Too Much or Too Little: DSM-V’s Gray Area on Sex Addiction

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This week, with the release of the DSM-V, the latest edition of the psychiatric bible that defines and diagnoses mental-health disorders, experts thought we’d finally get some answers about who’s just on the extreme end of the horny spectrum and who’s got an actual clinical problem. The term “sexual addiction” first showed up in the DSM-III in 1980, but was removed in the 1994 edition owing to lack of research. Now it’s back, but only mentioned in passing. The DSM-V doesn’t contain diagnostic criteria or treatment suggestions for sex addiction. In a professional manual that’s already controversial, the sex sections are subject to extra debate. In an overview of the DSM-V changes, the American Psychiatric Association offers a caveat to the section on sexual disorders: “Research suggests that sexual response is not always a linear, uniform process and that the distinction between certain phases (e.g., desire and arousal) may be artificial.” In other words: Even though you’re reading a book that’s designed to categorize and establish criteria for sexual disorders, aspects of sexuality don’t lend themselves to categorization. Okay, then.

Although the DSM-V will not include a full entry on hypersexuality — the clinical term for sex addiction — it will be listed among the conditions that require more research. “Many of us were hoping that there was going to be a category that recognizes the problem of impulsive and compulsive sexual behavior,” Dr. Eli Coleman, a psychologist, professor, and director of the program in human sexuality at the University of Minnesota Medical School, told me yesterday, the day the book was released. “But that was not included in this version. And I don’t know all of the reasons it wasn’t, but getting new categories included is difficult and needs to be supported by quite a bit of research.”

An official DSM classification would have clarified that sex addiction is a real disorder and not just a Hollywood punch line — or, perhaps more accurately, an escape hatch — as it’s become known. When a celebrity (usually male) is caught with his pants around his ankles, he typically announces he’ll be seeing a therapist and sometimes even does a stint in rehab to ceremoniously deal with his addiction to sex. Tiger Woods. David Duchovny. Charlie Sheen. Anthony Weiner. Many of the biggest male meltdowns in recent years have ended with a stint in the sex clink. Professional sex advisor Dr. Drew Pinsky even had a short-lived 2009 show on VH1 called Sex Rehab With Dr. Drew, a sort of cross between his recent Celebrity Rehab and nostalgic Loveline. Apparently sex addiction is so rampant that it deserved its own spinoff.

To those of us who don’t have to justify our bad behavior to the tabloids, sex addiction can look like merely a convenient excuse. While Americans generally don’t condone cheating, it seems absurd, almost Puritanical, to suggest that there’s an objectively quantifiable “right” amount of sex we should each be having, let alone “too much” sex. There’s a reason that “Don’t worry, you’re normal” is a constant refrain of sex-ed teachers: Sexual appetite varies from person to person, just like other sexual preferences and behavior, and even individuals’ sex drives can fluctuate over the course of a month or a year or a lifetime depending on partners and circumstances and hormones.

But for professionals like Coleman and other sex-addiction believers, the condition is defined in relation to mental health and happiness rather than empirical quantification. “Many people are skeptical about the idea of what I like to call “sexy addiction,” thinking it a spurious notion, invented primarily to help Hollywood film stars evade responsibility for their priapic excesses,” British comedian and self-professed sex addict Russell Brand writes in his memoir, My Booky Wook. “But I reckon there is such a thing. Addiction, by definition, is a compulsive behaviour that you cannot control or relinquish, in spite of its destructive consequences. And if my life proves nothing else, it demonstrates that this formula can be applied to sex just as easily as it can be to drugs or alcohol, both of which I know more than a bit about.”

Sex addiction is especially fraught in that regard. It’s tough to research because you can’t tell just by someone’s behavior — by counting the number of sexual partners, say — whether they’ve got a sex addiction. You’ve got to delve into their psyche and ask whether their desire for sex is harming them and affecting other areas of their life.

