Why Isn’t Sex Addiction in the DSM-5?

Sex addiction appears to be a highly controversial area among both the general public and those who work in the addiction field. Some psychologists adhere to the position that unless the behavior involves the ingestion of a psychoactive substance (e.g., alcohol, nicotine, cocaine, heroin), then it can’t really be considered an addiction. But I’m not one of them. If it were up to me, I would have given serious consideration to including sex addiction in the latest (fifth) edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Given that “gambling disorder” was reclassified from a disorder of impulse control to a behavioral addiction in the DSM-5, there is now no theoretical reason why other behavioral addictions can’t be added in the years to come. So why wasn’t sex addiction included in the latest DSM-5? Here are some possible reasons:

Some researchers think that sex addiction just doesn’t exist (for moral and theoretical reasons): Many scholars have attacked the whole concept of sex addiction, saying it is a complete myth. It’s not hard to see why, as many of the claims appear to have good face validity. Many sociologists would argue that “sex addiction” is little more than a label for sexual behavior that significantly deviates from society’s norms. The most conventional attack on sex addiction is a variation on the position outlined in my introductory post to this blog (that “addiction” is a physiological condition caused by ingestion of physiological substances and must therefore be defined physiologically). There are also attacks on more moral grounds, with people saying that if excessive sexual behavior is classed as an addiction it undermines individuals’ responsibility for their behavior (although this argument could be said of almost any addiction).

The word “addiction” has become meaningless: There are also those researchers within the social sciences who claim that the everyday use of the word “addiction” has rendered the term meaningless (such as people saying that their favorite television show is “addictive viewing,” or that certain books are “addictive reading”). Related to this is that those that work in the field don’t agree on what the disorder (e.g., “sex addiction,” “sexual addiction,” “hypersexuality disorder,” “compulsive sexual behavior,” “pornography addiction,” etc.) should be called and whether it is a syndrome (i.e., a group of symptoms that consistently occur together, or a condition characterized by a set of associated symptoms) or whether there are many different sub-types (pathological promiscuity, compulsive masturbation, etc.).

There is a lack of empirical evidence about sex addiction: One of the main reasons that sex addiction is not yet included in the DSM-5 is that the empirical research in the area is relatively weak. Although there has been a lot of research, there has never been any nationally representative prevalence surveys of sex addiction using validated addiction criteria, and a lot of research studies are based upon those people who turn up for treatment. Like Internet Gaming Disorder (which is now in the appendix of the DSM-5), sex addiction (or, more likely, “Hypersexual Disorder”’) will not be included as a separate mental disorder until the (i) defining features of sex addiction have been identified, (ii) reliability and validity of specific sex addiction criteria have been obtained cross-culturally, (iii) prevalence rates of sex addiction have been determined in representative epidemiological samples across the world and (iv) the etiology and associated biological features of sex addiction have been evaluated.

The term “sex addiction” is used an excuse to justify infidelity: One of the reasons why sex addiction may not be taken seriously is that the term is often used by high-profile celebrities as an excuse by those individuals who have been sexually unfaithful to their partners (e.g., Tiger Woods, Michael Douglas, David Duchovny, Russell Brand). In some of these cases, sex addiction is used to justify the individual’s serial infidelity. This is what social psychologists refer to as a “functional attribution.” For instance, the golfer Tiger Woods claimed an addiction to sex after his wife found out that he had had many sexual relationships during their marriage. If his wife had never found out, I doubt whether Woods would have claimed he was addicted to sex. I would argue that many celebrities are in a position in which they’re bombarded with sexual advances and they succumbed. But how many people wouldn’t do the same thing if they had the opportunity? It becomes a problem only when you’re discovered, when it’s in danger of harming the celebrity’s brand image.

