In the world of sex therapy, there is no consensus on what constitutes a sex addict.

On one end of the spectrum are people—usually men—who believe they might be sex addicts because they masturbate a couple times a week.

And then there are people like Josh, a 44-year-old retired military officer from California who couldn’t stop flirting with women online. These digital dalliances sometimes developed into in-the-flesh flings. Ultimately, Josh contracted herpes and infected his wife. As part of his therapy, he told her everything. Now, their marriage is on the rocks, and he fears he will lose the love of his life.

“She hasn’t said it in a long time—that she loves me,” the father of four told The Daily Beast.

Are both examples illustrations of sex addiction?

Answers from therapists vary wildly. And for now, nobody is right and nobody is wrong, as there is no standardized “sex addiction” diagnosis.

This could soon change, and a bitter battle is raging behind the scenes over whether it should change.

Although the concept of sex addiction gets an occasional profile boost from celebrity scandals of the sort that ruined the marriages of Tiger Woods, Anthony Weiner, and David Duchovny, it has never been fully accepted by the mental health establishment.

In 2010, there was a push to add “sex addiction” to the American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The idea was rejected. (Known as the DSM-5, the manual is considered the Bible of the U.S. psychiatry.) In 2012, another effort to add “hypersexual disorder” to the DSM-5 also failed, in part due to insufficient scientific evidence.

But things might be looking up for sex-addiction therapists who feel dismissed. The World Health Organization (WHO) has been quietly reviewing a proposal to add “sex addiction” to the International Classification of Diseases (ICD). Considered an industry-standard diagnostic tool like the DSM, the ICD is used for epidemiology, health management, and clinical purposes. But while the DSM applies to the United States, the ICD is international.

If WHO opts to add the new diagnosis—which is listed as “compulsive sexual behavior disorder”—to the ICD’s 11 th edition in 2018, the change could augur inclusion in the DSM. (The ICD proposal says the term can also be referred to as “sex addiction.”)

The debate could lead to real consequences for people who feel tortured by their own sexual behavior.

At present, sex addiction is considered a disease of privilege: Because it isn’t in the DSM, insurance companies deny coverage, meaning the expensive treatment tends to be available primarily to the affluent. Although listing “sex addiction” on the ICD wouldn’t immediately open the floodgates for billable coverage, it would crack open the door, said Stefanie Carnes, a certified sex-addiction therapist.

“People will be able to start advocating for insurance coverage as they do for substance use disorders (such as alcoholism) and other mental health problems,” she said.

More importantly, she added, “not having a diagnosis perpetuates the shame around the illness, affecting many, many people who end up feeling misunderstood and like they cannot share their ‘horrible’ and ‘weird’ secret with anyone.”

To skeptics of the concept of sex addiction, enabling therapists to bill insurers for sex-addiction treatment is a nightmare scenario on par with enabling quack practitioners to bill insurers for diagnosing women with hysteria or prescribing frontal lobotomies.

“Essentially, inclusion of a diagnosis like this in the ICD would just create more confusion and chaos, and drag this already well-beaten dead horse farther down the road,” said David Ley, a clinical psychologist and the author of The Myth of Sex Addiction.

Ley added that it’s uncertain whether adding “sex addiction” to the ICD would affect insurance coverage.

“Insurance companies load diagnoses by ICD, but not all diagnoses in the ICD are eligible for reimbursement,” he said.

Ley and other skeptics point to studies concluding that neither sex nor porn has the addictive qualities of, say, heroin or cocaine. Many in this camp ascribe high sexual activity or frequent porn viewing simply to high sex drive. They accuse their adversaries of profiteering off of people’s sexual shame, and of trying to roll back decades of social progress in the arena of sexual health by pathologizing masturbation, high sex drive, homosexuality, fantasies, bondage sex, and other unconventional sexual proclivities.

Doug Braun-Harvey, a sexual health author and psychotherapist, said the sex-addiction model lumps people involved with compulsive affairs or who masturbate for hours in front of a computer together with sexual predators.

“They are all in the same treatment programs, which I find irresponsible,” he said. “They are all called ‘sex addicts.’”

The sex- and porn-addiction believers include not only Carnes, but also Mormon anti-porn crusaders, an online Reddit forum with 250,000 subscribers who are trying to avoid porn and masturbation, and sex-addiction therapists.

This loose coalition often draws a distinction between sex addiction and porn addiction, but they generally agree that the inexorable rise of online pornography and dating apps has produced a groundswell of people—young and old, mostly male—who feel they’ve lost control of their ability to moderate their sexual behaviors.

“They’re getting arrested, they’re losing sleep, they are losing marriages,” said sex-addiction expert and author Rob Weiss. “And yet they say, ‘I don’t want to do this.’”

Both sides can point to peer-reviewed, credible studies to support their claims, underscoring how the science on this matter is far from settled.

The debate has, in some quarters, devolved far past the point of civility, and into the realm of all-out war.

Much of the strife revolves around a widely recognized sex researcher named Nicole Prause, whose high-profile studies in 2013 and 2015, conducted while she was at UCLA, landed like PR torpedoes on the controversial notion that sex or porn can be addictive like booze and drugs.

Prause, 38, has taken to Twitter to bad-mouth the nation’s largest training center for sex-addiction therapists, run by Stefanie Carnes. Called the International Institute for Trauma & Addiction Professionals (IITAP), the Arizona-based facility was founded by Carnes’ 73-year-old father—Patrick Carnes—who in the early ’80s coined the term “sex addiction” in his pioneering book Out of the Shadows.

IITAP, Prause has tweeted, needs to “stop supporting” therapists who practice gay-conversion therapy. She also accuses the institute of putting “profit over patients” and encouraging “sexism, stalking, and physically threatening scientists for profit.” She also charges that its screening tool for sex addicts is a “scam,” and it has a “racism problem.”

In April, Carnes struck back through her lawyer in the form of a cease-and-desist letter to Prause.

And Prause isn’t the only recipient of a legal threat from Carnes of IITAP, which represents 1,600 certified sex-addiction therapists.

Others include Joe Kort, a sexologist and former sex-addiction therapist who has defected, and who wrote a blog in late 2015 renouncing the sex-addiction model.

“I think it is... very harmful to gay and bisexual men,” Kort, who is gay, told The Daily Beast of the sex-addiction model. “It’s gotten a lot worse in the last five-to-seven years because it has gotten more religious. So they are looking at sex from a moral lens.”

Of the cease-and-desist letter, he added, “They scared me for a minute because anybody can sue you for anything and that’s a nightmare.”

Kort’s attorney responded with a stern letter asserting Kort’s freedom of speech. IITAP, which rejects the argument that sex-addiction therapy is harmful to the LGBT community, hasn’t contacted him since.

But Carnes isn’t the only one with a legal trigger finger.

Prause—who left UCLA and now operates her own lab, Liberos, in Santa Monica—has fired off at least five cease-and-desist letters through her attorney. Addressed to sex-addiction therapists and anti-porn bloggers, the letters demand that they stop spreading false rumors alleging that Prause has been funded by the porn industry, was fired from UCLA, has falsified her data, and—most salaciously—has appeared in porn herself. (UCLA officials have confirmed that Prause’s 2015 departure happened at the end of her contract and was not performance-related.)

While The Daily Beast wasn’t able to verify that all of these alleged rumors have indeed been circulating, some certainly have.

On a talk-radio show last year, for instance, Sen. Todd Weiler (R-UT) claimed that Prause’s 2015 UCLA study was “partially funded” by the pornography industry. Prause says the assertion is “dreamed out of whole cloth.”

Like many who butt heads with Prause, Weiler is Mormon, and often promotes research from Fight the New Drug, a Utah nonprofit founded by Mormons known for producing “Porn Kills Love” T-shirts and billboards. He has also succeeded in pushing a resolution through the Utah state legislature declaring porn a “public health hazard.”

Meanwhile, someone—Prause isn’t certain who—has filed a complaint about her to the California Board of Psychology in an apparent effort to revoke her psychology license. The board has opened an investigation. (Though she has a psychology license, Prause isn’t actively practicing.)

Then there’s anti-porn blogger Gary Wilson, who runs a website called Your Brain On Porn and wrote a book with the same title. He’s often quoted in news stories about the dangers of online porn, and has famously claimed that porn is fueling a rise in erectile dysfunction among young men—his TedX Talk on the topic has generated nearly 9 million views.

Wilson frequently critiques Prause’s studies on his website and also criticizes her in the comments sections of articles citing her work.

In turn, Prause has accused him on public forums of being a “stalker.”

“The author, Gary Wilson, is a stalker who has written my name on his website over 1,500 times,” she recently asserted in the comments section below an article about porn addiction. “He has multiple no-contact and cease and desist orders, most recently for stalking.”

Wilson says he has never initiated a single email exchange with Prause and knows of no no-contact order. She is trying, he said, to create a “mythology of herself as a victim... so that the content of the debate is ignored.”

Prause also points out that Wilson doesn’t have a college degree (a fact that he confirmed to The Daily Beast, though he did attend college for six years). “His pretending to represent science with no scientific training and fraudulent claims of expertise,” Prause says, “has led to a mass hysteria on par with the anti-vaccine movement.”

Despite her combative approach with critics, Prause has the support of many academics. Seven scientists and therapists have submitted letters to the California board in her defense.

University of Toronto sex researcher James Cantor praised Prause’s research as “top notch.”

“It is as rigorous as a scientist in this area really can get,” he said. “She is a central figure amongst top sex researchers.”

Ironically, Cantor disagrees with Prause on one big point: He believes “compulsive sexual behavior disorder” should be added to the ICD. He also believes that therapy for people in distress about their sexual behavior should be billable to insurance companies.

“The ultimate purpose—and it’s gotten so completely lost in the political discussions—the purpose of all of this is to help us help the patients,” he said. “Everybody has completely lost the point.”