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Disorder in the court: The approach to sex addiction in Canadian legal proceedings.

Hypersexual Disorder, often termed colloquially as sex addiction, does not appear as a diagnosis in the most recent edition of the DSM, as there was insufficient empirical support for the putative cluster of symptoms involving preoccupation with sexual thoughts, feelings, and behaviours. Despite the lack of scientific evidence for a sex addiction diagnosis, the popular media continue to discuss sex addiction, and individuals continue to present clinically seeking assistance with their out-of-control sexual behaviours. Importantly, "sex addiction" is being led as a defence in criminal and civil matters in several jurisdictions. Building on a recent American case law review, the current research systematically sampled Canadian court, tribunal, and arbitral case law to query how these venues are addressing the concept of sex addiction. Case law was identified using the comprehensive Canadian legal database, Quicklaw, using an exhaustive list of key terms. Of the 111 cases identified and screened, 63 were excluded, and 48 were included in the review. Results indicate sex addiction is being used most commonly in criminal law and family law matters but is also used at arbitral and professional disciplinary hearings, as well as in administrative proceedings (including employment, human rights and immigration hearings). The current article presents examples of how sex addiction is being used in these venues and offers commentary on the ways in which legal and scientific epistemologies differ.

KEYWORDS: Sex addiction, courts, case law, Canada

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Hypersexual Disorder was proposed and rejected as a new diagnosis in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed., [DSM-5]; American Psychiatric Association [APA], 2013). Some raised concerns that the proposed Hypersexual Disorder (HD) diagnosis did not have sufficient empirical evidence to achieve the status of a new disorder, lacked sufficient neuropsychological testing to verify the disorder, and had the potential for the misuse by overzealous members of the legal community (Reid & Kafka, 2014). Others raised concerns that HD should not be conceived of as a stand-alone diagnosis but is properly understood as a feature of other mental illnesses (Halpern, 2011; Moser, 2011). Others still argued that the proposed HD diagnostic language must be careful to not pathologize those sexual practices for which we tend to have little understanding yet at the same time hold in disdain (Wakefield, 1992).

The proposed and rejected criteria for a diagnosis of HD included non-paraphilic, uncontrollable fantasies, urges and behaviours leading to adverse consequences and clinically significant impairment in important areas of functioning, for at least 6 months (Kafka, 2010a; 2010b). Patients meeting these proposed criteria typically use sexual fantasies, urges and behaviours to cope with dysphoric moods or to manage stress and feelings of anxiety. Patients meeting the proposed criteria will have experienced many unproductive attempts to control their sexual fantasies, urges or behaviour, and will have experienced adverse consequences as a result of these fantasies, urges or behaviours.

Another issue hampering agreement on a HD diagnosis is the lack of epidemiological data on hypersexual behaviour. Early American research using a large convenience sample of males (N = 5300) found that approximately 7.6% had a mean total sexual outlet per week (i.e., frequency of orgasm) of at least 7 for 5 or more years consecutively (Kinsey, Pomeroy, & Martin, 1948), providing a vague initial guideline for the prevalence of some HD-type behaviour. While little research exists exploring females with HD, the research that does exist suggests a much lower prevalence of females with hypersexual behaviour (e.g. see McKeague (2014) for a recent review of the etiology, and clinical presentations of females with HD using an addiction model). More recently, Langstrom and Hanson (2006) conducted research exploring hypersexuality using a representative, large scale Swedish community sample (N = 2450, n = 1279 males). Findings indicated that high rates of masturbation and impersonal sex (common in HD) were associated with early separation from caregivers, relationship instability, sexually transmitted infections, substance abuse, and general life dissatisfaction in the 12.1% of the sample (n = 151 of 1244 males aged 18-60) designated hypersexual. While some epidemiological evidence suggests high frequency sexual behaviour may be correlated with relationship and personal distress, we note that results are based on individual researcher decisions about what constitutes "high sexual frequency" that suffer from potentially arbitrary cut scores. For example, recent Canadian research by Levaque, Sawatsky, and Lalumiere (2016) aimed to measure HD in an undergraduate sample (N = 717, n = 187 males) using instruments that are validated in testing for the problematic urges, fantasies, and behaviours described in the proposed and rejected DSM-5 HD diagnostic language. A significant number of the sample (5.0-23.0% of females, and 17.0%38.0% of males) were classifiable as hypersexual based on the existing criteria, calling into question both the validity and generalizability of some of the current HD criteria.

