystonic and lead to multiple negative consequences). We believe that well-defined criteria for CSB disorder will promote educational efforts including development of training programs on how to assess and treat individuals with symptoms of CSB disorder. We hope that such programs will become a part of clinical training for psychologists, psychiatrists, and other providers of mental health care services, as well as other care providers including primary care providers, such as generalist physicians. (emphasis added)

באַסיק פראגעס וועגן ווי בעסטער צו קאָנסעפּטואַליזע קסב דיסאָרדער און צושטעלן עפעקטיוו טריטמאַנץ זאָל זיין גערעדט. די קראַנט פאָרשלאָג פון קלאַסאַפייינג קסב דיסאָרדער ווי אַ שטופּ-קאָנטראָל דיסאָרדער איז קאָנטראָווערסיאַל ווי בייַטנ לויט דער ריי מאָדעלס זענען פארגעלייגט (Kor, Fogel, Reid, & Potenza, 2013). עס זענען דאַטן סאַגדזשעסטינג אַז קסב שאַרעס פילע פֿעיִקייטן מיט אַדיקשאַן (Kraus et al., 2016), אריינגערעכנט פריש דאַטן וועלכע וואקסן געוואקסן ריאַקטיוויטיוויטי פון שייַעך-שעדיקן מאַרך מקומות אין ענטפער צו קיוז פארבונדן מיט עראָטיש סטימיאַלייסאָרט, Snagowski, Laier, & Maderwald, 2016; Gola, Wordecha, Marchewka, & Sescousse, 2016; Gola עט על., 2017; Klucken, Wehrum-Osinsky, Schweckendiek, Kruse, & Stark, 2016; Voon et al., 2014). דערצו, פּרילימאַנערי דאַטע פֿאָרשלאָגן אַז נאַלטרעקסאָנע, אַ מעדאַקיישאַן מיט ינדאַקיישאַנז פֿאַר אַלקאָהאָל- און אָפּיאָיד-נוצן דיסאָרדערס, קען זיין נוציק פֿאַר באַהאַנדלונג קסבס (Kraus, Meshberg-Cohen, Martino, Quinones, & Potenza, 2015; Raymond, Grant, & Coleman, 2010). מיט רעספּעקט צו CSB דיסאָרדער ס פּראַפּאַגיישאַן קלאַסאַפאַקיישאַן ווי אַ ימפּאַלס-קאָנטראָל דיסאָרדער, עס זענען דאַטן סאַגדזשעסטינג אַז מענטשן זוכן באַהאַנדלונג פֿאַר איין פאָרעם פון קסב דיסאָרדער, פּראָבלעמאַטיק פּאָרנאַגראַפי נוצן, טאָן ניט אַנדערש זייַן אין טערמינען פון ימפּאַלסיוויטי פון די אַלגעמיינע באַפעלקערונג. זיי זענען אַנשטאָט דערלאנגט מיט געוואקסן דייַגעס (גאָלאַ, מיאַקאָשי, & סעסקאָוססע, 2015; Gola עט על., 2017), און פאַרמאַקאַלאַדזשיקאַל באַהאַנדלונג טאַרגעטינג דייַגעס סימפּטאָמס קען זיין נוציק אין רידוסינג עטלעכע קסב סימפּטאָמס (גאָלאַ & פּאָטענזאַ, 2016). בשעת עס קען נאָך נישט מעגלעך צו מאַכן די לעצט קאַנפעראַנסאַז וועגן קלאַסאַפאַקיישאַן, מער דאַטן ויסקומען צו שטיצן קלאַסאַפאַקיישאַן ווי אַ אַדיקטיוו דיסאָרדער אין קאַמפּערד מיט אַ שטופּ-קאָנטראָל דיסאָרדערKraus et al., 2016), און מער פאָרשונג איז דארף צו ונטערזוכן שייכות מיט אנדערע סייקיאַטריק טנאָים (Potenza עט על., 2017).

Like other psychiatric conditions, CSB disorder is likely heterogeneous with multiple contributory mechanisms. The form of CSB may represent an important factor to consider with respect to disorder heterogeneity. For example, distinctions may exist relating to participating predominantly in interpersonal sexual behaviors (e.g., risky casual sex with other people or paid sexual services) versus solitary behaviors (e.g., binge pornography use and masturbation; Efrati & Mikulincer, 2017). It is possible that the former may relate to high levels of impulsivity and sensation-seeking, and the latter may relate to high levels of anxiety, with each having different neural correlates as has been proposed for risky alcohol-use behaviors (Coleman, 1991, 2015; Gola עט על., 2015; Stark & Klucken, 2017); however, this possibility warrants direct examination.

Pharmacological and psychological treatment strategies for CSB disorder and possible subtypes should be examined. Currently, there are few systematic studies of CSB disorder, especially with consideration of potential subtypes like problematic pornography use. Such studies will need support from funding agencies (Potenza, Higuchi, & Brand, 2018). The study of non-substance or behavioral addictions like gambling disorder does not receive governmental support the way that disorders like mood, anxiety, psychotic substance use, and most other psychiatric do (Editorial, 2018). Given individual and public health concerns related to CSBs, we hope that governmental agencies and other stakeholders (including but not limited to producers and distributors of pornography, Internet providers, and digital device manufacturers) will support research into major questions related to the prevalence of CSB disorder and its subtypes, development of culturally informed and psychometrically validated screening and assessment instruments, potential impact of Internet pornography (particularly with respect to youth exposure and developmental trajectories), and identification of vulnerability factors that may place individuals at risk for problems with CSBs. These and other questions warrant attention to improve prevention, treatment, and policy efforts in order to promote sexual health at individual and societal levels. (emphasis added)

In our opinion, clear diagnostic criteria for CSB disorder as proposed for inclusion in ICD-11 set an important foundation for a long journey to address socially important questions. Addressing and answering such questions should provide an improved understanding of people suffering from and affected by those with CSB disorder and lead to improved sexual health for the general public.