Hypersexuality`s exclusion from DSM leaves clinicians without anchor

This past week I officially learned that the diagnosis of “hypersexual disorder” will not be included in the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), to be published in 2013. It will not even be incorporated into the DSM-5 appendix as a potential diagnosis in need of further research. This lamentable decision has left me and many other reasonably minded, well-versed addiction and mental health professionals feeling frustrated, disappointed and angry.

Much of my frustration stems from the fact that the master’s- and PhD-level clinicians who are seeing and treating sexually addicted clients have little to no input in the American Psychiatric Association’s (APA’s) decision-making process. The process of deciding on diagnosis appears to be far more political and insular than genuinely organized to help clinicians in the field who are actually treating individuals with real-life problems.

Does the field of sexual addiction require more research before its inclusion in the DSM as a stand-alone diagnosis? Yes. Even the author of the diagnosis, Martin P. Kafka, MD, of Harvard Medical School, agrees that the area needs more study before full inclusion. But to not even be part of the appendix means that there is no avenue for such research literature to be established, as part of what drives funding for National Institutes of Health (NIH) and university-based grants is the language that appears (and doesn’t appear) in the DSM—especially in the appendix.

I have written about our need for research in numerous articles, blogs and social media posts over the past 18 years. Those of us working in the field know beyond a shadow of a doubt that sexual addiction is a real and debilitating psychological disorder. We also know that the research paper and proposed hypersexual disorder definition that Kafka prepared for and submitted to the APA was a superb piece of work, and that his delineated hypersexual disorder criteria were right on target.

Keep up with the times

It is worth noting here the challenge that is presented to all of us when our professional “leaders,” those who create the diagnostic manual and those working with them, are working behind the times. It took nearly 13 years to produce a new DSM. Think of what has happened in terms of our human interaction with machines and information technology in that time. Thirteen years is an eternity in the digital age.

The general population today is dealing with some ugly problems that have been kicked up in relation to rapidly evolving technology. Yet we have no way to diagnose such problems. At a time when the tech-connect boom has greatly increased the average person’s ability to access in an anonymous and affordable fashion an almost unfathomable array of virtual sexual experiences (from webcams to alternate reality sex games), and to instantly geo-locate, contact and hook up with casual, anonymous and paid-for sex partners, the APA has inexplicably chosen to bury its metaphorical head in the sand in regard to compulsive and addictive sexuality.

This non-decision helps no one, and in fact is likely to perpetuate the harmful labels that many in our society currently attach to the unfortunate people who compulsively engage in problematic sexual behaviors. Continuing to have no labels for these individuals other than the culturally prevalent “sluts,” “nymphos” and “perverts” simply serves to exacerbate the anxiety, depression and other psychological conditions that underlie their disorder—in  much the same way that calling alcoholics “bums” and drug addicts “degenerates” once fed those addictive issues. Yet we have no diagnosis.

Consider this scenario. A man walks into a therapist’s office. He is 25 years old and has been steadily viewing hard-core porn online daily since he was 11. He comes to therapy because he finds he has little interest in sexual or intimate experiences other than the very casual (as in app-based hookups or paying for prostitutes). He would like to date, enter a primary relationship, etc., but when he has tried to do so he finds himself unable to maintain sexual or relationship intimacy—falling back time and time again to the more familiar online porn and casual sex, as for him it is far easier. He is depressed, anxious and self-hating because he cannot date, cannot mate and cannot join the type of family unit he so desires, because of his social, emotional and relational deficits combined with his dependency on online porn and casual sex.

What are we to tell this man? How are we to diagnose him? How do current diagnoses of depression, social problems or anxiety help a clinician properly lead him to healing, with no reference in the diagnostic literature that considers his 14-year porn “habit”?

Increasing numbers of clinicians all over the U.S. and in other cultures are seeing this type of client on a daily basis. So I ask the APA: What are we to tell him and how are we to help him now? What tools have you offered to those of us in the behavioral health treatment field if the DSM-5 in 2013 will have little to no mention of problems with Internet gaming, sex and the like?

Out here in the field, we lowly master’s- and PhD-level therapists (who do 90% of the hands-on addiction and mental health treatment work) have real, live, suffering individuals to help. To whom can we turn for leadership?

Robert Weiss, LCSW, CSAT-S, is the Founder of the Sexual Recovery Institute (www.sexualrecovery.com) in Los Angeles and Director of Sexual Disorders Services at The Ranch in Nunnelly, Tenn. He wrote the inaugural Process Addictions column in the January/February 2012 issue of Addiction Professional on the consideration of hypersexuality for possible inclusion in the DSM. His e-mail address is Rweiss@thesri.com.