Legislative control

Historians and social scientists have argued for some time that sex has been used as an instrument to police the boundaries of morality in society (Reference WeeksWeeks 1985, Reference Weeks1986; Reference HerdtHerdt 2009). Sex has always been seen as potentially dangerous. In Britain, the late 19th century saw the introduction of legislation which sought to control homosexuality and prostitution together, in pursuit of ‘protecting’ the bourgeois family from destructive forces. This thinking has not entirely gone away.

At the same time, sex was promoted as taking place appropriately only between a married man and woman in pursuit of procreation. No new law relating to homosexual practice had been introduced since Henry VIII’s anti-sodomy statute of 1533, which related to any non-procreative sex, regardless of the gender (or even species) of participants. Henry Labouchère’s 1885 Amendment (Section 11 of the Criminal Law Amendment Act) introduced the offence of gross indecency into British law, an offence whose precise nature was not spelled out, but which in practice was used to prosecute male homosexual acts where sodomy could not be proved. Oscar Wilde was the most significant early victim of this legislation. The rest of the Criminal Law Amendment Act concerned itself with sexual assaults on young women and the control of prostitution.

Public opprobrium

Against this background of increasing legislative control, the late 19th century in Britain and elsewhere in Europe saw a stand-off between forces fighting for a liberalisation of attitudes towards sex and sexuality, such as sexologist Magnus Hirschfeld’s Scientific Humanitarian Committee in Berlin, ranged against those in moral panic about sexual mores. One behaviour of great concern was masturbation.

From the 18th century, (male) masturbation had come to be seen as a dangerous form of sexual expression divorced from married fidelity. The idea that masturbation might lead to mental feebleness now strikes us as absurd, but compulsive masturbator, poet and (probably) homosexual Edward Lear is likely to have attributed his epilepsy to the ‘solitary vice’, according to at least one biographer (Reference Mars-JonesMars-Jones 2001). The attribution of epilepsy as punishment for masturbation was another myth of the time.

We mention Edward Lear because he was clearly preoccupied with his habit, as his diary of 1887 shows (Reference LearLear 1887). Typically, he indulged in it seven times a day, it was aversive to him, and he led a somewhat barren intimate life. He craved companionship and reciprocated physical and spiritual love with a young man, but this was to elude him. Might we be tempted to label him retrospectively a sex addict, albeit without the internet?

What is a moral panic?

Moral panics were first defined in the seminal work of sociologist Stanley Cohen, whose 1972 publication Folk Devils and Moral Panics examined the popular reaction to the ‘delinquent’ youth culture of mods and rockers, associated in particular with violence in Brighton. His title refers back to such ‘folk devils’ as the unfortunate women prosecuted as witches in the 17th and earlier centuries. He argued that ‘societies appear to be subject, every now and then, to periods of moral panic. A condition, episode, person or group of persons emerges to become defined as a threat to societal values and interests’ (Reference CohenCohen 1972: p. 9).

The concept of moral panic was later linked to sex and sexuality explicitly through analyses of 19th-century moral crusades against homosexuality and prostitution (Reference WeeksWeeks 1981; Reference Rubin and VanceRubin 1984). In recent history (Reference WatneyWatney 1987), moral panics surrounding sex have emerged through HIV/AIDS (which again demonised homosexual men), pro- and anti-pornography campaigns, further campaigns against prostitution but also those in favour of protecting the rights of sex workers: it is interesting in this connection that feminism has served both conservative and liberal impulses.

Sexual panics are a subspecies of moral panic (Reference HerdtHerdt 2009). In a true sexual moral panic, people become:

In the sexual scandals relating both to Oscar Wilde and former American President Bill Clinton, what began as scandal ended in spectacle, and both these events belong to the class of moral panics.

Child pornography : new folk devils

Recently, an intersection has been recognised between use of the internet and sexually prohibited activity. This is perhaps most clear in the West in terms of the production and use of child pornography. The number of prosecutions continues to mount, surrounded by fears that predatory paedophiles may be our virtual as well as actual neighbours, hiding who they are by masquerading as others (typically adolescents) on the internet. It might be argued that a moral panic is occurring specifically regarding the nefarious use of the internet by networks of paedophiles.

Linked with this is the emergence of stories of police officers charged with investigating child pornography, who have become offenders themselves. On 10 October 2010, the BBC reported the exposure of an internet paedophile ring in Spain which included two police officers, among other public servants (BBC News Europe 2010). This fits with a constitutive fear in sex panics – that the ‘folk devils’ will somehow proselytise, infect or convert others into themselves – an old fear in relation to homosexuality, though a realistic one in terms of paedophiles using the internet to groom victims.

Consenting adults?

In March 2003, Jane Longhurst, a special needs teacher, was strangled to death. Her killer, Graham Coutts, failed to persuade a jury that she died accidentally during consensual erotic asphyxiation and was convicted of murder. A campaign led by her mother Liz Longhurst calling for a ban on websites depicting violence against women culminated in legislation making possession of extreme pornography illegal in the UK (Criminal Law Policy Unit 2009). Sadomasochism (S&M or SM) groups argue that this is an overreaction criminalising people who consent to sexual activity (Reference ChampionChampion 2010). Lord Wallace of Tankerness called the legislation flawed because it makes illegal the possession of an image of behaviour, which in itself would not be an offence (Hansard 2008).

But how is it possible to establish that the participants in extreme pornography are truly consenting? Children never ‘consent’ to working in the sex industry and there is an established link between victims of human trafficking and child pornography (Office of the United States High Commissioner for Human Rights 2000). We support the policing of the internet against the sexual abuse of children.

