In May 2013, the American Psychiatric Association will release the next version of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Interestingly, sex
addiction, despite significant attention from mainstream media, will be omitted from the manual.
This omission presents a challenge to clinicians who treat sex addiction, and researchers aiming to
further our understanding of the issue. This commentary outlines some of the reasons sex addiction
was not included in the DSM-V, including a ‘chicken-and-egg’ conundrum, which makes it
difficult to generate research without a clear diagnosis, and difficult to establish a definitive
diagnosis without a supportive body of research.
The American Psychiatric Association (APA) has spoken. Sex addiction will not—in any way,
shape or form—appear in DSM-V, the forthcoming iteration of the
Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2012). Rather than settling the issue, however,
this exclusion is likely to intensify the debate about whether sex addiction is a meaningful and
valid clinical category. There is, after all, big money in the treatment of such a titillating
psychosocial concern. Yet, the diffuse, and often contradictory, clinical conceptualizations of
problematically excessive sexual behavior are a bane to those who hope to develop clear, broadly
applicable treatment protocols. Additionally, the absence of a consensus definition is a logistical
problem for researchers who aim to secure funding and support for projects examining the
manifestation or treatment of hypersexuality. Without an accepted diagnosis, what exactly are we
proposing to study, and to treat?
In general, researchers agree that we have a very incomplete understanding of the causes of
hypersexuality (Kaplan and Krueger 2010). In fact, we
don’t have a unified conceptualization of what sex addiction is (Kingston and Firestone 2008), or whether it is even a real condition
(Moser 2011). This is, in large measure, due to a paucity of
high-quality empirical research. Interestingly, this relative scarcity, and the absence of a unified
theory of causation, presents a ‘chicken-and-egg’ dilemma. Without an accepted
diagnostic category, it is difficult to clearly formulate (much less secure funding for) research
that will further our understanding of an evidently real problem; however, in the absence of
research that establishes a clear clinical picture of sexual addiction, it is difficult to justify
any proposed diagnosis. Without empirical evidence, we can’t agree on a diagnosis; without a
diagnosis, we can’t get empirical evidence.
Many practitioners, however, are undeterred by the lack of an accepted diagnostic framework; and,
to the good fortune of sex addicts (or ‘sex addicts,’ if you prefer), many of these
clinicians are highly trained, highly skilled professionals. Yet, while it can hardly be said that
charlatanism is rampant in the field of sex addiction, it is clear that opportunism is a problem in
this treatment area. The popular media’s sensationalizing of celebrity ‘sex
addicts’ and dubiously credible reports of epidemic sexual compulsion serve as convenient
marketing tools for profit-driven ‘therapists’ with varyingly credible credentials.
Moreover, celebrities routinely offer tearful confessions of ‘sexual addiction’ as a
kind of public excuse for their transgressions, further publicizing, and perhaps legitimating, the
issue in the public’s view. From sports stars like Tiger Woods to film stars like Russell
Brand and government figures like Lord Laidlaw, role models have been thrust into the limelight of
celebrity sex addiction. Role models who happen to be—or who have at least been claimed to
be—sex addicts. A cynical observer might speculate that for both celebrities and
non-celebrities, ‘sex addiction’ is often used as an excuse when one’s sexual
indiscretions have been exposed. And indeed researchers have suggested that the diagnosis is applied
in a wide range of cases, from discovered infidelity to unconventional sexual tastes, to simple
dissonance between partners’ respective views of sexuality (Levine 2010).
The hazy diagnostic picture makes epidemiological estimates quite difficult. Researchers in the
U.S. have suggested an overall prevalence of 3–6 per cent amongst American adults, although
these figures are rather dated, and it is unclear exactly how they were determined in the first
place (Black 2000, Coleman
1992). Data—even speculative data—is even scarcer for the UK. We do know that men
are much more commonly ‘diagnosed’ as sex addicts, though we don’t know why. This
is one of the clear problems in such a research-scarce area.
