Sex addiction: Explanation or excuse?
Ian Kerner is a licensed psychotherapist, certified sexuality counselor and New York Times best-selling author. Read more from him on his website, iankerner.com.
(CNN)From Anthony Weiner to Tiger Woods, there’s no shortage of so-called sex addicts these days. But is sex addiction a real condition?
Getting to the bottom of this question is the source of much controversy among therapists. On one end of the spectrum are sex therapists (myself included), who tend to doubt that sex can be addictive and view the label as potentially shaming.
On the other end are sex addiction therapists who believe that for a small group of people, sex and the behaviors surrounding it can be as destructive and addictive as any drug.
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The concept of sex addiction gained traction in the 1980s, when Patrick Carnes published “Out of the Shadows,” one of the first books to identify compulsive sexual behavior, a problem he likened to an addiction.
Soon, treatment centers, 12-step programs and other resources grew around this new label, despite the fact that it has never been an accepted clinical diagnosis in the “Diagnostic and Statistical Manual of Mental Disorders,” which is widely viewed as the authoritative guide for psychiatric diagnosis and treatment.
“To me, ‘sex addiction’ is a cultural myth,” said psychotherapist Joe Kort. “Thirty years ago, we didn’t have a better way to describe people who worried that their sexual behavior was out of control, so it made sense to call it addiction. But it’s not an actual diagnosis.”
But should it be one? I asked several of my colleagues on both sides of the debate to weigh in on claims and myths surrounding sex addiction. Here’s what they said.
Is sex addictive?
This is perhaps one of the greatest controversies about sex addiction. Though some believe that sex can affect the brain in ways similar to drugs and alcohol — habituation, withdrawal, escalating risk-taking behaviors, alteration of brain structures — many proponents believe that sex addiction is more similar to a gambling addiction in that it involves a behavior, not a substance.
At present, gambling is the only addictive disorder in the American Psychiatric Association’s fifth edition of the “Diagnostic and Statistical Manual (DSM-5)” that would be considered a process or behavioral addiction.
And it may not even be the actual act of sex that’s the issue.
“It’s not about the kind of sex you have, who you have it with or even how often you have it,” explained certified sex addiction therapist Robert Weiss. “We don’t base the definition of alcoholism on the type of alcohol someone drinks. Like alcoholism, the sex addiction diagnosis is based on whether or not that individual’s behavior repeatedly creates profound problems and crisis in their day-to-day life functioning.”
Instead, Weiss sees sex addiction as a process addiction, in which the hunt for sex, whether that means searching for online porn or surfing for hookups on Tinder, creates in some people an anticipatory arousal that creates more of a rush than the act itself.
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Yet some critics question whether there’s a concern at all. “Sex addiction has become the label du jour to explain why people without an understanding of their own desires now struggle and feel out of control in a world that’s increasingly sexually permissive,” said David Ley, a psychologist. “They tend to be people who grew up in religious households who have been taught that sex should make them feel guilty and ashamed.”
Indeed, for some, the label of sex addiction may simply be a response to that shame, said Michael Aaron, a sex therapist. “Many of the ‘sex addict’ clients I see aren’t addicts at all. They’ve been told by a partner or someone else that their behavior, like watching porn or having a high libido, is a problem.”
Other therapists fall somewhere in the middle. “I do believe that a subset of people struggle with out-of-control sexual behavior,” said sex therapist Douglas Braun-Harvey. “They may have sexual urges, thoughts and behaviors that are consensual but that they feel they can’t control. I view this a sexual health problem, though, not an addictive disorder.”
What does the research say?
It’s tempting to look to science to settle this debate, but research only seems to feed the both sides of the debate.
In a well-publicized 2015 study, a researcher at the University of California, Los Angeles, Nicole Prause, used EEG to measure brain activity in 122 men and women, some of whom reported having problems controlling their viewing of online pornography. After showing the volunteers a set of photographs, some of which were sexual in nature, she found that the pattern of brain responses in subjects with porn viewing problems was the opposite of that seen in all other proposed addictions, including cocaine, tobacco and gambling. This suggests that self-reported sex addicts don’t exhibit any different brain activity than people who just have high libidos.
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But other studies have found some differences. In a 2014 study, a University of Cambridge researcher, Valerie Voon, used functional magnetic resonance imaging to scan the brains of 38 men, half of whom struggled with compulsive sexual behavior, while they viewed either porn videos or sports footage. She found that three regions of the brain were more active in people with compulsive sexual behavior compared with the other volunteers. These were the same regions that are activated in drug addicts when shown images of drugs.
