You’re Addicted to What?

Periodically, some famous politician, athlete, or entertainer gets caught with his or her pants down, damaging or even destroying their reputation, livelihood, and marriage. Within hours, my email starts buzzing, as media vultures circle the fresh carcass and want my expert opinion: Is Tiger Woods a sex addict? Was Katharine Hepburn? How about Eliot Spitzer, David Duchovny, Charlie Sheen, John Edwards?

The twenty-four-hour cable/Internet news cycle doesn’t want experts to talk seriously about this—they simply want people (Maury! Tyra! The ladies on The View!) who will announce, with just the right mix of scorn, smirk, gravity, and total confidence that so-and-so is a sex addict.

The schadenfreude is so thick you can cut it with a knife. Moralism stands in for sympathy. High dudgeon stands in for nuanced understanding. From all corners, we hear a Greek chorus of voices linking someone’s extramarital affairs to feminism, testosterone, the Internet, sadomasochism, consumerism, or even 9/11. And then they inevitably wheel in the heavy gun: “sex addiction.”

Most importantly, these public thrashings are a chance for the audience to condemn sexual acting out while vicariously enjoying it. America loves an excuse to sneakily enjoy unauthorized sex. The fall of the rich and famous is a bonus.

So when USA Today calls about Eliot Spitzer’s high-end escorts, or CNN emails about Anthony Weiner’s sexting, I’m usually pretty slow to respond to the ghoulish invitation.

I don’t diagnose people I haven’t met. More importantly, I don’t use the diagnosis of sex addiction. In thirty-one years as a sex therapist, marriage counselor, and psychotherapist, I’ve never seen sex addiction. I’ve heard about virtually every sexual variation, obsession, fantasy, trauma, and involvement with sex workers, but I’ve never seen sex addiction.

New patients tell me all the time how they can’t keep from doing self-destructive sexual things; still, I see no sex addiction. Instead, I see people regretting the sexual choices they make, often denying that these are decisions. I see people wanting to change, but not wanting to give up what makes them feel alive or young or loved or adequate; wanting the advantages of changing, but not wanting to give up what makes them feel they’re better or sexier or naughtier than other people. Most importantly, I see people wanting to stop doing what makes them feel powerful, attractive, or loved, but since they don’t want to stop feeling powerful, attractive or loved, they can’t seem to stop the repetitive sex clumsily designed to create those feelings.

The conflict over sex addiction is important to humanists for several reasons. “Sex addiction” is a special weapon now used by the religious right to combat perceived liberalism, to ignore science, and to ignite fear. It also helps legitimize anti-sex moralism and bigotry. And psychologists, judges, legislators, and the media are buying it.

When people refer to themselves or others as “sex addicts,” what are they actually talking about? More than anything, simple narcissistic character structure: the familiar “I guess I thought I could get away with it,” “Deep down, I don’t really believe the rules apply to me,” or “When I hurt, I want relief, and I don’t care so much about breaking promises or hurting others.”

If that sounds like normal people—if that sounds like you—it’s not surprising. Narcissism is a common human condition. So here’s my evaluation of almost everyone who is diagnosed as a sex addict—by themselves, their loved ones, or an addictionologist: it’s someone who is unhappy with the consequences of their sexual choices, but who finds it too emotionally painful to make different choices. You know, the way some of us are with cookies, new sweaters, or watching the Kardashians on TV.

Which is to say, it’s not about the sex. It’s about the immature decision-making.

The rest of the people who are in pain about their sexual decision-making are generally struggling with one or more of the following: compulsivity, impulsivity, obsessive-compulsive disorder, bipolar disorder, borderline personality disorder, or post-traumatic stress disorder. An idiosyncratic response to medication can even be a factor.

So when people talk about sex addiction, they’re really talking about all of these, and more. When someone says, “sexually, I’m out of control,” that doesn’t tell us very much. When we know someone has affair after affair; or that someone regularly masturbates to the point of pain; or that someone constantly pressures his wife for sex regardless of how unrealistic it is (she’s post-partum, she has the flu, his parents are in the next room, they had a big fight just a few hours ago); or that someone is pursuing anonymous sex in public parks in a way that’s begging for jail time and loss of career; or that someone watches three hours of porn per night, we simply don’t know very much about the person.

On the other hand, anyone who says “sexually, I’m out of control” is automatically welcomed into the fellowship of sex addicts—without any attempt to evaluate that person’s mental state. Sex therapists generally don’t get distracted by the sexual part of patients’ stories. Those without training in sexuality—like so-called sex addiction counselors—often do.

Let’s examine this cultural phenomenon in more detail.

The origin of “sex addiction”: NOT in sex therapy

Perhaps the most interesting thing about the sex addiction movement—and certainly the most telling—is that it did not arise from the field of sex therapy or any other sexuality-related field. Rather, it was started in 1983 by Patrick Carnes, whose background is in counselor education and organizational development. He claims no training in human sexuality.

“Sex addiction” has been adopted enthusiastically by the addiction community, and to a lesser extent by the marriage and family profession—the latter historically undertrained and uncomfortable with sexuality. You can, for example, become a licensed marriage counselor without ever hearing the words vibrator, clitoris, spanking, tongue-kissing, or panties during your education.

Almost thirty years after its invention by Carnes, “sex addiction” is still not a popular concept in the fields of sex therapy, sex education, or sex research. Of course, the media loves it, decency groups love it, and those who identify as some other kind of addict (alcohol, food, drugs) love it, especially if they’re fans of the Twelve Steps.

The SAST

So, again, what is “sex addiction”? The key evaluation tool (and just about everything you need to know about the concept) is the Sexual Addiction Screening Test (SAST). I encourage everyone to take the SAST (it’s easy to find online at www.sexhelp.com—just click on the “Am I a sex addict?” link). Most non-sex addicts are quite surprised at how high they rate on this instrument.

An enormous percentage of the test asks about non-normative behavior, as well as ambivalence about or rejection of one’s sexuality—feelings like guilt, shame, and remorse. Sample questions inquire if:

You regularly purchase porn or romance novels
You have multiple romantic involvements
You use sex or romantic fantasies for escape
You’re a regular participant in S/M behavior
You’re worried your sexual behavior will be discovered
You feel preoccupied with sexual or romantic thoughts
You’re concerned that your sexual behavior isn’t normal
Your partner complains about your sexual behavior

For most Americans, the answer to at least some of these questions is, “sure—isn’t this normal?” And this is part of the problem with diagnosing “sex addiction”—too much common sexual behavior and experience gets pathologized.

So what the SAST really measures is:

Did you grow up in a sex-negative culture?
Does your sexuality have any dark side to it?
Do you have questions about sex or your sexuality?
Do you feel 100% comfortable with your sexuality?

If people are being honest their answer to the first three is “of course” and the answer to the last is “of course not.” But when someone is anxious about questions that basically ask, “am I normal?” or has an angry spouse, or an interest in non-normative eroticism, and has the sex-negativity of religion or family whispering in their ear, it’s easy to interpret their SAST answers (“yes, I’ve sometimes wondered if my sexuality is stronger than I am”; “yes, I’ve hidden aspects of my sexuality from others,” and so on) as reflecting mental illness.

So the diagnosis of sex addiction is in many ways a diagnosis of discomfort with one’s own sexuality, or of being at odds with cultural definitions of normal sex, and struggling with that contrast. A sex-negative culture like America breeds that discomfort and contrast. Calling these symptoms of sex addiction entirely omits the role that sex-negative culture plays in shaping people’s distress with their sexuality, which they often channel into repetitive behavior (in some cases unsatisfying, in others highly satisfying) that can be hard to fathom.

No actual diagnostic criteria

So other than a high SAST score, how does a professional decide that someone is a sex addict?

Three decades after the term’s introduction, there’s still no consensus on a definition. Not surprisingly, however, nonprofessionals are increasingly using the term. The phrase anal retentive is analogous; saying someone is “anal” used to have specific, technical meaning, and is now used casually to suggest anything from being well-organized to anxious to controlling. Similarly, the expression “sex addict” is now thrown around by counselors, fictional characters, prosecutors, and everyone else to mean practically anything, from high desire to obnoxiously aggressive to trapped with a fetish to kinky to ashamed to anxious. It simply has no real meaning.

