Leading Edge / Summer 2010
Addicted to Love

The American Psychiatric Association is considering whether “hypersexual disorder” should be included in its next guide to mental illness


Is “sex addiction” an excuse for philandering or is it a mental illness? The jury is out, but perhaps not for long. The American Psychiatric Association is proposing to include “hypersexual disorder” in the next edition of its Diagnostic and Statistical Manual of Mental Disorders. Dr. James Cantor is head of the Law and Mental Health Research Section at the Centre for Addiction and Mental Health and a professor at U of T. He spoke recently with U of T Magazine editor Scott Anderson about what “sex addiction” is and is not.

Prior to this proposal to define “hypersexual disorder” as a mental illness, how was this kind of behavior classified?
The DSM has several catch-all categories. In the sexual and gender disorder section, this was “sexual disorder not otherwise specified.” In psychoanalytic literature, the terms used were nymphomania and satyriasis. A lot of terms have been used over the years.

But are they essentially describing the same set of symptoms?
People will describe feeling that they don’t have control over some aspect of their sexual life. But because there’s little research literature, we don’t know if people have one problem but are mislabeling it to avoid the stigma of another label, or if we’re even talking about one disorder or many.

Read
proposed revisions to DSM listing of sexual and gender identity disorders

Consider people who complain to their doctor of a headache. A headache associated with a migraine is completely different from a headache associated with a brain tumour, which is completely different from a headache caused by hitting your head on the floor. So even though we can put together everyone who complains of the same symptom, we’re not necessarily talking about people with the same problem. And we have no reason to believe that they would respond the same way to the same treatment. What’s really going on depends on where the problem started and what’s likely to happen if we intervene or not intervene.

It’s the same with sex addiction. People come in the door saying, “Doc, I think I’m a sex addict,” but that doesn’t mean that they’re literally a sex addict; they’re just describing their symptom.

Why is hypersexual disorder being proposed for the DSM now?
Clinicians have been talking about an entity that they call sexual addiction for many years. But it’s difficult to include it in a book that is supposed to be based on science when there hasn’t much been scientific research on it. The consensus now seems to be, “We’re convinced there is a discrete entity and we need to pick a term for it.”

What is the difference between someone who enjoys having a lot of sex and someone who is “sexually addicted”?
When someone comes into the clinic and says, “Doc I think I have a sex addiction,” my first question is always the same: “What makes you think so?” Usually, they don’t have the vocabulary to describe precisely what is going on in their sex lives, but they have heard the term sex addiction. They see it on Oprah, and it’s the closest term that seems to capture their suffering. But in my experience, I have every reason to suspect that these people are talking about something very different.

For example, I’ll get a male patient who says he believes he’s a sex addict because he has uncontrollable sexual fantasies about men. The immediate thought in my head is “You’re not a sex addict, you’re gay.” But the word “gay” for this person holds more stigma than the term “sex addiction” does. The best thing we can do is to help him come to grips with being gay rather than trying to control – or get rid of – his sexual interest in men.

Another example: some people say they spend many hours a day masturbating or surfing for porn on the web and they’re not getting work done. They call themselves sex addicts. But what these people are doing is using masturbation to avoid whatever task it is that they normally need to be doing. It’s an issue they have about their work. When you help these patients develop better work habits, the sex just goes away.

Some people have enormous amounts of sex. Most of them are fine with it. People start looking for help when they – or when people in their lives – think their behaviour is causing a problem. When they’re failing grades, being put on probation at work or causing family members to suffer is when we would start saying the person is addicted.

Some people describe hypersexuality as an addiction, akin to alcohol or gambling; others see it as a compulsive behavior more like OCD. What’s your stance?
In my experience, people who treat addictions tend to interpret this problem as an addiction. People whose theoretical orientation is about compulsions see this as a compulsion problem. People tend to design their theories based on what they’re used to rather than from careful consideration of the data.

Should sexual addiction be defined as a mental illness?
Yes. If not now, then certainly in time, though I don’t know precisely what form this would take. My intuition is that there are actually several different disorders.

