Sunday, 18 October 2015

Is there such a thing as Sex Addiction?

The Debate: Is Sex Addiction a True Addiction?

Whether or not sex addiction is real and should be diagnosed and treated as an official disorder (currently, sex addiction is not recognized in the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5) is definitely not a new debate. In fact, sex addiction is a highly controversial area among both the general public and professionals in the field of addiction and mental health.

Proponents for legitimizing sex addiction in the next edition of the DSM and other important diagnostic references believe it’s a very real, underreported and undertreated disease that’s common among those with early-life trauma, including childhood sexual abuse. In addition, these mental health professionals argue that the brains of sex addicts react to sexual stimuli in the same way the brains of drug addicts respond to substances.

Those opposed to making sex addiction an official diagnosis, recognized by the American Psychiatric Association (APA) — which publishes the DSM-5 — and by other leading authorities in the realm of mental health, say that there is little to no scientific proof that there is any amount of sex that’s unhealthy (or healthy) and that the terms “sex addict” and “sex addiction” themselves are based on social and moral values toward sex. Naysayers also argue that labeling problematic sexual behavior as “addiction” undermines the individual’s personal responsibility for that behavior. Some have gone on to say that sex addiction is just a media-inflated term abused by high-profile celebrities (Tiger Woods, John Edwards, Anthony Weiner, David Duchovny, to name a few) looking to justify serial infidelity. asked Robert Weiss, LCSW, CSAT-S, senior vice president of clinical development at Elements Behavioral Health, and the author of Always Turned On: Sex Addiction in the Digital Age, and David J. Ley, PhD, a clinical psychologist in Albuquerque, New Mexico, and author of The Myth of Sex Addiction, to share their expertise on this complex, controversial issue.

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by Robert Weiss, LCSW, CSAT-S (See all authors)

Is Sex Addiction a True Addiction?

Weiss: “Yes. The question of whether sex addiction exists is really a non-issue. We know that it exists, we know what causes it and, most important, we know how to provide useful treatment.”

“Sexual addiction (as a diagnosis), readily meets the criteria that have been used for decades to identify both substance addictions and other behavioral addictions/compulsions (gambling, spending, video gaming and even eating disorders). And hypersexual behavior, as is seen in sex addicts, is already acknowledged as appearing in concert with several mental health diagnoses, such as mania and some forms of ADD. Furthermore, we have enough clinical research to support sex addiction as a stand-alone diagnosis. We know that it exists, we know what causes it and, most important, we know how to provide useful treatment. Nevertheless, sex addiction is an under-acknowledged, underreported emotional disorder, highly subject to misinterpretation and ongoing political posturing within the American Psychiatric Association (APA). In some ways, the creation of a stand-alone diagnosis of sex addiction has sadly become both a political and cultural ‘hot potato’ issue.

To more fully understand what sex addiction is all about, I suggest reading some of the tier-one, peer-reviewed research, or take some time to check out one of many books I’ve authored on the subject — all now revised and updated to reflect the ways in which digital technology now so thoroughly impacts sexual addiction. In addition to my work, many others have written highly useful self-help books, scholarly articles and personal accounts, all focused on understanding and healing from sexual addiction. For a personal experience of the issues as presented by addicts themselves, it is well worth attending an open 12-step sexual recovery meeting at Sexaholics Anonymous, Sex Addicts Anonymous, Sexual Compulsives Anonymous or Sex and Love Addicts Anonymous. Note that these meetings are the very same places where tens of thousands of self-identified sex addicts seek no-cost help and support daily. Frankly, these programs provide the most telling evidence that sexual addiction exists, causing the same basic problems as any other addiction. I mean, why would all these people, from all over the world, voluntarily attend and participate in a 12-step sex addiction recovery group? Why would they waste precious time in this way unless they had, in fact, found an environment that offers them both hope and direction toward sexual behavior change?

That said, all you really need to know is that sex addicts universally experience the following:

  • Preoccupation to the point of obsession with sex (both fantasies and actual behavior)
  • Loss of control over sexual behaviors, most often evidenced by failed attempts to quit or curtail those behaviors
  • Directly related negative life consequences – such as relationship trouble, issues at work or in school, declining physical health, depression, anxiety, diminished self-esteem, isolation, financial woes, loss of interest in nonsexual activities, etc.

I think it is important to state here that the internal and external experience of sex addicts mirrors that of other addicts. For example, recent research shows that the brains of sex addicts respond to sexual stimuli differently than the brains of non-sex addicts. Furthermore, sex addicts’ brains respond to sexual stimuli in the same way that drug addicts’ brains respond to drug-related stimuli. These findings, when coupled with earlier research, strongly suggest that sexual addiction most definitely exists and that it forms and manifests in profoundly similar ways to more commonly accepted forms of addiction such as alcoholism and drug addiction.

