It’s not exactly a clinical secret that most of the sex addicts who enter therapy do so in response to their addiction’s related symptoms—disintegrating relationships, depression, severe anxiety, inability to focus at work or in school, social isolation, and the like. Rarely do these individuals walk in the door say, “You know, I think maybe I’m a sex addict, and that’s probably the first thing I need to deal with.” Instead, sex addicts will tell you that they’re unhappy, and that they’re having a variety of life and relationship problems. In my previous blog I discussed the fact that therapists should always ask at least a few specific but non-graphic questions about sexual activity during assessment in an effort to unearth sex-related issues. These questions may include the following:
Led by Dr. Valerie Voon, a group of researchers at the University of Cambridge (UK) recently published a detailed fMRI study showing that the brain activity in sex addicts, when they are shown pornography, mirrors the brain activity in drug addicts when they are exposed to drug-related imagery. This study strongly suggests that sexual addiction not only exists, but in fact manifests in profoundly similar ways to other more readily accepted forms of addiction like alcoholism, drug addiction, and Internet addiction.
A few weeks ago, after writing and publishing a blog titled “Treating Sexual Addiction” on the Counselor Magazine website, links to this fairly brief article made its way into various LinkedIn forums, including the Professional Sexology group (1,700 members), a forum that leans heavily toward the “sex addiction is a myth” school of thought. Generally, in virtual professional forums I am willing to answer questions, but I try to avoid ruffling feathers. As such, I typically don’t post about sex addiction in the groups that don’t want to hear about it (such as Professional Sexology). That said, I do believe an occasional debate is good for everyone involved—and we certainly have had (and are still having) a good one in the Professional Sexology forum. So far, the link to my little Counselor Magazine blog has received well over 100 comments, with more appearing every day. When I printed this material out, I was shocked to see that it had generated more than 30 single-spaced pages of commentary.
In a nationally distributed, recently published study a group of researchers argued that what is often called “sexual addiction” or “sexual compulsivity” could be better understood as a pathological variation of “high sexual desire.” After the publication of this article, released with great fanfare to the broadcast and print media, a multitude of media outlets suggested that the conclusions of this study demonstrate that there is no scientific basis for the diagnosis of sexual addiction. This response occurred despite the study being the first of its kind, riddled with methodological errors, and at best inconclusive. Nevertheless, the research has garnered a great deal of media attention, most likely because it addresses volitional problematic human sexual behavior, which is always a media attention -grabber (former US Congressman Anthony Weiner, former San Diego Mayor Bob Filner, etc.)
As an addiction and sexual disorders specialist, I often write about sexual addiction. As most readers are “psychologically minded” in venues like this one, I typically assume that you already understand what that term means and does not mean. Nevertheless, it seems like a good idea to at least occasionally state what sexual addiction – aka, sexual compulsion, hypersexuality, hypersexual disorder, etc. – means to those of us who treat it. To that end I have provided below a brief overview of what sexual addiction is and is not.
My last three blogs have been about sexual offending. Frankly, after completing the series I’d hoped to move on to lighter topics. Unfortunately, the recent situation in Ohio – Ariel Castro allegedly kidnapping and repeatedly raping and torturing three young women for more than a decade – requires comment, particularly in light of Castro’s statement to police that he is a “cold blooded sex addict,” along with his reference to sexual addiction in an attempted suicide note.
Last week we learned that the proposed diagnosis of Hypersexual Disorder, more commonly known as sexual addiction, would not be included as a criteria-based diagnosis in the forthcoming DSM-5. As I have written previously, I did not expect Hypersexual Disorder to “make it” into the DSM-5 as a standalone diagnosis. I did, however, expect it to be listed in the Appendix of next spring’s publication as a potential diagnosis requiring further research. Lamentably, the APA apparently lacks the political will to even consider the idea that consensual sexual behavior, for some people, can be problematic. Frankly, the organization’s decision has left me (and a whole lot of other highly trained, eminently reasonable, forward-thinking mental health and addiction professionals) feeling frustrated, disappointed, and downright angry.
What the Heck is a Paraphiliac?
Within the therapeutic community there is considerable confusion as to what constitutes sexual addiction, what constitutes paraphilic behavior, and what constitutes sexual offending. In part this is caused by our collective inability as sexual addiction professionals, sex therapists, and sex offender treatment providers to engage in useful, integrated discourse, perform research, create conferences, and most of all to work together. Complicating matters is the APA’s lamentable inability/unwillingness (so far) to provide diagnostic criteria defining Hypersexual Disorder (sexual addiction), despite the way our twenty year tech-connect boom has dramatically increased the average person’s ability to affordably and anonymously access endless amounts of highly graphic pornography, casual sex, online prostitution, and information about and/or depictions of fetishistic and illegal sexual behaviors. As those of us working in the field are well aware, this proliferation of access has led to and/or escalated problematic sexual behavior – be it addictive, paraphilic, illegal, or some combination thereof – in numerous individuals with pre-existing addictive or other psychological disorders such as social inhibition, profound childhood or adult trauma, depression, anxiety, etc.
The proposed Hypersexual Disorder diagnosis now being considered by the APA for inclusion in the forthcoming DSM-5 has generated a great deal of heat in the therapeutic community. And frankly, there should always be significant dialog before any form of inherently healthy human behavior (eating, sleeping, sex, etc.) is clinically designated as pathological. After all, the power to “label” must always be carefully wielded to avoid turning social, religious, or moral judgments into clinical diagnoses (as occurred with homosexuality in the DSM-I and DSM-II). That said, equal care must be taken to not avoid researching and creating diagnostic criteria for such behaviors when they go awry. To that end, Dr. Marty Kafka of Harvard proposed a definition for Hypersexual Disorder to the DSM’s Workgroup on Sexual and Gender Identity Disorders, and a UCLA-led group of researchers embarked on a major study of the proposed criteria’s viability—the results of which are published in full in the October 2012 issue of The Journal of Sexual Medicine.[i]
Over the past several months I have been writing blogs for Psych Central that extensively explain the DSM-5 Hypersexuality Diagnosis and the concept of sexual addiction. I have written about the basics of what it means to be a sex addict, how sex addicts can (like someone with an eating disorder) achieve “sobriety,” and the great effect technology is having on those with impulsive and compulsive sexual problems. These blogs have generated a great deal of discussion among clinicians in the multiple forums and groups where they have been posted around the globe. One of the more emphatic threads of comment I often receive is a judgment of sorts—that those who recognize sexual addiction as a treatable disorder must somehow be “sex negative,” that those who acknowledge and treat sexual addiction somehow believe that anyone who engages in ego-dystonic sexual behavior or enjoys sexual proclivities that do not mirror the larger culture’s values is a sex addict. This is not the case. In fact, nearly all sexual addiction specialists readily acknowledge that most of the vast range of human sexual behavior is neither problematic nor evidence of an addiction.