In addition to the lack of epidemiological data on HD, tied inevitably to diagnostic ambiguity, HD-type behaviour has been conceptualized in a diversity of ways (for recent review articles examining the etiological and theoretical underpinnings of HD see Kaplan & Krueger, 2010; MontgomeryGraham, 2017; Stewart & Fedoroff, 2014). HD has been conceptualized as falling on the obsessive compulsive spectrum (Black, Kehrberg, Flumerfelt, & Schlosser, 1997), as an impulse control disorder (Barth & Kinder, 1987), as sexual sensation seeking associated with sexual risk taking, (Coleman, 1987; 1992), and as a combination of low inhibition and high excitation tendencies within the Dual Control model (Bancroft, 1999; Bancroft, & Janssen, 2000). HD has also been broadly discussed using an addiction model, like alcohol or illicit drug addiction (Carnes, 1989), which has been a common conceptualization in popular media and clinical literature more than in empirical research (Ley, Prause, & Finn, 2014). Recently neuroimaging (see Kuhn & Gallinat, 2014; Miner, Raymond, Mueller, Lloyd, & Lim, 2009; Prause, Steele, Staley, Sabatinelli, & Hajcak, 2015; Voon, et al., 2014), attachment theory (Faisandier, Taylor, & Salisbury, 2012; Gilliland, Blue Star, Hansen, & Carpenter, 2015; Leedes, 1999; Zapf, Grenier, 8c Carroll, 2008) and executive cognitive dysfunction (Mulhauser, Struthers, Hook, Pyykkonen, Womack, & MacDonald, 2014; Reid, Karim, McCrory, & Carpenter, 2010; Reid, Garos, Carpenter, & Coleman, 2011) are being explored as possible frameworks that may assist in shedding light on a common underlying construct. Despite all of this ongoing discussion, no conceptualization of HD has gained wide acceptance.

Even though no scientific consensus has emerged about HD or sex addiction, a recent analysis of the themes emerging in the popular media (i.e., newspapers, blogs, and magazine articles) about pornography and its impact on couples found that pornography addiction and sex addiction emerged in over half of the articles reviewed (N = 101), demonstrating the prominence of the idea of sex addiction in our North American consciousness (Montgomery-Graham, Kohut, Fisher, & Campbell, 2015). Recently Ley, Brovko, and Reid (2015) explored the extent to which popular understandings of sex addiction are having a significant influence on the American legal system in the areas of criminal, civil, and administrative law. This article offers observations regarding the use of sex addiction outside of the US context. Ley and colleagues' methodology (2015) inspired the current two pronged inquiry into how Canadian courts and tribunals are defining sex addiction given its uncertain scientific status, as well as how sex addiction is being used by lawyers and judges. No other articles of which we are aware examine how Canadian courts and tribunals are addressing the use of sex addiction in the courtroom and its legal consequences given the lack of scientific consensus. This article will be the first to do so.

METHOD

In November 2015, I searched the Canadian legal database Quicklaw (QL), which is the Canadian electronic legal research database most commonly used by Canadian lawyers and legal academics. QL searches case law (i.e., the reported decisions made by Canadian courts, including the courts' reasons for those decisions) and legal commentary back to the early 1800s. No date restrictions were added to limit the QL search. Case law searched included all Canadian provinces' and territories' civil matters (e.g., personal injury, employment law, child custody, and child protection), criminal matters, and administrative tribunal decisions (e.g., human rights, immigration, professional discipline, Review Boards assessing mental competence, Workplace Safety, as well as grievances of unionized employees under the jurisdiction of arbitrators). In November 2015, we used the following search terms: sex addiction, and compulsive sexual behaviour. After a thorough review of the case law discovered from the November 2015 search, in July 2016 the initial searches were updated and re-run, and two further terms were used to broaden the scope of the inquiry: hypersexual disorder, and hypersexual.

RESULTS

The initial November 2015 searches of the term sex addiction yielded (n = 27) instances of cases using this term, and (n = 6) instances of cases using the term compulsive sexual behaviour. The replication of these search strings in July 2016 revealed one new case for each term sex addiction and compulsive sexual behaviour. Following review of these initial 33 cases, it became apparent that two further terms should be added to ensure an exhaustive review of the use of sex addiction and related terms in the Canadian case law. Thus, when the search terms hypersexual disorder (n = 0) and hypersexuality (n = 76) were added as search strings, 76 cases were added to the list of cases to be reviewed. In total, 57 cases were discarded for lack of sufficient content to allow analysis, 9 cases were removed as they were duplicative cases already reviewed, and 3 additional relevant cases were found because they were mentioned by courts in cases discovered using search terms, for a total of 48 cases reviewed in the preparation of this article. Fifty three cases that had been found using the search term hypersexual were discarded because the search term only appeared one to two times in these decisions, was incidental to the decision, provided no analysis by experts, and tended to be used in passing only in reference to hypersexual behaviour during a manic phase of Bipolar Disorder. Discarded cases were decisions rendered by the Ontario Review Board (n = 42), the British Columbia Review Board (;n = 5; which oversees hearings of persons found not to be criminally responsible for alleged misconduct on the basis that it arose as a result of a legally defined mental illness), and the Ontario Consent and Capacity Board (n = 6), which assesses the mental capacity of individuals within the legal system to make decisions for themselves. See Figure 1 for a detailed explanation of the inclusionary and exclusionary process of cases for this article.

HD (or sex addiction) surfaces as a legal issue worthy of some discussion by experts and judges within the following areas of law: criminal law (n = 30), family law (n = 9), and administrative law (n = 9), which includes professional discipline, human rights and immigration tribunal hearings. The case law reviewed for this article had judgments rendered in the following Canadian provincial jurisdictions: Ontario (n = 14), Alberta (n = 10), Manitoba (n = 8), British Columbia (n = 7), Newfoundland (n = 4), Saskatchewan (n = 4), and Quebec (n = 1). Note that while the province of Quebec is governed by a Civil Code rather than a common law system like the other Canadian provinces and Territories, the one Quebec case reviewed was a criminal matter which is governed by the Criminal Code of Canada ([Criminal Code Consolidation C-46], 1985), which is federal legislation governing all Canadian provinces and Territories.