For example, there’s another class of disorders called the personality disorders. Among these are histrionic personality disorder and borderline personality disorder. In each, one of the symptoms is hypersexual behavior. If you look at the person’s entire presentation, one will often see the other symptoms of the personality disorder. But if one is paying attention only to the sex, ignoring everything else about the person, then one comes out saying, “Look at all the sex this person is having, I think it’s a sexual problem.”

My suspicion is that there are a small set of people who would be accurately called hypersexual, but others would be better diagnosed as having other disorders.

What percentage of the population does this disorder affect?
It’s difficult to come to a consensus over whether hypersexuality exists, and then how to define it. Different definitions lead to relatively larger or fewer people being captured into it. If someone attempts such a survey no doubt people will argue over the result because they disagree with how the survey defines the disorder.

For example, somebody in the gay community could be having sex with dozens of people a year. It would be perfectly typical among that person’s peer group and would have no negative effect on his or any other person’s life.

If a married heterosexual male does the same thing, we have a very different set of expectations of what’s typical. So he could be having the same amount of sex with the same number of partners but for him there might be a problem. A survey for amount of sex doesn’t always capture what’s going on.

One rarely hears in the media about women who suffer from hypersexual disorder. Why is this?
There are no formal surveys on it, but any sex researcher or clinician who sees these patients with any frequency all say the same thing: it’s a very strongly male phenomenon. Conversely there’s another disorder called hyposexuality where the person has no sex drive. Women are overrepresented in this group.

Some people have suggested that behaviours once considered character flaws are now being defined as mental illnesses. What do you think of this observation?
I’ve seen a lot of people use the term “sex addiction” for a lot of different reasons. It’s very easy to imagine that someone would use the term to curry favour with the public, with the media or during a divorce, but this is hardly the only diagnosis that this happens to. People blame many different kinds of moral failings on many different things. But we also want to be very careful and not make the opposite mistake. Just because there are people who abuse the term and the concept, doesn’t mean that there’s no such thing.

It may be the same critics who also say that by including more problems in the DSM-V, drug companies simply gain the opportunity to sell more drugs. What’s your opinion of this?
It’s entirely true that diagnoses get added but that doesn’t necessarily mean that more people are getting diagnosed. It often means that we know more about a particular disorder and are able to more accurately diagnose people as one subtype or another. It’s the same number of people being diagnosed, but now we have a finer grain analysis of what we’re doing.

Although I share the public’s cynicism over how corporate interests can influence science or clinical practice, we don’t want to over-correct either. The answer is in the science. It’s always worth asking the question, is there a bias here somewhere? But I think it’s a mistake when people won’t take no for an answer.


Reader Comments

# 1
Posted by Abraham L. Halpern MD%201952 on August 7th, 2010 @ 9:16 am

Commentary on proposed DSM-V “hypersexual disorder” diagnosis (updated May 17, 2010)

The intent of this Commentary is to discuss one of the “Criteria for Change in the Current Diagnostic Classification” (as stipulated in the Guidelines for Making Changes to DSM-V) that is lacking in the Sexual and Gender Identity Disorders Work Group’s Rationale for its proposed diagnostic category, “Hypersexual Disorder* (with one of seven possible specifiers: Masturbation, Pornography, Sexual Behavior With Consenting Adults, Cybersex, Telephone Sex, Strip Clubs, or Other).” The criterion that is lacking in the Rationale is: “A discussion of possible unintended negative effects of its proposed change, if it is made, and a consideration of arguments against making the change should also be included.”

Let me start by asserting that specifically medicalizing (psychiatrizing) an aberrant sexual activity when there already exists a number of DSM diagnoses that more than adequately cover the subject is inimical to the best interests of the persons who experience the “disorder” and, more important, to society itself.