In addition to the shortage of research data to clarify the epidemiological picture, or validate
a particular diagnostic framework (and, indeed, there have been many varyingly
divergent labels suggested), pragmatic concerns have been voiced. For instance, if a sexual
addiction category were included in the DSM, might it be used as a legal defense
for sexual crimes, like exhibitionism, or sexual assault? Interestingly, the latter concern did not
deter the APA from including ‘pedophilic disorder’ in DSM-V. While the
same legal concerns apply for both categories, a larger body of interdisciplinary research justifies
the inclusion of pedophilic disorder. Additionally, some aspects of pedophilic behavior—such
as contact with vulnerable underage populations, and the use of child pornography—are more
clearly entrenched in legal statute than many of the behaviors associated with sex
addiction—such as use of legal pornography, marital infidelity, and hazier legal areas such as
prostitution. Thus, the socio-political field further confounds researchers and clinicians already
frustrated by a shortage of research on sex addiction.
In my assessment, at least, it is quite clear that we need significantly more research on sex
addiction. Despite the skeptical, or anti-diagnostic, stance of some researchers (Moser 2011, Winters 2010), the
primary obstacles are logistic. Ours is an era where funding is increasingly limited, and a
substantial portion is allocated, understandably, to more quantifiably drastic health concerns and
‘proven earners’ where clear, tangible outcomes can be expected. Unsurprisingly,
it’s very difficult to secure funds for sex addiction research. Additionally, like other
sexual health concerns, there is shame associated with sexual addiction. If sex addiction is in some
measure symptomatic of a maladaptive response to difficult thoughts and feelings—and there is
good reason to think this is part of the clinical picture (Kafka 2010)—then sex addicts could be less equipped to manage and communicate
their experience, and less enthusiastic to participate in research than individuals with more
ideologically neutral health concerns. And, of course, the crux of my argument here is that the
absence of an accepted conceptual framework is a key factor. Researchers from all areas are likely
familiar with the challenge of securing funding for ill defined, or significantly contested,
research topics. It is very difficult to get money to study sex addiction without being able to say
definitively what it is.
So, what can we do? Part of the solution likely consists in the development of high-quality, but
small-scale research projects. As with anything, in the health sciences it is usually easier to
mobilize smaller resource pools, and secure more modest research grants. Smaller projects can also
be more feasibly hosted or sponsored by independent institutions and private clinics, and indeed
there are a number of researchers and practitioner-investigators conducting modestly sized but
important research projects. Obviously, smaller projects tend to be less scientifically convincing
than the big ones. But it’s a commendable, and necessary, start.
Another possibility is that drug companies, with their abundant research and development dollars,
may start funding research on treatment avenues. In fact, some creative physicians already prescribe
antidepressants in the SSRI family to treat sex addicts. It has long been known that SSRIs
incidentally affect sex drive and sexual responsiveness (for the latter reason, they are also
regularly used to treat premature ejaculation). It is not unreasonable to think that similar
compounds, or even the same drugs, could be approved for the treatment of sexual addiction. For the
time being, though, without an officially diagnosable pathology to treat, national health agencies
are unlikely to recertify off-label drug therapies for such a purpose.
Even if a drug company were to introduce a clinically efficacious treatment, this is ultimately
only a partial solution. In addition to the inevitable non-responders and ineligible patients, drug
therapies only address one facet of a multidimensional problem. Despite the availability of some
very thoughtful speculation and promising preliminary work, we really don’t know if sex
addiction has an exclusively, or even primarily, physiological pathway. Especially since the advent
of Viagra, many sex therapists have loudly decried the exclusive use of drug therapies, on the basis
that they fail to address the inevitable psychological and social dimensions of sexual problems. Sex
addiction is subject to the same concerns.
Ultimately, the problems associated with sex addiction research are much bigger than just sex
addiction. The sexual health disciplines are fractured, largely by sub-disciplinarily, and by the
endemic competition for resources, especially research dollars, that accompanies contemporary health
sciences research. Psychotherapists and psychological researchers often take a different tack from
bio-medical researchers, and clinicians often work in environments where interdisciplinary treatment
is limited to referral, rather than direct collaboration. It just so happens that these clinical and
research obstacles are particularly challenging for a diagnostic issue as inchoate as sex
addiction.
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