DISCUSSION

The following review and discussion is framed by two questions: first, how are Canadian courts and tribunals defining sex addiction, given its lack of diagnostic status and scientific consensus? Second, how is the concept of sex addiction being used by counsel in Canadian courts and tribunals, and ultimately by judges and other decision makers, in addressing the issues before them? Each of these questions will be explored below, highlighting those specific cases in which the Court engaged in a thorough discussion of sex addiction and its impact on the parties.

Defining "Sex Addiction"/Hypersexual Disorder

Canadian courts and tribunals receive varying definitions of sex addiction or HD and descriptions of its scientific status depending upon whether or not experts are brought in to provide opinions, and the weight attributed to those expert opinions by the decision maker. Sometimes experts are brought before the courts to explain the state of the science on HD, and judges have the benefit of that instruction. In Owens Corning Canada Ltd v. Union of Needletrades, Industrial and Textile Employees, Local 1350 (2005), for example, an employee, G.C., (1) grieved his termination after the employer discovered he had watched hundreds of hours of pornography on a workplace computer, logged into chat lines while on his shifts, and visited at least 3600 pornography websites while at work. The grievor claimed that while he was aware his behaviour was contrary to his employer's workplace policies, his increased computer use over the course of his employment resulted from his sex addiction, which he described as a disease. A forensic psychiatrist for the employer testified that sex addiction was not an acknowledged diagnosis in the then current DSM-IV-TR (APA, 2000). The family doctor who diagnosed the grievor used a non-empirically validated scale to make his sex addiction diagnosis; a strategy which ultimately failed as employer council painted the grievor as a dishonest individual who not only engaged in something akin to time theft when he looked at pornography during his shift, but also as an individual who resorted to reliance on a dishonest diagnosis in an effort to achieve reinstatement to his former job. While the nuanced discussion of the science behind HD was not discussed in this judgment, the point was made by an expert and accepted by the judge that sex addiction is not an official diagnosis.

In some instances, popular media accounts of sex addiction appear to influence the course of judicial decision-making. Lay sources tend to frame sex addiction using the notion of tolerance, borrowed from an addiction model. The concept of tolerance, meaning either a need for increasing doses of a substance over time to achieve the same desired effect, or a markedly diminished effect with continued use of the same amount of the substance, comes from Substance Use Disorders diagnoses of DSM-5 (APA, 2013). The preface to substance-related and addictive disorders specifically states that other excessive behavioural patterns, or behavioural addictions including sex addiction, are specifically excluded from the DSM-5 because of a lack of sufficient peer-reviewed evidence to establish the diagnostic criteria as mental disorders. Nonetheless, the notion exists in popular culture that sex addiction is a mental disorder and sex is an addictive behaviour for which a tolerance can increase (MontgomeryGraham, Kohut, Fisher, & Campbell, 2015). The sex addiction model posits that over time, sex addicted men become uncontrollable and unrecognizable versions of themselves when overcome by their addiction; their increasing tolerance (or inability to be sated by) sexual behaviour or material may ultimately escalate into a preference for paraphilic content (often including child pornography) that becomes inexplicable to the sex addict himself. (2)

We see this narrative in R. v. H.T. (2010), which involved a 72-year-old man with no prior criminal record who was convicted of possession and distribution of child pornography. A forensic clinical psychologist provided a report explaining that the accused did not have a pedophilic disorder. Given that the psychological report was filed with the court instead of the clinical psychologist providing viva voce testimony (i.e., oral, in-person evidence), there was less opportunity to clarify specific psychological issues that arose during sentencing. For example, the judge stated that the psychologist's report was consistent with the accused's testimony in that much of his life had been "characterized by a severe sex addiction" (R. v. H.T., 2010, para. 75). On the one hand, it seems odd that a clinical psychologist would not mention the controversy surrounding HD or sex addiction as a diagnosis. Having said that, since we do not have the benefit of the full psychological report to review, but only the judge's summation of the report, it seems likely that the issue asked of the psychologist was not is the accused a sex addict but rather does the accused have pedophilic disorder, since a diagnosis of the latter is relevant to sentencing and an increased risk of recidivism.

Unexpectedly, a popular self-help book, In the Shadows of the Net: Breaking Free of Compulsive Sexual Online Behaviour (Carnes, Delmonico, & Griffin, 2009) was filed as evidence with the court without the benefit of expert testimony to explain or challenge it. A portion of the Carnes and colleagues' (2009) text even appeared in the judgment to explain what the judge called the "power and danger of the Internet" (R. v. H.T., 2010, para. 78). The judge accepted the accused's testimony that he was a sex addict. The judge cited with approval the accused's testimony that "Sex Addicts Anonymous made me understand that I was an addict, and, as such, was powerless to control my behaviour" (R. v. H.T, 2010, para. 81). Finally, the judge was of the view that: "[the accused] immersed himself in the Twelve Step program of Sex Addicts Anonymous which has been his salvation" (R. v. H.T., 2010, para. 80).