Then there’s the other end of the spectrum, or hypoactive sexual-desire disorder, or low sex drive. The DSM-V includes a gender-specific dysfunction, female sexual interest/arousal disorder, which is a jargony way of describing women who don’t ever crave sex and can’t get wet (or what science calls “lubrication-swelling response”). On the heels of this news, Sunday’s New York Times Magazine features an article about Lybrido, a pill that aims to amp up women’s sexual urges by targeting psychological issues. “Viagra meddles with the arteries; it causes physical shifts that allow the penis to rise,” writes Daniel Bergner, the article’s author. “A female-desire drug would be something else. It would adjust the primal and executive regions of the brain. It would reach into the psyche.”

And there it is again: The notion that desire for sex — whether it’s deemed too high or too low or juuuust right — is more about psychology than biology. In particular, women’s psychology. Even though anyone can suffer from lack of sexual desire, pharmaceutical researchers and, consequently, the Times article, frame it as more or less a women’s problem. “Lack of lust, when it creates emotional distress, meets the psychiatric profession’s clinical criteria for H.S.D.D., or hypoactive sexual-desire disorder,” according to the Times. “Researchers have set its prevalence among women between the ages of about 20 and 60 at between 10 and 15 percent. When you count the women who don’t quite meet the elaborate clinical threshold, the rate rises to around 30 percent.”

Contrast this with all of those male celebrities making headlines for wanting too much sex, and it’s all starting to feel very stereotypical. Men who are too hot; women who are too cold. “I still think that the sexual dysfunctions were created and recognized out of the sexual revolution,” Coleman says. “We started to recognize that more repressive attitudes were causing people to have difficulties functioning, and kind of overthrew the Victorian attitude that good people were not sexual. If anything, I feel that there’s some concern that labeling strong sexual desire as problematic would be potentially going back to those moralistic and puritanical views.”

What’s tricky is that defining problematic behavior — which is what the DSM aims to do for clinicians, researchers, lawmakers, and insurance companies when the American Psychiatric Association updates it about once a decade — also tends to define what’s “normal” by contrast. And as the popular interpretations of the new DSM start to disperse through the media, those definitions of normal tend to get reified without ever being put in concrete terms. Anecdotally, the Times article tells us that women who suffer from hyposexuality don’t even desire sex once a week but perform it like a religious wifely duty. So we infer that “normal” women are feeling horny more often than that. Anecdotally, sex addict Russell Brand has said that, at the peak of his addiction, he had ten or more regular sex partners, plus the occasional sex worker and bar hookup. So we infer that having fewer than ten regular sex partners is the norm. It may indeed be true that the average woman wants sex more than once a week and the average man does not have double-digit partners at any given time.

But “normal” isn’t defined by behavior, as Coleman pointed out, it’s defined by the psychological effect it has. So if you’re happy with ten partners or happy having sex once a month, either could be your norm. What matters is what makes you feel good.

Mandy Stadtmiller, a columnist for xoJane who identifies as a sex addict, was quick to correct an interviewer with the New Inquiry who asked her about sex sobriety. “My interpretation of the [Sex and Love Addicts Anonymous]  sobriety is that it’s you abiding by your bottom line. For me, my bottom line is not being intimate with someone where it’s destructive or unsafe or bad for me. I have a longtime friend who I’ll hook up with occasionally. Do I think he’s contributing to addiction? No. I have a friend in Overeater’s Anonymous and she doesn’t do flour and sugar because those are her triggers. For me, if I were to actually go on Craigslist and volunteer to be the woman in a three-way with two strangers who would murder me or something, that would not be abiding by my bottom line, triggering really unsafe, abusive patterns.” To figure out where the most common bottom line is, for not just Stadtmiller — who is apparently that rare woman who suffers from hypersexuality — but for all of us, requires more research.

“That’s one of the purposes of the diagnostic manual, is to really define clinical energies,” Coleman says. The exclusion of sex addiction has already spurred more research. “I think we’ll eventually see some kind of diagnostic category in future revisions.” Until then, it’s on each of us and our therapists to figure out what behavior is worthy of sex rehab and what’s simply getting off.

Too Much or Too Little: DSM-V’s Gray Area on Sex