This post is in response to American Sex and American Psychiatry by Christopher Lane

First, I want to say how important Dr. Chris Lane's book, Shyness, was in the writing of my own recent book, The Myth of Sex Addiction. Lane's in-depth research into the political and personality-driven processes of the American Psychiatric Association's DSM committees was illuminating, and disturbing. Lane's book revealed what we all knew, which was that the APA is a body of humans, influenced by nonscientific motivations and pressures.

As a specific addictive disorder, sex addiction was roundly rejected by the APA's Addictive disorders subcommittee. Specifically, it was rejected due to a lack of empirical evidence. Even though lots of people believe strongly in sex addiction, the strength of their beliefs do not equal scientific evidence. But, at the same time, a proposal for Hypersexual Disorder was put forth to the sexual disorders subcommittee. Personally, I think this interesting event reveals something about the sex addiction community — it is split. There remains a large group of dogmatic, committed true believers in sex addiction, and the original Carnes idea that addiction to sex is the same as addiction to drugs. But, there is a new group of researchers and therapists (including a few psychiatrists and psychologists) who argue for hypersexuality as a concept that does not include the addiction language, and merely describes in very non-moral terms, a syndrome of high levels of sexual behaviors that may pose a problem for people. The argument is that Hypersexual Disorder should at least be included in the Appendix of the DSM, for future study. But, the arguments for Hypersexual Disorder are problematic as well.

The proposal for hypersexuality suggests that evidence of hypersexuality has been around for a very long time, and references Dr. Benjamin Rush, a physician and signer of the Declaration of Independence. Rush apparently identified highly sexual behaviors as a problem as well, and the proponents of hypersexual disorder see that as evidence of the validity of the concept. Notably, they neglect to mention that Dr. Rush commonly prescribed leeches for treatment of this condition, and believed that blindness resulted from excessive masturbation (it is Dr. Rush we have to blame for this mythical effect of self-pleasure). They also neglect to mention that it is likely that all the symptoms that Dr. Rush saw as the effects of excessive sexuality were actually the symptoms of untreated and then unknown sexually-transmitted diseases such as syphilis and gonorrhea.

The proposed criteria for hypersexual disorder include an overwhelming focus on male sexual behaviors: masturbation, infidelity, use of prostitutes, use of pornography, going to strip clubs and phone sex. While some women engage in these behaviors, they are predominantly behaviors associated with masculine erotic behaviors. Studies of sex addiction and hypersexuality reveal that 85-95 percent of them are male. Usually white men in upper income tax brackets. Why are we creating a disorder that pathologizes excessive male sexuality? What is that anyway? Masculine eroticism is already excessive, at least compared to female sexuality. What is the norm that "excessive" is compared to? As Dr. Lane points out, no one knows, and neither he nor I trust a committee of the APA to decide and tell us what is normal.

Women are largely ignored in sex addiction, and even the proposal for the DSM 5 admits that little is known about women and sex addiction. But, it references the long history of diagnosis of nymphomania as evidence that female sex addiction is real. What? Nymphomaniacs through history were subjected to horrific treatments, from lobotomy and clitorectomy, to institutionalization. It is accepted that this disorder actually reflected a social fear/stigma upon female sexuality, not an actual disorder. (I refer the interested reader to Carol Groneman's fabulous work on the history of nymphomania). We're going to use that disturbing history to support applying this diagnosis to women, especially when there is evidence that the sex addiction label is still used to pathologize female libido?

Dr. Martin Kafka, psychiatrist and lead author of the hypersexual disorder proposal, originally proposed to set a numeric limit on sexuality, identifying that an orgasm a day for three months was a defining threshold of "too much sex." Unfortunately, as I argue in Myth, this would potentially pathologize as much as 40 percent of the male population at one time or another. Further, it pathologizes all those people who would have sex every day if they could. Comedian Bill Maher has said "A day without sex is a day wasted." Obviously, Mr. Maher must be a sex addict? This numeric criterion was eventually dropped, but it shows the weaknesses of this concept, and the degree to which the proponents of hypersexual disorder ignore the wealth of existing research on normative human sexuality, in favor of their own subjective experiences of allegedly out of control sexually-obsessed clients.

Dr. Lane's book Shyness really calls the APA to task for subjectivity and poor scientific basis for diagnostic decisions. The APA is actually trying quite hard in this current process to base their decisions on empirical evidence, as demonstrated by the rejection of sex addiction. The proponents of hypersexual disorder and sex addiction argue that there are more publications and case studies of excessive sexual behavior than ever existed for the behaviors of frotteurism, a fetishistic diagnosis. Again, they suggest that this is validation for their arguments that hypersexuality is a genuine disorder. Like the issue with the citation of Dr. Rush, this argument is very thin, and ignores real problems in their alleged data. This high number of cases is mostly because the many varying definitions of hypersexuality and sex addiction have been so exceedingly broad and subjectively defined. As a result, anybody who engages in sexual behaviors somebody else doesn't like can be called hypersexual or addicted, even when the issue is really just a matter of mismatched libidos in a marriage. It has created a very broad net that captures very nonspecifically, and pathologizes not a syndrome, but merely high libido, or an internal conflict between one's sexual values (or society's), and one's sexual desires. One study of alleged sex addicts found that the sex addicts had as much sex as non-sex addicts wanted to have, but couldn't or didn't. Get that? The level of desire is thus normal, but what is now seen as a disease is the degree to which a man fulfills that desire, or the degree of their success at picking up women?

I believe that we need to support the APA to continue their focus on empirical evidence, and to do it right this time. If they choose to include hypersexual disorder in the appendix, they have to be wary that they are merely giving "cover" to the true believers in sex addiction, who will use the hypersexual label, merely to continue diagnosing sex addiction, based upon unproven concepts that assume sex is an addictive disease. They also must demand that the research on hypersexual disorder validate this construct, distinguishing it from high libido, and from normative sexual behaviors, and aspects of normal sexual development. Finally, they must address the huge issue that hypersexual disorder is likely a culture-bound syndrome, only occurring in cultures where sexuality is viewed with fear and distrust, and where excessive male sexuality is seen as a negative. We don't see folks in Latin America called sex addicts for having multiple mistresses, nor in the Middle East, where male virility is held up as a virtue. Per the DSM, we're not supposed to diagnose a disorder, when the problem is really a conflict with cultural values.

 You can follow David Ley on Twitter, @DrDavidLey

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