is there such a thing as sex addiction?

For years there's been a debate about whether sexual addiction should be included in the DSM V and we don't seem to be any closer to an answer.





Last year, psychologist and researcher Jim Pfaus wanted to drop a bombshell in a somewhat obscure men’s magazine for all those curious whether there’s really such a thing as sex addiction in the wake of several celebrity scandals and declare that sex addiction was merely a convenient myth invented and promoted by the same industry that gave us the twelve step program, and is not, in fact, a diagnosis any mental health professional even makes. Since he wrote this op-ed for an online magazine ran by a men’s grooming company and not a major publication, I managed to stumble across it by pure chance when doing research for another post idea. So while you’d expect a critique of social mores holding people down in a classic think piece about modern sexuality given the venue, but if anything, it’s a very science infused critique of potential diagnostic criteria for hypersexuality in clinical contexts which boldly tackles some big questions. Sadly, it manages to fall on its face in the end by conflating ethics and science in a very un-clinical way.

One of Pfaus’ biggest targets are morality groups which seem to believe that addiction to sex and pornography runs rampant in society based only on the prudish ideals their founders espouse. I agree that they’re absolutely wrong in every claim they make, so much so, that I wrote a long post to address as many of these claims as possible, analyzing the relevant statistics about the relationship between porn and sex. He’s right that not only do they refuse to understand the difference between sexual expression and addiction, there’s not even a diagnosis of sex addiction in the DSM V. While it was discussed and considered, it was rejected because experts didn’t want to turn forms of sexual expression into a pathology based solely on political ideology, which is fair. But on this third point, Pfaus goes a little too far by insisting that we also have to link an addiction to chemical dependency…

During withdrawal, the brains of addicts create junctions between nerve cells containing the neurotransmitter GABA. This process more or less inhibits the brain systems usually excited by drug-related cues — something we never see in the brains of so-called sex and porn addicts.

To counter this logic, morality groups frequently cite bursts of dopamine in the minds of the sexually active and those watching porn, but as Pfaus very astutely notes, dopamine is released for every action your body enjoys, so to use these dopamine bursts as a diagnostic criterion instantly turns everyone into an addict of everything. However, do we need to go so far that addicts need to feel physical and chemical pangs of withdrawal before they can be diagnosed as such? The DSM V recognizes addiction for substance abuse on the basis of 11 indicators. All but one of them can applied to hypersexuality, focusing on a patient’s inability to function in the real world and choosing to seek out and use with no regard for basic obligations like paying bills, doing homework, showing up to work on time, and ignoring dangers to oneself to keep feeding the urges. If 10 out of 11 criteria fit, isn’t that a strong case?

Now, it’s at this point that we should pause for a minute and make it crystal clear that I am not talking about people with high sex drives, or people who engage in casual sex because they find it fun and fulfilling. Like Pfaus, I am completely against moralizing research into sexuality or mental health, and everything I’ve ever written on the subject over eight years, on this blog and in other publications, has said exactly this. No, I’m talking about people who feel like they absolutely need to seek out sexual stimuli despite not wanting to do it anymore, and being tired of the sex they claim they no longer want but can’t seem to refuse, people who feel like they lost control of their own sexuality. Having had a few encounters you wish never happened would not meet any criteria for hypersexuality, and neither would anyone enjoying his or her hectic, but sex-filled life. So with that said, let’s get back to the issue of what constitutes the final criterion for addiction: withdrawal.

Given that we do know that there are people with sexual compulsions who feel like their life suffers in the process of finding sex, Pfaus’ insistence that only physiological withdrawal should count comes off as condescending to people with real concerns, downplaying their urges and discomfort by liking what they’re going through to little more than an exercise in basic impulse control which tremendously downplays their conditions…

A sex addict without sex is much more like a teenager without a smartphone. Imagine a kid playing Angry Birds. He seems obsessed, but once the game is off and it’s time for dinner, he unplugs. He might wish he was still playing, but he doesn’t get the shakes at the dinner table. There’s nothing going on in his brain that creates an uncontrollable imbalance.

Except we’re not talking about a kid who puts down his phone in time for dinner. We’re talking about a kid who runs away with his smartphone so he can play Angry Birds instead of eating, sleeping, or going to school, and the only time he stops playing it is if the phone dies and he can’t recharge it, but as soon as he does, he’ll start playing again. We’re talking about a kid whose entire life revolves around the game and nothing else seems important. Yes, Pfaus is right to have a high standard for addiction, but he seems to insist on using the colloquial definition of the word as it applies to sex addicts. There may not be obviously abnormal chemistry that’s a dead giveaway, and they might not experience the kind of violent withdrawal that opiate addicts and alcoholics tend to suffer when they can’t find a partner, but to say that such a lack of certain symptoms and not finding a perfectly matching diagnosis in a constantly revised diagnostic manual means their problem isn’t real seems rather unscientific and dismissive in a broader context.

