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Over the past two decades, the internet has allowed instant access to a wide variety of content, including sexual content that portrays a variety of sexual activities such as masturbation, oral sex, vaginal and anal intercourse, and group sex. During the normal sexual developmental phase (usually between the ages of 9 and 16 years), one of the most common sexual activities is consumption of pornography, either intentional or accidental exposure. In the United Kingdom, 53% of adolescents aged 11 to 16 years have seen online pornography at least once, and the vast majority have viewed pornography before the age of 14.

 In the United States, 20% to 30% of children aged 10 to 12 years have reported some exposure to pornography.

In most cases, consumption of pornography does not promote the development of mental health disorders and reflects a normal exploration of sexuality.

 However, in 10% to 18% of all adolescents, consumption of pornography reflects compulsive sexual behavior. The disorder is characterized by extensive pornography use and masturbation, use of paid sexual services, risky sexual behaviors, and an intense preoccupation with sex. These behaviors often lead to impaired social or occupational functioning, distress, and negative affect.

How can we identify compulsive sexual behavior among adolescents? And, what are the best practices to treat compulsive sexual behavior?

Human beings are sexual and beginning in childhood are capable of sexual responses.

 Many youngsters report experiencing sexual interest, arousal, and desire before puberty around the age of 10 years, when adrenal glands mature. Adolescence marks the onset of considerable changes in sexual and reproductive maturity that coincide with significant changes in cognitive, emotional, and social functioning.

The progression of sexual events among adolescents follows a fairly consistent sequence: kissing and holding hands, breast and chest fondling, manual genital contact, touching under clothes or without clothes, touching genitals directly, oral sex, and penile-vaginal intercourse. Sometimes these are followed by less common variations, such as anal sex. Although most adolescents show a normal sexual development, some develop compulsive sexual behavior.

ICD-11 includes compulsive sexual behavior as a disorder. This impulse control disorder is characterized by a repetitive and intense preoccupation with sexual fantasies, urges, and behaviors that leads to clinically significant distress or impairment in social and occupational functioning and to other adverse consequences.

 Moreover, it compulsive sexual behavior often promotes sexual objectification of women and risky sexual behavior.

A recent study showed that consumption of pornography as part of compulsive sexual behavior predicted objectification of women over time by sexualizing women’s buttocks, breasts, belly, and body size.

 They also fond objectification of women affected adolescents’ courtship strategies (eg, girls say “no” but really mean “yes”).

 that comprised 967 adolescents aged 13 to 14 years indicate that exposure to pornography was linked with more permissive personal sexual norms (eg, sex before marriage is OK if you are in love), greater incidence of sexual harassment (eg, grabbed or pulled at a schoolmate’s clothing in a sexual way), and higher probability of oral sex and/or sexual intercourse two years later.

A series of studies explored the facets of compulsive sexual behavior among adults and adolescents.8 Four facets of compulsive sexual behavior were identified that are in keeping with the definition of compulsive sexual behavior disorder and that manifest among adults and adolescents.

1) Unwanted consequences because of sexual fantasies.

 Sexual fantasies, urges, and behaviors promote self-harm as well as harm to close others such as family members, colleagues, and peers.

 Constant uncontrolled engagement with sexual fantasies, urges, and behaviors with numerous unsuccessful efforts to significantly reduce repetitive sexual behavior.

 Negative feelings and distress accompanied by guilt and shame because of sexual fantasies, urges, and behaviors.

 Escape to sexual fantasies, pornography, and sexual behaviors because of pain, stress, and distress.

 identified two aspects of compulsive sexual behavior: individual-based and partner-based. Individual-based compulsive sexual behavior refers to inner conflicts of individuals who constantly engage in sexual fantasies, compulsive sexual thoughts, and masturbation. Partner-based compulsive sexual behavior includes interpersonal sexual conquests and repeated infidelity.

Here lies one of the key differences between adults and adolescents in the manifestation of compulsive sexual behavior. Whereas adults often exhibit both individual-based and partner-based compulsive sexual behavior, individual-based compulsive sexual behavior is much more prevalent than partner-based among adolescents because most of the experiences during adolescence do not include physical intimacy.

The range of human sexual activity is quite variable and it is difficult to differentiate normal from abnormal sexual behavior in form and frequency. Compulsive sexual behavior is not so much mere form or frequency of sexual behavior; rather, it is a pattern of sexual behavior that is initially pleasurable but becomes unfulfilling, self-destructive, and one that the individual is unable to stop. Compulsive sexual behavior refers to a loss of control over one’s sexual thoughts and behaviors that causes negative consequences in one’s life.

The ability to differentiate normal from abnormal sexual behavior among adolescents is even more challenging. For example, Adelson and colleagues argued that “in defining hypersexuality [another term for compulsive sexual behavior], it is crucial to acknowledge the challenges to establishing norms of child and adolescent sexual development and the complexity of variables that influence it.”

One of the most reliable ways to identify compulsive sexual behavior among adolescents is the self-report Individual-Based Compulsive Sexual Behavior (I-CSB) Scale.

 The I-CSB comprises 24 items that quantify the aforementioned four facets of compulsive sexual behavior.

 “I feel that my sexual fantasies hurt people around me.”

 “Although I promised myself that I would stop thinking about sexual desires, I find myself doing it again and again.”

 “I feel bad after being exposed to sexual content on the internet.”

 “When I’m stressed or restless, exposure to sexual content on the internet relaxes me.”

The I-CSB has a clinical cut-off that helps identify compulsive sexual behavior with a high degree of certainty.

Excessive and uncontrolled use of pornography is one reason for seeking professional help among both youths and adults.

 Despite the high prevalence of compulsive sexual behavior, research shows that a majority of clinicians have received little to no training in the treatment of compulsive sexual behavior. In addition, many do not feel competent or comfortable treating this disorder.

 This lack of training and education may promote misperceptions about the difficulties associated with problematic sexual behavior among clinicians, how to recognize these issues, and/or what factors to target in treatment. When seeking to refer a patient for compulsive sexual behavior, psychiatrists should look for a therapist who specializes in treating sexual disorders.

To date, there are no placebo-controlled studies on any treatment modality for compulsive sexual behavior. Most recommendations are based on case studies and/or on studies using small samples without control groups; the studies mainly comprise adults. The most promising modalities are cognitive behavioral therapy (CBT), cognitive analytic therapy (CAT), and mindfulness.

The aim of CBT is to identify underlying dysfunctional thoughts and utilizing cognitive tasks and behavioral interventions allow patients to avoid the triggers for compulsive sexual behavior. (See Birchard

 for a detailed review.) It begins by a formulation of therapeutic goals to create a blueprint for the intervention, to prevent therapeutic drift, and to keep the work on target. Diagrammatic explanations of the history and function of a problematic sexual behavior are used to bring order into what would otherwise be chaos and uncertainty. During this phase, factors that cause the patient to turn to their harmful behavior are recognized. Next, using various cognitive techniques these factors are targeted to break the link between them and the harmful behavior. For example, therapist may use the Socratic questioning method to elicit new understandings for the patient, helping them to think about the problem in a new way.

CAT is a relational and collaborative three-phase, time-limited psychotherapy that integrates cognitive and analytic principles.

 The first phase is assessment, which leads to a narrative reformulation of the patient’s difficulties. The next phase is enhancing the recognition of the problematic states and procedures. This recognition is gained via production of a sequential diagrammatic reformulation accompanied by self-monitoring between sessions to enhance self-awareness of the problematic patterns. The third and final phase is revision, which focuses on change and culminating in an exchange of farewell letters between therapist and patient. CBT and CAT share commonalities; the main difference is the cognitive versus the narrative construction of the problematic behavior (eg, history of relations with parents).

Mindfulness-based therapy focuses attention to thoughts, emotions, and bodily sensations in the present in a nonjudgmental manner. It is often taught through a variety of meditation techniques. Mindfulness may be a meaningful component of successful therapy among patients seeking help for compulsive sexual behavior by improving affect regulation, stress coping, and increasing tolerance for desires to act on maladaptive sexual urges and impulses.

 The main focus of mindfulness-based therapies is the reduction of shame-related cognitions; by doing so, it allows for decreased sexual dysfunction and increased enjoyment from sexual exploration.

Adolescents explore their sexuality. In most cases, this exploration is normative and has no negative consequences. At times, however, compulsive sexual behavior is developed and maintained. In these cases, it needs to be treated or it will affect functioning and relationships in adulthood.

Although several modalities of therapies have been examined, avoiding compulsive sexual behavior is even more important than treating it. Research highlights one key factor that relates to avoiding compulsive sexual behavior-open communication about sexuality between parents and children.

 Communication reduces shame, promotes sexual exploration in a supportive environment, and enables the development of healthy romantic relationships. Healthy sexuality promotes a health society.

 is Founder and Head of the Israeli Center for Healthy Sexuality, and Assistant Professor, Beit-Beri College, Kfar Saba, Israel. He reports no conflicts of interest concerning the subject matter of this article.

1. Livingstone S, Haddon L, GÃ¶rzig A, Ãlafsson K. EU Kids Online II: Final Report; 2011.

2. Romito P, Beltramini L. Watching pornography: gender differences, violence and victimization. 

3. Efrati, Y. Problematic and non-problematic pornography use and compulsive sexual behaviors among understudied populations: children and adolescents. Curr Addic Rep. (In press).

4. O’sullivan L, Thompson A. Sexuality in adolescence. In Tolman DL, Deborah L, Diamond LM, et al, Eds, 

, Vol 1. Washington, DC: American Psychological Association; 2014: 433-486.

5. Gola M, Potenza MN. The proof of the pudding is in the tasting: data are needed to test models and hypotheses related to compulsive sexual behaviors. 

6. Ward LM, Vandenbosch L, Eggermont, S. The impact of men’s magazines on adolescent boys’ objectification and courtship beliefs. 

7. Brown JD, L’Engle KL. X-rated: sexual attitudes and behaviors associated with US early adolescents’ exposure to sexually explicit media. Comm Res. 2009;36;129-151.

8. Efrati Y, Mikulincer M. Individual-based Compulsive Sexual Behavior scale: its development and importance in examining compulsive sexual behavior. 

9. Delmonico DL, Griffin EJ. Cybersex addiction and compulsivity. 

Internet Addiction: A Handbook and Guide to Evaluation and Treatment

. New Jersey: John Wiley and Sons, Inc; 2011; 113-134.

10. Adelson S, Bell R, Graff A, et al. Toward a definition of “hypersexuality” in children and adolescents. 

11. Mitchell KJ, Wells M. Problematic internet experiences: primary or secondary presenting problems in persons seeking mental health care. 

12. Reissing ED, Giulio GD. Practicing clinical psychologists’ provision of sexual health care services. Prof Psychol. 2010;41;57.

13. Birchard T. CBT for Compulsive Sexual Behaviour: A Guide for Professionals. New York: Routledge; 2015.

14. Kellett S, Simmonds-Buckley M, Totterdell P. Testing the effectiveness of cognitive analytic therapy for hypersexuality disorder: an intensive time series evaluation. 

15. Reid RC, Bramen JE, Anderson A, Cohen MS. Mindfulness, emotional dysregulation, impulsivity, and stress proneness among hypersexual patients. 

16. Efrati Y, Gola M. Adolescents’ compulsive sexual behavior: the role of parental competence, parents’ psychopathology, and quality of parent-child communication about sex. 

Adolescents explore their sexuality. In most cases, this exploration is normative. At times, however, compulsive sexual behavior is developed and maintained.

Normal Versus Abnormal Sexual Behavior in Adolescents

Four clinical reports indicate that in the last 30 years, we have come a long way in the exploration and study of sex and sexual disorders.

Sex and Sexual Disorders: Special Report

Psychiatrists and other mental health professionals are frequently called on by the media to give their expert opinion about public figures whose behavior raises a question about their mental health or fitness. Often, this involves colorful, eccentric, or flagrant misbehavior in the sexual or financial realm.

Consider, for example, former Congressman Anthony Weiner who resigned his seat June 16, 2011, amid revelations of his repeated lewd online behavior: Mr Weiner 

 In the summer of 2013, while running as a mayoral candidate in the Democratic primary in New York City, it was revealed that he had continued to post lewd images of himself online, and he was pressured (unsuccessfully) to quit the race.

Understandably, the media sought commentary from mental health experts. How, they asked, was the public to understand such apparently self-destructive behavior?

Some mental health professionals suggested Mr Weiner’s indiscretions might be an addiction. Others theorized that he might be driven by sexual needs that were unmet in his marriage and by feelings of inadequacy about his masculinity. Still others raised the possibility of a mood disorder.

As psychiatrists, we have expert knowledge about human behavior and mental illness. Thus, we have a potentially unique-and powerful-influence in the discussion of public figures. But what professional and ethical obligations should we follow in this role? Are we to relate to the public as expert clinicians, commentators, or educators-or some mix of these roles?

To answer the question, a bit of historical perspective is instructive. Just before the 1964 presidential election, a muckraking and now defunct magazine called 

 decided to survey members of the American Psychiatric Association (APA) for their professional assessment of Senator Barry Goldwater of Arizona, the Republican nominee running against President Lyndon B. Johnson.

 Ralph Ginzburg, the magazine’s notoriously provocative publisher, had heavily advertised the issue in advance, saying it would call into question Mr Goldwater’s character.

APA members were asked whether they thought Mr Goldwater was fit to be president and what their psychiatric impressions of him were. It was not American psychiatry’s finest hour. The survey, highly unscientific even by the standards of the time, was sent to 12,356 psychiatrists, of whom 2417 responded. The results were published as a special issue: “The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater.”

The psychiatrists’ assessment was very harsh. Half of the respondents judged Mr Goldwater psychologically unfit to be president. They used terms like “megalomaniac,” “paranoid,” and “grossly psychotic.” Some offered specific diagnoses, including schizophrenia and narcissistic personality disorder. Only 27% of the respondents said Mr Goldwater was mentally fit, and 23% said they did not know enough about him to make a judgment.

There were several attempts at a psychodynamic formulation of Mr Goldwater’s character. One unsigned comment called the candidate “inwardly a frightened person who sees himself as weak and threatened by strong virile power around him,” and added that “his call for aggressiveness and the need for individual strength and prerogatives is an attempt to defend himself against and to deny his feelings of weakness.”

Whatever their motivation, these physicians had given very specific and damaging psychiatric opinions, using the language and art of their profession, about a man whom they had not examined and who surely would never have consented to such damaging statements. The remarks were immediately condemned by both the American Medical Association and the APA, and Mr Goldwater brought a $2 million libel suit against Fact and Mr Ginzburg. The Supreme Court awarded the senator $1 in compensatory damages and $75,000 in punitive damages-and, more importantly, set a legal precedent that helped change medical ethics.

The APA had the Goldwater debacle in mind when, in 1973, it first drafted its 

Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry

 These Principles, in particular sections 5 and 7, delineate a set of ethical requirements for communicating with the media. Section 7.3 has come to be known as the Goldwater Rule:

On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.

Likewise, the American Psychological Association’s code of ethics stipulates that psychologists provide expert opinion only for individuals they have directly examined.

In short, since 1973 the ethical standard has been very clear: psychiatrists and psychologists can comment on mental health issues in general, but it is unethical for them to offer a professional opinion about an individual without directly examining that person and getting his or her permission to comment.

The guidelines are clear enough, but what, exactly, is the ethical reasoning behind them? Other than to avoid another professional embarrassment such as the critique of Barry Goldwater, why must psychiatrists and psychologists avoid offering their medical opinions of public figures?

For a mental health professional-or any physician-to publicly offer a diagnosis of a nonpatient at a distance not only invites public distrust of these professionals, but also is intellectually dishonest and is damaging to the profession. After all, a professional opinion should reflect a thorough and rigorous examination of a patient, the clinical history, and all relevant clinical data under the protection of strict confidentiality, none of which is possible by casual observation of a public figure. To do otherwise is unethical because it violates this fundamental principle and thereby misleads the public about what constitutes accepted medical and nonmedical professional practice.

This does not mean, however, that mental health professionals must remain silent. For example, the APA’s Principles clearly enjoin psychiatrists to share their knowledge and expertise with the public

A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated (section 5).

Psychiatrists may interpret and share with the public their expertise in the various psychosocial issues that may affect mental health and illness (section 7.2).

Thus, mental health professionals have a potentially important role in educating the public about mental health issues-and a great opportunity to dispel the stigma of mental illness by doing so. The critical distinction is between offering general information about a condition as it pertains to a public figure and rendering a professional opinion about an individual, involving a specific diagnosis, prognosis, or both.

So a psychiatrist who commented on Mr Weiner’s actions would be well within ethical bounds to speak generally about psychological principles that help the public understand his behavior. Consider what Dr Richard C. Friedman (no relation), a clinical professor of psychiatry at Weill Cornell Medical College in New York, said about Mr Weiner in an interview with the 

 “It’s almost as if a little child were playing at being a politician and trying to hide something. . . .The level of denial is so great, and it’s so incompatible with major responsibility, that the psychological puzzle is not only to find out why he’s doing the particular behavior, but why somebody would be functioning at such an uneven level.”

Regarding Mr Weiner’s habit of texting women pictures of his penis, Dr Friedman said that this suggested someone with a deep insecurity about his body image and his masculinity. “There’s a different type of narcissism that’s based on self-esteem problems, in which the person then defensively covers up by saying: ‘Aren’t I wonderful? Look at my wonderful organ. Isn’t it beautiful?’”

Dr Friedman used general psychological terms (eg, denial, body image, self-esteem, narcissism) to speculate about Mr Weiner’s psychology, which served to educate the public about the symptoms and psychology of narcissism in general. The public is then free to decide whether this information applies to Mr Weiner. This commentary was clearly within the ethical bounds of the Goldwater Rule. If, on the other hand, Dr Friedman had said that Mr Weiner had narcissistic personality disorder, he would have moved beyond educating the public to rendering a diagnosis from afar and, as such, he would have clearly violated this ethical principle.

One can expect that some public figures, including politicians, will be psychiatrically or cognitively impaired, given the high prevalence of psychiatric and substance abuse disorders. An estimated 46% of American adults will experience a mental or substance abuse disorder in their lifetime, according to the National Comorbidity Survey Replication.

Should a question arise about the cognitive functioning of a politician, it would be perfectly within ethical guidelines for a psychiatrist to suggest neurocognitive testing, as long as the suggestion was free of diagnostic speculation. After President Reagan left office, he revealed that he had Alzheimer disease.

 Given his well-known reputation for absentmindedness, it was speculated that he might have been cognitively impaired while in office. We do not know if he had neurocognitive testing as president, but it would have been reasonable and ethically permissible for a mental health professional to suggest neurocognitive assessment of a sitting president whose cognitive functioning was in question.

Are there instances in which the Goldwater Rule can be violated? In 1991, Dr Jerrold M. Post, a psychiatrist, provided a psychological profile of Saddam Hussein during a public Congressional testimony.

 On the basis of several biographies and interviews with persons who knew Hussein, Dr Post diagnosed him with malignant narcissism, a severe personality disorder marked by grandiosity, cruelty, and paranoid behavior.

Although Dr Post was criticized for breaking the Goldwater Rule, he invoked a Tarasoff-like principle stating that he had a duty to warn because this psychiatric knowledge could be instrumental in shaping policy decisions that could save many lives, just as a psychiatrist has a duty, under the Tarasoff ruling, to break confidentiality if a patient is an imminent threat to a third party and to warn that person of the risk.

 While the predictive validity of psychiatric analysis of an individual at a distance is debatable, if it is deemed vital to public safety or national security, one could reasonably defend it even if it violates the profession’s code of ethics and is personally damaging to that individual.

What about biographies and other scholarly works in which public figures are subjected to psychiatric scrutiny? For example, consider the psychobiography of President George W. Bush by Dr Justin A. Frank, a psychiatrist, who characterized the president as a “paranoid megalomaniac” and an “untreated alcoholic.”

 These are clearly diagnostic assessments that seem to violate the Goldwater Rule, but Dr Frank’s view is that his book is a scholarly psychobiography, not expert opinion, and is thus outside the purview of the APA ethics guideline.

Perhaps, but the line between a scholarly psychiatric profile and a casual off-the-cuff diagnosis of a public figure is not so clear. Even if the intent of the mental health professional in both scenarios is very different-understanding the psychology of the person (psychobiography) or attacking the character of a reviled political candidate (the Goldwater case)-both share a similar ethical problem: unauthorized psychiatric assessment of a person who is not examined by the professional.

Psychiatrists have unique knowledge and expertise and can play an important role in the discussion about the mental health of public figures. Our comments should be geared toward general information about the nature and course of psychiatric illnesses and their treatments. We should always remember that our role is not to provide unsolicited or unauthorized professional opinions, but rather to educate the public.

Dr Friedman is Professor of Clinical Psychiatry and Director of the Psychopharmacology Clinic at Weill Cornell Medical College in NY. He reports no conflicts of interest concerning the subject matter of this article.

 Hernandez R. Weiner resigns in chaotic final scene. 

http://www.nytimes.com/2011/06/17/nyregion/anthony-d-weiner-tells-friends-he-will-resign.html

?pagewanted=all. Accessed January 30, 2014.

 Hernandez JC. Weiner admits to more lewd exchanges but denies an addiction. 

. July 25, 2013. http://www.nytimes.com/2013/07/26/nyregion/weiner-admits-more-online-exchanges-with-women-after-quitting-house.html. Accessed January 30, 2014.

 Taylor K, Hernandez JC. Weiner’s behavior prompts a question: why did he do it? 

. July 29, 2013. http://www.nytimes.com/2013/07/30/nyregion/weiners-behavior-prompts-a-question-why-did-he-do-it.html. Accessed January 30, 2014.

 Ginzburg R, ed. 1189 Psychiatrists say Goldwater is psychologically unfit to be president! 

, 414 F2d 324, 337 (2d Cir 1969), cert denied, 396 US 1049, 90 SCt 701, 24 LEd2d 695.

The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry

. Arlington, VA: American Psychiatric Press Inc; 2008.

 American Psychological Association. Ethical principles of psychologists and code of conduct. 

 Kessler RC, Berglund P, Jin R, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. 

 Altman LK. While known for being forgetful, Reagan was mentally sound in office, doctors say. 

. October 5, 1997. http://www.nytimes.com/1997/10/05/us/while-known-for-being-forgetful-reagan-was-mentally-sound-in-office-doctors-say.html. Accessed January 30, 2014.

 Post JM. Ethical considerations in psychiatric profiling of political figures. 

 Goleman D. Experts differ on dissecting leaders’ psyches from afar. 

. January 29, 1991. http://www.nytimes.com/1991/01/29/science/experts-differ-on-dissecting-leaders-psyches-from-afar.html?pagewanted=all&src=pm. Accessed January 30, 2014.

Bush on the Couch: Inside the Mind of the President

As psychiatrists, we have a potentially unique-and powerful-influence in the discussion of public figures. But what professional and ethical obligations should we follow in this role?

Discussions About Public Figures: Clinician, Commentator, or Educator?

What treatments have you found to be helpful for someone with a sexual addiction who has gotten into trouble via "sexting"? What studies have you found in the recent literature that offer helpful insights?
 
The list below includes a very preliminary review of the literature, which focuses mostly on youngsters.

We welcome your thoughts and insights about treatment approaches for patients whose sexual addiction takes the form of sexting. 

Dir AL, Coskunpinar A, Steiner JL, Cyders MA. Understanding Differences in Sexting Behaviors Across Gender, Relationship Status, and Sexual Identity, and the Role of Expectancies in Sexting. 

Gordon-Messer D, Bauermeister JA, Grodzinski A, Zimmerman M. Sexting among young adults. 

Benotsch EG, Snipes DJ, Martin AM, Bull SS. Sexting, substance use, and sexual risk behavior in young adults. 

Judge AM. "Sexting" among U.S. adolescents: psychological and legal perspectives. 

Mitchell KJ, Finkelhor D, Jones LM, Wolak J. Prevalence and characteristics of youth sexting: a national study. 

Wiederhold BK. Should adult sexting be considered for the DSM? 

Ferguson CJ.  Sexting behaviors among young Hispanic women: incidence and association with other high-risk sexual behaviors. 

We welcome your thoughts and insights about treatment approaches for patients whose sexual addiction takes the form of sexting.

Treatment Options for "Sexting" Addiction?

In an effort to address sexual violence against both men and women, the  

. Because the aftermath of such violence can result  in suicidal feelings, depression, PTSD, and other mental disorders, clinicians  play an important role in treating both victims and perpetrators and helping to  prevent further damage.

In terms of prevention, the following efforts have been made or are in  process:

modernized the definition of  rape used to collect our nation’s crime statistics

•The DOJ is working with law enforcement agencies to implement this change  in definition to develop new guidelines for investigating sexual assault cases

 is funding training that will help communities address their backlogs of rape  kits and improve prosecution of sexual assault crimes

 is supporting the development of a telemedicine center that will help bring  sexual assault forensic exams to victims in rural and isolated communities

Violence  Against Women Act Reauthorization

, originally drafted by then Senator Joe  Biden (D-DE) and passed in 1994. This legislation mandates states to set aside  funds to develop programs “that meaningfully address rape and sexual assault  including those committed by strangers, acquaintances, and intimate partners as  well as alcohol and drug facilitated rapes. This means more training for law  enforcement and prosecutors and more resources for victim services”

•College campuses must provide orientation programs to new students about  dating violence and sexual assault and must develop clear, written policies  about how these cases will be handled

•Federally subsidized housing programs must protect sexual assault victims from  being evicted or denied housing due to the assault committed against them, and  must help a victim transfer to another housing unit if necessary

 is working to raise  awareness about domestic violence and sexual assault

Both men and women can be victims of sexual assault and rape-1 in 5 women  and 1 in 71 men in their lifetimes and over 1 million rapes occur every year.  According to the White House, sexual violence is “an affront to human dignity  and a crime no matter where it occurs.”

The White House. Recognizing Sexual Assault Awareness Month. 

http://www.whitehouse.gov/blog/2013/04/08/recognizing-sexual-assault-awareness-month.

Because the aftermath of sexual violence can result in suicidal feelings, depression, PTSD, and other mental disorders, clinicians play an important role in treating both victims and perpetrators and helping to prevent further damage.

Helping Victims of Sexual Assault and Rape

This is the saddest moment in my 45-year career of studying, practicing, and teaching psychiatry. The 

Board of Trustees of the American Psychiatric Association

 (APA) has given its final approval to a deeply flawed DSM-5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public-be skeptical and don’t follow DSM-5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication. Just ignore the 10 changes that make no sense.

Brief background. DSM-5 got off to a bad start and was never able to establish sure footing. Its leaders initially articulated a premature and unrealizable goal-to produce a paradigm shift in psychiatry. Excessive ambition combined with disorganized execution led inevitably to many ill-conceived and risky proposals.

These were vigorously opposed. More than 50 mental health professional associations petitioned for an outside review of DSM-5 to provide an independent judgment of its supporting evidence and to evaluate the balance between its risks and benefits. Professional journals, the press, and the public also weighed in-expressing widespread astonishment about decisions that sometimes seemed not only to lack scientific support but also to defy common sense.

