The Codification of Sex and the Problem with Sex Addiction

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

How, then, is sexual addiction defined? And by whom?

Sex addiction, at least according to the medical literature, does not actually exist at all. Though it exists in the media and in the popular imagination, the term is entirely absent from scientific discourse—I myself have used it. While addiction appears in the names of various twelve step groups, such as Sex Addicts Anonymous and Sex and Love Addicts Anonymous, medical literature uses different terminology, including hypersexual disorder, dysregulated sexuality, sexual impulsivity and problematic pornography use. But not sex addiction.

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

One reason is the 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. But, since sex is a natural behaviour, abstinence is considered unacceptable to our post-sexual revolution society. We are wary of pathologising sexual behaviour based on what is considered normal or morally and socially acceptable. And, since sex is an everyday activity, the question of how much is too much is difficult to answer. In recent years, the approach has been to err on the side of caution.

However, this open-minded approach is relatively new.

The Diagnostic Statistics Manual (DSM) is updated 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 clinicians. There are several entries on sexual disorders, including objectively harmful and criminal behaviours, such as paedophilia. But older versions of the DSM contained entries on sexualities either deemed illegal or simply outside the mainstream: homosexuality, nymphomania and BDSM-related practices.

But, as public opinion on sexuality has changed, so has the DSM. Previously considered mental disorders, homosexuality was removed in 1973 and nymphomania in 1980. Entries related to BDSM were altered in the most recent edition. If you practised fetishes prior to 2013, you were considered to have a mental disorder. Thereafter, fetishes became only diagnosable if they caused 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 changes belie its scientific objectivity.

A version of sex addiction called hypersexual disorder was proposed for the 2013 DSM, but, despite considerable debate, it didn’t make the final cut. This was partly for technical reasons: the DSM requires proof of a physiological response before something can come under the heading of a disorder. For example, a response to alcohol can be recorded, hence alcoholism can appear under substance abuse disorders. Prior to 2013, there wasn’t sufficient evidence linking pornography use with a specific physiological response. Though neuroimaging studies conducted since 2013 seem to lend support to the notion of a physiological porn addiction, the evidence is not definitive.

Other objections to the inclusion of hypersexuality in the DSM revolved around the proposed criteria: four out of five of which were needed for a diagnosis. One criterion was the amount of time engaged in sexual activity: “excessive time is consumed by sexual fantasies and urges … and engaging in sexual behaviour.” The proposed inclusion came unstuck because of the word excessive. No standard for how much masturbation is too much could ultimately be agreed upon.

Another criterion was “repetitively engaging in these sexual fantasies, urges, and behaviour in response to dysphoric mood states” (i.e. profound states 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 that there is “nothing inherently unhealthy about acting to alleviate one’s dysphoria.” If watching porn relieves you of your dysphoria, that shouldn’t be diagnosable in itself.

Another criterion to come under fire was “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 feeling sexual urges is wrong. This hinted at a moral indictment, rather than an objective medical yardstick.

Ultimately, it was felt that there was a risk of proposing a medically sanctioned standard, which would end up suppressing normal, healthy sexual development, 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 it into the DSM V, but it will be up for reconsideration in the DSM VI.

Within the wider US mental health community, the topic of sex addiction is hotly debated. Some are wary of a sex addiction industry, using quack science to fleece a gullible public. Opponents of the notion of sex addiction also argue that any rise in porn consumption should fall under the wider umbrella of internet addictions, such as social media addiction, online gambling etc. As such, this is not necessarily a sexual issue.

There have been other criticisms. One worry is that—if some practising homosexuals meet the criteria for promiscuity—the diagnosis risks re-stigmatising homosexuality, by stealth. Another fear is that men might dishonestly use a diagnosis of sex addiction as an excuse for errant behaviour. Lastly, there is a fear that criminal offenders may plead the diagnosis as a mitigating factor in court cases.Polarisation around these issues merely adds fuel to the debate.

Outside the US, views on sexual compulsivity also differ. When the DSM shelved hypersexuality, elsewhere in the world it was decided that a diagnostic category was needed, to cover the growing numbers of people presenting for sexual issues, especially in relation to porn use.

While the DSM is the diagnostic Bible in the US, the rest of the world uses the WHO’s International Classification of Diseases (ICD). No category of 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 is needed for 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 ICD entry comes with several caveats and the diagnostic guidelines explicitly caution against over-pathologising sexual behaviour. The mere presence of a high level of sexual interest does not warrant a diagnosis. Population groups—adolescents, for example—who may engage in an above average amount of masturbation shouldn’t be considered to be suffering from a mental disorder. The guidelines also caution against making a diagnosis where there may be some underlying disorder—such as bipolar disorder—that comes with a high risk of promiscuity.

At first glance, the CSBD criteria look similar to those for 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 about activities 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 doesn’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. While these conflicts may cause the individual to experience 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 important. Both groups are deserving of a therapeutic intervention, should they seek one, but the distinction is important, not least in deciding on a course of treatment.

The creation of the diagnostic category in the ICD has several practical implications. People seeking treatment can, where possible, use the diagnostic code to be reimbursed by their medical insurers. This is not the case in the US, 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 the lack of standardised measures, which makes it difficult to discern exactly what issues exist and to what extent. Research will also decide the future status of CSBD in the ICD. It will remain in the impulse control disorder category until proof or disproof of a physiological response is found.

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

Whether you regard the classification of too much sex as a disorder as medical overreach and an unnecessary intrusion into the privacy of our bedrooms; see concern over a perceived rise in porn consumption as a mere moral panic; or think there is 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 itself is a messy business.