After more than twenty years spent treating, speaking about, and writing about sexual addiction, I’ve heard all the arguments (and then some) both in favor of and against utilizing an addiction-focused model of diagnosis and treatment to identify and help individuals who self-report repetitive, problematic patterns of impulsive and/or compulsive sexual behavior. For the most part, those who believe that sexual addiction (also known as sexual compulsivity and hypersexual disorder) is simply a myth tend to offer some combination of the five challenges presented below. I thought it might be both interesting and useful to examine the validity/reality of these concerns here.
Challenge Number One:
“Sex Addiction” is Sex Negative
This anti-sex addiction sentiment stems from a fear that sex addiction therapists are the new “sex police,” imposing moral, cultural, and/or religious values on sexuality, thereby creating a narrow version of sexual health. Apparently many highly educated sex therapists seem to think that specialists treating sex addiction will automatically label anyone who engages in forms of sexual expression outside the heterosexual/married/monogamous norm as sexually addicted, especially when it comes to pathologizing males who want to have lots of sex with lots of different people. One UK-based clinician wrote the following in a relatively recent LinkedIn discussion: “Using therapy to get people back into these norms and societal values turns therapy into a psychological police regime.”
To be perfectly honest, I agree with the stance described above. I cannot deny that there are moralist and highly religious therapists out there who routinely misapply the sex addiction diagnosis, using it to marginalize and pathologize sexual behaviors that don’t mesh with their personal and/or religious belief systems. Homosexuality, bisexuality, recreational porn use, casual sex, and fetishes – all of which are well within the spectrum of normal and healthy adult sexual behaviors – have all been misdiagnosed as sex addiction by these misguided clinicians.
In reality, sex addiction has nothing whatsoever to do with who or what it is that turns a person on. Instead, sexual addiction is about using the excitement and intensity of a potential sexual experience to emotionally numb out. In other words, sex addicts engage in their addictive patterns as a means of escape and dissociation from life stressors, emotional discomfort, and the pain of underlying psychological conditions such as depression, anxiety, attachment deficits, unresolved childhood or severe adult trauma, and the like. (This is the exact same reason that drug addicts use, compulsive spenders shop, and compulsive gamblers shoot craps.) When talking about sex addiction, whether a person is gay or straight or into bondage is irrelevant.
Challenge Number Two:
Sex Addiction is a Diagnosis Created to Lure Frightened People into Expensive, Unnecessary Treatment
In the same LinkedIn conversation referenced above, another anti-sex addiction therapist writes: “Sex addiction is a made-up term…used in treatment centers to bring patients in for inpatient, costly, long-term therapy. [We are being] duped by the huge addiction industry, which [is focused] on making money rather than helping patients.”
Well folks, breaking news here: Therapy is big business, no matter the specialty. People who treat depression get paid for it. People who treat anxiety get paid for it. People who treat early-life trauma get paid for it. And yes, people who treat extremely personal and painful addictions get paid for it. And it’s not as if the clinicians screaming the loudest about sex addiction treatment facilities and therapists making money are giving away their own professional services. Yes, therapy is a helping profession, and we choose it because we want to help people. And yes, some therapists and treatment centers offer a sliding scale for lower income clients. But at the end of the day, this is how we make our living – no matter our specialty. Furthermore, many thousands of self-identified sex addicts find help in 12-step and faith-based support groups, venues that provide support free of charge.
Challenge Number Three:
Sex Addiction is Simply an Excuse for Bad Behavior
Like challenge number one, this objection to sex addiction is legitimate – though also misappropriated. The simple truth is that a lot of people who get caught in some embarrassing or objectionable or illegal sexual behavior want to use sex addiction as a catch-all excuse, hoping to avoid or at least minimize the judgment and/or punishment they might experience. Sometimes these individuals really are sexually addicted, but just as often they are not. Either way, a diagnosis of sexual addiction is never intended to justify bad behavior or to let people off the hook for what they’ve done. Rather than providing an excuse or a justification, a sex addiction diagnosis provides an obligation to recognize the issue and to behave differently in the future. Under no circumstances are sex addicts absolved of responsibility for the problems their choices have caused. In fact, part of sex addiction recovery is admitting what you’ve done, accepting any consequences, and making amends as best you can.
