Sex addiction divides mental health experts

Sex addiction talk seems to be everywhere. But mental health experts are split on what underlies such behavior.

The American Psychiatric Association has proposed that out-of-control sexual appetites be included as a diagnosis in the next edition of the psychiatrists' bible, the "Diagnostic and Statistical Manual of Mental Disorders," to be published in 2013.

Unlike compulsive gambling, which also is proposed for addition to the new DSM (to be called DSM-5), the proposed diagnosis -- hypersexual disorder -- stops short of categorizing the problem as an addiction, and for a reason.

"If we are looking at a disorder, it's not clear what that disorder is," said Michael Miner, a professor of family medicine and community health at the University of Minnesota who advised the DSM-5 committee on sexual disorders. "There is not an agreed-upon name. The research is in its infancy."

Patterns of extreme sexual acting out are described variously by therapists as an addiction, as a type of obsessive-compulsive disorder or as a symptom of another psychiatric illness, such as depression.

The lines specialists draw between what is sexually normal or abnormal have long been in flux. Some behaviors, such as pedophilia, are almost universally considered abnormal and have been described in the DSM for decades. Homosexuality was once considered deviant, but that reference was dropped from the DSM decades ago.

Therapists who see patients -- mostly men -- with problems caused by repetitive sexual behaviors, whether sex with consenting adults, pornography or cyber-sex, said the addition of a hypersexual behavior category was long overdue.

"There is no doubt in my mind that this condition exists and that it's serious," said Dr. Martin P. Kafka, an associate clinical professor of psychiatry at Harvard University who was a member of the DSM-5 work group on sexual disorders.

"There are definitely men who are consumed by porn or consumed by sex with consenting adults -- who have multiple affairs or multiple prostitutes. The consequences associated with this behavior are very significant, including divorce, pregnancy" and sexually transmitted disease, he said.

Some studies suggest that hypersexual behavior is indeed similar to an addiction, akin to the loss of control that seizes compulsive gamblers or shoppers.

For example, in a 1997 survey of 53 self-identified sex addicts in a 12-step recovery program, 98 percent said they had three or more withdrawal symptoms, 94 percent that they had tried unsuccessfully to control their behavior and 92 percent that they spent more time engaging in sexual behavior than they intended to.

In addition, screening tests designed for sexually addicted individuals have also been shown to accurately identify people with substance abuse problems, implying that the disorders have similarities.

Based on the addiction model, several sex addiction treatment centers have opened in recent years -- including Pine Grove in Hattiesburg, Miss., where rumors have placed Woods. Twelve-step programs, often the foundation of substance abuse treatment, are a staple of such facilities.

But they may not reach far enough, Kafka said. Many patients with hypersexual behavior relapse after 12-step programs, he said, because they haven't addressed other issues in their lives. He believes that certain moods or psychiatric conditions cause sexual behavior to become disinhibited and abnormal.

In a 2004 study of 31 self-defined sex addicts, for example, researchers at the Kinsey Institute for Research in Sex, Gender and Reproduction at Indiana University found that most of the individuals had an increased interest in sex when they were in depressed or anxious emotional states.

The ramped-up sexual behavior may be linked to changes in levels of key brain chemicals, such as serotonin, that occur when people experience mood disorders, some scientists think. These chemical changes might lift sexual inhibitions.

Impulsivity scores are also higher in sexually overcharged men, Miner and colleagues found in a study comparing eight men with compulsive sexual behavior to a control group.

The report, published in November in the journal Psychiatry Research, was one of the few studies to examine the brain physiology of such individuals. It showed that the hypersexual men had distinct patterns of activity in the frontal lobe region of the brain. The pattern, however, did not match that of patients diagnosed with other kinds of impulse control problems.

Maureen Canning, director of the sexual disorders program at the Meadows treatment center in Wickenburg, Ariz., has another theory.

Based on anecdotal experience, she said, she believes that trauma in childhood, such as sexual abuse or witnessing of sexual behavior, disrupts normal development and drives hypersexuality in adulthood.

"When these children grow up ... they become obsessed about correcting the trauma," said Canning, author of the 2008 book "Lust, Anger, Love: Understanding Sexual Addiction and the Road to Healthy Intimacy."

Attempting to understand what causes hypersexual behavior goes beyond curiosity: It lies at the heart of crafting effective treatments. But there are few studies on what works, Kafka said.

Meanwhile, some outspoken critics doubt that hypersexual behavior is a disorder at all. They argue against creating a label that can stigmatize people or provide excuses for what is plain poor conduct.

It's alarming "for a group of psychiatrists to try to legislate how much sex we can enjoy before we're labeled mentally ill," said Christopher Lane, a Northwestern University literature professor and author of a 2007 book criticizing mental health professionals for ever-expanding ideas of what constitutes abnormal behavior.

Lane suggested that the rush to reclassify some behaviors as treatable conditions was driven in part by business interests: Treatment centers pop up. The pharmaceutical industry offers pills as remedies.

What is out-of-bounds sexual activity varies by culture, Miner said.

"Sex in the United States is a very odd phenomenon. We are probably one of the more sexualized societies in the world and also one of the most puritanical," he said. "You wonder, if Tiger Woods was a French golfer, whether this ... would have been such a big deal."
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ABOUT HYPERSEXUAL DISORDER

The proposed addition to the Diagnostic and Statistical Manual of Mental Disorders involves several key symptoms.

Psychiatrists have proposed adding hypersexual disorder to the next edition of the "Diagnostic and Statistical Manual of Mental Disorders." A description of the disorder includes having four or more of the following criteria over at least six months. The symptoms must be severe and not caused by something else, such as drug abuse or medication.

A great deal of time is consumed by sexual fantasies and urges and by planning for and engaging in sexual behavior.

Repetitively engaging in this behavior in response to certain moods, such as anxiety or depression.

Repetitively engaging in this behavior in response to stressful life events.

Repetitive but unsuccessful efforts to control or reduce the behavior.

Repetitively engaging in the behavior while disregarding the risk for physical or emotional harm to self or others.

Source: Times staff reports; DSM-5 proposed revision, American Psychiatric Association.

More information: (c) 2010, Los Angeles Times.
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