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Hypersexual Disorder Debates

Why wasn’t sex addiction included in the DSM-5?

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Sex addiction appears to be a highly controversial area among both the general public and those who work in the addiction field. Some psychologists adhere to the position that unless one's behavior involves the ingestion of a psychoactive substance (alcohol, nicotine, cocaine, heroin), it cannot really be considered an addiction.

I’m not one of them.

If it were up to me, I would have given serious consideration to including sex addiction in the latest edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Given that "gambling disorder" was reclassified from a disorder of impulse control to a behavioral addiction in the DSM-V, there is now no theoretical reason why other behavioral addictions cannot be added in the future.

So why wasn’t sex addiction included in the latest DSM-V? Here are 5 possible reasons:

1. Some researchers think that sex addiction doesn’t exist (for moral and theoretical reasons).

Many scholars attack the concept of sex addiction, calling it myth. Many claims appear to be valid; the most conventional attack is that "addiction" is a physiological condition caused solely by ingestion of substances, and should therefore be defined physiologically. Some sociologists argue that "sex addiction" is little more than a label for sexual behavior that significantly deviates from society’s norms. Others say that if excessive sexual behavior is classed as an addiction, it undermines individuals' responsibility for their behavior—although this moral argument could be said of almost any addiction.

2. The word "addiction" has become meaningless.

Some social science researchers claim that the daily use of the word "addiction" has rendered the term meaningless. Some professionals don’t agree on what the disorder should be called ("sex addiction," "sexual addiction," "hypersexuality disorder," "compulsive sexual behavior," "pornography addiction," etc.) and whether it is a syndrome (a group of symptoms that consistently occur together, or a condition characterized by a set of associated symptoms) or whether there are many different subtypes (pathological promiscuity, compulsive masturbation, etc.).

3. There is a lack of empirical evidence about sex addiction.

Empirical research about sex addiction is relatively weak. Although there has been extensive research, there have never been any nationally representative surveys of sex addiction using validated addiction criteria; a lot of research studies are based upon those people who turn up for treatment. Like Internet Gaming Disorder (which is now in the appendix of the DSM-V), sex addiction (or, more likely, "hypersexual disorder") will not be included as a separate mental disorder until:

  • the defining features of sex addiction have been identified;
  • the reliability and validity of specific sex addiction criteria have been obtained cross-culturally;
  • prevalence rates of sex addiction have been determined in representative epidemiological samples across the world; and
  • etiology and associated biological features of sex addiction have been evaluated.

4. The term "sex addiction" is used to excuse infidelity.

The term "sex addiction" is often used by high-profile celebrities as an excuse when such individuals who have been unfaithful to their partners (e.g., Tiger Woods, Michael Douglas, David Duchovny, Russell Brand). In some of these cases, sex addiction is used to justify an individual’s serial infidelity. This is what social psychologists refer to as a "functional attribution." For instance, professional golfer Tiger Woods claimed an addiction to sex after his wife found out that he had many sexual relationships during their marriage. If his wife had never found out, one doubts whether Woods would have claimed he was addicted to sex. I would argue that many celebrities are in a position to succumb to sexual advances from a number of people. But how many people wouldn't do the same thing if given the same opportunity? It becomes a problem only when it's discovered, or if there's potential to hurt a celebrity’s brand image.

5. The evidence for sex addiction is inflated by those with a vested interest.

We have no idea how many people genuinely experience sex addiction. Sex addiction specialists, like Patrick Carnes, claim that up to 6 percent of all adults are addicted to sex. If this was really the case, there would probably be sex addiction clinics and self-help support groups in every major city worldwide, which isn’t the case. Sex addiction may exist, but the size of the problem may not be on the scale that Carnes suggests. Further, therapists treating sex addiction may have a vested interest—many make their living treating the disorder. Getting the disorder recognized by leading psychological and psychiatric organizations (the American Psychiatric Association, World Health Organization) legitimizes the work of sex addiction counselors and therapists, so it is not surprising that such individuals claim how widespread the disorder is.

There may be other reasons why sex addiction is not considered a genuine disorder. Compared to behavioral addictions like gambling disorder, the empirical evidence base is weak. There is little in the way of neurobiological research (increasingly seen as "gold standard" research when it comes to legitimizing addictions as genuine). But carrying out research on those who claim to have a sex addiction can be difficult. For instance, is it ethical to show pornography to a self-admitted pornography addict while participating in a brain neuroimaging experiment? Is the viewing of such material likely to stimulate and enhance the individual’s sexual urges and result in a relapse following the experiment?

There are also issues surrounding cultural norms. The normality and abnormality of sexual behavior lies on a continuum. What is considered normal and appropriate in one culture may not be viewed similarly in another. (Sociologists call this "normative ambiguity.")

Personally, I believe that sex addiction is a reality, but that it affects only a small minority of individuals. Many sex therapists claim that it is increasing, particularly due to the availability of sexual materials on the Internet. If sex addiction makes it into future editions of the DSM, perhaps it will be as a sub-category of Internet Addiction Disorder rather than as a stand-alone condition.

References and further reading

Dhuffar, M. & Griffiths, M.D. (2015). A systematic review of online sex addiction and clinical treatments using CONSORT evaluation. Current Addiction Reports, 2, 163-174.

Goodman, A. (1992). Sexual addiction: Designation and treatment. Journal of Sex and Marital Therapy, 18, 303-314.

Griffiths, M.D. (2000). Excessive internet use: Implications for sexual behavior. CyberPsychology and Behavior, 3, 537-552.

Griffiths, M.D. (2001). Sex on the internet: Observations and implications for sex addiction. Journal of Sex Research, 38, 333-342.

Griffiths, M.D. (2001). Addicted to love: The psychology of sex addiction. Psychology Review, 8, 20-23.

Griffiths, M.D. (2010). Addicted to sex? Psychology Review, 16(1), 27-29.

Griffiths, M.D. (2012). Internet sex addiction: A review of empirical research. Addiction Research and Theory, 20, 111-124.

Griffiths, M.D. & Dhuffar, M. (2014). Treatment of sexual addiction within the British National Health Service. International Journal of Mental Health and Addiction, 12, 561-571.

Kafka, M. P. (2010). Hypersexual disorder: A proposed diagnosis for DSM-V. Archives of Sexual Behavior, 39, 377–400.

Orford, J. (2001). Excessive sexuality. In J. Orford, Excessive Appetites: A Psychological View of the Addictions. Chichester: Wiley.