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.
Much of my frustration and anger stems from the fact that the Masters and PhD level clinicians who are seeing and treating sexually addicted clients on a regular basis had very little input in the APA’s decision-making process. In fact, the organization’s procedure for deciding on diagnoses and potential diagnoses appeared from the outset to be insular and more weighted toward biology and medication management than genuinely intended to assist the thousands of active, in-the-field clinicians who regularly see, diagnose, and treat real-world individuals with real-life problems.
Does the field of sexual addiction require more research before Hypersexual Disorder is included in the DSM as a standalone diagnosis? Yes, absolutely. I have written about this need for research in numerous articles, blogs, and social media posts over the past several years. Even the author of the proposed diagnosis, Dr. Marty Kafka of Harvard, agrees that Hypersexual Disorder requires a great deal more tier one, peer reviewed research before full inclusion. (We particularly need more research on female sex addicts.) Unfortunately, the APA’s decision to completely exclude Hypersexual Disorder from the DSM-5 means there is no formal avenue for that research to take place, as funding for NIH and University based studies is driven in large part by the language that appears (and doesn’t appear) in the DSM – especially in the “potential diagnoses in need of further research” section of the Appendix. So the APA formally requested a literature review and diagnostic proposal, chose not to include the proposed diagnosis because there was not enough research to support (or deny) it, and then followed up by not providing an avenue for future research. To me, this makes no sense.
Sadly, our professional “leaders,” the men and women who create and approve the DSM, appear to be socially, politically, and perhaps even morally behind the times. Their lack of action mirrors the organization’s tendency to avoid “pushing the envelope” in any meaningful way. This conservatism stems in part from the APA membership’s growing lack of involvement in the day-to-day, real-world challenges that people face in the digital age. So the practicing therapeutic community is left with an exceedingly difficult challenge: How are we to effectively diagnose and treat the people who walk into our offices on a daily basis seeking help for self-reported, problematic patterns of compulsive sexual behavior?
Oddly, the APA’s decision arises at a time when the general public and the media have come to recognize and accept sexual addiction and (to a lesser degree) romantic addiction as genuine, seriously destructive issues – every bit as real and debilitating as alcoholism, compulsive gambling, and drug addiction. At the same time, avenues toward the development, maintenance, and escalation of sex and love addiction are increasing by the minute. Every new technological advance, it seems, can be utilized for its intended purpose… and also for sex. The simple, undeniable fact is the tech-connect boom has greatly increased the average person’s ability to anonymously and affordably access intensely stimulating sexual imagery (pornography), to engage in an almost unfathomable array of virtual sexual experiences (webcams, teledildonics, alternate reality sex games, etc.), and to instantly geo-locate, contact, and hook-up with casual, anonymous, and paid-for sexual partners. While this is not problematic for the majority – similar to drinking alcohol or gambling – some people are truly lost in this sexual quagmire. And thanks to the APA’s continued ignorance – be it feigned or willful – we have no way to accurately assess and diagnose these individuals, as apparently their problems don’t exist.
Consider the following client:
Zach is a 25-year-old graduate student. He has been viewing hardcore pornography online daily since he was 11 years old. He entered therapy because he has little to no interest in relationship-based sexual or intimate experiences. In fact, the only in-the-flesh encounters that seem to turn him on are the anonymous encounters he sets up using his smartphone sex locater apps (Blendr, Skout, and Ashley Madison). Even this type of sex is becoming less and less fulfilling. He says that what he really wants is to date a girl seriously and eventually get married, but every time he tries to do that he finds himself fearful of relationship intimacy and unable to perform sexually. So he returns to online porn and anonymous hookups. Now he is depressed, anxious, and self-loathing because he can’t date, can’t mate, and can’t create the type of family unit he desperately desires (and deserves).
What is a therapist supposed to tell this man? How can we diagnose him? Certainly we can say that he is depressed and suffering from anxiety and low self-esteem, but these issues are symptoms of the underlying problem (sexual addiction) rather than the problem itself. For as long as his compulsive sexual behaviors continue, so too will his depression, anxiety, and self-hatred – along with his inability to develop and implement adult intimate attachment skills. Assessing and treating (using past diagnostic labels) a sexually addicted client’s concomitant symptoms is, at best, a stopgap measure that will not in any meaningful way lead him toward long-term emotional and psychological health.
So I ask the APA, what are we to tell Zach and the tens of thousands of other clients who present with similar sexual and romantic issues? What tools have you offered to those of us actively working in the mental health treatment field? We, the lowly Masters and PhD level therapists – the individuals who perform 80% or more of the hands-on mental health and addiction treatment work in this country – have real, live, suffering individuals to help, yet you, our leadership, have presented us with a painfully inadequate toolbox with which to work. Even worse, your lack of action indirectly perpetuates the harmful labels that many in our society attach to the unfortunate people who compulsively engage in problematic sexual behaviors. We brand these individuals as sluts, nymphos, and perverts – much as we used to call alcoholics bums and drug addicts degenerates – which only serves to exacerbate the anxiety, depression, and other psychological conditions that accompany and drive sexual addiction. Perhaps it is time for MDs to step aside as the sole decision makers in this area, allowing the clinicians providing treatment to the “working well” to help define the problems we treat.