DSM-5 has neither been able to self-correct nor willing to heed the advice of outsiders. It has instead created a mostly closed shop-circling the wagons and deaf to the repeated and widespread warnings that it would lead to massive misdiagnosis. Fortunately, some of its most egregiously risky and unsupportable proposals were eventually dropped under great external pressure (most notably “psychosis risk,” mixed anxiety/depression, internet and sex addiction, rape as a mental disorder, “hebephilia,” cumbersome personality ratings, and sharply lowered thresholds for many existing disorders). But APA stubbornly refused to sponsor any independent review and has given final approval to the 10 reckless and untested ideas that are summarized below.

The history of psychiatry is littered with fad diagnoses that in retrospect did far more harm than good. Yesterday’s APA approval makes it likely that DSM-5 will start a half or dozen or more new fads which will be detrimental to the misdiagnosed individuals and costly to our society.

The motives of the people working on DSM-5 have often been questioned. They have been accused of having a financial conflict of interest because some have (minimal) drug company ties and also because so many of the DSM-5 changes will enhance Pharma profits by adding to our already existing societal overdose of carelessly prescribed psychiatric medicine. But I know the people working on DSM-5 and know this charge to be both unfair and untrue. Indeed, they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies. Theirs is an intellectual, not financial, conflict of interest that results from the natural tendency of highly specialized experts to over value their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM-5 to real life clinical practice (particularly in primary care where 80% of psychiatric drugs are prescribed).

The APA’s deep dependence on the publishing profits generated by the DSM-5 business enterprise creates a far less pure motivation. There is an inherent and influential conflict of interest between the DSM-5 public trust and DSM-5 as a best seller. When its deadlines were consistently missed due to poor planning and disorganized implementation, APA chose quietly to cancel the DSM-5 field testing step that was meant to provide it with a badly needed opportunity for quality control. The current draft has been approved and is now being rushed prematurely to press with incomplete field-testing for one reason only-so that DSM-5 publishing profits can fill the big hole in APA’s projected budget and return dividends on the exorbitant cost of $25 million that has been charged to DSM-5 preparation.

This is no way to prepare or to approve a diagnostic system. Psychiatric diagnosis has become too important in selecting treatments, determining eligibility for benefits and services, allocating resources, guiding legal judgments, creating stigma, and influencing personal expectations to be left in the hands of an APA that has proven itself incapable of producing a safe, sound, and widely accepted manual.

New diagnoses in psychiatry are more dangerous than new drugs because they influence whether or not millions of people are placed on drugs-often by primary care doctors after brief visits. Before their introduction, new diagnoses deserve the same level of attention to safety that we devote to new drugs. APA is not competent to do this.

So, here is my list of DSM-5’s 10 most potentially harmful changes. I would suggest that clinicians not follow these at all (or, at the very least, use them with extreme caution and attention to their risks); that potential patients be deeply skeptical, especially if the proposed diagnosis is being used as a rationale for prescribing medication for you or for your child; and that payers question whether some of these are suitable for reimbursement. My goal is to minimize the harm that may otherwise be done by unnecessary obedience to unwise and arbitrary DSM-5 decisions.

(1) Disruptive Mood Dysregulation Disorder: DSM-5 will turn temper tantrums into a mental disorder-a puzzling decision based on the work of only one research group. We have no idea whatever how this untested new diagnosis will play out in real life practice settings, but my fear is that it will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children. During the past two decades, child psychiatry has already provoked 3 fads-a tripling of Attention Deficit Disorder, a more than 20-times increase in Autistic Disorder, and a 40-times increase in Childhood Bipolar Disorder. The field should have felt chastened by this sorry track record and should engage itself now in the crucial task of educating practitioners and the public about the difficulty of accurately diagnosing children and the risks of over-medicating them. DSM-5 should not be adding a new disorder likely to result in a new fad and even more inappropriate medication use in vulnerable children.

(2) Normal grief will become Major Depressive Disorder, thus medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life.

(3) The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder, creating a huge false positive population of people who are not at special risk for dementia. Since there is no effective treatment for this “condition” (or for dementia), the label provides absolutely no benefit (while creating great anxiety), even for those at true risk for later developing dementia. It is a dead loss for the many who will be mislabeled.

(4) DSM-5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs.

(5) Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM-5 has instead turned it into a psychiatric illness called Binge Eating Disorder.