Moreover, sex addicts (like most other addicts) are nearly always the adult survivors of early-life trauma – neglect, emotional abuse, physical abuse, overt and/or covert sexual abuse as well as profound parental enmeshment. These trauma survivors start to self-medicate their emotional discomfort relatively early in life via sexual fantasy and self-stimulation – most often during adolescence but sometimes even before. Over time this process of self-soothing can also involve addictive substances and/or food. However, many children also learn (or are taught) that they can distract and soothe themselves with sexual behaviors (including fantasy and masturbation), usually by eroticizing and mentally reenacting some aspect of early trauma. In fact, self-soothing through eroticized reenactment is a relatively common response to early abuse.

Unfortunately, though sexual behaviors can be pleasurable and distracting in the moment (much like alcohol, illicit drugs, gambling), over time they sometimes create more problems than they solve. This, of course, increases the person’s day-to-day fears and anxiety, creating an even greater need for escape and distraction. Many such trauma survivors eventually find themselves mired in cycles of self-hatred and sexual shame, temporarily alleviated by sexual fantasy and activity, followed by still more self-hatred and shame. In short, their escapist addictive sexual fantasies and behaviors repeatedly trigger the need for more of the same. This is the basis of the never-ending downwardly spiraling cycle of sexual addiction.”

Dr. Ley: “No, sex addiction is not a true addiction and never has been.”

“Since its inception, sex addiction has been a concept based on social and moral values toward sex, tainted by subjectivity and reliance upon anecdotes as evidence. Like the old idea of nymphomania, sex addiction is an attempt to medicalize the belief that there is a ‘right’ amount or form of sex, despite the fact that science has shown that sexual desires and behaviors occur in a great diversity, and there is no amount or type of sex that is inherently unhealthy. However, in recent years, many core components of the sex addiction model have been empirically tested and researchers have consistently found that addiction is a poor way to explain sexual behavior problems.

In 2010, Jason Winters, PhD, of the University of British Columbia demonstrated that alleged sex addicts appear to have just as much self-control as their counterparts; that libido predicts sexual behaviors much better than measures of addiction; and that an internalized religious-moral conflict over sex is at the core of the sex addiction label. Joshua Grubbs, PhD, of Case Western Reserve University recently replicated this latter finding, showing that self-identification as a porn addict was predicted by moral conflict and religiosity and not by levels of porn consumed.

Nicole Prause, PhD, and other researchers at UCLA have demonstrated that there is no evidence of the brain patterns associated with chemical addictions in those who are self-described sex addicts, and in fact, pre-existing traits such as libido and sensation-seeking explain far more of the variance in people’s behaviors. Sex addicts are seen by others and by self-report as having executive function deficits in areas such as impulsivity and self-control. However, Rory Reid, PhD, of UCLA has conducted research showing that neuropsychological testing reveals that sex addicts actually demonstrate no measurable problems in impulse control and executive functioning.

Overwhelmingly, the research invoked by proponents of the sex addiction model is based on cross-sectional data, with poor research design, extreme sample bias and core assumptions which are rarely, if ever, considered or tested. For instance, sex addiction therapists have commonly assumed that when they see a man who is depressed having lots of sex or watching lots of porn, that the sex or porn are causally related to the depression. Instead, longitudinal research has revealed in multiple cases that sex and porn are ways in which males commonly, and effectively, cope with negative emotions. In other words, sex addiction mistakes a symptom for the cause. While many life problems are commonly blamed on sex, these problems most often reflect conflict with social and relational expectations, and with moral conflicts. “Sexual addiction” problems are always symptoms of other issues – this is tantamount to diagnosing and treating “sneezing disorder” and distracts from assessment and treatment of the more complex underlying issues.

What is commonly called sex addiction is a label without explanatory power applied to a heterogeneous group of people and problems. Calling something a sex addiction seems to imply an explanation, a cause and a treatment. But unfortunately, this is really nothing more than naming something we don’t understand — giving it a name relieves some anxiety, but does nothing to further greater comprehension. Indeed, the label is a distraction, because by asserting that sex is addictive, it deters further investigation into the complex, nonsexual issues involved in these behaviors. But this is not just a semantic debate. The sex addiction label negatively distracts from addressing the many other significant emotional, personality, social and relational issues involved in sexual behavior problems. This focuses attention on sex in a manner that is a disservice to patients. It promotes treatment based on an addiction theory — treatment for which there is no evidence of effectiveness in the area of sexual problems.