He (almost all “hypersexual” individuals are male) gets involved with a mental health therapist when he (1) becomes depressed (DSM-IV-TR 296.2, 296.3, 300.4, 311, 296.5, 296.80, 293.83, or 296.90) because of any number of reasons (e.g., contracting AIDS, charged with a crime, heavily addicted to a narcotic, etc.); (2) seeks help for a compulsive disorder (301.4), having frequently failed to resist the urge to engage in sexual activity; (3) is hospitalized for treatment of a psychotic disorder [e.g., 295.3), or is in prison for having committed a serious crime [the treatment being sought would be for hypersexual conduct prior to the institutionalization (because, obviously, hypersexual activity, at least with the opposite sex, is not ordinarily possible in these settings)]. A diagnosis of “Hypersexual Disorder” is entirely unnecessary because the criteria for the diagnoses mentioned are correctly met in any particular case.

Thus, hypersexually-behaving persons are not “a distinct group of people who need appropriate clinical attention.” In other words, “Hypersexual Disorder” is not “sufficiently distinct from other diagnoses to warrant being considered a separate diagnosis.” It does not contribute to “better conceptualization of diagnoses or to better assessment and treatment.”

The Work Group’s Rationale states: “”There is a significant research-associated need to consolidate an operational definition for such a condition so that research from varying theoretical perspectives can coalesce with a common set of criteria.” The Work Group also asserts that “A DSM-V-based empirically derived definition should significantly enhance research efforts to explore some of the additional diagnostic validators for which there are no current data.” Having had very little involvement in research, I discussed the Work Group’s position with an experienced research psychiatrist at Harvard Medical School. I asked: Can meaningful research be undertaken without varying theoretical perspectives coalescing with a common set of criteria? Can studies (by intelligent, ethical, well-trained and experienced researchers) to explore some additional diagnostic validators be undertaken without a DSM-V-based empirically derived definition? My consultant found no basis for the Work Group’s assertions that the special conditions are necessary to conduct research on hypersexuality. He emphasized that research that the Work Group deems necessary and important can be undertaken on the basis of hypotheses developed for research on psychological or psychiatric disorders, indeed for research in any field.

Although I am not suggesting that hypersexuality is even remotely as serious a problem as some of the sexual disorders described in DSM-IV-TR (especially 302.84), I would like to remind the DSM-V Work Group of the controversies in the APA during the Fall and winter of 1985 when “Sexual Assault Disorder,” “Paraphilic Rapism,” and “Paraphilic Coercive Disorder” were successively under consideration (by the Work Group to Revise DSM-III) for inclusion in the Paraphilias section of the chapter on Gender and Sexual Disorders. I do so because the type of problems that I believed would have occurred had a diagnosis such as “Sexual Assault Disorder” been included in the DSM, would without doubt, in my opinion, be experienced if the diagnosis of “Hypersexual Disorder” were included in DSM-V.

Much earlier, in the first draft of DSM-III in March, 1976, it was proposed (by the APA Task Force on Nomenclature and Statistics) that the rapist be officially recognized as a patient suffering from a mental disorder. The following operational (diagnostic) criteria for “Sexual assault disorder” were listed:

A. The fantasy of sexual assault is erotically exciting.
B. There is significant motivation to translate the exciting fantasy into action. The individual has committed an act of sexual assault, or inevitably will in the near future. If the act has been committed in the past, there is significant motivation to repeat it.

A DSM-III Conference was organized to review the proposals of the APA Task Force on Nomenclature and Statistics. The meeting was held on June 10-11, 1976, in St. Louis, Missouri, under the auspices of the Department of Psychiatry of the University of Missouri-Columbia School of Medicine. At this conference, as a representative of the American Academy of Psychiatry and the Law, I pointed out during the brief period allocated for a discussion of the proposed “Sexual assault disorder” diagnosis, that we were then facing a countrywide movement to stop the holding of the victim of rape as responsible for the crime and to focus instead on the criminal. I said that while at first blush the introduction of the classification of rape as being due to a “Sexual assault disorder” might seem harmless, it could be considered by some as a move on the part of the American Psychiatric Association to foster the decriminalization of rape. In the statement I submitted prior to the Conference, I wrote that classifying sexually assaultive behavior under a specific psychiatric diagnosis would have the effect of minimizing the wrongfulness of the perpetrator’s conduct and would open the door to even more widespread misuse of psychiatry than existed at that time. Prosecutors would seek to hospitalize offenders when there was insufficient evidence to convict, and defense attorneys would seek to hospitalize offenders when there was overwhelming evidence making conviction otherwise inevitable. Sexual assault, I pointed out, is not a disorder—it is a crime; DSM-III is a classification of mental disorders, not a classification of criminal conduct.

