The codification of sex and the problem with addiction

An old joke in psychological circles is that a sex addict is anyone having more sex than the therapist. If we accept – as psychoanalysis claims – that every joke contains a grain of truth, this quip reveals a number of things. First, the parameters of sex addiction (and its subset porn addiction) are poorly defined. Second, the arbiter of sexual excess in the modern age is the so-called expert. Last, that same expert’s judgement may be clouded by their personal biases. 

How then is sexual addiction defined? And by who?

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The first thing to note is that sex addiction, at least according to the medical literature, does not actually exist at all. The term – though it exists in the media and, subsequently, in popular imagination – is entirely absent from scientific discourse.  While ‘addiction’ does appear in the names of various 12 Steps groups, such as Sex Addicts Anonymous and Sex and Love Addicts Anonymous, a scan of the medical literature reveals different terminology.  These terms include: hypersexual disorder, dysregulated sexuality, sexual impulsivity, and problematic pornography use. But no sex addiction.

Why is this and why does the medical community hesitate to use this particular term?

One reason relates to negative connotations of the word addiction. If sex is an ‘addiction’ and if addiction – according to the medical model – is a disease, the cure is abstinence. Sex being a natural behaviour, abstinence – in a post-sexual-revolution society – is considered unacceptable. The fear is of over-pathologising sexual behaviour based on what is considered normal or morally and socially acceptable. And sex being an everyday activity, the question of how much is too much, based on whose standard, has proven a difficult one to answer. In recent years, the approach has been to err on the side of caution.

However, such an open-minded approach has not always been the case.

In the U.S., the Diagnostic Statistics Manual (DSM) isupdated every decade or so by the American Psychiatric Association. A repository of the full spectrum of psychological disorders, the DSM is the official bible of psychologists, psychiatrists, and other clinicians. There are several entries for sexual disorders including those objectively harmful or criminal such as paedophilia. There have also been – in older versions of the DSM – entries for sexualities either deemed illegal or simply outside the mainstream; homosexuality, nymphomania and BDSM related practices.

But as public opinion on sexuality has changed, so have entries in the DSM. Previously considered mental disorders entries for homosexuality were removed in 1973 and nymphomania in 1980. Entries related to BDSM (no relation to DSM) were altered in the most recent edition. If you practised fetishes prior to 2013 you were considered as having a mental disorder. Thereafter, fetishes are only diagnosable if they cause you or others distress. So your spanking fetish is fine, but only as long as you enjoy it.

Some argue that – at least where sexuality is concerned –  the DSM’s fickle nature belies its scientific objectivity.

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A version of sexual addiction, hypersexual disorder, was proposed for the 2013 version of the DSM, but despite considerable debate didn’t make the final cut. One reason is technical, the DSM requiring proof of a physiological response before something comes under the heading of ‘disorder’. For example, a response to alcohol can be recorded, hence it can appear under ‘substance abuse disorder’. Prior to 2013, as far as pornography was concerned, there wasn’t a sufficient evidence linking it with a physiological response. Though neuroimaging studies since 2013 seem to lend support to the notion of ‘physiological’ porn addiction the evidence is not fully definitive. 

Other objections to the inclusion of hypersexuality in the DSM revolved around the proposed criteria, of which four out of five were needed for a diagnosis. One criteria was based on the amount of time engaged in sexual activity, whereby ‘excessive time is consumed by sexual fantasies and urges … and engaging in sexual behaviour’. One reason the proposed inclusion came unstuck related to the definition of excessive.  No agreed standard for how much masturbation is too much could ultimately be reached.

Another criteria was ‘repetitively engaging in these sexual fantasies, urges, and behaviour in response to dysphoric mood states’ (that is, a profound state of unease or dissatisfaction). One critic argued that people engage in all sorts of activities to avoid experiencing unease, but these are never touted as mental disorders. He added, there is ‘nothing inherently unhealthy about acting to alleviate one’s dysphoria’. If watching porn relieves you of your dysphoria, that shouldn’t of itself be diagnosable.

Another of the criteria to come under fire was that of the individual’s ‘repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, and behaviour’. This was felt to carry the implication that an individual’s fantasies should be controlled or reduced, or that having sexual urges is wrong.  This criterion carried the hint of a hidden moral indictment rather than an objective medical yardstick.

Ultimately, it was felt there was a risk of creating a medically sanctioned standard which would end up supressing normal, healthy sexual development; a danger of creating a ‘new class of worried well’, wherein the potential for false positives risked catching members of an unwitting public in a diagnostic dragnet. In the end the diagnosis didn’t make the DSM V, but it will – along with all other mental disorders – be up for reconsideration in the next version, the DSM VI.

