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Key points
- Sex addiction is a highly contested diagnostic label.
- Excessive sexual behavior may, or may not, be problematic, often depending on an individual's moral perceptions of it.
- Moral incongruence might be a better fit than the label of "sex addiction."
Another week, another sex addict. Or so it seems.
In the most recent case of a celebrity claiming 'sex addiction' in explaining their questionable behavior, actor James Franco has paid $2.2 million to settle a 2019 lawsuit brought by two women who attended his acting school. The suit claims that Franco duped the women into filming explicit sex scenes. He admitted having sex with his students and claims to have been in recovery from sex addiction since 2016.
The case raises the question of the status of 'sex addiction' as a psychological category. Let's explore.
Is 'Sex Addiction' a Valid Diagnosis?
'Addiction' designations are given to behaviors and substance use patterns that meet six criteria:
- Salience: The addictive behavior or substance is an important aspect of the individual's life.
- Mood modification: The addictive behavior or substance is used as a method of regulating emotion, with consumption or activity engagement being linked to a temporary improvement in affect.
- Tolerance: Increasing amounts of the addictive behavior or substance need to be engaged with or used in order to experience the desired effect.
- Withdrawal effects: Negative emotional or physical symptoms are experienced in response to not engaging with the addictive behavior or using the addictive substance.
- Conflict: Engaging with or using the addictive behavior or substance leads to interpersonal and occupational difficulties for the individual.
- Relapse: Attempts to stop engaging with or using the addictive behavior or substance are unsuccessful, leading to recurrence of problematic behavioral patterns that may be more severe than earlier bouts.
There are two key diagnostic manuals used by mental health professionals to make clinical decisions about the labels ascribed to patient presentations regarding sexual behavior. The American Psychiatric Association's Diagnostic and Statistical Manual (DSM), now in its fifth edition, used to refer to "distress about a pattern of repeated sexual conquests or other forms of nonparaphilic sexual addiction, involving a succession of people who exist only as things to be used," but this was removed in 2000. There were calls to include hypersexual behavior as a diagnostic category in the most recent edition, but these were eventually rejected due to a lack of evidence for producing reliable indicating criteria.
The International Classification of Diseases (ICD), published by the World Health Organization, does include a diagnosis of compulsive sexual behavior disorder:
Compulsive sexual behaviour disorder is characterised by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it. The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g., 6 months or more), and causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement.
This definition does appear to meet a number of the criteria for addiction. For example, sexual behavior becoming a central focus of an individual's life indicates salience. Neglecting health, personal care, other interests, and responsibilities indicates conflict. Recurrent unsuccessful attempts to reduce sexual behavior might indicate relapse processes. However, there are key aspects of the addiction definition that are not present in the description of compulsive sexual behavior disorder. For example, there is no suggestion that sexual behavior becomes more frequent, intense, or deviant over time (thus not meeting the tolerance indicator). There is also no suggestion in the definition that sex is used as a method of emotional regulation (thus not meeting the mood modification indicator).
There is also an argument to be made about the 'problematic' nature of compulsive sexual behavior. Whether the frequency of sexual behavior causes harm or distress might, to some degree, be dependent upon the individual's own evaluations of these indicators. In this sense, a pattern of sexual arousal or behavior might only be considered problematic at the level of the individual, rather than being designated as such as a diagnostic category.
The Moral Incongruence Argument
Of particular note in the ICD definition of compulsive sexual behavior disorder is the exclusion of a diagnosis if the cause of distress is linked to moral judgments of sexual behaviors, interests, or urges. This is important as it prevents diagnosis because of individual views about sexual behavior, with emerging evidence suggesting that this is precisely the driver of perceptions of 'sex addiction'.
This work has been driven by Joshua Grubbs, who has published a number of peer-reviewed papers showing how self-labeling as a 'sex addict' is driven in large part by an individual's level of religiosity and moral disapproval of sexual activity. Under this model, 'sex addiction' is not necessarily a description of excessive or problematic levels of sexual activity in terms of frequency, but is instead a label ascribed to sexual behavior that the individual finds morally wrong.
Linked to this is the emerging trend of describing potentially immoral sexual behavior (including high-profile incidents of sexual transgressions of the sort admitted by Franco) in the language of 'addiction'. The medicalization of sexual behavior, in the very limited circumstances in which we often see this process occur, might be understood to serve an important purpose of removing responsibility and excusing problematic behavior. In this context, an individual is thought to not be responsible (or, at least, to have mitigating circumstances) for engaging in problematic sexual behaviors because they are 'addicted'.
This highlights the importance of criticality in the reading of news items referring to 'sex addition' (and other forms of behavioral addiction). A consideration of the empirical literature and engaging with ongoing clinical debates about the validity of such labels may limit the extent to which such stories reflect real psychological conditions.
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