Further research by Josh Grubbs, PhD, published in 2015, demonstrates that self-perception as a porn addict is contributing to psychological difficulties. In longitudinal research, Grubbs and his team have shown that regardless of how much porn one consumes, emotional distress is causally related to self-identity as an addict. In other words, porn consumption or sex don’t predict distress, but believing that oneself is addicted to sex does.

Our society’s adoption of the idea that one’s sexual desires are addictive is a form of iatrogenic harm, which leads to shame and fear of one’s sexuality. When proponents of sex addiction argue that they are being compassionate and supportive of people in need, their methods may in fact be part of the problem. Until it can be empirically demonstrated that sex addiction is the best and most effective explanation for these problems, it is unethical to render this experimental, unproven and informal diagnosis.”

What’s your response to those who say the terms “sex addict” and “sex addiction” are just a way to excuse bad behavior?

Weiss: “In many ways I find this question amusing because I don’t think I’ve ever met an alcoholic, drug addict, sex addict (or any kind of addict) who didn’t race to treatment at least in part hoping that by going people would feel more sorry for them than angry. And I’m amused because, here’s the thing, if a treatment program itself is well-managed, insightful and incisive, then the addict’s initial motivation for attending is really moot. What matters is that they got there! What matters is what happens while they are there! In residential addiction treatment settings (rehab), we are nearly always working with people who enter our care to get out of trouble, only to find themselves working harder and longer than they thought possible once in our care to face down their own demons. Getting the client to simply enter treatment, regardless of their self-identified reason, is the goal. because once they are there, the treatment process itself has it’s own way of pushing them beyond any initially shallow and/or self-serving motivations toward change.

Where I do worry is when serious sex offenders try to deflect blame and minimize punishment for their more violating sexual behaviors by self-identifying as being ‘sex addicts,’ thus misusing the sex addiction diagnosis to make their serious sexual misconduct seem less so. I also worry that people who are uncomfortable with their sexual orientation or their other sexual turn-ons may mislabel these desires and behaviors as sexual addiction, or worse, that some unethical clinician will support them in this quest, mislabeling their orientation or fetishistic arousals as being ‘addiction.’ And, sadly, this does sometimes happen, even though the problem of active sexual addiction is actually unrelated to who and/or what it is that turns you on.

As for sex addiction as a label being used to excuse people caught red-handed engaging in inappropriate, problematic or possibly even illegal sexual activity, that’s just a flat-out misuse of the sex addiction diagnosis. This is as true for the man who wants to excuse his first affair by calling it ‘sex addiction’ (when found out by his wife), as it is for the violent sex offender who wants to excuse his truly heinous sexual behavior as ‘just an addiction.’ Further, an addiction diagnosis of any kind can never be used to justify anything, including bad behavior.

Instead, an addiction diagnosis brings with it a responsibility and obligation for the person to truly own and take responsibility for any past harm caused. And clients are strongly encouraged to be vigilant in staying away from any future triggers or roads back into the disorder. This is done to discourage and prevent future addictive behavior from reoccurring and to help them gain a sense of personal integrity. All addicts learn in treatment to be fully accountable for their past and present actions; not to hide them under a rug. Under no circumstances are sex addicts absolved of responsibility for the pain and problems their choices have caused. So no matter how shameful it may be to face the reality of a past sexual misdeed, doing so is integral to emotional healing and recovery.”

Dr. Ley: “[According to] 2013 research for the DSM-5 trials of the proposed but rejected construct hypersexual disorder, the majority of people in residential treatment for sex addiction were white men who made over $80,000 per year. The concept of sex addiction sprang into being just as society began to apply the same sexual expectations toward men that had been imposed upon women. As powerful men could no longer expect sexual privilege, the idea that their sexual misbehaviors reflected a disease offered a way to diminish their personal responsibility and accountability. Sadly, the concept of sex addiction is often invoked by such men in legal proceedings in the U.S. as a means to avoid legal accountability.

But the idea of sex addiction is a powerful one in our society because it serves many different purposes. In that same research for DSM-5, gay and bisexual men were at three times the risk of being labeled a sex addict compared to heterosexuals. The sex addiction model has become a vehicle for moral and religious forces to mask their moral judgments behind pseudo-scientific and quasi-healthcare-related facades. Religiously motivated groups have adopted the concept of sex addiction as a means to attack homosexuality, alternative sexualities and pornography. Various forms of addiction are commonly blamed for ‘causing’ homosexuality and used as justification for treatments that mirror gay conversion treatment. I’ve spoken with countless individuals who were told that their sexual attractions were a disease and evidence of an addiction, when in fact these were men struggling with being gay or bisexual, in conflict with their family’s religious values.

