There has been a discussion in the media and mental health field about the appropriate diagnostic model and label for the set of problematic sexual behaviors that are frequently referred to as sexual addictions. In response, we, the Society for the Advancement of Sexual Health (SASH), wish to publicly articulate our position on the matter.
Having reviewed the available evidence, SASH is clear that there are several diagnostic models currently proposed (both formally and informally) and under investigation, all of which reflect an underlying clinical condition requiring dedicated assessment, and treatment. “Sexual Addiction” and “Pornography Addiction” are two such models. Additional models include “Hypersexual Disorder,” “Out of Control Sexual Behavior,” “Unspecified Impulse Control Disorder,” and “Sexual Compulsivity,” amongst others. A growing body of empirical research supports the serious clinical concerns on which these various models seek intervention.1 Among this empirical evidence are dozens of studies supplying neuroscience evidence consistent with the presence of addiction, primarily in Internet pornography users, but also in “sex addicts” generally. There is research evidence also supporting other diagnostic labels, such as “Hypersexual Disorder.”
Perhaps the issue of nomenclature is leading to confusion for some. We would like to take this opportunity to shed some light on that, and raise further concerns about diagnoses in this field.
Nomenclature and Diagnostic Classifications
Nomenclature changes over time. As mentioned above, many terms have been used to describe the phenomenon of problematic sexual behavior. Many of these terms overlap and some are used interchangeably. For example, although some people believe that sex addiction and pornography addiction should be referred to separately, others address them collectively as ‘sexual addiction.’ Some terms have become less popular over time for various reasons.
It is legitimate for our professional community to debate the most appropriate taxonomy and terminology, but there is no debate about the reality that there are people who struggle with sexual behavior disorders that cause them serious consequences. The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), issued in 2013, does not list alcoholism or drug addiction as diagnoses, but instead refers to them as “Substance Use Disorders.” Nevertheless, “addiction” remains the name most publicly identified with these conditions, despite the DSM-5’s carefully chosen terminology. Similarly, clients recognize that their sexual behavior has become uncontrollable and that they need treatment for what they themselves experience and label as their “addiction.” Almost all professionals--regardless of conceptual formulations--recognize that people may experience negative consequences related to their sexual urges, thoughts, or behaviors.
Some of those who have not been adequately educated in the various diagnostic and treatment models of problematic sexual behavior have intentionally or unintentionally promoted myths about its treatment in general and SASH’s position about it specifically. So let’s be clear:
SASH does not pathologize any consensual sexual behaviors or identities (fetishes, sexual orientation, gender identity, etc.). The focus is not about particular sexual behaviors or urges, but rather it is about individuals’ inability to exercise control when they choose.
SASH does not encourage therapists to be moralistic or judgmental about what is sex positive or negative for clients. Clients personally make the decision about what is sexually healthy for them. That is part of the treatment process.
SASH does not advocate for any particular model of treatment. It encourages the application and use of research-based therapies and interventions that are outcome driven. SASH also encourages multi-faceted treatment approaches, including trauma, psychodynamic, attachment, addiction, gestalt, narrative, and behavioral treatment models. Many members of SASH are sex therapists; others are sex addiction therapists. Some are both.
Empirical Evidence for the Addiction Diagnostic Label
The preponderance of the recent neuroscience research examining possible evidence of addiction-related brain changes in Internet pornography users points to substantial evidence of such changes. The game changer appears to be the new technology-saturated environment. Some experts observe that today's streaming pornography is potentially addictive.2 Others warn that streaming pornography may help explain non-organic, psychogenic sexual dysfunctions and abnormally low sexual desire in some users, whether or not they are addicted.3
When pornography viewing becomes problematic, however it may be labeled, (“Sex Addiction, “Out of Control Sexual Behavior” Disorder due to addictive behavior,” “Hypersexual Disorder,” “Compulsive Sexual Behavior,” etc.), it can be viewed as a mental health disorder. For example, consider the definition set out by clinical experts at the American Society of Addiction Medicine:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.4
Evolution of Diagnostic Manuals
The DSM-5 introduced Internet Gaming Disorder as a behavioral addiction disorder warranting further research5 but not any of the problematic sexual behavior models, even though an increasing weight of evidence supports the inclusion of this mental health struggle. The beta version of the ICD-11 proposes “Compulsive sexual behavior disorder” with “sex addiction” as a narrower term in the “Impulse control disorders” section, described as follows:6
SASH favors the inclusion of problematic sexual behaviors in both diagnostic manuals, depending on the etiologies of the particular disorders. There are a number of ways that the field of mental health may choose to accomplish this in the future. For example, there is research that lends support to the inclusion of “Internet pornography disorder” as a subtype of the ICD-11’s “Disorders due to substance use or addictive behaviours.”7 There is also evidence that some people develop problematic sexual behaviors due to pre-existing mental health disorders, childhood trauma and attachment struggles, or genetic predisposition.
As a forward-looking organization with experts across clinical and academic domains, SASH urges the diagnostic committees of both manuals to consider incorporating “diagnostic homes” for all of these sufferers of problematic sexual behaviors.
Though we actively advocate for rigorous scientific and clinical debate between various competing diagnostic models, our first duty is to help clients, regardless of the terminology chosen for their problematic sexual behavior. SASH is committed to engaging clinicians and researchers to help these individuals find the joy, happiness, and sexual health that they so desperately seek. We do so without judgment and with respect for racial, cultural, and sexual diversity. As an organization, we encourage sex-positive solutions to these problems. As clinicians, we encourage a sex-neutral position to allow our clients the ability to reflect and decide what is positive for them. Clinicians working with this population will likely benefit from training across multiple disciplines including, but not limited to, human sexuality, psychiatric illness, addiction, spirituality, pharmacology, biology, psychology, and neuroscience. We believe treatment efforts should strive to be informed by empirical research and best practices, while acknowledging such standards continue to evolve in this rapidly growing field.