There will always be controversy—as there should be—when any forms of inherently normal human behaviors such as eating or sex are clinically designated as pathological. And while the power to “label” must always be carefully wielded to avoid turning social, religious or moral judgments into diagnoses (as homosexuality was in the DSM-I and -II), equal care must be taken not to avoid researching and creating diagnostic criteria for these otherwise healthy behaviors should they go awry.
To this point, the past 25 years has wrought a troubled and inconsistent history in the attempts of the psychiatric and mental health communities to accurately label and diagnose the problem of excessive adult consensual sexual behavior, commonly known as sexual addiction.
In 1987, the American Psychiatric Association’s (APA’s) Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) added the concept of sexual addiction for the first time as a specific description to be utilized under the more general diagnosis of sexual disorders-not otherwise specified. The DSM-III-R then stated that this descriptor could be applied if the individual being assessed displayed “distress about a pattern of repeated sexual conquests or other forms of non-paraphillic sexual addiction, involving a succession of people who exist only as things to be used.”
Subsequent versions of the manual (DSM-IV and DSM-IV-TR) retracted the term due to “insufficient research” and “lack of expert consensus.” In hindsight, this appears to have been an unfortunate decision that left the clinical community without adequate direction for the assessment, diagnosis and treatment of those with problem patterns of consensual adult sexual behavior.1
Notably during this same 25-year period of clinical disagreement, the Internet (along with its progeny of social media and smart phones) has dramatically increased the average person’s ability to access endless amounts of highly graphic pornography, casual sexual experiences and online prostitution affordably and anonymously. This proliferation of access is causing tremendous problems for many individuals with pre-existing addictive disorders, social inhibition, early trauma, and attachment and mood disorders, along with those who are more profoundly mentally ill—all of which can contribute to long-term, repetitive patterns of sexual acting-out.
For reasons as varied as the individual, the increasing availability of intensely absorbing sexual content and experience has become a “drug of choice” for those clients able to abuse sexual intensity and fantasy-based dissociation as a replication of intimacy, or those who use the search for romance and sex to self-regulate and tolerate stressors that unconsciously evoke past trauma or abuse.
There are few American outpatient psychotherapists and addiction counselors today who have not had someone recently appear on their doorstep seeking help for self-reported problems such as “I disappear for multiple hours daily into online porn” or “I feel lost on a never-ending treadmill of anonymous sexual conquests and multiple affairs,” not to mention the client struggling to stay sober from a combination of stimulant abuse and long periods of intense sexual activity.
With help from the media, the international rise of 12-Step sexual recovery groups, and the much-publicized problem sexual behaviors of many political and sports figures, the general public appears to have embraced the concepts of sex addict, porn addict, and romantic and sexual addiction. Ironically, at the very same time that both the APA and the National Institutes of Health (NIH) backed away from both defining and providing the research dollars to help define addictive sexual behavior, the concept itself has gained widespread public acceptance and grudging therapeutic legitimacy.
Among the chief contributors to this change is the work of addiction pioneer Patrick Carnes, PhD, along with many hardworking and lesser-known individuals who continue to evolve both the research and treatment of sexual addiction. Today tens of thousands of people daily attend international 12-Step support groups such as Sex Addicts Anonymous, Sexaholics Anonymous, Sexual Compulsives Anonymous, and Sex and Love Addicts Anonymous both in person and online, voluntarily attempting to alleviate their self-diagnosed struggles with problem sexual behavior.
The APA, in its work on the 2013 DSM-5 and well aware of these rising concerns, offered a potential DSM-5 diagnosis called “hypersexual disorder,” and in so doing sought current research data and a review of the issue. And while “hypersexual disorder” is not an ideal description of a problem that more accurately involves the lengthy search and pursuit of love and sex, rather than the sex act itself, today there seems little doubt that “hypersexuality” is a legitimate, serious and not uncommon clinical condition associated with the related concerns of disease transmission, family and relationship dysfunction, separation, divorce, anxiety, unplanned pregnancy, mood disorders, job loss, and even suicide.
Current review of hypersexual disorders research, along with documented evidence offered by treatment providers, demonstrates that the number of researched and reported “cases” of “sexual addiction” now greatly exceeds documented past research and reporting of several sexual disorders currently defined and classified in the DSM-IV-TR (prominent examples include fetishism and frotteurism).