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In the U.S. – beyond authorship of the DSM – within the wider mental health community, the topic of sex as an addiction is hotly debated; as polarised as any topic there. One major criticism is of a ‘sex addiction industry’ using quack science to fleece a gullible public. Opponents of sex as addiction also argue any rise in porn consumption should fall under the wider umbrella of internet ‘addictions’, such as social media addiction, online gambling etc. As such is not necessarily a sexual issue.

There are other criticisms. One worry is – if some practising homosexuals meet the criteria for promiscuity – the diagnosis risks re-stigmatising, by stealth, homosexuality. Another fear is of the possibility of men dishonestly using a diagnosis of sex addiction as an excuse for errant behaviour. Last, there is a fear of criminal offenders using the diagnosis as a mitigating factor in court cases.

Polarisation around these particular issues merely adds fuel to the debate.

Outside the U.S. views on sexual compulsivity also diverge. Whereas hypersexuality got shelved, elsewhere in the world it was decided that, with growing numbers of people presenting for sexual issues, especially in relation to porn use, a diagnostic category was needed.

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If the DSM is the diagnostic bible in the U.S., the rest of the world uses the WHO’s International Classification of Diseases (ICD). No category for dysregulated sexual behaviour existed internationally until 2018 when the authors of the ICD added ‘compulsive sexual behaviour disorder’. CSBD comes under the umbrella of the ‘impulse control disorders’ which don’t require the same standard of physiological proof as the DSM.

The ICD entry reads in part: CSBD is characterized by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests … and continued repetitive sexual behaviour despite adverse consequences…’ The full entry is the bottom of the article.

The ICD entry comes with several caveats, the diagnostic guidelines explicitly cautioning against over-pathologising sexual behaviour. Merely exhibiting a high level of sexual interest does not warrant a diagnosis. Population groups – adolescents, for example – who may engage in above average masturbation shouldn’t be considered as suffering a mental disorder. The guidelines also caution against making a diagnosis where there may be some underlying disorder – such as bipolar – that comes with a high risk of promiscuity.

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At first glance the CSBD criteria look similar to those of hypersexuality.  However, there is one crucial sentence at the end of the ICD entry; ‘distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement.

This cautions both the clinician and the individual against making moral judgements that seemingly violate either social norms or their own moral standards. Sleeping with multiple partners or attending sex parties may not be how everyone swings, but engaging in them don’t indicate a mental disorder.

Similarly, there are individuals who present for therapy who may identify themselves as sex addicts or porn addicts. Rather than suffering a diagnosable condition these individuals may be experiencing a moral conflict between their sexuality and religious or societal expectations.  Other individuals may have a misunderstanding of what constitutes ‘normal’ sexuality. Whereas these conflicts may cause the individual to experiencing shame or guilt, they aren’t of themselves diagnosable.

The distinction between those who merely believe they have a sexual disorder and those who actually have one is an important. This doesn’t mean that both groups are not deserving of a therapeutic intervention should they seek one, but the distinction is important, not least in deciding on a course of treatment.

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The creation of the diagnostic category in the ICD has several practical implications. People seeking treatment can, where possible, using the diagnostic code, be reimbursed by their medical insurers. This is not the case in the U.S. states where most states require a DSM diagnosis. In addition, now that a diagnostic category actually exists, funding can be made available both for treatment centres and for future research. One major issue in sexuality research is a lack of standardised measures, making it difficult to discern exactly what issues exist and to what extent. The research is so muddled that you could take any position, on say pornography, and find a study to back it up. Standardised measures will assist in this regard. Research will also decide the future status of CSBD in the ICD. It will remain in the impulse control disorder category until proof or otherwise of a physiological response is found.

And finally, one hope of the ICD’s authors is that creation of the diagnosis will reduce stigma for distressed individuals. The hope is that by creating a diagnostic category, providing a tool for addressing previously unmet clinical needs, sufferers will no longer have to hide in the shadows.

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Whether you see the classification of ‘too much sex’ as medical overreach, an unnecessary intrusion into the privacy of our bedrooms; or whether you see concern over a perceived rise in porn consumption as mere moral panic; or whether you see a growing societal problem for which the creation of CSBD acts as a necessary correction to diagnostic oversight, one thing seems clear; the codification of sex is itself a messy business.

¹ Compulsive sexual behaviour disorder is characterized by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it. The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g., 6 months or more), and causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement.