Scientifically speaking, “nymphomania” doesn’t exist. While French doctor M. D. T. Bienville’s first detailed study Nymphomania, or a Dissertation Concerning the Furor Uterinus in 1771 identified many potential causes of excessive sexual desire in women, such as consuming too much chocolate and reading novels, today’s clinicians, doctors and psychiatrists continue to debate whether “hypersexuality”—the more accepted term—is a disorder, a pathology, or merely an unconventional life choice.

Danish filmmaker-provocateur Lars von Trier has never exactly been a credible source for anything—after all, he restaged the American South without ever having visited the U.S.—but his latest Nymphomaniac, which follows the sexual exploits of Joe (played at different life stages by Stacy Martin and Charlotte Gainsbourg), has some surprisingly valid things to say about the condition.

We spoke with Dr. Rory C. Reid, an Assistant Professor and Research Psychologist within UCLA’s Department of Psychiatry and Biobehavioral Sciences, about Lars von Trier’s case study. Dr. Reid, who is the principal investigator in a current research study exploring the DSM-V criteria for “Hypersexual Disorder,” discussed what von Trier gets right, what he gets wrong, and how a patient like Joe could be treated.

Sloan Science and Film: So what does Nymphomaniac get right?

Rory Reid: There’s this element of using sex to cope with difficult unpleasant emotions or stressful situations which we often see with patients. In the movie, there’s a scene when Joe’s father is dying and she’s at the hospital having sex with one of the orderlies instead of being by her father’s bedside. You can tell she’s using sex to escape the pain of her father passing. Another idea in the movie that is consistent with what we see clinically is the notion that sex is void of any kind of love or connecting experience—that’s very common, as well. In the movie, the girl’s club portrays this aversion to even using the word love. Many hypersexual patients have also become so desensitized that they lack empathy or compassion for others and disregard the possible risks or consequences of their choices. There are several scenes where Joe juggles multiple sex partners in the same day and in one of them a partner (a married man with children) wants a more meaningful relationship but Joe simply wants him to leave so she can prepare for her next partner. However, the wife of the man shows up unexpectedly and confronts Joe for destroying her family. Collectively, several of these scenes are consistent with what we see in patients seeking help for hypersexual behavior.

SSF: In what areas does the film go against the research?

RR: For women that are hypersexual, there’s a lot more prevalence of sex abuse than there is for men, but we don’t have any evidence of that in the character’s childhood in the movie. But the idea that there were some development challenges and disconnect between Joe and her mother is not uncommon in this population, so maybe that’s an accurate depiction. However, many women who become hypersexual use sex as a way to feel validated and receive affirmation from a man. But in the case of this movie, Joe seems opposed to this for the most part.

SSF: What about Joe’s vacillation between self-loathing and pride in her behavior?

RR: The shame dynamic is very common. I’ve published three research articles on shame and this phenomenon. What I would characterize as maladapted shame—feelings of inadequateness and brokenness—happens a lot. Shame is different from guilt. Shame says: I am bad. Guilt says my behavior is bad. People with shame develop this attitude of: “I don’t care, it doesn’t matter, I feel bad about myself. Nobody cares about me.” And that gets projected onto other people: “If nothing matters, why should I care about you? If nothing maters, it doesn’t matter if I use you or take advantage of you.” Because they’re feeling used and flawed, there’s this lack of empathy and compassion for self. If I don’t love myself, how is it ever possible for me to love and care about someone else? We see this dynamic again and again in the movie.

SSF: The film also suggests there’s a slippery slope from sex addiction to sadomasochistic sexual behavior. Are they related?

RR: This occurs for some patients but it’s the exception, not the rule. A lot of people who engage in hypersexual behavior don’t get into fetishes or S&M. So that’s not characteristic of this population. If someone is masturbating excessively or having lots of sex with commercial sex workers or having serial sex affairs, that’s not masochism. Masochism is humiliation of the self or experiencing pleasure in being subjected to pain; in some cases, it’s looking for a dominant person to inflict this pain, humiliation or suffering. People who engage in that behavior usually do so for different reasons. Someone with lots of stress, responsibilities, or burdens can let go in those situations and be told what to do as opposed to being in charge and carrying responsibility. It’s just a very different dynamic sexually.

SSF: How do you treat a character like Joe?

RR: What we’re discovering in our research is that there are sub-types. This is not a homogeneous group. There are different types who seek help on this issue. Some have very normal psychological profiles. They appear to just engage in this sexual behavior because it feels good, and they do it again and again until it becomes habitual but also causes problems. That’s not pathological. But then we see other patients who are opportunistic, impulsive and suffer from disorders such as ADHD. Then there’s this third group, who appear to be emotionally deregulated and may suffer from mood or anxiety disorders; they’re using sex to deal with stress and escape their problems. So we don’t treat all these patients the same. A lot of patients, we refer them to group therapy, because in group therapy, it normalizes the shame—knowing that other people struggle with it too and there’s this feeling: “Maybe I’m not such a bad person, after all.” Cognitive behavioral therapy is also used, where we can challenge irrational thinking patterns. One of the things we’re finding is mindfulness meditation, in our research, seems to be very helpful: It helps people cope with difficult emotions effectively, and with stress more effectively, and through it people increase their tolerance for sexual cravings and urgings. For some patients, we might put them on medication. Therapy can also be augmented by having patients attend self-help groups or self-help readings. Those are some of things that we’re finding helpful but we continue to research therapy outcomes to discover what is the best approach.

SSF: What’s the issue of identifying sexual addiction? Why is it not an accepted category or disorder?

RR: I don’t call it sex addition. I call it hypersexual behavior. First of all, it’s not a sanctioned disorder by the American Psychiatric Association. It also needs more research. My team at UCLA did find evidence for reliability and validity of the criteria proposed by Dr. Marty Kafka from Harvard for “hypersexual disorder” that was recommended to APA. But the APA said they wanted more evidence that such behaviors constituted a disorder. The proposal for hypersexual disorder specifically sought to avoid the “addiction” model because it suggests brain pathology and at present, despite what anyone may say, we don’t have evidence of that. We don’t have genetic, neuroscience, or neuroimaging studies to support that claim that this is a scientific “addictive” disorder. To the average person, they see obvious parallels with addictive behavior: people escalate, they take risks associated with their behavior, the person continues to engage in the behavior despite consequences, there are multiple unsuccessful attempts to change their behavior, the behavior is interfering with their relationships and their work and family life and so forth. So if people want to use that label, fine, but scientifically, we don’t use that label.
In some brain studies at UCLA and also work that’s been done in Germany and the University of Minnesota, the data all appears to be converging to suggest that the brain doesn’t respond to sex in the way it does with other patterns common to addictive disorders such as drug and alcohol dependence. There are a lot of other models that might offer explanations for these issues, such models of impulse control, compulsivity, or reward sensitivity models. So for example, hypersexual behavior might be more of an impulse control disorder the way pathological gambling used to be characterized. Hypersexuality might not be a pathology or disorder at all. Personally, I don’t believe it has to be a disorder for someone to receive help. We all know people who are perfectionists, for example. And that can interfere with their lives, with their work, but perfectionism isn’t a disorder. However, I can help that person. And in that same manner, I believe mental health professionals can still offer help to people who suffer from some kind of dysregulated sexual behavior such as hypersexuality without it being classified as a disorder.