At least once a month Jordan Rullo has someone come into her Salt Lake City counseling office emphatically stating they're a porn addict.
Rullo, a board-certified clinical health psychologist and sex therapist, will start a thorough 90-minute assessment and ask them about their viewing habits.
They'll sheepishly report they watch porn once a week for 20 minutes at a time.
Then she'll ask them how often they view television.
Every day, they say, for a few hours after work.
"But you're not a TV addict?" she says.
"It is quite common for this moral piece to come in, where they're beating themselves up so much for this once-a-week, 20-minutes-at-a-time (behavior)," she said. "Is that really an addiction or moral distress that has become unbearable?"
That question is at the heart of a new diagnostic code added to the World Health Organization's International Statistical Classification of Diseases and Related Health Problems — a move intended to get help for those who need it, and redirect those who may be tempted to misapply it.
The latest version of the classifications added "compulsive sexual behavior disorder" to the 55,000 unique codes for injuries, diseases and causes of death, allowing "health professionals to share health information across the globe," according to the WHO. The updates will be reviewed and presented to the World Health Assembly in May 2019, and come into official use January 2022.
Although the disorder hasn't yet been added to the Diagnostic and Statistical Manual of Mental Disorders — the primary handbook used for mental health diagnoses in the United States — for certified sex addiction therapists like Stefanie Carnes, president of the International Institute for Trauma and Addiction Professionals, getting any official diagnosis is a "watershed moment" for the field, validating decades of work.
But for therapists on the other side of the issue, such as those in the American Association of Sexuality Educators, Counselors and Therapists, of which Rullo is a part, the diagnosis is premature at best and pathologizing at worst.
"Not everybody is on board," acknowledged Shane Kraus, director of the Behavioral Addictions Clinic at the Edith Nourse Rogers Memorial Veterans Hospital and part of the WHO working committee that crafted the diagnostic proposal.
"There are people who say behaviors can be pathological, some people say, it's truly an addiction — we're still trying to figure it out," he said. "This proposal is the best fit, I think, to try to move forward in a way that’s meaningful, that would engage and allow people to seek treatment and reduce stigma."
Just like an addiction
The new code indicates someone might have "compulsive sexual behavior disorder" if their behavior has caused "marked stress or significant impairment" for at least six months.
Maybe they're viewing porn, visiting sexual chat rooms or paying prostitutes so often they've stopped engaging in other activities. Perhaps they've tried to stop and can't, or they keep doing it despite negative consequences or failing to enjoy it.
"The general public will forever call (that) sex addiction," Carnes says, who embraces the term in her professional work.
Robert Weiss uses the term "sexual addiction" more than "compulsive sexual behavior" in his work as a licensed clinical social worker and certified sex addiction therapist, because that's the language his clients use, but to him, the labels are interchangeable.
"The behavior is the same regardless of what we call it," he said. "Alcoholism by any other name is still alcoholism. Sex addiction, by any other name, is still sex addiction."
But the international classification working committee deliberately didn't use the word addiction in the new diagnosis, nor did it place it in the addictive behaviors category. Instead, the committee took a "relatively conservative position," and kept it in the impulsive behaviors category, noting that it may evolve as research continues.
That may not mean much for struggling people who feel caught in a "tug-of-war of dialogue and semantics," says Dan Gray, a licensed clinical social worker and certified sex addiction therapist, as well as clinical director and co-founder of LifeStar, a Salt Lake-based therapy program and network.
"(People are) too worried, and sometimes therapists are too concerned about trying to label it accurately," Gray said. "But diagnoses are tricky … because the brain is this vast universe that is so complex and we're just dealing with symptoms."
Having a diagnosis may help people feel validated, but it's also crucial for billing insurance companies for treatment costs — and there's no indication yet of whether this new diagnostic code will be accepted, experts say.
That doesn't bother Rod Jeppsen, a clinical mental health counselor and a certified sex addiction therapist who practices in South Jordan and sees a significant number of self-pay clients, who don't need to worry about insurance codes.
"It really doesn't matter what's in the manual, what the diagnosis is, whether you file a claim or not," said Jeppsen. "At the end of the day, you've got a human being across from you, how are you going to help them?"
Deeper issues at play
For therapists on the other side of this issue, the best way to help someone is not to make them a victim by telling them they're addicted. Instead, they prefer using words like "hypersexuality," or "out-of-control sexual behavior."
The word "addiction" has been tossed around so cavalierly in society that it has become a verbal placeholder to mean that someone is doing something more than they want to — but that doesn't mean it's a disorder, says Joshua Grubbs, an assistant professor of psychology at Bowling Green State University who studies the psychologies of religion and spirituality, human sexuality and addiction.
Rather than labeling sexual behavior or porn use as the ultimate problem, Grubbs says he considers those behaviors warning signs, much like a stomachache. The pain itself is not a diagnosis, but requires further questioning and tests. Is it an ulcer? Stomach cancer? Indigestion? Appendicitis?
"Having problems with porn doesn't tell me you have an addiction," says Grubbs. "We need to investigate further."
Maybe the underlying issue is unaddressed anxiety or depression or even undiagnosed attention deficit or bipolar disorder.
"I've been at this for a long time, and I have never seen a man or a woman who was having this level of sexual behavioral problems and didn’t have other issues going on in their life," said David Ley, clinical psychologist and critic of the sex addiction label.
The international classification working committee indicated that other mental health factors should be considered and ruled out before the new compulsive sexual behavior diagnosis can be applied.
But sex is sexy, says Ley, which means sex problems often get more attention than mental health problems, often leading people to incorrectly self-diagnose.
Religion and porn
The people most likely to label themselves as "addicts" are those who are highly religious, where any sexual misbehavior clashes with their beliefs and creates jarring moral incongruence.
A recent Gallup poll found that 43 percent of Americans say pornography is morally acceptable — the highest percent since Gallup began measuring this in 2011.
Yet, of Americans who say religion is very important, only 22 percent morally condone pornography, compared to the 76 percent who say religion is not very important.
Another recent nationally representative survey by Grubbs found that nearly 11 percent of men and 3 percent of women agreed at least somewhat with the statement that "I am addicted to pornography."
After accounting for all other factors, researchers found that the greater the feelings of moral incongruence, the greater the likelihood of feeling addicted.
"I'm not saying porn addiction is not real, or that it is real," said Grubbs. "Rather, I'm trying to say that we need nuance in how we talk about it. We're trying to frame it in terms of what the science and data show us and correctly label what is a problem, not moral hysteria."
Because of this, the ICD-11 working group deliberately included a final caveat in the new diagnosis: "Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement."
That means that someone's wife, parent or pastor cannot demand a professional diagnosis just because they disagree with or disapprove of the behavior.
It also means that someone who feels moral distress over their sexual behavior but can't demonstrate ICD-11 listed factors, may not need a diagnosis, but "it doesn't mean the person is not having a problem," said Meg Kaplan, associate clinical professor of psychology in psychiatry in the department of psychiatry at Columbia University.
That person may still need help, but experts like Rullo say those interventions may not focus on breaking an addiction, but rather helping someone understand their personal sex drive, and staying true to their core sexual values — whether that means engaging only in consensual, non-exploitative sex or not using sex or porn as a way to cope with difficult feelings.
"Despite my mixed feelings about this (new diagnosis), people come into my office with these concerns and feeling like their sexual behaviors are out of control," said Rullo. "Something exists, whether we call it a disorder or not, (it's) something ... that people need help with."