A moral panic requires more than a disproportionate reaction. There has to be consensus that there is a genuine threat to social values. There is no good evidence of a widespread belief that viewing images of consenting adults indulging in fantasy behaviour is damaging.

In the terms outlined above, it appears that there is no moral panic specifically about sex addiction and the internet, at least not yet. The sex addict as represented in the media by, for example, Tiger Woods, is likely to be seen as deserving of sympathy, pathetic or simply not believed: sex addiction is his excuse. The media has, however, played an important role in publicising sex addiction, starting with celebrities, and this may influence some people’s self-labelling as sex addicts. In 1997, David Duchovny (star of The X Files) was labelled a ‘sex addict’. He denied the charge at the time, but in 2008 he admitted to several years of addiction (Reference SerjeantSerjeant 2008).

DSM-5

The pathology of behaviour has been an area of considerable discussion in the formulation of the first draft of DSM-5, currently available only online, although referenced in various press releases (American Psychiatric Association 2010). It is proposed that problems people experience taking illicit drugs should be re-conceptualised as compulsive drug-seeking behaviour, rather than neurochemical addiction. This leaves the door open for many subjectively compulsive behaviours to be bracketed with more traditional addictions. Consequently, behaviours such as excessive gambling, shopping, computer game use, contact sexual behaviours and the use of internet pornography become seen as health problems.Footnote †

Gambling addiction is currently in DSM-5, albeit in a distinct section on impulse control disorders. Internet addiction was considered for inclusion there, but rejected. No mention was made of internet sex addiction (DSM-5 Task Force 2012a). The concept of excessive internet use as an addictive behaviour has previously been reviewed in this journal by Reference Murali and GeorgeMurali & George (2007), who concluded that debate on the diagnostic validity of the concept was slowing progress in its delineation.

In the DSM-5 drafts (DSM-5 Task Force 2012b), gambling disorder is defined as a persistent and recurrent maladaptive behaviour as indicated by five (or more) of the following:

1. 1 preoccupation with gambling (e.g., reliving past gambling experiences, planning the next venture, or thinking of ways to get money with which to gamble)

2. 2 the need to gamble increasing amounts of money to achieve the desired excitement

3. 3 repeated unsuccessful efforts to control, cut back, or stop gambling

4. 4 restlessness or irritability when trying to cut down or stop gambling

5. 5 using gambling as a way of escaping from problems or of relieving dysphoria (e.g., feelings of helplessness, guilt, anxiety, depression)

6. 6 after losing money gambling, returning another day to get even

7. 7 lying to conceal the extent of gambling

8. 8 jeopardising or losing a significant relationship, job, or educational or career opportunity because of gambling

9. 9 relying on others to provide money to relieve financial straits caused by gambling.

All of these criteria could have direct equivalents in internet sex addiction apart from criterion 6. Much of the fear in the media regarding internet sex addiction arises from the equivalent of criterion 2 – an internet sex addict would have to seek out ever more extreme or bizarre forms of pornography to achieve the same release. It is easy to postulate that this might lead to progression from adult to child pornography. However, evidence that it does so is very thin on the ground.

Psychiatry unlimited and the DSM-5 diagnosis

Just as you can substitute the words internet pornography for the word gambling to generate a new disorder, so you can for a huge number of other words representing behaviours that are known to be taken to extremes. Golf is a good example. The concept of the ‘golf widow’ has long been in the lexicon. Keen golfers are known to be happy on the golf course (criterion 5), talk about little other than golf (criterion 1) and spend ever-increasing time on it (criterion 3). Other criteria in the DSM-5 list might be similarly applied. Thus, DSM-5 might open up many areas of new ‘illness’. In fact, it follows that there will be no pleasurable pastime that could not potentially attract a psychiatric diagnosis.

Behaviours in context

Therefore, before excessive interest in an activity or behaviour is declared an illness, effort must be taken to put it into a cultural and societal context. There are two elements to this. First, there is often (although not always) an inner drive. In internet sex, this is the libido. The fact that excessive internet sex is used to fulfil a sexual urge or drive that is an in-built human need will always make it seem more problematic than excessive behaviours for which there is no equivalent drive. Control of the excesses of human libido has been of great societal concern as far back as one cares to research, as outlined above.

Second, there is the status of the behaviour in the social context. Sexual behaviour has a unique position in society, and it is judged to a very different standard than other behaviours. The threshold at which sexual activity is seen as excessive, and consequently a problem, is largely culture bound. Societies tend to assess behaviour in terms of its goal direction, linked to social roles and values. Work attendance, home maintenance, worship and recreation are dependent on social learning, not the waxing and waning of an appetite. Sleep, sex, eating and drinking are appetite driven: they are reduced by satiation and are further behaviourally modified by social values and culture.

Excesses in sexual activity, as in gambling or similar behaviours, can be assessed using objective measures such as occupational impairment. However, society’s reaction to excessive sexual activity is very different from its reaction to excessive gambling. Consequently, the standard approach of measuring distress in the subject and disquiet in their social network using instruments such as the Sexual Compulsivity Scale (Reference Kalichman, Johnson and AdairKalichman 1994) is likely to result in overdiagnosis of that excessive sexual activity.

As stated earlier, internet sex addiction is rarely encountered in the adult psychiatrist’s daily NHS work. The rare presentations are usually highly dependent on the social context. Commonly, there is a crisis of disclosure: the individual’s family or employer has discovered their use of the internet for sexual purposes. Reactions on being found out vary. Some present with shame and depressive attitudes, perhaps asking why they do it and requesting medication or a cure. Others wonder what is all the fuss is about, but must be seen to be going through the motions of treatment.