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.
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.