Sex Addiction Beyond the DSM-V
How the APA's decision affects therapists who actually treat sex addiction.
Posted Dec 21, 2012
Hypersexual Behavior Disorder will not be in the Fifth Edition of the Diagnostic Statistical Manual for Psychiatric Disorders (DSM-V). Opinions about this decision by the American Psychiatric Association (APA) vary among mental health professionals. Some therapists have interpreted the APA’s decision to omit this diagnosis from the DSM-V as a victory against a “sex-negative” diagnosis. However, therapists who treat this problem have a different understanding of this omission from the DSM-V, anticipating a few significant implications:
1) Without formal diagnostic criteria to determine the presence of problematic sexual behaviors, therapists might conduct therapy in a way that exacerbates the problematic effects of compulsive sexual behaviors
2) Treatment for sexually compulsive behaviors will not be reimbursed by insurance companies, making proper treatment inaccessible to many individuals
As a therapist who repeatedly sees the devastating results of out-of-control sexual behaviors, I am disappointed with the APA’s verdict that Hypersexual Disorder is not an official psychiatric disorder. The effects of this are both an issue of public health and personal wellbeing, because unmitigated sexual behaviors that have gone out of control cause significant psychological, social, relational and financial distress for individuals and their families. And in their worst scenarios, can lead to sexually transmitted infections, the breaking up of families and a string of legal problems. And while I believe that the problem is one of sexual addiction, the diagnosis of Hypersexual Behavior Disorder could have been a step in the right direction of legitimizing this problem.
The argument that sex addiction is an agenda put forth by “sex-negative” clinicians, completely disregards the pain, confusion, trauma, fear and hopelessness experienced by sex addicts and their families. This leaves marriage therapists (who usually address marital concerns within a framework of monogamy) with very few options to explain the behaviors of a spouse who continually pursues sex outside of the marriage. In these types of situations, how does a marriage therapist offer support to a person who is repeatedly betrayed by a spouse’s infidelities? Does that therapist simply explain “your husband is a narcissist”? Or that “your wife struggles with borderline personality disorder”? These explanations are reductive, often inaccurate, and offer little therapeutic support when someone is trying desperately to understand a spouse’s chronic patterns of betrayal and infidelity.
Most people do not want to betray the trust of a loved one, and even fewer people would want their betrayals to become a chronic pattern which destroys the cohesiveness of their family. But this is what we see in people who are struggling with addiction, whether the addiction is to alcohol, drugs or gambling. Why would we not consider chronic patterns of sexual behavior that are destructive to family life, professional life, and personal life as a possible sign of addiction?
As mental health professionals, along with relying on the DSM, we need to also give credence to our observations – even when our observations don’t point to any official diagnoses. Symptoms commonly associated with Post Traumatic Stress Disorder and Traumatic Brain Injury were first described in 1915 by English physician Charles Myers. In his time, critics of Myers suggested that “shell shock” was not a legitimate condition, and was instead a series of fake symptoms acted out by cowardly World War I soldiers. However, 65 years after Myers first wrote about shell-shock, the APA included Post Traumatic Stress Disorder as a legitimate psychiatric disorder in the DSM-III.
Similar to PTSD, most disorders in the DSM only become official diagnoses following lengthy periods of research and debate. Unfortunately, this glacial nature of the DSM puts mental health professionals in a predicament every time they are faced with consistent patterns of psychological distress that do not line up with any diagnosis within the DSM. Should the therapist conceptualize the problem through the filter of an existing diagnosis that doesn’t quite fit the bill? Or should the therapist move beyond diagnosis and conceptualize the problem based on carefully observed patterns of behavior? This is the reality faced by therapists who see patterns of addiction in their clients’ sexual behaviors. We can conceptualize the pattern of out-of-control sexual behavior as an addiction (despite the omission of sex-addiction in the DSM-V). Or we can try to understand the pattern of out-of-control sexual behavior through the diagnosis of a depressive disorder, an anxiety disorder, a relational problem, or a personality disorder; but when we do this, we don’t really get to the core of the issue.
When we conceptualize chronic sexual behaviors that are destructive to a person’s life as an addiction, we have a roadmap for offering treatment, support and a hope for new patterns of behavior. We utilize a treatment plan which moves a person away from destructive sexual behaviors toward higher daily functioning, in the same way other addiction treatments do. This includes support groups, motivational interviewing, psycho-education, and cognitive behavioral therapies offered in either outpatient or inpatient settings. All of these treatment options are aimed at establishing emotional sobriety from specific sexual behaviors that are destructive and problematic for the addicted individual. This process of sobriety coincides with the establishment of a support network, in the same way Alcoholics Anonymous has created social support for alcoholics for decades. By being open to the idea that sexual addiction exists, therapists don’t have to feel their way through the dark when they are helping someone with a pattern of out-of-control sexual behaviors. Instead, the therapist can design a treatment plan that builds upon everything we’ve already learned through decades of treating other addictions.
Throughout my career, I’ve met numerous therapists who questioned the validity of sexual addiction until they came face-to-face with it in their therapy office. Ironically, most of these therapists quickly learned that they didn’t have to scrutinize every other client as a possible sex addict because the signs and symptoms were fairly obvious. These therapists learned to look for patterns of personal, emotional, financial, relational, legal, or professional problems as a direct result of someone’s sexual behaviors. If you suspect a client is struggling with problematic sexual behaviors, consult with a professional who specializes in sexual addiction. Most will offer some free professional insight. And if you are feeling uncertain on how to move your client forward, consider referring this person to a therapist who has been certified as a sex addiction therapist by the International Institute of Trauma and Addiction Professionals.