Two issues from the judgment are worth noting. First, the judge stated that the viewing of child pornography was the "latest manifestation of [the accused's] sex addiction" (R. v. H.T., 2010, para. 75). In combination with excerpts cited favourably from the Carnes and colleagues' (2009) self-help book about Internet compulsive sexual behaviour, the judgment gives the impression that the accused developed a tolerance for "regular" (viz., adult) pornography, which over time was no longer arousing to him, causing him to view illegal child pornography. We have found no empirical evidence scientifically examining the notion accepted by the judge of a tolerance developing in sex addicts such that sex addicts desire increasingly paraphilic imagery to become sexually aroused.

As well, the trial judge believed in the validity of the 12 Step program, which forms the basis of Sex Addicts Anonymous, and gave significant weight in his judgment to the accused's active role in Sex Addicts Anonymous. Individuals may report success with 12 step programs anecdotally but the efficacy and effectiveness of this treatment approach remains in question (for a review of treatment approaches for Hypersexual Disorder, see Montgomery-Graham, 2016). In the end, the judge in this case sentenced the offender to 90 days in prison (along with three years' probation, plus a $4000 fine). While this decision may or may not be legally correct, the methodology used by the judge poses a problem. In his decision, he relies on unvalidated and problematic science based on self-help books and creates a precedent for future judges to rely upon in subsequent child pornography sentencing decisions.

In some of the case law reviewed there is a wealth of scientific opinion available to the decision maker, yet the forensic experts are at odds and cannot reach a consensus on what inferences should be drawn. In such instances, the trial judge must make the best decision he or she can. R v. S [full case name redacted] (2010) is an instance of a judge not relying exclusively on either of the experts' testimony to arrive at a reasonable legal decision. The case involved an application by the Crown to have the accused designated a dangerous offender, which is permitted if a sentencing court believes that the offender constitutes a threat to the life, safety, or physical or mental well-being of the public. Such a designation can lead to the incarceration of the offender for an indeterminate length (in other words, for as long as the offender remains dangerous) (Criminal Code Consolidation C-46, 1985). The 20 year-old offender in this case had demonstrated a pattern of aggression, rage, and inappropriate sexual behaviour. He pleaded guilty to assault causing bodily harm and sexual assault with a weapon. The accused referred to himself as a sex addict throughout his testimony. The accused met many of the proposed HD diagnostic criteria (Kafka, 2010a) including: using sex to regulate negative affect (especially depressed mood), relying on prostitutes for most of his sexual interactions, heavy involvement in chat rooms, high sexual acting out via masturbation or dyadic interaction (3-4 times daily), a good deal of his daily life being consumed by sexual fantasy, and difficulties with intimacy. Whereas the expert psychiatrist diagnosed the accused as a sexual sadist with multiple paraphilias (as well as Borderline, Anti-Social, and Narcissistic personality disorders), and found his sexual behaviour disorder to be rooted in his sexual sadism, the expert psychologist maintained that the accused's sexual acting out was likely rooted in a combination of anger and impulsive disorders. The psychologist posited that the offender may have had Fetal Alcohol Spectrum Disorder (which includes impulsivity, an inability to learn from experience, and executive cognitive dysfunction), with co-morbid Attention Deficit Hyperactivity Disorder. Another difference between the experts was that the psychiatrist thought the accused had a moderately-high to high risk of sexually violent recidivism, while the psychologist thought he had a low moderate risk of recidivism.

The judge devoted much of the 119-page judgment to attempting to find commonality in the expert testimony. He finally ruled that the decision as to whether or not the offender failed to control his sexual urges was a factual determination within the judge's purview, rather than a psychological exploration for experts, and declared the offender to be a dangerous offender. While the results of this case may be interesting, the more important point (from a scientific perspective) is that it illustrates a judge's discretion to determine how to resolve disagreements between experts, when the opinions of experts matter, and which aspects of an expert's testimony to reject or accept, decisions that the judge often makes without the benefit of first-hand scientific knowledge. The large amount of judicial discretion around how to address various expert opinions becomes problematic given that no ethical rule insists that lawyers bring the most scientifically correct expert to educate the judge. As a result, the expert whose opinion is most in line with their client's case is often the one who ends up testifying before the judge. When the science is uncertain as it is with sex addiction, there is latitude for poor decisions to be made based on factors other than high quality scientific evidence.

Finally, judges sometimes have scientific evidence but rely on intuition rather than empiricism in rendering a decision. R. v. L [full case name redacted] (2006) was a sentencing hearing for an offender from whom police seized 8800 files of violent child pornography. A forensic psychiatrist called as an expert witness diagnosed sex addiction as a result of the accused's loveless and deprived childhood. He testified that the accused's voyeuristic fantasies became a surrogate outlet for his narcissistic sexual indulgences with children. Given there were neither conclusions of psychopathy, nor official diagnoses of mental or personality disorders, the witness assessed the accused's prognosis for recovery as extremely favourable provided the accused received ongoing treatment. The psychologist, who was referred to as a sexual addiction therapist, agreed with the psychiatrist's prognosis and risk assessment although she did testify that sex addiction was not an accepted scientific diagnosis. Interestingly, the lack of actual DSM diagnostic language seemed to make the trial judge doubt the opinions of both experts. The judge was clearly troubled by the experts' testimony and their conclusions although he stated that their evidence remained valid for his consideration. He wrote in his judgment that he could not reconcile the fact of the accused's vast collection of child pornography, (and no accompanying adult pornography) with the psychiatrist's view that the accused did not exhibit an exclusive pedophilic orientation. The judge also found the psychologist's view that the offender was unlikely to re-offend to be unpersuasive. Of course, after hearing the expert opinions it is the job of the trier of fact (i.e., a judge or a jury) to determine the probative value of the facts at trial as well as to assess the inferences experts draw from those facts. While a judge is entitled to ignore the expert testimony of both witnesses if he or she does not find it compelling, a judge is ill advised to opine on areas of scientific expertise that were not before the court, which the judge in this case went on to do. After he concluded the psychologist's risk assessment was "undoubtedly well intentioned" (R. v. L, 2006, para. 31), he opined that addicts are never recovered but are instead always recovering. Further, he opined: "there is no graduation from the addiction, rather, there is a daily reprieve dependent on the quality of the addict's recovery program and their involvement in and commitment to it" (R. v. L, 2006, para. 32). Since no other substance use disorders are mentioned in the case, these comments can only be in reference to the accused's sex addiction. The judge seems to be drawing on popular notions regarding alcohol addiction; for example, Alcoholics Anonymous (AA) believes alcoholism is a chronic disease, like diabetes, from which afflicted individuals never fully recover. Recent evidence from addiction researchers suggests that most of the individuals who change their problematic drinking do so without any treatment (including AA), a significant percentage of these people retain recovery at year 8 follow up, and many formerly problem drinkers can maintain non-problematic moderate alcohol use without becoming re-addicted (Arkowitz & Lilienfeld, 2008). This case is an instance of a judge extrapolating beyond the available scientific evidence.

In sum, we see courts and tribunals defining HD and sex addiction scientifically through the use of strong expert testimony, anecdotally when strong evidence is not available, and intuitively when judges cannot reconcile the testimony before them.

How Sex Addiction is being Used Legally

Having examined the various definitions of sex addiction making their way into Canadian legal decisions, let us turn to the second question, namely, how sex addiction is being used by lawyers and judges. We review briefly the sex addiction cases surfacing in family law, criminal law, professional discipline, and immigration law.

Family Law: Custody and Access

In child custody and access case law, the best interests of the child are paramount in awarding custody and access to either or both of the child's caregivers. To discredit men in custody cases--both fairly and unfairly--some women have advanced the argument that their soon-to-be ex-husbands are sex addicts. The allegations of sex addiction rarely carried much weight in the small number of family law cases reviewed (n = 9) because this sample of female spouses presented as angry, theatrical, or mentally unwell, and awarding custody to these particular mothers would not have been in the best interests of their children. Only one family law sex addiction case involved a father losing access to his children until his psychiatrist deemed him fit to have supervised access; this case involved a man who had received voluntary psychiatric committal as well as inpatient treatment of combined depression and what was referred to as sex addiction (S v. S, [full names redacted] 2012).

CRIMINAL LAW

In the criminal case law, in an unusual turn of events a female sexual assault victim was labelled a "sex addict" by the accused. In R. v. T [full names redacted] (2011) the accused argued he acted in a sexually aggressive way with the victim, a female RCMP officer, because the male offender alleged the female victim had told the accused that she was a sex addict. The trial judge found the female victim's testimony to be logical, credible and consistent whereas the accused's testimony was "... preposterous and completely unsupported by the evidence ..." (R. v. T., 2011, para. 43). The accused's defence of "mistaken belief in sex addiction" failed, and the accused was convicted of sexual assault.

More commonly in the criminal case law addressing sex addiction, we see decreased sentencing for individuals who attend 12 Step groups like Sex Addicts Anonymous. When a judge is tasked with sentencing an individual convicted of a crime, public safety and offender rehabilitation are two of the enumerated goals to be considered (Criminal Code Consolidation C-46, 1985). Judges generally perceive attendance at Sex Addicts Anonymous as an acknowledgement by the accused that the accused has a problem with sexual acting out and is seeking to address it and a reduced sentence is seen as appropriate. While attendance at 12 Step sex addiction programs comes up often to reduce sentence length, there is as yet no empirical research that demonstrates 12 Step Sex Addicts Anonymous groups are effective (Montgomery-Graham, 2016) nor indeed as discussed at length whether sex addiction is an appropriate diagnosis. While it is possible for hypersexual acting out (or sex addiction) to co-occur with sex offending behaviour, there is no scientific research to suggest that all or even most individuals with HD act out sexually against others in illegal ways (i.e., as sex offenders). Problematically, and much like the American sex addiction case law (Ley, Brovko, Reid, 2015), some of the Canadian sex addiction cases appear to misapply an addiction model to sex offending behaviour. While sex offenders may or may not have HD, we need empirical research in the court room so sex offenders receive empirically validated diagnoses and sex offender treatment rather than intuitively derived diagnoses and referrals to 12 Step Sex Addicts Anonymous self-help groups. It would be a very positive development to see research on the efficacy of the 12 Step groups (like Sex Addicts Anonymous) in the court room so that sentencing is only decreased when offenders attend at an empirically validated program that is appropriate to their individual needs.

ADMINISTRATIVE LAW: PROFESSIONAL DISCIPLINE

Sex addiction also surfaces in professional disciplinary proceedings. Dr. K was an intensive care specialist physician whose license to practice medicine in Ontario was suspended for inappropriate and sexually suggestive acting out with friends and spouses of patients, staff and visitors of clinical settings in which he worked (Re K, [full name redacted] 2010). Dr. K was also charged criminally for sexual assault of a staff member. Dr. K argued sex addiction was an underlying reason for his acting out in sexually inappropriate ways. Many medical experts testified regarding the underlying cause of Dr. K's sexual acting out. One psychiatric expert diagnosed courtship disorder, and posited that Dr. K may have had "hypersexualism" (presumably HD-type symptoms or colloquially sex addiction), personality disorders (including narcissistic and OCD traits), as well as frontal lobe disorder (which would tend to cause disinhibition and executive dysfunction). A different forensic psychiatrist diagnosed Non-Specific Paraphilia with fetishistic interests in shoes, legs, and pubic hair. The second expert also agreed with the first expert diagnosing OCD-type traits if not the full-blown OCD diagnosis, in addition to ADHD. An addiction medicine specialist labelled Dr. K a sex addict, while a fourth and final expert maintained that ADHD, non-paraphilic hypersexuality, dysthymic disorder and paraphilic disorder (including scatologia, and partialism, e.g., sexual interest in a human body part other than genitalia) were at the heart of Dr. K's problematic sexual behaviours. The issue for the Ontario College of Physicians and Surgeons Discipline Committee was that the various treatments recommended to treat the out-of-control sexual behaviour potentially conflicted with one other, and may have ultimately exacerbated rather than quelled Dr. K's hypersexual acting out. For example, if a diagnosis of ADHD were accepted, and treated with Dexedrine or Adderal, these stimulant medications may have served to aggravate Dr. K's hypersexual behaviours. As well there were differing expert opinions as to which selective serotonin re-uptake inhibitor would best keep Dr. K's hypersexuality in check while treating his depression.

Arguably, of all the decision makers referenced in this article, the Disciplinary Committee of the Ontario College of Physicians and Surgeons is the committee best positioned to understand and assess the scientific evidence before it; at least two of the four panel members were physicians. Ultimately Dr. K's license to practice medicine in Ontario was not reinstated. The committee's reasons for not reinstating him were grounded in his pattern of compulsive sexual acting out which led to his abuse of power with patients. Regardless of the quality of the science presented regarding sex addiction, the panel was not prepared to allow someone back into the profession even with conditions given what the committee saw as an ongoing risk to the public. Despite all of the experts retained to assess Dr. K's file, the disciplinary committee was of the view that none of the experts had completed an ecologically valid assessment regarding the former physician's sexual acting out in the workplace. Instead all of the experts had relied on Dr. K's self-report. There was thus insufficient evidence on recidivism to allow reinstatement of Dr. K's medical license. Interestingly, the testimony of one physician who was prepared to diagnose Dr. K a sex addict was accorded little evidentiary weight because he had assessed Dr. K 8 years before the hearing date. By disregarding this evidence, the panel was able to refrain from engaging with the scientific uncertainty surrounding the diagnosis and management of sex addiction.

In another administrative law case, the Law Society of Upper Canada was asked to assess the "good character" of a recent paralegal graduate. The paralegal was a former police officer who called himself a "sex addict," and had been dismissed from his job as a Police Officer for having oral sex with an 18 year old woman while on duty, as well as two incidents of having sex with a woman with whom he was having an affair while on duty (N. [full name redacted] v. Law Society of Upper Canada, 2014). After being dismissed from his job as a police officer, Mr. N attempted to obtain a licence to practice as a paralegal. Because of his history of professional discipline in his former policing career, his good character was in issue and the Law Society Panel had to assess whether Mr. N should be granted a paralegal licence. Mr. N argued that his past behaviour was excusable as it was a result of sex addiction, anxiety and stress as well as undiagnosed depression during the time of the incidents, which caused him to act hypersexually. While no medical, psychological, or empirical evidence was furnished before the Law Society hearing panel, the panel was convinced that years of properly managing his "condition" meant Mr. N was of sufficient good character to be granted a paralegal licence to practice.

