The recently published book Compulsive Sexual Behavior Disorder: Understanding, Assessment, and Treatment reviews the controversial diagnosis of compulsive sexual behavior disorder (CSBD). With the inclusion of CSBD in the International Classification of Diseases, 11th revision (ICD-11), which went into effect in January 2022, the book is a timely contribution to the literature for both general and forensic audiences.
The book comprises 12 chapters. It opens with an introductory chapter by editors Richard Balon, MD, and Peer Briken, MD, who familiarize readers with the controversy around the adoption of the CSBD diagnosis and the uncertainty about how best to classify its etiology. The book then offers chapters on various topics related to CSBD, including its etiological overlap with substance and other behavioral addictions (Chapter 2), clinical evaluation (Chapter 6), pharmacotherapy (Chapter 7), psychotherapy (Chapter 8), and its manifestation in women (Chapter 9). The content, at times, is self-referential, with many of its authors highlighted in the various studies cited throughout the text. This format underscores that the book is a collection authored by persons who are heavily involved in guiding the exploration of this topic. Included among its authors are members of the American Academy of Psychiatry and the Law as well as the broader international forensic community. Such a collaboration is welcome considering the differential acceptance of the diagnosis in America and abroad.
Regarding structure, the chapters within the book are brief, making the collection accessible and easy to read in a short amount of time. The content is engaging, and the use of vignettes throughout the book helps consolidate the material for readers. The text, however, often reads as one extended literature review with studies described in rapid succession. Although this is likely helpful for the forensic or research audience who may wish to explore these studies further and desire a thorough understanding of the current state of the literature, this approach may be daunting for the average practitioner seeking clinical pearls and guidance. The various chapters all generally start by recapitulating the definition of the ICD-11 diagnosis of CSBD. If one is to read the book cover-to-cover in a brief amount of time (which is a reasonable feat given its length), this redundancy is noticeable and tedious. This structure gives the book a quality that each chapter is siloed from the others, rather than working in concert to build upon itself. For a casual reader who might reference one chapter at a time, however, such a reintroduction allows the chapters to stand on their own.
The editors are uniquely qualified to offer the end product. Dr. Peer Briken is a forensic clinician and researcher based primarily in Hamburg, Germany. He is the Director of the Institute for Sex Research and Forensic Psychiatry in Hamburg, an organization that evaluates and treats sexual offenders on an outpatient basis. Dr. Briken is also at the forefront of research on the pharmacological treatment of sexual offenders. Dr. Briken’s background thus makes his contribution, both as chapter author and editor, an obvious choice, as he is well versed in the questions raised by the authors of DSM-5 on the proposed diagnosis of Huntington’s disease as well as the benefits and limits of our current pharmacological offerings for those with sexual paraphilias and compulsive sexual behavior. Dr. Richard Balon holds professorships in the Departments of Psychiatry and Behavioral Neurology as well as Anesthesiology at Wayne State University School of Medicine in Detroit, Michigan. He has authored articles and books on the effects of cannabis and antidepressants on sexual experience and articles on sexual dysfunction, medical student and resident education, and pharmacology. He is a seasoned editor, having served on multiple editorial boards including FOCUS, Psychiatric Times, Journal of Clinical Psychiatry, Journal of Sex and Marital Therapy, and Academic Psychiatry.
The subject of the book, CSBD, is an important one for forensic audiences involved in criminal evaluations. Throughout the book, the authors repeatedly allude to the DSM-5 authors’ concerns of the potential misuse of the diagnosis by the court system. This concern is well-founded in a society where sexual crimes are considered particularly abhorrent and the legal system allows for the civil commitment of sexual offenders, as well as their continuous monitoring in the community. This is not the only concern, but is certainly the most relevant and specific to the field of forensic psychiatry, as forensic clinicians will not only need to navigate the education of the court system on this topic but will also be called upon to negotiate the ramifications of its use.
The fact that ICD-11 has made the decision to include CSBD provides a more grounded definition by which researchers and clinicians can start to diagnose patients. It is an important step for patients who are struggling with symptoms of CSBD and seek to better understand their condition. But it leaves the American forensic community on unsteady ground. Brad Booth, MD (Chair of the AAPL Sexual Offender Committee) and colleagues point out in their chapter on forensic aspects of CSBD (Chapter 10), that the state of research on CSBD is in its infancy, which raises concerns about its admissibility in the American court system. On the other hand, the vignettes in the book (and my own experience), suggest that cases do arise in which such a diagnosis should at least be considered; what to do beyond that consideration remains unclear.
Ultimately, this book is an excellent place to start for forensic clinicians who wish to rapidly immerse themselves in the literature. By no means, however, should it serve as the only education on the topic. Forensic clinicians, particularly those who are involved in the adjudication of sexual offenses, should be watchful of literature which, hopefully, will expand more rapidly with a formal diagnosis now presented and adopted.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
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