And so therapists are willing to diagnose people they’ve never met (like Tiger Woods). Similarly, angry or frightened women are diagnosing their husbands and sending them to therapy, often saying “either get yourself diagnosed and treated for sex addiction, or don’t come home, because it means you’re just a selfish bastard.”

Exactly how sophisticated can a psychiatric diagnosis be if (1) a professional can diagnose someone without ever meeting them, and (2) lay people with no training whatsoever can use the diagnosis?

Lacking empirical studies or an understanding of the complexity of (and cross-cultural variations in) human sexuality, addiction counselors have attempted to define a sexual “disorder” based on the chemical dependency model. And so they talk about things like:

Being preoccupied with or persistently craving sex; wanting to cut down and unsuccessfully attempting to limit sexual activity.
Continually engaging in the sexual behavior despite negative consequences, such as broken relationships or potential health risks.
Feeling irritable when unable to engage in the desired behavior.

Non-criteria like these resemble the SAST itself—ambiguous, rooted in assumptions about what’s “normal,” and substituting subjective judgments for rigorous assessment.

Another way to conceptualize sex addiction is as a violation of society’s moral standards, along with someone’s distress about that violation. One should not masturbate too much, according to common norms; one should not have too much indiscriminate sex; cheat on one’s spouse; be too sexually involved with porn, objects, or those with whom there’s no romantic love to redeem the sex (such as casual pickups or sex workers). The sex addiction concept helps patrol these arbitrary moral boundaries.

How do you treat the thing?

Heroin addiction treatment programs never suggest that the addict cut down to 3 or 4 injections per week. “You’re an addict, so you can never use heroin—or alcohol—ever again” is far closer to what we’d expect.

Then how about using the same model for treating sex addicts: “You’ll just have to give up sex altogether,” or “You can never masturbate again.” No? If the model works for other “addictions,” why not for sex? Two answers come to mind: (1) the whole sex addiction model doesn’t have nearly that much theoretical rigor, and (2) the market for a treatment plan that aims toward complete sexual abstinence is, well, rather limited.

It’s bad enough that the vague model of sexual health or sobriety encouraged by Sex Addicts Anonymous (SAA) and Sexaholics Anonymous (SA) is relentlessly heterosexual, monogamous, and intercourse-focused. It doesn’t make theoretical sense, but it’s obviously a more marketable product than abstinence. And both programs adapt the Alcoholics Anonymous model of asking participants to acknowledge their powerlessness over their addiction, and to ask God to remove their shortcomings.

Without question, there are many helpful things about twelve-step groups for some people. The advantage of these features is amplified in the case of sex, where there’s so much shame, cultural judgment, and self-imposed isolation. When you go to SA or SAA, they welcome you no matter what. Of course people love going there—imagine that you’re struggling, you have secrets or your spouse is angry or you feel bad about yourself or you wonder if you’re normal. Suddenly, here’s a group that says, “We’re so glad to see you! We’ve been waiting just for YOU!” It must feel like such a relief; one almost feels like a scrooge critiquing it.

But the charm of the twelve-step experience doesn’t mean that these groups actually cure (or even treat) an actual problem.

Obviously, there are legitimate problems out there regarding sexual behavior. There are people having affair after affair, seemingly unable to keep from hurting those they love. There are people for whom sex without danger has no excitement whatsoever. There are people spending hours every night on the Internet, typing with one hand, clicking on one exciting babe after another. And there are people who can’t seem to keep away from massage parlors, escorts, strip clubs, and lap dances. They try, but they can’t.

As a psychotherapist, sex therapist, and couples counselor, I see it first-hand. I pick up the pieces and help people put their lives back together.

I just don’t find the sex addict label clinically valuable, nor do I find it helpful to lump sexually troubled people together in this way. I also resent the repeated statement that if I don’t conceptualize these people as sex addicts, I’m either ignorant or I lack compassion. When some progressive Colonial physicians refused to diagnose patients as possessed by the devil, that didn’t mean they lacked compassion. They just didn’t believe in the diagnosis.

By the way, it’s fair to ask how I treat these people clinically. I do it with psychotherapy and occasionally with sex therapy; medication can also play a valuable role with some patients. Generally, my approach works pretty well.

New junk science

You may have observed that this is the decade of the brain, involving attempts to find neurological explanations for every facet of human emotion, motivation, and behavior.

