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 Debate

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]

When All You Know How to Use Are Hammers, Doesn’t Everything Resemble a Nail?

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.

Will I Go Blind?

Of all the types of sexual acting out, compulsive masturbation, with or without pornography, is the most secretive and isolating—and also the most common (in both men and women). Because many individuals view sexual self-stimulation as shameful, dirty, or sinful, those who engage in the practice compulsively are unlikely to discuss it with others, even a therapist.

If and when a compulsive masturbator does seek help, he or she is unlikely to do so for his/her sexual acting out. Instead, that individual is far more likely to report anxiety, depression, feelings of loneliness and isolation, and the inability (or lack of desire) to form intimate relationships with other people.

Some people who masturbate compulsively do so as part of their daily routine. These are “morning, noon and night” people who masturbate on a regular schedule, almost like clockwork—when they wake up, before they go to bed, when they’re in a particular place, when some “thing” happens, or when they experience a certain (usually uncomfortable) feeling.

Other individuals are binge masturbators, “losing themselves” for hours or even days at a time, sometimes continuing to masturbate even after physically injuring their genitalia. Binge masturbation is occasionally accompanied by illicit drug use, usually stimulants like cocaine or crystal meth.

Binge masturbators can lock themselves in their home or a motel room for days on end, losing all track of time and life in the real world.

In David J. Ley’s recently published book, The Myth of Sex Addiction, Dr. Ley argues that the concept of sexual addiction is based on questionable research and subjective moral judgments. He believes that labeling problematic sexual behavior as addiction undermines the individual’s personal responsibility for that behavior.

He also believes that the sexual addiction treatment “industry” is driven by economic greed.

Sadly, sexual addiction is not a myth and the treatment “industry” is barely in its infancy. As a licensed sexual addiction specialist with over 20 years experience in the field of sex and intimacy, I have seen thousands of individuals whose sexual behaviors satisfy every criteria of addiction.

These individuals—both men and women—act on those sexual behaviors repeatedly and, once headed down that path, without the ability to stop. They also develop a tolerance to their sexual activities, most often causing them to engage in those behaviors for longer periods of time or to seek out more intensely arousing situations, images, etc.

To say that these people are not suffering from an addiction is to deny reality.

What is “Hypersexual Disorder”?

The American Psychiatric Association (APA), recognizing the increasing public and clinical acceptance of the concept of sexual addiction, has requested and received extensive Tier 1, peer reviewed research data, along with an exhaustive literature review (Shout out to Dr. Marty Kafka of Harvard!) toward its consideration of a potential DSM-5 Hypsersexuality Disorder diagnosis.

While “Hypersexual Disorder” may not be the ideal term for a problem that more accurately involves the lengthy search and pursuit of sexual and romantic intensity rather than just the sex act itself, the proposed criteria as written do point to problem patterns of excessive fantasy and urges that mirror most aspects of what we have come to know more commonly as “sexual addiction.”

Is Sex Addiction Real?

There will always be controversy – as there should be – when any form of inherently healthy human behavior such as eating, sleeping, or sex is clinically designated as pathological. And while the power to “label” must always be carefully wielded to avoid turning social, religious, or moral judgments into diagnoses (as was homosexuality in the DSM-I and DSM-II), equal care must be taken to not avoid researching and creating diagnostic criteria for healthy behaviors when they go awry due to underlying psychological deficits and trauma.

Pre-Internet sexual addiction research in the 1980s suggested that approximately 3 to 5 percent of the adult population struggled with some form of addictive sexual behavior. Those studied were a self-selected treatment group, mostly male, who complained of being “hooked” on magazine and video porn, multiple affairs, prostitution, old-fashioned phone sex, and similar behaviors.

More recent studies indicate that sexual addiction is both escalating and simultaneously becoming more evenly distributed among men and women. This escalation in problem sexual behavior appears to be directly related to the increasingly high-speed Internet access to both intensely stimulating graphic pornography and anonymous sexual partnering.

Today these connections are furnished not only through the use of home and laptop computers, but also via smart-phones and the related geo-locating mobile devices we now carry in our pockets and briefcases.

In the world of addiction treatment, there are two major areas of concern: addiction to substances, and addiction to patterns of behavior. Substance addictions involve abuse of and dependency upon chemicals such as alcohol, nicotine, prescription drugs, and illegal drugs like heroin and cocaine.

Behavioral addictions, often called “process” addictions, involve problematic repetitive behavior patterns involving potentially pleasurable or compulsive activities such as gambling, sex, working, spending, eating, etc. Some individuals struggle with both types of addiction simultaneously.

Sadly, the general public often mistakenly views process addictions as “moral flaws” or as “less serious” than substance addictions, yet those of us who treat these concerns directly witness firsthand the countless ways in which out-of-control impulsive, compulsive, and addictive behaviors wreak as much havoc on families, careers, and lives as drug addiction and alcoholism.

We also see that process addictions often contribute significantly to substance abuse relapse.