This case stands in contrast to Dr. K's failed attempt to become reinstated to practice medicine. Both Dr. K (the physician seeking to reclaim his medical license) and Mr. N (the Police officer fired from policing who sought to become a paralegal) breached the standards of their professional licensing bodies. As well, both Dr. K and Mr. N relied upon their sex addiction diagnoses to explain violating professional boundaries with patients and the public respectively. Despite the fact that there was no expert testimony in Mr. N's good character paralegal hearing, while there was a good deal of expert evidence in the medical licensure reinstatement matter, on a case-by-case basis, each makes sense. In the medical licensure case, Dr. K testified to having acted out sexually with patients and their families as well as having over 5000 encounters with sex trade workers, and demonstrated a pattern of relapse despite extensive inpatient and outpatient treatment by at least 15 different specialists in Canada and the United States over 7 years. By contrast Mr. N, the paralegal who was terminated from being a police officer because of inappropriate sexual conduct and abuse of power, was able to demonstrate a long period of managing environments that tended to trigger his sexual acting out. Fortuitously, it appears that sound legal decisions were arrived at in each of these individual disciplinary matters. What is more problematic is the fact that both decisions open the door for subsequent court and tribunal decisions to treat sex addiction as an existing medical-legal phenomenon without strong empirical evidence. These cases also demonstrate how the law relating to sex addiction continues to develop incrementally and idiosyncratically without being guided by careful empirical study.

ADMINISTRATIVE LAW: IMMIGRATION

Finally, sex addiction has been used in one case involving immigration law; specifically, as a basis to resist a deportation order. (A. [full name redacted] v. Canada (Minister of Public Safety and Emergency Preparedness), 2011). Mr. A, an American ex-patriot who had been living in Canada for 22 years without a fixed address had been ordered deported back to the United States. Mr. A had a long history of property crimes, failure to attend court, obstruction of the peace, in addition to more serious drug trafficking crimes. Mr. A claimed that he was a sex addict and an individual with a substance use disorder. While no medical evidence was before the Immigration and Refugee Board to challenge these diagnoses, the Board agreed to stay Mr. A's deportation order for 4 years. The Appellate Board accepted the evidence that Mr. A could not have accessed the same type of care for his addictions were he deported to the United States.

FUNDAMENTAL WAYS SCIENCE AND LAW ARE AT ODDS

Regardless of the jurisdiction within Canada, what this review has highlighted is that fundamental differences exist in the epistemologies of law and science. Whereas the law is concerned with resolving an individual conflict, as in the case of HD or sex addiction, science is more concerned with identifying a global underlying pattern of symptoms. The legal system of dispute resolution is predicated on the notion that an adversarial process--including a battle of adversarial experts will somehow yield "the truth." The goal for each side in a legal dispute is to present a one-sided, highly partisan view of the facts at issue to win at trial. Taking these partisan submissions as their only source of evidence, the judge is expected to render judgment based on the "true" facts of the case. Particularly troubling is the fact that, as we may expect, legal representation is not shared equally among all people in need of lawyers. If an individual can afford more experienced legal counsel (who is also more expensive), this increases their likelihood of improved outcomes. What this means for an evolving diagnosis like HD is that a wealthier legal claimant who can afford to hire more competent and experienced legal counsel can also be introduced through his or her counsel to better prepared and more "legal system friendly" sex addiction experts who can testify on whichever side of sex addiction is most favourable to his or her case.

A second way in which we might assert that law and science differ is that whereas legal systems require certainty, scientific evidence is provisional (Findlay & Chalifour, 2013). The use of language in each discipline reveals their underlying epistemological differences. Whereas in law counsel aims to prove something to the trier of fact with as much evidence as possible, science would never use such language. Instead, science aims to find empirical evidence to demonstrate strong support for a theory and against its alternatives. Legal proof must be final, whereas science continues to evolve. While appeal of a legal decision exists, appeals are eventually exhausted, and a legal decision stands until years of evolving case law or a new Act of Parliament change the direction of the law. By contrast, science is constantly changing and one new, well-designed scientific study can immediately change the way science is understood and practised. In the sex addiction case law, once the evidence has been heard, expert and lay witnesses have testified, and credibility has been weighed and assessed by the trier of fact, the truth has been "decided" and proven--either on the balance of probabilities in a civil matter, or to a more exacting criminal standard of proof beyond a reasonable doubt. If the judge says that the offender is a sex addict, then (for all legal purposes) he is: end of story, subject to any rights of appeal. By contrast science is tentative, as witnessed by the struggle over the DSM-5 diagnosis of HD. In the sex addiction case law forensic research experts specializing in hypersexual disorder might plausibly testify about the lack of diagnostic language for sex addiction in the DSM. An expert might testify that no scientific consensus exists about its etiology (e.g., is it a behavioural addiction, an impulsive disorder, or a compulsion that lies along the OCD spectrum). Nonetheless, we are beginning to see evidence of clusters of symptomology consistently resurfacing that provide indicia that sex addiction may in future become an agreed upon diagnosis. Importantly, people are presenting as significantly impaired and are reaching out to a multi-million dollar sex addiction rehabilitation industry for assistance. Were a judge or jury to hear evidence with such scientific uncertainty, it would stand in stark to contrast to the legal certainty required to make a decision. Moreover, it may be difficult to make sense of equivocal scientific testimony within a legal process, which is often constrained by binary decision making (Ellsworth, 2011). For instance, is the accused a sex addict or not? And if so, can he still have access to his children, or not? Or in a criminal case, does the accused go to prison, or not? Can he still practice his trade, or not? Does he lose his job or is he reinstated? While there can be nuances within these decisions like supervised access for the sex addicted dad, or conditional sentencing (i.e., house arrest) for the sexual offender, science tends to be more provisional; a theory or a diagnosis may or may not exist now, but, in future, should we gain further empirical evidence indicating we have misconstrued a diagnosis in some way, we will make revisions.

