Sex addiction has gotten a lot of airtime in the past month after a number of famous men were exposed as serial predators and claimed the affliction as the cause of their disturbing behavior. Both Harvey Weinstein and Kevin Spacey checked themselves into the same sex rehab clinic, with Weinstein saying he will go on a journey to “conquer my demons.”
Addiction is not an excuse for criminal behavior. (Indeed, it’s quite possible that these powerful men don’t have an addiction—though attempting to diagnose mental health conditions from afar is never acceptable.) Rather than stating this irrefutable fact, many public figures and members of the media have taken a different angle, arguing that alleged sexual predators should be denied sympathy not because of their criminal acts, but because sex addiction “doesn’t exist.”
Much of this denial is likely motivated by a well-meaning desire to see sexual predators brought to justice in a system that overwhelmingly fails women. But, in the face of plenty of evidence to the contrary, the argument reflects a troubling attitude towards mental health and its intersection with criminality. Perpetrators want to give the impression that they aren’t bad, but mad. Naysayers, meanwhile, argue that perpetrators can’t be mad, and so are therefore bad.
The disturbing idea here is that mental health conditions cause criminal behavior. If you believe that, you believe there is a neat divide between those with malicious intent and those who suffer from mental disorders. The troubling implication is that a “true” mental health condition would make criminal behavior beyond the perpetrators’ control, recasting abominable acts as symptoms of their struggles, and, essentially, rendering them innocent.
This is simply false. “There is no evidence that sexual harassment or sexual assault are related to the proposed features of sexual addiction,” neuroscientist Nichole Prause told Vice. Mental illness affects both criminals and saints. And except in extremely rare cases and for conditions such as schizophrenia, which causes hallucinations and delusions, mental disorders do not lead people to behave criminally.
“We shouldn’t have simplistic views: You’re either ill or not, criminal or not,” says Steve Hyman, director of the Stanley Center for psychiatric research at the Broad Institute of MIT and Harvard. The excuse that “my brain made me do it” is much like the defense “the devil made me do it” that was invoked by past generations, he adds. At most, says Hyman, “your brain makes it hard for you to resist, but it doesn’t make you do it.”
Denying the existence of sex addiction won’t hurt the likes of Weinstein and Spacey. But it will hurt others: the men and—yes—women, who have never assaulted anyone but who suffer considerable distress from an addictive relationship to sexual desire, and who now must face the worry that if they talk about their problems they will be recast as a sex criminal.
There is considerable debate in the medical community about whether sex addiction is a distinct condition. The conversation is complex, and deserves space to be explored through clinical findings and psychiatric thought; when depicted as a reflection of criminal behavior, discussions of sex addiction will inevitably be reductive. Many of those quick to deny sex addiction point to the fact that it’s not included in the fifth (and latest) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This, though, entirely misunderstands how mental health conditions are treated and categorized.
“If one reads the disclaimers in the introductory material provided by the American Psychiatry Association, the DSM does not pretend to capture nature as it is,” says Hyman. “The DSM is not a magic mirror. It is not a Bible. It is simply a classification, which is a schema humans create and place on data to make it useful. It has some strengths and many weaknesses.”
The DSM uses checklist criteria to diagnose mental illness, a system that follows the model of diagnosing infectious diseases and is far from perfect. Many mental health conditions, like many physical conditions, affect people along a spectrum. (Only this week, the guidelines on what level of high blood pressure counts as “hypertension” was formally changed, a reflection of just how difficult it is to draw a neat line between “healthy” and “unhealthy.”) Manuals like the DSM can help clinicians understand and treat mental health disorders, but they should not be used to definitively state whether someone is suffering or not—or whether a particular cause of psychological distress exists or does not.
There’s currently no formal diagnostic term for hypersexual behavior, though there are clear medical guidelines on how to treat such symptoms. The latest edition of the International Statistical Classification of Diseases and Related Problems (ICD) does have codes for “excessive sexual drive” and “other specific sexual dysfunction.” (US healthcare practitioners are legally mandated to follow ICD diagnostic codes, which are developed alongside the World Health Organization. They are not mandated to follow DSM guidelines.) And the next edition of ICD, due to be published next year, is considering including “compulsive sexual behavior disorder” as a distinct condition, with a draft definition published online.
Marc Potenza, psychiatry professor at Yale School of Medicine, says that there’s “a clinical need” to treat excessive sexual behaviors. “People seek help for different forms of problems with sexual behaviors. Some of those are engaging in sexual behaviors excessively or compulsively,” he says.
The debate within the field of psychiatry focuses on whether such sexual behaviors should be considered an addiction, an impulse control disorder, or another type of disorder. A similar discussion is happening around gambling, which was called “pathological gambling” in the DSM-4 and then “gambling disorder” in the DSM-5. “Based on the existing data, pathological gambling, now gambling disorder, was re-classified, moving from classification as an impulse control disorder to being classified together with substance use disorder as an addictive disorder,” says Potenza.
The proposal currently under consideration for the next edition of the ICD would classify compulsive sexual behavior as an impulse control disorder rather than a behavioral addiction. There’s certainly evidence that points to differences between sex addiction and drug addiction, though there are also findings that brain activity in sex addiction (and, as a subset of that category, porn addiction), mirrors that of drug addiction. Currently, “these studies are at an early stage,” says Potenza. There’s considerable uncertainty over how to diagnose and treat sex addiction, as well as other behavioral addictions such as gaming, shopping, and exercise.
Such debates are hardly new to psychiatry—it wasn’t that long ago that there was disagreement over whether depression was a “real” mental health condition. In fact, there’s a long history of denying the existence of mental health conditions, and of falsely depicting those with mental disorders as criminals. That troubling perception of mental health is fading, but it lingers on; denying that people can really suffer from compulsive sexual behavior is only the latest manifestation.
Those who commit crimes such as sexual assault must be punished. And those who struggle with sex addictions must be listened to and helped. Only when we’re able to do both will we have a truly enlightened approach to mental health.