Even worse, it could lead people who have a strong case for being treated by professionals to stop seeking help since they’re told that their problem is not real, it’s just a lack of discipline. Here too, Pfaus raises an important point of concern by noting that many programs which claim to treat hypersexuality are in fact based on 12 step recovery paradigms which tend to have a rather mediocre 5% to 10% success rate, and many of them will be ill-informed and offer advice that’s totally useless, but then quickly veers off into a sweeping generalization which should really be analyzed a little closer…

By misdiagnosing patients from the start, they gloss over the underlying issues that might make someone more prone to compulsive sexual behaviors, including Obsessive Compulsive Disorder and depression. [C]ompulsive, ritualistic sexual behaviors aren’t addictions; they’re symptomatic of other issues.

Well yes, it’s entirely plausible that hypersexual behaviors can be symptoms of pathologically low self-esteem, co-dependency, or depression. But we can say the same thing about many addictions, can’t we? Substance abuse could also be a symptom of depression, using the high to drop inhibitions and try to loosen up, or find an escape from troublesome thoughts in the soothing stupor. Likewise, for someone using sex to fill a void in his or her life which led to depression and other mental problems, the hypersexual behavior is a symptom, but that doesn’t mean it couldn’t be classified as an addiction if it takes over the patient’s life. After all, we don’t say that compulsive, ritualistic drinking is not an addiction just because it may be a coping mechanism for the addict, and the DSM V debates considered eating disorders, a very close analog to hypersexuality, as addictions, even though they are symptoms of a whole host of mental and social problems experienced by the patient.

But here’s the part that seems to get to the heart of the issue Pfaus seems to think is the real problem, and it explains to some extent why he’s so loath to label sexually compulsive behavior as an addiction. You see, his focus is on the sex-negative stigmas promoted by cultural conservatives and he sees the classification of hypersexuality as an addiction as a sort of get out-of-moral-jail free card to excuse their problematic and unbecoming behavior…

Such porn-shaming isn’t all that different from the guilt conservatives attach to sex, even though conditioning men to feel bad about their sexual behaviors only leads to the kind of secretive, damaging behaviors evidenced in the Duggar story. What’s worse: when sexuality is labeled a “disease” like addiction, guys no longer have to own their sexuality — or their actions. It’s unnecessary to explain why they cheated because it’s beyond their control.

This train of thought ironically criticizes conservative orthodoxy in regards to sex only to use its tenet that one’s addiction is a moral failure rather than a legitimate psychological problem. And that’s a shame because the Duggar scandal actually makes a strong case for hypersexuality being an addictive behavior. Growing up in a cultish movement which prides itself on just how much it micromanages the sexuality of its members, insists that casual sex causes cancer — but only for women — in its sex ed pamphlets, and brushes aside frighteningly common cases of sexual abuse in their families, couldn’t have been healthy for Josh Duggar in any way, shape, or form. The odds he grew up with mental hangups regarding sex and intimacy, as well as self-esteem and anxiety issues are certainly quite high. And as an adult, he too readily engaged in self-destructive behavior to pursue sexual acts.

Basically, this is a guy with everything to lose undermining his livelihood in search of sexual stimulation on cheating sites, with porn stars, and through abusive behavior. Just like Pfaus posits, these compulsive behaviors are very obviously symptoms of something deeply wrong with Duggar. But where he ventures into Calvinist territory of seeing disease as a moral failure is when he refuses to call these behaviors addictions by admitting he doesn’t want to be seen as granting a moral license for unsavory sexual misdeeds because it may imply that Duggar was compelled to engage in them, rather than made some bad choices. However, this seems like a pretty blatant conflation of the clinical and the moral. Duggar may be an addict, but that doesn’t mean that he is now immune from criticism, or that his actions were now justified just because they may be signs of his mental distress. He knew what he did was wrong and that’s something from which no clinician can absolve him.

And Pfaus’ revulsion at the idea of Woods, Dugger, and other public figures caught behaving badly and citing sex addiction to escape the consequences of their actions makes me wonder about the framing of his arguments. Is he simply trying to totally disqualify hypersexuality as an addiction, or even an acceptable diagnosis, not because he’s convinced that without physiological withdrawal symptoms there’s no addiction, but because he’s afraid that the current approach to treatment which sees addiction as a disease enslaving the addicts would absolve those he suspects are abusing the definition and concept addiction of all responsibility? Because if that’s his reasoning, all of his arguments become deeply unscientific and very suspect…