The evidence for sex addiction is inflated by those with a vested interest: One of the real issues in the field of sex addiction is that we really have no idea of how many people genuinely experience sex addiction. Sex addiction specialists like Patrick Carnes claim that up to 6% of all adults are addicted to sex. If this was really the case I would expect there to be sex addiction clinics and self-help support groups in every major city across the world – but that isn’t the case. However, that doesn’t mean sex addiction doesn’t exist, only that the size of the problem isn’t on the scale that Carnes suggests. Coupled with this is that those therapists that treat sex addiction have a vested interest. Put simply, there are many therapists worldwide who make a living out of treating the disorder. Getting the disorder recognized by leading psychological and psychiatric organizations (e.g., American Psychiatric Association, World Health Organization) legitimizes the work of sex addiction counselors and therapists so it is not surprising when such individuals claim how widespread the disorder is.

There may of course be other reasons why sex addiction is not considered a genuine disorder. Compared to behavioral addictions like gambling disorder, the empirical evidence base is weak. There is little in the way of neurobiological research (increasingly seen as “gold standard” research when it comes to legitimizing addictions as genuine). But carrying out research on those who claim to have sex addiction can face ethical problems. For instance, is it ethical to show hard-core pornography to a self-admitted pornography addict during a brain neuroimaging experiment? Is the viewing of such material likely to stimulate and enhance the individual’s sexual urges and result in a relapse following the experiment?

There are also issues surrounding cultural norms. The normality and abnormality of sexual behavior lies on a continuum, but what is considered normal and appropriate in one culture may not be viewed similarly in another (what is often referred to by sociologists as “normative ambiguity”). Personally, I believe that sex addiction is a reality, but that it affects a small minority of individuals. However, many sex therapists claim it is on the increase, particularly because the Internet has made sexual material so easy to access. Maybe if sex addiction does eventually make it into future editions of the DSM, it will be one of the sub-categories of Internet Addiction Disorder rather than a stand-alone category.

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    5 Responses to Why Isn’t Sex Addiction in the DSM-5?

    1. Avatar
      irvsails January 8, 2016 at 7:47 am #

      i do not agree with with the concept that sex addiction should not be categorized. Yes, some people label themselves as sex addicts and probably not just as some would consider themselves alcoholic and probably aren’t. Sex addiction goes beyond the act of sex. Not everyone who has sex with multiple partners is a sex addict but a sex addict may be having sex with multiple partners if that makes any sense. More is explained on my blog onsexaddiction.net

    2. Avatar
      John Johnson February 26, 2016 at 8:53 pm #

      Maybe the reason why sexual addiction is not in the DSM 5 is more political than clinical. The APA at one time claimed that homosexuality was a mental disorder and eventually had to recant their position. Because sexuality is a controversial topic, I suspect the APA committee does not want to take a stand on it. Meanwhile, they recognize that internet gaming is a problem, eating too much is a problem, not eating enough is a problem, bingeing and purging is a problem, gambling is a problem, excessive use of alcohol, tobacco, caffeine, cannabis, prescription drugs, and illicit drugs are all a problem. But excessive sexuality is not a problem. You don’t know crap about sexual addiction Mark. You are not even qualified to write this article.

    3. Avatar
      Larry Salberg March 11, 2016 at 8:43 am #

      Something left out of this hypothesis as to why Sexual Addiction was left out if DSM-5 is two-fold:

      1. History of the DSM – remember that homosexuality was once a mental disorder in earlier editions of the DSM and, at the time, was truly viewed as a sickness.

      2. Political Correctness – If Sexual Addiction were to be added, what then are it’s boundaries? Considering the DSM’s history (see #1), it might it be construed to be a bit too close to boundaries and behaviors of the gay community, typically notorious for high-risk-taking and more frequent sexual behaviors? What, then, might distinguish between the two? Gender preference only?

      I’m leaning towards these two reasons, perhaps in combination with the author’s suggestions, as the more likely rationale that the DSM “powers that be” just didn’t want to touch this one due to possible “hypocrisy” from its earlier stances.

