There's an old joke in psychiatry: A sex addict is someone who has more sex than the therapist.
Appropriately, psychiatrists are taking another stab at what laypeople call sex addiction, that most timely of maladies, as Tiger Woods prepares to re-emerge from the shelter of the Pine Grove Behavioral Health and Addiction Services clinic to address the world today.
"Hypersexual disorder" is being proposed for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Rewritten every decade or so, the DSM classifies mental illnesses and is currently being revised for 2013.
The controversial proposal has critics worrying the criteria are linguistically too vague, and the chances for misdiagnosis and bogus pharmaceutical treatment too great.
To be diagnosed with the disorder, a patient would have to chronically experience four of the following five situations: spending a "great deal of time" consumed by sexual fantasies and urges; using sexual behaviour to deal with stressful life events (or anxiety, depression, boredom or irritability); disregarding the "physical and emotional harm" to those involved and trying but failing to curb the behaviour. As well, patients must have suffered distress and harm to their everyday life.
"Hypersexuality has been around for hundreds of years," said Martin Kafka, a clinical associate professor of psychiatry at Harvard Medical School, who spent a year and a half reviewing literature before penning the revision.
He says the "serious but still neglected contemporary psychiatric disorder" causes everything from marital dysfunction and divorce to increased risk of unintended pregnancies and sexually transmitted diseases.
"By the time people come to me, they're very distressed," Dr. Kafka said of the patients who see him at McLean Hospital in Belmont, Mass., where he is a senior clinical associate.
Currently, they are diagnosed with Sexual Disorder Not Otherwise Specified - "a diagnostic wastebasket," as Dr. Kafka puts it.
Most of the people who contact Peggy Kleinplatz's sex therapy practice about sexual addiction are not the patients.
"They're people calling hoping to drag their spouses into my office," said Dr. Kleinplatz, of the faculty of medicine at the University of Ottawa.
She said the "vast majority" of those who approach her for sex-addiction treatment are in a "tug of war over the amount of sex in their relationship" - which makes them good candidates for couples sex therapy, not a mental disorder diagnosis.
"What will be more common in my experience is one person is saying, 'You're a sex addict,' and the other person is saying, 'You're undersexed.' There's a power struggle going on in the relationship and it's being played out in the marital bed. Who has the right to determine which one of them is pathological?"
Dr. Kleinplatz points out that history has long played into which sexual behaviours the DSM normalizes and which it pathologizes. The first two editions listed nymphomania (an obsession with sex in women) and satyriasis (the male version). In 1980, both diagnoses were removed from the DSM-III for gender bias - and because "after the sexual revolution, too much sex was no longer seen as pathological," Dr. Kleinplatz said.
"Instead they added a new diagnosis for people who didn't want sex enough called inhibited sexual desire and which we now call hypoactive sexual desire disorder. … Apparently the tides have turned again and this time we'll be diagnosing both too much sex and too little sex. The question is, given the subjective nature of diagnostic criteria, how much will be too little and how much will be too much?"
Paul Fedoroff, director of the Sexual Behaviours Clinic at the Royal Ottawa Mental Health Centre, said the hypersexuality criteria are "too all-inclusive."
"They seem to me to capture normal states," said Dr. Fedoroff, who questioned whether sex in response to stress was unhealthy, and what "a great deal of time" consumed by sexual fantasies and urges amounted to.
It is a clause Dr. Kafka acknowledged he "really struggled" with because "It might be different for a 20-year-old than a 50-year-old." But he reiterated: "None of the single criteria themselves are bad or good. They are dimensions of behaviour that add up to a possible sexual disorder."
Other critics say Dr. Kafka's proposal points to a further medicalization of sexuality.
"Sexual disorders are a very fresh example of the medicalization of ordinary life. Wherever there is a possibility of blurring the lines between a medical disorder and ordinary life, there is a great opportunity for a very large pharmaceutical market," said Ray Moynihan, an Australian journalist and author of Sex, Lies and Pharmaceuticals, due out this fall.
Mr. Moynihan examined female sexual dysfunction, which has appeared in the DSM under a number of names since 1980, and since been targeted by a number of pharmaceutical companies marketing pills, creams and testosterone patches.
"Within the small circles of experts that debate [sexual disorders] there's constant argument, contention, debate, backwards and forwards," Mr. Moynihan said. "All of that complexity gets lost when there are large corporate interests trying to portray these disorders in a way that will maximize their markets."
Although Dr. Kafka has treated some of his patients with SSRIs (selective serotonin reuptake inhibitors), he says: "The last thing I'm trying to do here is promote a pharmaceutical agent."
He argues that requiring four out of five criteria will minimize the risk of "too many false positives" and notes that those criteria will be field-tested in American clinics this summer, "to see whether they capture this condition."
Still, he understands why critics are leery of the proposal.
"You don't want to pathologize people who don't have a problem," he said, adding, "You can't nail it 100 per cent. You do your best."
Proposed criteria for hypersexual disorder
A. Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges, and sexual behaviour in association with four or more of the following five criteria:
(1) A great deal of time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behaviour.
(2) Repetitively engaging in these sexual fantasies, urges, and behaviour in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability).
(3) Repetitively engaging in sexual fantasies, urges, and behaviour in response to stressful life events.
(4) Repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, and behaviour.
(5) Repetitively engaging in sexual behaviour while disregarding the risk for physical or emotional harm to self or others.
B. There is clinically significant personal distress or impairment in social, occupational or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges, and behaviour.
C. These sexual fantasies, urges, and behaviour are not due to the direct physiological effect of an exogenous substance (e.g., a drug of abuse or a medication).
Specify if: masturbation, pornography, sexual behaviour with consenting adults, cybersex, telephone sex, strip clubs, or others.
Source: American Psychiatric Association