(6) The changes in the DSM-5 definition of Autism will result in lowered rates-10% according to estimates by the DSM-5 Work Group, perhaps 50% according to outside research groups. This reduction can be seen as beneficial in the sense that the diagnosis of Autism will be more accurate and specific-but advocates understandably fear a disruption in needed school services. Here the DSM-5 problem is not so much a bad decision, but the misleading promises that it will have no impact on rates of disorder or of service delivery. School services should be tied more to educational need, less to a controversial psychiatric diagnosis created for clinical (not educational) purposes and whose rate is so sensitive to small changes in definition and assessment.

(7) First-time substance abusers will be lumped in definitionally with hard-core addicts, despite their very different treatment needs and prognosis and the stigma this will cause.

(8) DSM-5 has created a slippery slope by introducing the concept of Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot. Watch out for careless over-diagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets.

(9) DSM-5 obscures the already fuzzy boundary of Generalized Anxiety Disorder and the worries of everyday life. Small changes in definition can create millions of anxious new “patients” and expand the already widespread practice of inappropriately prescribing addicting antianxiety medications.

(10) DSM-5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.

DSM-5 has dropped its pretension to being a paradigm shift in psychiatric diagnosis and instead (in a dramatic 180-degree turn) now makes the equally misleading claim that it is a conservative document that will have minimal impact on the rates of psychiatric diagnoses and in the consequent provision of inappropriate treatment. This is an untenable claim that DSM-5 cannot possibly support because, for completely unfathomable reasons, it never took the simple and inexpensive step of actually studying the impact of DSM on rates in real-world settings.

Except for autism, all the DSM-5 changes loosen diagnosis and threaten to turn our current diagnostic inflation into diagnostic hyperinflation. Painful experience with previous DSM’s teaches that if anything in the diagnostic system can be misused and turned into a fad, it will be. Many millions of people with normal grief, gluttony, distractibility, worries, reactions to stress, the temper tantrums of childhood, the forgetting of old age, and ‘behavioral addictions’ will soon be mislabeled as psychiatrically sick and given inappropriate treatment.

People with real psychiatric problems that can be reliably diagnosed and effectively treated are already badly shortchanged. DSM-5 will make this worse by diverting attention and scarce resources away from the really ill and toward people with the everyday problems of life who will be harmed, not helped, when they are mislabeled as mentally ill.

Our patients deserve better, society deserves better, and the mental health professions deserve better. Caring for the mentally ill is a noble and effective profession. But we have to know our limits and stay within them.

DSM-5 violates the most sacred (and most frequently ignored) tenet in medicine-First Do No Harm! That’s why this is such a sad moment.

The changes in the newly approved DSM-5 loosen diagnosis and threaten to turn our current diagnostic inflation into diagnostic hyperinflation.

DSM-5 Is A Guide, Not A Bible-Simply Ignore Its 10 Worst Changes

Recently, I was examining the stenographic record of a meeting held by a special commission of the German Parliament in November 1968. The legislators and psychiatric experts were discussing the efficacy of a relatively new treatment at the time for sex offenders-cyproterone acetate, an antiandrogen, widely marketed as Androcur-as they considered a law governing its uses. As I read the transcript of the discussion, Dr Ursula Laschet (then Director of the Psychoendocrinology Department of the Palatinate Psychiatric Clinic) made her appearance and was asked to talk about her department’s early experiences with the treatment.

At one point, Dr Laschet made a remark that caused me do a double-take: “Around a third of the 80 patients undergoing medication treatment came to outpatient care due to marriage difficulties-Don-Juanism.”

Surely that was a colloquial expression at the time, I thought, although I still wasn’t entirely sure what she meant by this. Moreover, these male patients were voluntarily undergoing what was commonly referred to as “chemical castration” to deal with their “Don-Juanism.”

Then, a few pages later, Dr Werner Krause, a Professor and Researcher at the Institute for Sexual Research at the University of Hamburg, joined the conversation to make a point. He insisted it was important to distinguish those who are sexually “addicted” but do not get in trouble with the law from those whose sexual addictions lead them to commit crimes: “Don-Juanism and promiscuity are not the same thing,” he noted. “From our perspective, Don Juan was ill; Casanova was simply promiscuous.”

 There it was again, this Don-Juanism, used by a second prominent researcher and, this time, associated with addiction.

This piqued my curiosity: I was going to have to do a little digging. A quick google search of Don-Juanism in German led to results on “womanizing” and the study of Don Juan in literature and the arts. However, another definition appeared-

-as well as a citation in a work by the psychoanalyst Alfred Adler from 1920.

Wikipedia and chat forums not being what I would consider the most reliable sources of information, I turned to some standard historical databases. A picture began to emerge. Often talked about in the same breath with 

was indeed a recognized diagnosis that referred to forms of male hypersexuality. In history, it was most commonly known as 

Historical records reveal Don Juan syndrome was a recognized diagnosis that referred to forms of hypersexuality and sex addiction.

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