    4. Avatar
      Dean Rosen Psy.D. March 28, 2016 at 1:00 pm #

      I take one issue with your blog posting, about the celebrities taking on the label of sexual addict only after they have been caught. I have been treating sexual addiction for 30 years and have seen at least 200-300 patients. No one, and I mean no one, has ever sought treatment with me before they were discovered by their wife, employer or the police. This does not mean it isn’t a real problem. It means that the shame of the disorder and the denial mechanisms used to continue the behavior prevent people from seeking any help to stop it as long as no one knows it is occurring.

    5. Avatar
      colette October 14, 2016 at 2:56 pm #

      I would like to weigh in on this discussion in a little bit different way. The DSM-5 does however consider personality Disorders. Maybe sex addiction fits under one of the following disorders.

      What do you call someone who fits the criteria below, with sex being the fuel that ignites? A sociopath a psychopath or a sex addict? Take for example someone who continually pays for sex, knowing it is a crime. Prostitution in the US is a crime, and so the behavior of a sex addict often engages in behavior that may lead to their arrest. Oh, I should add that those who purchase, or I should say rent the humanity of another person without remorse, or caring, to that persons well being, is violating the rights of another. Dean is absolutely correct rarely do sex addicts come forward unless caught by someone, Yes, usually a wife or partner. Even when they are caught they will habitually lie, even if the evidence is right in front of them. Sex addicts, are masters of manipulation telling those around them anything, fanciful or not, to continue the behavior. Not just hurting those around them but leaving them like war victims within their wake. Not caring if their action cause their partners or anyone else trauma that many time is so overwhelming it truly is PTSD. Sex addict study the behavior of those they interact with and like chameleons change with the environment they find themselves in. Sex addicts exhibit behavior of those considered unethical, immoral, irresponsible, or in violation of social norms and expectations. Now we can argue as to whether sex addiction is rooted in environmental causes, genetically based. I’m sure there are elements of both. Sex addicts fit into almost every category if not all listed below. Now Dean, correct me if I am wrong but is this not what you see with most of the clients that you treat for sex addiction?

      1. Callous unconcern for the feelings of others.

      2. Gross and persistent attitude of irresponsibility and disregard for social norms, and obligations
      3. Incapacity to maintain enduring relationships, though having no difficulty in establishing them.

      4. Very low tolerance to frustration, a low threshold for discharge of aggression, including violence.

      5. Incapacity to experience guilt or to profit from experience, particularly punishment.

      5. Markedly prone to blame others or to offer plausible rationalization for the behavior that has brought the person into conflict with society.

      DSM-5 Category: Personality Disorders
      APD (Antisocial Personality Disorder) is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), diagnosis assigned to individuals who habitually violate the rights of others without remorse (American Psychiatric Association, 2013). People with Antisocial Personality Disorder may be habitual criminals, or engage in behavior which would be grounds for criminal arrest and prosecution, or they may engage in behaviors which skirt the edges of the law, or manipulate and hurt others in non-criminal ways which are widely regarded as unethical, immoral, irresponsible, or in violation of social norms and expectations. The terms psychopathy or sociopathy are also used, in some contexts synonymously, in others, sociopath is differentiated from a psychopath, in that a sociopathy is rooted in environmental causes, while psychopathy is genetically based.

      I have a hard time with the comment about, what is the norm in one culture is not necessarily the norm in another, so sex addiction is not so easily defined. If you would ask those that find themselves victims of a sex addicts behavior in any culture what their experience may be. I think their answers would generaly be the same, even if they do not have the ability to publicly say it. I have no clinical research, just human observation through listening, talking ,and interacting with sex addicts and those who find themselves partners or family of sex addicts. So, my question is, if the DSM-5 Category: Personality Disorders is clarified as an illness. Why then, is sex addiction so difficult to classify as an illness. As I see it there are very subtle differences at best.

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