One of the unfortunate, but predictable, outcomes of the horrific Georgia shooting at the massage parlors is the rash of news articles talking about how Sex Addiction isn’t real. Most of what people are saying tends to focus on the lack of inclusion in the DMS-V and how sex addiction can be confused with moral incongruence. (Click here for a previously written post regarding moral incongruence)
At the moment, I do not have the time to write a full blown narrative regarding the research on sexual addiction that has been conducted since the publication of the DSM-V in 2013. I will, however, leave you with a few paragraphs regarding the topic that I recently included in a sentence mitigation report.
Diagnostic and Statistical Manual of Mental Disorders– V: (DSM-V)
In the current edition of the DSM, there is no stated mental disorder that encompasses the concept of sexual addiction, be that sexual addiction, sexual compulsivity, hypersexual disorder, etc. To simply negate a mental health phenomenon because it is not in a version of the DSM that is currently almost 8 years old is to negate both the history of the disorder with the DSM and the body of research that has been conducted since the DSM-V work group decided against including Hypersexual Disorder.
Prior to the publication of the newest edition of the DSM-V in 2013, the Sexual and Gender Identity Disorders Workgroup (Kafka, 2014) considered the inclusion of Hypersexual Disorder into the upcoming edition of the DSM. The suggested diagnostic criteria were as follows:
- 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 criteria:
- Excessive time is consumed by sexual fantasies and urges and by planning for and engaging sexual behavior.
- Repetitively engaging in these sexual fantasies, urges and behaviors in response to dysphoric mood states (e.g., anxiety, depression, boredom, and irritability).
- Repetitively engaging in these sexual fantasies, urges and behavior in response to stressful life events.
- Repetitive and unsuccessful attempts to control or significantly reduce the sexual urges, fantasies, and behavior.
- Repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others.
- There is clinically significant personal distress or impairment in social, occupational, or other important areas of functioning associated with the frequency and intensity of sexual fantasies, urges or behavior.
- These sexual fantasies, urges and behavior are not due to the direct physiological effects of exogenous substances (e.g., drugs of abuse or medication), a co-occurring general medical condition or to a manic episode.
- The person is at least 18 years of age.
Specify if masturbation, pornography, sexual behavior with consenting adults, cybersex, telephone sex and strip clubs.
It was ultimately decided that Hypersexual Disorder would not be included into the DSM-V. The main reasons cited for the lack of inclusion were concerns around diagnostic accuracy, moral and cultural confounds and a lack of research supporting the concept (Kafka, 2014).
In the nearly 8 years since the publication of the DSM-V, a vast body of scientific research in peer reviewed journals has been published seeking to understand the concept of sexual addiction and compulsivity which has also been termed hypersexuality.
A recent metanalysis was published by Grubbs et. al. (2020) that systematically reviewed the scientific research on the topic. Research on the topic, alternatively called sexual addiction, sexual compulsivity, hypersexuality, and compulsive sexual behavior began in the mid 1990’s. Research into the topic increased during the time that the DSM-V was in development. Research on the topic continues to expand. The Grubbs et. al. (2020) metanalysis included 371 papers published in peer reviewed scientific journals documenting the results of 471 individual scientific studies.
The Grubbs et. al. (2020) meta-analysis yielded several findings. On the negative side, the study found that there was a lack of rigorous outcomes studies for the treatment of Compulsive Sexual Behavior. Therefore, to date, there is no gold standard approach to treating the issue. The study did reveal that the Hypersexual Behavior Inventory (Reid et. al., 2011) is a well validated and clinically useful tool to assess Compulsive Sexual Behavior. The main finding pertinent to this case is that there is “clear evidence that CSB is a real phenomenon with clinical implications.” (Grubbs et. al., 2020, p 11)
International Classification of Diseases – 11 (ICD-11)
The ICD-11 is the international equivalent of the DSM-V in the United States. The International Statistical Classification of Diseases is published by the World Health Organization and its most recent version was published in 2019 (WHO, 2019). Like the DSM, prior to any condition being accepted into the ICD there is a process of extensive debate and consideration. The ICD-11 does include a diagnosis of Compulsive Sexual Behavior Disorder (CSBD) which is classified under impulse control disorders. The diagnostic criteria share some traits with the proposed DSM-V diagnostic criteria for Hypersexual Disorder.
The Diagnostic criteria for Compulsive Sexual Behavior Disorder (ICD-11)
Essential (required) features for compulsive sexual behavior disorder:
- A persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behavior, must be manifested by one or more of the following:
- Engaging in repetitive sexual activities has become a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities, or responsibilities.
- The person has made numerous unsuccessful efforts to control or significantly reduce the repetitive sexual behavior.
- The person continues to engage in repetitive sexual behavior despite adverse consequences (repeated relationship disruption, occupational consequences, negative impact on health, etc.).
- The person continues to engage in repetitive sexual behavior even when the individual derives little or no satisfaction from it.
- The pattern of failure to control intense sexual impulses or urges and resulting repetitive sexual behavior is manifested over an extended period of time (e.g., 6 months or more.)
- The pattern of repetitive sexual behavior causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning NOTE: Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges or behaviors is not enough to meet this criterion.
The inclusion of the rule out relating to erotic conflict or moral incongruence is a necessary criterion to address historical concerns about pathologizing sex with a label of addiction or compulsivity. Simply engaging in a sexual behavior that is non-normative or outside of a person’s religious or moral belief is not sufficient to diagnose Compulsive Sexual Behavior Disorder according to the ICD-11.
Bothe, B., Potenza, M.N., Griffiths, M.D., Kraus, S.W., Klein, V., Fuss, J., & Demetrovics, Z. (2020). Journal of Behavioral Addictions 9(2), 247-258.
Gola, M., Lewczuk, K., Potenza, M.N., Kingston, D.A., Grubbs, J.B., Stark, R. & Reid, R. (2020). What should be included in the criteria for compulsive sexual behavior disorder. Journal of Behavioral Addictions published online November 25, 2020.
Grubbs, J.A., Hoagland, K.C., Lee, B.N., Grant, J.T., Davison, P, Reid, R.C. & Kraus, S.W. (2020). Sexual Addiction 25 years on: A systematic and methodological review of empirical literature and an agenda for future research. Clinical Psychology Review (82), 1-15.
Kafka, M.P. (2014). What happened to hypersexual disorder? Archives of Sexual Behavior, 43(7), 1259-1261.
Reid, R.C., Garos, S. & Carpenter, B.N. Reliability, validity, and psychometric development of the hypersexual behavior inventory in an outpatient sample of men. Sexual Addiction and Compulsivity, 18(1), 30-51.