The must of lust discussed: Why isn’t sex addiction in the DSM-5?

Please note: A shorter and slightly different version of this blog first appeared on addiction.com

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 behaviour 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 behavioural addiction in the DSM-5, there is now no theoretical reason why other behavioural 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 behaviour that significantly deviates from society’s norms. The most conventional attack on sex addiction is a variation on the position outlined in my introduction (i.e., 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 behaviour is classed as an addiction it undermines individuals’ responsibility for their behaviour (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 every day 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 behaviour’, ‘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) 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 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 where they were bombarded with sexual advances from other individuals and 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 claims 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. Out 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 behavioural 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 hardcore pornography to a self-admitted pornography addict while participating in 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 behaviour 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 standalone category.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Dhuffar, M. & Griffiths, M.D. (2014). Understanding the role of shame and its consequences in female hypersexual behaviours: A pilot study. Journal of Behavioural Addictions, 3, 231–237.

Dhuffar, M. & Griffiths, M.D. (2015). A systematic review of online sex addiction and clinical treatments using CONSORT evaluation. Current Addiction Reports, DOI 10.1007/s40429-015-0055-x

Goodman, A. (1992). Sexual addiction: Designation and treatment. Journal of Sex and Marital Therapy, 18, 303-314.

Griffiths, M.D. (2000). Excessive internet use: Implications for sexual behavior. CyberPsychology and Behavior, 3, 537-552.

Griffiths, M.D. (2001). Sex on the internet: Observations and implications for sex addiction. Journal of Sex Research, 38, 333-342.

Griffiths, M.D. (2001). Addicted to love: The psychology of sex addiction. Psychology Review, 8, 20-23.

Griffiths, M.D. (2010). Addicted to sex? Psychology Review, 16(1), 27-29.

Griffiths, M.D. (2012). Internet sex addiction: A review of empirical research. Addiction Research and Theory, 20, 111-124.

Griffiths, M.D. & Dhuffar, M. (2014). Treatment of sexual addiction within the British National Health Service. International Journal of Mental Health and Addiction, 12, 561-571.

Kafka, M. P. (2010). Hypersexual disorder: A proposed diagnosis for DSM-V. Archives of Sexual Behavior, 39, 377–400.

Orford, J. (2001). Excessive sexuality. In J. Orford, Excessive Appetites: A Psychological View of the Addictions. Chichester: Wiley.