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Sex Addiction: A Disease Or An Excuse?

Sex addiction, nymphomania or sexual compulsion might sound like the stuff of novels or over-hyped celebrity angst. Yet excessive sexual behaviors have been documented for over two centuries in American medical literature. In fact, one of the signers of the Declaration of Independence, Benjamin Rush, wrote about it in his book Medical Inquiries and Observations upon the Diseases of the Mind, the first textbook of mental illness in the U.S.

A lithograph of men and women dancing in a mental asylum, 1917. i i

Treatment for mental illness has come a long way from the days of simply throwing people in a "madhouse," like this 1917 lithograph shows. George Bellows/Library of Congress hide caption

itoggle caption George Bellows/Library of Congress
A lithograph of men and women dancing in a mental asylum, 1917.

Treatment for mental illness has come a long way from the days of simply throwing people in a "madhouse," like this 1917 lithograph shows.

George Bellows/Library of Congress

Rush wrote that sexual appetite, "when excessive, becomes a disease both of the body and mind." He also concluded that "promiscuous intercourse with the female sex" or excessive masturbation could cause impotence, dyspepsia, vertigo, dimness of sight, memory loss, and even death. (He didn't mention the risk of political downfall, loss of sponsorships, or inescapable media obsession.)

Still, even though excessive sexual behavior has been described for a long time, it has yet to be officially recognized by the psychiatrists' bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM). Instead, the category resides in the book's appendix.

Dr. Martin Kafka, a Harvard professor and psychiatrist at the med school's McLean hospital, and his colleagues are trying to push it out of that back-of-the book diagnostic "wastebasket." They're proposing that "hypersexual disorder" be added to the next edition of the DSM. Kafka says research over the last few decades supports that idea that these extreme sexual behaviors are symptoms of a mental disorder.

The problem goes beyond just having a lot of sex; it's when a person cannot stop engaging in things like promiscuity, porn, masturbation — and this behavior causes significant impairment and stress in the person's life. (It's worth noting that even the DSM struggles to actually define what a mental disorder is. The working definition is that it's a clinically recognized syndrome that causes serious distress or impairment of the person's ability to function.)

The proposed hypersexual disorder would be categorized alongside other sexual disorders, such as fetishistic disorder and exhibitionistic disorder.

Criteria for hypersexual disorder would include spending a lot of time consumed by sexual fantasies and repetitively engaging in these sexual fantasies in response to stress, anxiety, boredom or depression. The person also makes repeated but unsuccessful attempts to control the behavior, and engages in the behavior disregarding the risk of physical or emotional harm for himself or others. And, to be diagnosed with hypersexuality, this behavior would have to cause the person significant distress or impairment.

That last criterion is the kicker — the person needs to present with "clinically significant personal distress." And how do you measure that — as opposed to say, a politician who is caught sleeping with another woman and blames a sex addiction? Drawing the line between guilty indiscretions and an actual mental disorder has a lot of the public skeptical.

"It's not often a condition you can tell from afar," says Kafka. "The only way to know if it's a moral excuse or a real disorder takes knowing the person, the extent of the behaviors, have they tried to control it, what risks have they taken."

Kafka and the working group stops short of calling the sexual problem an addiction. He says the science just isn't there yet to prove that the behavior is addictive, that it operates the same way as, say, alcohol dependence. Addictions are defined by out-of-control drug use, cravings and activation of the brain's reward centers. There just hasn't been enough research to show that excessive sexual behavior works the same way as drug dependencies, says Dr. Charles O'Brien, the vice-chair of psychiatry at the University of Pennsylvania and director of UPenn's Center for Studies of Addiction.

With someone with extreme sexual behavior, he says, " if you show them porn, it does activate this part of the brain (associated with addiction), but we don't have any evidence that this is associated with a loss of control. In the case of an addict, the brain activation makes them want to go out and use the drug."

Instead, the proposed category would label the behavior as a disorder, more akin to anxiety or depression.

Even without an official category for hypersexuality, people do seek help for this kind of sex problem. Currently most people are treated with fairly standard addiction treatment, says Kafka, which might mean individual therapy or 12-step groups based on chemical dependence quitting programs. An NYT reporter noted that Tiger Woods public apology speech mirrored several steps of the common 12-step recovery program.

Does the treatment work? The scientific literature on treatment varies, says Kafka, and much more study is needed.

Typically, when a new mental disorder gets added into the DSM, its inclusion stimulates a good deal of research on the topic. If accepted, the new definition could help garner more scientific attention.

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