Perhaps one of the most unusual aspects of Canadian legal process might be that triers of fact hear all of the evidence available, and they then "deem" something to be a fact. Appellate courts are deferential to courts and tribunals of first instance who are believed to have been best positioned to "find facts," and loathe to interfere with lower court findings. Whereas science discovers facts through empirical research, the law may hear scientific evidence of one scientist, then another, and then accept the evidence of one side, or in some cases, for various reasons, the trial judge may accept the evidence of neither expert (viz., an expert was not qualified to opine on a specific topic, acted as an advocate instead of as an unbiased expert, or an expert was discredited in cross-examination). Scientists untrained in giving convincing legal testimony may inadvertently force the other side's position to be favoured.

In R. v. FWM (2001) the trial judge was tasked with sentencing the offender and deciding whether he would be declared a dangerous offender. Once the trial judge heard the expert psychological testimony, he decided it was persuasive and weighted it heavily in his decision making process, whereas he found the psychiatrist to be "a strong advocate expressing strong views ... [which] ... led [the trial court judge] to approach his testimony with some care" (R. v. FWM, 2001, para. 23). The role of the expert witness is to provide independent assistance using unbiased opinion in relation to his or her expertise. A sobering fact for which some scientists are unprepared is the showmanship of the legal process. If a scientist's evidence is not persuasively delivered (i.e., confidently, assertively, without too much qualification or equivocation, and in plain language), it can be ignored, even if it is the best scientific evidence available. Haack (2009) argues that the adversarial character of the legal system tends to draw in witness scientists who are outliers or unconventional in that they are the kind of scientists who are prepared to provide expert opinion despite equivocal scientific evidence.

This is not to criticize a trier of fact's unenviable position. Judges are not experts in science but are experts in certain areas of the law and can only render decisions based on what is presented to them by the lawyers. Judges and triers of fact can rely on information presented in court, precedents, scholarly writings, but they cannot draw on information that is not within the legal system. Facts can only be found by triers of fact if evidence is put before the judge to be discovered. However, if a fact is not helpful to a legal client's case, that fact will be explained away by the party's lawyer. In fact, the same set of facts will be presented by opposing counsel to highlight completely different issues, and ultimately nudge the decision maker to draw the most favourable inferences and conclusions. By contrast, if scientific evidence is ambiguous, scientists can collect new data to resolve the question (Ellsworth, 2011); they are not constrained by one study or a set of studies that have been placed before them by individuals whose interests are at odds with each other.

SUMMARY AND CONCLUDING DISCUSSION

We have reviewed the Canadian legal decisions in which sex addiction surfaces and, as we might expect given the state of the science of sex addiction, like the American case law, the Canadian case law is determined on a case-by-case basis. Overall, in Canada, the moniker of sex addict might be used to inculpate, exculpate an accused, or serve as a neutral factor in judicial, arbitral, and panel decisions. In an ideal research world, Canadian sex scientists would have endless research funding devoted to the scientific study of sex addiction. Likewise, in an ideal Canadian legal system, rather than legal council selecting only those expert witnesses who advance their client's legal position, we would have experts appearing before decision makers who served as amicus curiae (i.e., friends of the court) who are not parties to the litigation but are invited to give neutral, objective advice on a pertinent matter. The reality we face is that sex research is not as well funded as we would like, and like all scientific exploration, learning and discovery happen slowly. Once the science of HD is more certain, it must make its way through the courts and into a carefully considered judgment for the Bar and Bench to consider. In the meantime, while we await the outcome of a HD or sex addiction diagnosis in DSM-6, it remains to be seen whether, over time, claims of sex addiction will continue to be advanced or whether they will be avoided as unhelpful legal strategies that do not advance legal interests in Canadian contexts. From a mental health perspective, sex researchers and therapists look forward to further research shedding light on sex addiction so we may gain insight into individuals presenting with clinically significant distress as a result of out-of-control sexual behaviour, which will on occasion bring clients, and sex researchers and therapists, into contact with the legal system.

NOTES

(1) While all of the cases discussed in this article are available in the public domain and in many instances include the full names of the parties to the litigation, the expert witnesses, and the judges, panel members, and arbitrators, case names have been anonymized with initials used in place of full case names for this article. Throughout the article the phrase: [full case name redacted] indicates the names of parties to the litigation have been removed. Republicizing the names of individuals in a scientific journal when sensitive mental health information is included served no purpose. Interested readers are directed to explore the full case names in the References section of this article.

(2) The masculine pronoun is used because overwhelmingly HD and sex addiction research involves men exclusively.

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Stephanie Montgomery-Graham (1)

(1) Department of Psychology, Western University, London, ON

Correspondence concerning this article should be sent to Stephanie Montgomery-Graham, LL.M., M.Sc., Department of Psychology, Western University, London, Ontario. E-mail: smontgo9@uwo.ca

doi: 10.3138/cjhs.2017-0002

Caption: Figure 1. Inclusionary and exclusionary process for case inclusion in the literature review
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