Is Sexual Addiction Real?
When a new TV seasons starts up and one of the hit shows is about sex addiction, suddenly everyone is focused on sexual addiction. “Look, a new disorder!” “Look, David Duchovny actually has it!” Like most other compulsive behavioral conditions, sexual addiction is not recognized as a “real” disorder by the psychiatric diagnostic book, the Diagnostic and Statistical Manual of Mental Disorders (the DSM).
However, unlike most other behavioral compulsions, sexual addiction does have a fairly rich and long research history (over 550 citations appear in PsycINFO on sexual addiction). The concept of sexual addiction, according to Levin and Troiden (1988), first came from a member of a Boston-area Alcoholics Anonymous chapter, who recognized his sexual behaviors as something he called “sex and love addiction.” He then adopted the 12 steps to this problem, which then began to spread and was eventually picked up by psychology clinicians and researchers. The first professional conceptualization and description of sexual addiction in the research literature appeared in 1983 (by Carnes, an ex-prison psychologist, who claimed he actually discovered the problem in the 1970s but didn’t write about it until years later). Debate swirled back and forth about the legitimacy of these labels when they first appeared on the scene.
Sexual addiction, like other behavioral compulsions outside of gambling, has never made it into the DSM, however (contrary to what is claimed in the Wall Street Journal article, which inaccurately states it was in the DSM-III [don’t newspapers fact-check any more?]). In fact, the DSM-IV, the most current revision of this book, makes absolutely no mention of the concept of sexual compulsions or addiction, not even under categories for further study. Given that the DSM-IV was published in 1994, a full decade after the concept of “sexual addiction” made it onto the research scene, it does suggest that this is a category that was never seriously considered a full-blown disorder unto itself.
So Why Isn’t Sexual Addiction a Recognized Disorder?
It’s hard to say with any certainty. Levin and Troiden (1988) argue that simply shifting societal values are the main reason to blame. They also bemoaned both the soft science underlying the supposed condition and the spate of media attention of “sexual addiction” in the 1980s (not unlike the media attention given to this same concern nearly 20 years later!). Levin and Troiden also level many additional criticisms at “sexual addiction” as a stand-alone disorder, but most of them are comparatively weak and technical in nature.
Compulsions, as defined by the DSM-IV, are not something that bring a person pleasure. That is why gambling is defined as simply “pathological” and not “compulsive.” The only recognition in the DSM-IV that a person might engage in an enjoyable sexual activity to some extreme is the inclusion of a class of sexual disorders known as paraphilias. Paraphilias are “recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving (1) nonhuman objects, (2) the suffering or humiliation of oneself or one’s partner, or (3) children or other nonconsenting persons.” So while arguably the DSM-IV recognizes sexual compulsions, it’s only in the context of some sexual object, scene or person.
One can’t deny the people who flock to clinicians’ doors looking for treatment for sexual addiction, however, no more than one can deny that people believe they are “addicted” to the Internet. What is both amazing and a little disturbing, however, is to see entire professional societies, such as the Society for the Advancement of Sexual Health, spring up around a disorder that isn’t even officially recognized as such. And despite no clinical agreed-upon criteria for sex addiction, the Society estimates that 3 to 5% of Americans have it.
Despite there being no agreed-upon clinical definition of the disorder, clinicians and doctors are happily treating thousands of patients for this disorder every year. The treatments of choice? Antidepressants and 12 step programs:
Considerable debate exists about the appropriate conceptualization of this clinical syndrome and its place in psychiatric nosology. Some investigators have suggested that this condition constitutes a nonpharmacologic addiction; others have suggested it constitutes an obsessive-compulsive spectrum disorder. Finally, an impulse control model has been proposed. Nevertheless, there have been encouraging outcomes with psychotherapeutic and psychopharmacologic treatments. Currently, a number of treatments have been suggested as potentially effective: “Twelve-Step” programs, behavioral therapy, cognitive therapy, and several medications, including antiandrogens and selective serotonin reuptake inhibitors (Vesga-Lopez et al., 2007).
And despite there being an entire journal devoted to the condition (Sexual Addiction & Compulsivity), there are surprisingly few outcome studies conducted on what is the best or most effective treatments for this hypothetical disorder. One of the problems is the lack of broad agreement on the definition of the problem; without such a basic building block, it’s hard to conduct comparative, reliable studies on the phenomenon.
Our take on sexual addiction is very similar to our stance on “Internet addiction.” Any behavior taken to an extreme can be considered pathological, especially those behaviors which bring a person some degree of pleasure (such as watching television, pathologically following a particular sports team, gambling, texting, drinking coffee, reading a book, or shopping, amongst the dozens of behaviors that people pathologically take to an extreme everyday). Those behaviors with a social component not surprisingly seem to be more attractive to people than those without. (Heady insights here, I know.)
We’re not clear where one draws the line with such behaviors, except to use that always reliable catch-all that accompanies all diagnoses in the DSM — “the behavior causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.” With that in mind, however, we would suggest a far broader pathological behavior category that encompasses all reinforcing stimuli, since there’s absolutely zero research to show that engaging in mutually consensual sex, playing games on the Internet, or texting one’s friends are inherently dangerous or maladaptive behaviors.
Wall Street Journal: Is Sex Addiction a Sickness, Or Excuse to Behave Badly?
The New York Times: Some Sexual Behavior Viewed as an Addiction (from 1984, also filled with some factual inaccuracies)
Carnes, P. (1983). Out of the shadows: Understanding sexual addiction. Minneapolis, MN: CompCare Publications.
Levin, M.P. & Troiden, R.R. (1988). The myth of sexual compulsivity. The Journal of Sex Research, 25(3), 347-363.
Vesga-Lopez, O., Schmidt, A. & Blanco, C. (2007). Update on sexual addictions. Directions in Psychiatry, 27(2), 143-158.
Grohol, J. (2008). Is Sexual Addiction Real?. Psych Central. Retrieved on August 24, 2016, from http://psychcentral.com/blog/archives/2008/09/30/is-sexual-addiction-real/