Challenge Number Four:
Sex Addiction Does Not Meet the Accepted DSM Criteria for Addiction
In his book The Myth of Sex Addiction David Ley suggests that the medical field has traditionally classified a substance as addictive if its users demonstrate the following:
- Continued use despite consequences
- An inordinate amount of time and resources spent on obtaining, using, or recovering from use
Ley then argues that nobody experiences tolerance or withdrawal related to sex, and therefore sex can’t be an addiction. This argument is misguided on two fronts. First of all, there are eleven (rather than four) potential criteria for substance use disorders, and only two of those criteria need to be met for a diagnosis. These criteria include:
- Loss of control (substance often taken in larger amounts or over a longer period than intended)
- Unsuccessful efforts to cut down or quit
- Excessive time spent obtaining the substance, using the substance, and recovering from use
- Cravings (a strong desire to use the substance)
- Recurrent use resulting in failures to meet obligations at school, work, or home
- Continued use despite negative consequences
- Because of use, important social, occupational, or recreational activities are reduced or given up
- Recurrent use even when it is physically hazardous
- Recurrent use even when it causes or exacerbates physical or psychological problems
Again, only two of these eleven criteria need to be met to qualify for a substance use disorder diagnosis. So even though tolerance and withdrawal are two of the eleven potential signs of addiction, they are hardly definitive, and neither is necessary for a diagnosis.
This brings me to my second point, which is that sex addicts do experience both tolerance and withdrawal. (Tolerance occurs because the addict’s brain chemistry – mostly the dopamine rewards system – adjusts to continual use/abuse). Most of the time when tolerance sets in, addicts escalate their addictive behavior. For instance, drug addicts take more of their drug of choice and/or they switch to a stronger drug. In similar fashion, sex addicts increase the time they spend engaging in compulsive sexual activity and/or they increase the intensity of that activity (looking at more graphic versions of porn, engaging in dangerous sex, etc.) In other words, porn addicts don’t start out looking at porn four hours a night. They escalate to that level over time.
Sex addicts also experience withdrawal, most often evidenced by things like depression, anxiety, and irritability. Basically, because their dopaminergic system has been badly abused, they react with cravings for sex, depression, anhedonia, etc. These withdrawal symptoms are certainly less overtly physical than, say, the delirium tremens sometimes experienced by chronic alcoholics, but in truth only a small percentage of newly sober alcoholics experience physical symptoms that severe.
Challenge Number Five:
Sex Addiction is Not an Official DSM Diagnosis
Sadly, the American Psychiatric Association has chosen to not include sexual addiction in the DSM-5 – this despite the American Society of Addiction Medicine’s (ASAM) very clear recognition of behavioral addictions (including sex) as identifiable, diagnosable, and treatable. ASAM’s definition of addiction reads, in part:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. [Emphasis added.] Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response.
One relatively common objection to an official DSM sex addiction diagnosis is that we don’t know what constitutes “addictive” sexual behavior, and yet we are applying a label of pathology to that very same concept. In this vein I am often asked, “How much sex makes a person a sex addict?” I usually respond by asking, “How many drinks does it take to make an alcoholic?” Then I am sometimes asked, “What type of sex makes a person a sex addict?” To this I usually respond by asking, “What type of liquor makes a person an alcoholic?” The simple truth is that there’s no real answer to any of these questions. We don’t know how many drinks it takes to make an alcoholic, nor do we know why some alcoholics are beer drinkers while others guzzle bourbon. But this doesn’t prevent us from recognizing that alcoholism is a debilitating disorder. The same is true with amounts and types of sexuality. In reality, each individual responds to alcohol and/or sexual activity differently, and the criteria for addiction must be applied as such. If a person is preoccupied to the point of obsession, has tried to stop but can’t, and is experiencing negative life consequences as a result, then we’re talking about addiction – regardless of whether that person drinks six beers or twenty, and regardless of whether that person looks at porn for twenty minutes or six hours. It’s not the amount or type, it’s the effect.
