Does Compulsive Sexual Behavior Qualify as Addiction?

In recent years, the Diagnostic and Statistical Manual of Mental Disorders (the American Psychiatric Association’s “diagnostic bible”) has backed away from use of the term addiction. In fact, the most recent incarnation, released in early 2013, now calls alcoholism and drug addiction “Substance Use Disorder.” The APA’s motivation for this “anti-addiction” stance is more than a little bit perplexing, especially at a time when public acceptance and understanding of addiction (in all of its forms) is at an all-time high. Even more concerning is the fact that sexual addiction was excluded entirely from the latest DSM, with no explanation why.

Perhaps the APA simply thinks that sex can’t meet the criteria they’ve outlined for other addictions. As of now, the APA lists eleven potential indicators, and if any two or more are present then the individual in question qualifies for the diagnosis. These indicators include:

1. Loss of control (substance often taken in larger amounts or over a longer period than intended)
2. Unsuccessful efforts to cut down or quit
3. Excessive time spent obtaining the substance, using the substance, and recovering from use
4. Cravings (a strong desire to use the substance)
5. Recurrent use resulting in failures to meet obligations at school, work, or home
6. Continued use despite negative consequences
7. Because of use, important social, occupational, or recreational activities are reduced or given up
8. Recurrent use even when it is physically hazardous
9. Recurrent use even when it causes or exacerbates physical or psychological problems
10. Tolerance
11. Withdrawal

If we replace the word “substance” with the word “sex,” then we have eleven criteria for sex addiction (or “hypersexual disorder,” or “compulsive sexual behavior,” or whatever the APA might want to call this). And again, any two or more of these would qualify an individual for this particular diagnosis. And ALL of these are present in many (maybe even most) sexually addicted men and women. Much of the time the people arguing publicly against making sexual addiction an official APA diagnosis will point to “tolerance” and “withdrawal,” saying nobody ever develops tolerance to sex or experiences withdrawal when they don’t get enough. However, these individuals simply don’t understand sexual addiction, as sex addicts usually do experience both tolerance and withdrawal.

Tolerance, with all forms of addiction, occurs because the addict’s brain chemistry—mostly the dopamine rewards system—adjusts to continual overstimulation by producing less dopamine and/or reducing the number of dopamine receptors. To overcome this, addicts typically escalate their behavior. For instance, drug addicts take more of their drug of choice and/or they switch to a stronger drug. Similarly, sex addicts increase the time they spend engaging in compulsive sexual activity and/or they increase the intensity of that activity (looking at more graphic versions of porn, engaging in more intense sexual activity, etc.)

Sex addicts also experience withdrawal—usually evidenced by things like depression, anxiety, and irritability. Essentially, because their dopaminergic rewards system is used to constant stimulation, they react with cravings for sex when they are separated for any length of time from the “rush” that it provides. And they get mean and cranky or sad and morose if/when they can’t get that dopamine rush. Yes, these withdrawal symptoms are less overtly physical than, say, the delirium tremens that is sometimes experienced by chronic alcoholics and certain hardcore drug addicts, but in truth only a small percentage of newly sober substance abusers experience physical symptoms that severe. Much more often, their withdrawal is similar to that experienced by sex addicts.

It is clear, when looking at the “Use Disorder” criteria, that if sexual activity has spiraled out of control and is resulting in negative consequences, it DOES meet the APA’s standards for addiction. Why the APA has chosen to ignore this fact, especially in today’s increasingly “addiction-informed” world, is a mystery. Unfortunately, this mystery is unlikely to be solved any time soon. In the interim, addiction treatment specialists can rely on the more inclusive diagnostic criteria recommended by other professional organizations, including the American Society for Addiction Medicine’s definition of addiction.