I recommended that “302.850 Sexual assault disorder” be excluded from DSM-III. In this recommendation I was joined by women’s groups throughout the country. Subsequent drafts of DSM-III (April 15, 1977, and January 15, 1978) did not include the diagnosis of “Sexual assault disorder,” and, of course, it did not appear in the 1980 edition of DSM-III.

The DSM-V Gender and Sexual Identity Disorders Work Group appears to be unaware that competent lawyers would have no problem advancing “Hypersexual Disorder” as a mitigating factor in the defense of a “hypersexual” felonious criminal defendant. More specifically, however, I believe that the proposed diagnoses of “Hypersexual Disorder (with specifier ‘Pornography’)” and “Hypersexual Disorder (with specifier ‘Cybersex’)” have ominous implications for forensic psychiatry and the criminal justice system. Were the diagnosis of “Hypersexual Disorder” included in DSM-V, arrestees charged with having committed violations of laws prohibiting either child pornography or cybersex involving solicitation of sex with a minor, and facing long periods of imprisonment, could easily be coached to claim that they “suffer” from at least four of the symptoms listed in Criterion A of the diagnoses “Hypersexual Disorder (with specifier ‘Pornography’)” or “Hypersexual Disorder (with specifier “Cybersex’),” respectively.

A “Cautionary Statement” [such as DSM-IV-TR’s “The purpose of DSM-IV is to provide clear descriptions of diagnostic categories in order to enable clinicians and investigators to diagnose, communicate about, study and treat people with various mental disorders. It is to be understood that inclusion here, for clinical and research purposes, of a diagnostic category such as Pathological Gambling or Pedophilia does not imply that the condition meets legal or other non-medical criteria for what constitutes mental disease, mental disorder, or mental disability. The clinical and scientific considerations involved in categorization of these conditions as mental disorders may not be wholly relevant to legal judgments, for example, that take into account such issues as individual responsibility, disability determination, and competency.“ (p. xxxvii)] is certain to be included in DSM-V. As has been the case with prior DSMs, such a cautionary statement would be totally disregarded by lawyers and judges—they would use DSM-V as the primary (more likely, only) authority in psychiatry (the “Bible” of psychiatry).

In conclusion, I believe that specifically medicalizing, psychologizing, or psychiatrizing an aberrant sexual activity (hypersexuality) in addition to the diagnostic categories already adopted and generally accepted by the psychiatric and psychological professions all over the world, is at best a useless redundancy and, at worst, an invitation to the anti-psychiatry movement, and others, to scorn and ridicule the American Psychiatric Association.

Abraham L. Halpern, M.D.
Professor Emeritus of Psychiatry,
New York Medical College;
Past president, American Academy
of Psychiatry and the Law

________________________________________________________
*Hypersexual Disorder (Proposed)

A. Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges, and sexual behavior in association with four or more of the following five criteria:

(1) Excessive time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior.

(2) Repetitively engaging in these sexual fantasies, urges, and behavior in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability).

(3) Repetitively engaging in sexual fantasies, urges, and behavior in response to stressful life events.

(4) Repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, and behavior.

(5) Repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others.

B. There is clinically significant person distress or impairment in social, occupational or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges, and behavior.

C. These sexual fantasies, urges and behavior are not due to direct physiological effects of exogenous substances (e.g., drugs of abuse or medications) or to Manic Episodes.

D. The person is at least 18 years of age.

Specify if:

Masturbation

Pornography

Sexual Behavior With Consenting Adults

Cybersex

Telephone Sex

Strip Clubs

Other

Specify if:

In Remission (During the Past Six Months. No Signs or Symptoms of the Disorder Were Present)

In a Controlled Environment

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