Fortunately, “sex addiction” is not going to be in the upcoming fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, which describes mental illnesses for clinicians, the criminal justice system, the insurance industry, and graduate students. The primary reason for the exclusion is that there’s no consensus on what this “disease” is, and there are no rigorous scientific studies that determine the features or trajectory of its pathology.

But sure enough, various clinicians and researchers are trying to establish the scientific basis for sex addiction—by referring to neurology and hormones, as measured by brain scans. Such researchers have discovered that when so-called sex addicts are involved in sex (for example, when watching pornography), the part of their brain that lights up (the mesolimbic pathway) is the same part that lights up when a heroin addict has injected heroin.

Compelling proof of sex addiction? Not even close. That’s the same part of the brain that lights up when we see a sunset, the Golden Gate Bridge, the perfect donut, a gorgeous touchdown pass, or our grandchild’s smile. Our brain, our blood, and our hormones always react to pleasure—including sexual pleasure. The last 150,000 years of evolution at least accomplished that much with us poor humans.

The latest entry into the sex addiction/brain chemistry sweepstakes is the new junk science of “porn addiction.” One primary proponent, Judith Reisman (who also claims that Alfred Kinsey was a pedophilic fraud), refers to poisonous “erototoxins” released into the bloodstream during the viewing of pornographic material. Another proponent, Marnia Robinson, claims that teens’ brains are so plastic that boys easily become addicted to porn, which then damages their ability to function sexually with actual partners. Not a shred of evidence clouds Reisman’s or Robinson’s judgment about how people become addicted to their own body chemicals when those chemicals are related to sex rather than, say, a walk through the park or a production of King Lear.

Sex addiction and porn addiction crusaders complain that porn is terrible sex education. I agree, just as watching a car chase in an action movie is a terrible way to learn to drive.

Why it matters what you call it

In response to questions such as “Is there such a thing as sex addiction?” and “How should we conceptualize sexual behavior that appears or feels like it’s out of control?” I’m astounded by the number of professionals who collapse into responding, “What does it matter what we call it? The goal is to help these poor people.”

When homosexuality was called a mental illness, it mattered. When women were called frigid or nymphomaniacs or hysterics, it mattered. When a patient is diagnosed as possessed by the devil instead of schizophrenic it clearly matters: it determines the treatment to be used, and who is qualified to administer the treatment. How can people who make their living using words say that it doesn’t matter what you call it?

It also matters what you call it because the model of sexuality is built into the model of disease. In obsessive-compulsive disorder, we don’t say the problem is hand washing, and we don’t send people to hand-washing clinics. But in sex addiction, the problem is sex, and people are sent to sex addiction clinics.

Finally, it matters because calling this behavior an “addiction” validates the idea that these people are out of control. Instead, we need to say that feeling out of control isn’t the same as being out of control. Most “sex addicts” don’t like the consequences of their sexual choices, but they keep making those choices. We have a word for this behavioral pattern—neurosis; and we have a treatment for it—psychotherapy (sometimes supported by pharmaceuticals). The addiction model starts with “we admitted we were powerless.” The therapy model starts with “you’re responsible for your choices; I wonder why you keep doing what gives you what you say you don’t want?”

What this means for humanists

The sex addiction movement exploits people’s fear of their own sexuality. As humanists we oppose anything that exploits fear.
Recalling that sex addiction is a fairly new concept, we can observe the historical and cultural context from which the movement emerged—not a sexological context as much as a narrative about fear, danger, powerlessness, and victimization.
The sex addiction model inevitably tells us that eroticism needs to be controlled, and that erotica and commercial sex are dangerous and problematic. This means that the sex addiction movement, with the help of the religious right, supports public policy focused on controlling sexuality. Unfortunately it has been very successful in that regard.
The sex addiction model tells us that imagination has no healthy role to play in sexuality. This fundamental misunderstanding of human nature is very much our business.

The issue of what to call sexual behavior that is described as out of control is important not just for society in general, but for humanists in particular. To the extent that the sex addiction movement trivializes science as just one of many different perspectives, it affects us. To the extent that it tries to squeeze people into a small normative box of sexual behavior, it’s relevant to our cause. And to the extent that it pathologizes behavior that doesn’t hurt other people, it’s a prime example of what a humanist public policy would replace.