The idea that pornography and alternative sexual behaviors are addictive is also used by secular and political groups as a tactic to justify a widening range of sexual restrictions. Cries that people must be protected from the dangerous, addictive effects of sex are used to justify censorship of Internet access in Great Britain, as well as claims that pornography should be restricted because it causes erectile dysfunction or sex crimes. These claims are universally based upon hyperbolic and nonscientific concerns, and ignore a wealth of research regarding the positive effects of sexuality and even pornography.

So, yes, the idea of sex addiction is sometimes used as an excuse for men who choose not to exert control over their sexual behaviors. But it is also used just as frequently to shame and suppress the sexual behaviors of others, reflecting moral and religious values towards sex. Ultimately, these dynamics reveal that the concept of sex addiction is based upon the idea that there is a ‘right’ form or amount of sex. This is a moral concept, not one based on scientific or medical research.”

In closing, what would you like those who don’t agree with your views to know?

Weiss: “Considering all the conflicting cultural, moral, ethical, political, personal and religious messages we receive every day about something as basic as sex, it’s no wonder that there is escalated conflict over what might define a sexual problem. These challenges are today amplified, as past legitimate bodies of psychology and psychiatry have mislabeled non-pathological sexual behaviors (homosexuality, transgenderism, fetishes and kink), as diagnosable disorders — only later to change their rules, in sync with (but more often behind) our sociocultural evolution. In 1965, homosexuality was considered an incurable, chronic mental illness for which long-term institutionalization was a serious option. In 2015, two men can marry and two women can marry.

All fields of science are vulnerable to being tainted by human interference. Perhaps nowhere is this more true than in the area of human sexuality. In sex addiction, this plays out when highly moralistic or religiously focused therapists act out of their beliefs, by misusing the term ‘sex addiction’ by applying it to any sexual behavior that doesn’t fit their belief system. As a result, fears have evolved that some self-proclaimed sex addiction therapists are actually people with a pre-set agenda about what defines healthy mating; sadly, sometimes these fears are well-founded. These therapists, armed with a clinical license and a biased view of what defines healthy sex, sometimes misdiagnose people as sexually addicted in an attempt to promote sexual conservatism. Homosexuality, bisexuality, transgenderism, recreational porn use, casual sex, polyamory and fetishes — all of which fall well within the spectrum of normal and healthy adult sexuality — have at times been misdiagnosed in this way. This, despite the fact that, as stated earlier, sexual addiction is unrelated to who or what it is that turns a person on.

Unfortunately, clinicians who inappropriately use the sex addiction diagnosis as a form of cultural, moral or religious control have done a great deal of harm over the years. Some have become quite wealthy by playing on people’s sexual shame and self-hatred toward their own personal gain. Their actions have created unnecessary confusion and even acrimony within the treatment community, all of which makes diagnosing and treating people who truly are sexually addicted more difficult than it should be. And, sadly, because of this, combined with our general cultural avoidance of all things sexual (as opposed to sexy), we are still debating the existence and nature of sex addiction 45 years after it was first identified, instead of working to accurately assess, diagnose and treat those who suffer from it.”

Dr. Ley: “Challenging sex addiction has been an eye-opening issue for me. I’m a psychotherapist and work with people in pain, many of whom have been horribly shamed by the label of sex addict. My writing and advocacy is on their behalf, because I regularly see the harm that is done under the idea of preventing or treating sex addiction. So it saddens me when I am regularly attacked as being unethical, blind or uncompassionate, simply because I disbelieve sex addiction.

I’ve been called a sex addict in denial more times than I can count (by sex addiction therapists) and even had my family and friends attacked online, merely due to questioning the validity and value of the idea of sex addiction. I recognize that many people have adopted the concept of sex addict into their sense of identity, and they experience my challenge to the concept as though it is a deeply personal attack on their core sense of self.

My challenges are never meant to be personal, but come from an ethical commitment that health care and medicine should never be used to assert or impose morality, particularly around sexuality. I believe that understanding, accepting and owning one’s sexuality is the first step towards gaining the ability to feel in control of oneself. Sadly, I think that the concept of sex addiction often moves away from that personal responsibility, understanding and acceptance.

As a clinician and a scholar, I believe it’s critically important for us to recognize that health care (and mental health care especially) can do great harm when we allow treatment to be based on morality rather than science. We’ve seen this many times, in the treatment of homosexuality, nymphomania and recovered memory. The field of sex addiction represents a similar intrusion of moral judgment about sex into health care, without sound science. As a result, we should be extremely skeptical of it.”

What do you think: Is sex addiction a true addiction?

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