These people also exhibited higher levels of desire toward the porn even though they didn’t say they enjoyed the videos, a phenomenon also found in people with other types of addiction. Yet Voon and her colleagues concluded that their findings aren’t proof that porn addiction exists.
How should we treat it?
Whether or not we call it sex addiction, it’s clear that some people are struggling, whether they feel like they can’t stop viewing porn, they’re cheating on their partner or they’re allowing sexual behavior to disrupt their work and relationships. How that’s treated, however, depends on whom you see. Although some people who identify as sex addicts may find support in 12-step programs similar to those used for drug and alcohol addiction, others seek counseling from certified sex addiction therapists.
In any given week, there are well over 1,000 Sex Addicts Anonymous meetings across the United States. And according to the National Institute on Drug Abuse, there are now over 14,500 treatment centers in the US, with revenues of $35 billion in 2014. While the majority of these rehab centers primarily treat drug and alcohol abuse, sex addiction treatment is increasingly prominent. And in the spirit of “once an addict, always an addict,” many of these centers deploy a clinical approach based on 12-steps programs.
“I think people underestimate how deeply sex addiction therapists are looking at roots of the problem,” said certified sex and sex addiction therapist Alexandra Katehakis, who believes many cases of sex addiction stem from a traumatic childhood. “There’s not a moral or shaming component; we’re trying to help them integrate sex into their lives in a healthier way and help them feel whole.”
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A common criticism of sex addiction therapy is that it is akin to reparative or conversion therapy used by religious groups to tamp down a client’s homosexual urges or other sources of judgment and shame. Though the potential for misuse exists, the industry has taken steps to help prevent it.
“Any solid training program has ethical guidelines against reparative therapy,” explained Stefanie Carnes, a certified sex addiction therapist and president of the International Institute for Trauma and Addiction Professionals. “We ask our professionals to sign an ethics contract attesting that they won’t misuse their training in this way.”
But how do sex therapists — who, in large part, overwhelmingly question the legitimacy of sex addiction as a diagnosis — treat clients with out-of-control sexual behavior?
“Regardless of what we label it, therapists have been helping clients with these problems for years,” said psychotherapist Michael Crocker. “There are many valid models of working with out-of-control sexual behaviors. I personally believe there are underlying issues related to why individuals struggle with (this) behavior,and approach treatment this way.”
In my professional experience, some people who are worried they are sex addicts may be grappling with other treatable issues, such as:
Mental health concerns such as depression. In my experience, when people are depressed and isolated, they tend to masturbate more and kill time watching porn, which contributes to their low mood. But the main issue that needs to be treated is the depression and not its symptom. On the other extreme, a person with bipolar disorder might experience bouts of mania that lead to hypersexuality, but again, this is not an addiction issue.
Sexual gratification as a primary coping mechanism. In theory, there’s nothing wrong with having an orgasm as a way of distracting oneself. But sex shouldn’t be the only way we manage anxiety and difficult emotions.
A libido discrepancy. When one partner in a couple has a higher libido than the other, they may worry that they are an addict rather than just different.
An erotic conflict. Someone who doesn’t want to admit that he’s gay, for example, may self-label himself as an addict when having sex with men or watching gay porn. In short, he’s trying to disavow a part of his identity that he’s uncomfortable with.
Avoiding responsibility for one’s actions. For example, a serial cheater may feel more comfortable self-labeling as a sex addict than meaningfully exploring why he’s unable to stay monogamous.
I personally know many good therapists who subscribe to the sex addiction model and are doing very thoughtful work with their patients. Many of them even identify as recovering sex addicts themselves, giving them an extra stake in the passion of their convictions.
One of the issues, though, is that their good work stands atop a long history of shaming and pathologizing that goes back to the Victorian era of vilifying masturbation as form of sex addiction. Today, popular culture has embraced the sex addiction label ahead of evidence-based research, making it difficult to separate fact from fiction.
In my own practice, many people come to me labeling themselves or their partners as sex addicts. Although I don’t believe that sex is addictive, I respect that this is how my patients are experiencing their relationship with sex: as something that feels out of control.
This may be what gets clients talking, but that conversation shifts to a deeper understanding of underlying causes and how to address them. I don’t try to change their language, but most of my patients end up expanding their formulation of their problem beyond the addiction lens. Sex addiction is often the beginning of the conversation, not the end.