Another common objection to a DSM diagnosis is that sexuality is a natural process that our bodies, brains, and behaviors are designed to pursue and enjoy. And in truth most people are able to be sexual in healthy, life-affirming ways. Similarly, people also need to eat, and the vast majority are able to do so in healthy and life-affirming ways. This does not, however, mean that eating disorders don’t exist. Nor does it mean that sexual addiction doesn’t exist. The fact that it is difficult for people who don’t suffer from these disorders to understand that others feel compelled to engage in these otherwise healthy activities to the point of pathology does not negate their existence.
Do I blame the APA for stalling on the inclusion of sexual addiction in the DSM? Yes. The APA’s primary decision-makers are an ivory-tower bunch terrified of change (no matter how desperately that change is needed). Yes, there will always we controversy and consternation – as well there should be – before any form of inherently life-affirming behavior (sex, eating, sleeping, and the like) is clinically designated as potentially pathological. In fact, it is absolutely correct to exercise caution in such matters so as to avoid turning social, religious, and moral judgments into psychiatric diagnoses (as occurred with homosexuality in the DSM-I and DSM-II, for instance).
At the same time, equal care must be taken to effectively address in a timely fashion the issues that do need to be dealt with, such as sexual addiction. The APA burying its collective head in the sand helps nobody. And this isn’t the first time the APA has been reluctant to accept change. For instance, it took them way longer than necessary to officially acknowledge alcoholism and drug addiction (now termed Substance Use Disorder). So did substance addiction not exist in the lengthy period prior to its inclusion in the DSM? Hardly. In similar fashion, the APA’s current refusal to officially acknowledge sex addiction does not mean it doesn’t exist, or that it’s not destroying hundreds of thousands of lives right this very moment.
The simple truth is many of our current diagnoses are driven more by the pressure that various DSM committees experience from the medical profession, the drug companies, the insurance companies, and public opinion than by research. For instance, Marty Kafka’s lengthy proposal for inclusion of Hypersexual Disorder as an official DSM-5 diagnosis is supported by six pages of peer reviewed research. Nevertheless, caving to outside pressure, the APA chose to not include this rather obvious and much needed diagnosis in the DSM-5.
Where Do We Go From Here?
Lamentably, at the same time the APA has backed away from officially acknowledging sexual addiction, technology has been feeding it. Simply put, our ongoing tech-connect boom has dramatically increased the average person’s ability to anonymously and affordably access powerfully stimulating sexual content and an endless array of potential sex partners. For most healthy people this is just fine, but individuals predisposed to addictive disorders (through genetics and/or a history of early-life attachment trauma) can easily find themselves drowning in a sexual quagmire. Simply put, as access to highly stimulating sexual content and activities has increased, so too has the number of people self-reporting issues with out-of-control sexual fantasies and behaviors. It seems to me that these individuals and the therapists who treat them could benefit greatly from the guidance the APA could, but doesn’t, provide.
Yes, it would be nice to have an official sex addiction entry in the DSM. A formalized diagnosis would help clinicians to clearly identify men and women who struggle with impulsive, compulsive, and addictive sexuality, and to direct them toward useful, accurately planned models of treatment. Unfortunately, the APA simply lacks the political will needed to make this much needed leap forward. In lieu of this, clinicians can rely on useful guidance from the American Society of Addiction Medicine and organizations like the Society for the Advancement of Sexual Health and the International Institute for Trauma and Addiction Professionals.