Andrew was in his late 30s when he started feeling that his masturbation habit was getting out of control. He was indulging several times a day, while using pornography. These regular sessions were easy to schedule, as he was single and working from home. But his preoccupation with porn was getting in the way of the rest of his life. He wasn’t going out with friends or pursuing leads for work. “It inhibited my income,” he says. “It inhibited my relationships.”
Feeling increasingly isolated and ashamed, Andrew tried raising these problems in therapy, but his therapist was uncomfortable talking about sex. When a friend mentioned he was going to 12-step meetings for sex addiction, he was fascinated, even relieved. It was the early 2000s and he wasn’t aware that such a thing existed. “I thought, ‘Wow, there’s this thing called sex addiction? That sounds like what I have’,” he recalls.
Andrew started going to 12-step meetings and found it “tremendously useful” to have a place where he could talk about his problem and plan constructive ways to address it. He became more introspective, masturbated less and eventually stopped using porn. He felt so grateful for these changes that he decided to become a certified sex-addiction therapist himself.
For people like Andrew who are troubled by the scale or nature of their sexual desires, the notion that they are suffering from a disease can be a comforting one. After all, the sick cannot be held fully responsible for their actions; addiction blurs the line between culprits and victims. That may help explain why Harvey Weinstein, who spent decades abusing women without showing signs of remorse, is reported to have checked into sex-addiction rehab when the storm broke.
Yet a growing number of therapists and addiction specialists are questioning whether these problems should be seen as an addiction at all. They argue that by pathologising certain sexual desires, we are failing to deal with the underlying causes of this behaviour.
Given how often the term is bandied about in the news and on therapists’ couches, it is worth probing what we are really saying when we label someone a sex addict. More importantly, what does using this label encourage us not to explore, not to say?
The notion of sex addiction first came to light in 1983 with the publication of “Out of the Shadows”, a book by Patrick Carnes, a prison psychologist in Minnesota. Carnes tells the stories of people whose sexual behaviour consistently gets them into trouble: a man whose fantasies lead him to harass a female stranger; a husband who gets arrested for exhibitionism. These people may seem like scoundrels, but Carnes explains that their self-destructive choices are like those of an alcoholic – that is, they have no choice at all. “The addiction is in charge.” Carnes recommended adapting the 12-step treatment programme of Alcoholics Anonymous to the needs of sex addicts, as it offered a ready-made support network and a clear path to sobriety.
Carnes’s theory of sexual misbehaviour was timely. Ronald Reagan was president, the AIDS crisis was on the rise and the pendulum was swinging away from the sexual liberalism of the 1970s. Conservatives and religious leaders were calling for a return to traditional family values (“AIDS is God’s way of weeding his garden,” said Pat Robertson, a Christian evangelist). Meanwhile, new research on the science of addiction meant that addicts, once maligned as drunks or junkies, were being treated with greater compassion. Betty Ford, a former First Lady of the United States, and others were coming forward to lend a respectable face to what was increasingly regarded as a treatable disease. For those who were nervous or anxious about their sexual needs and cravings, the label of addiction offered some relief. “Having a disease that offers some sort of redemption is very appealing for people whose only other choice is to be a pervert,” says Doug Braun-Harvey , a psychotherapist and author of the book “Treating Out of Control Sexual Behaviour”.
This new 12-step approach spread quickly. People who have trouble regulating their sexual behaviour tend to feel lonely, isolated and ashamed, so being in a room full of people with similar predilections can be reassuring. “I felt so comforted when I went to my first meeting and was surrounded by 20 or 30 guys, all of them sex addicts, sharing their stories,” says Arthur, a married father in his 50s who is working to control his appetite for porn and voyeurism. “I felt like I had a new family.” Meetings are free and the atmosphere is compassionate. Today there are well over 1,000 Sex Addicts Anonymous (SAA) meetings across America any given week, and others in countries as varied as Guyana, Iran and Slovenia.
The movement spawned an industry. Treatment centres for drug addiction and alcoholism began to offer inpatient options for sex addiction, which insurance companies and patients were willing to pay for. Therapists and counsellors who specialised in addiction suddenly had a whole new demographic of people they could treat. “I think that there was this whole economic aspect to this,” says Eli Coleman, director of the Programme in Human Sexuality at the University of Minnesota. Tyler, a 28-year-old in New York who identifies as a sex addict, says he is still in debt for his 38-day stay at the Keystone Centre treatment facility in Pennsylvania eight years ago, which cost him $25,000. A 2014 survey of inpatient treatment centres that handle pornography and sex addiction found that the average cost was $677 a day.
Many swear by the 12-step process, which encourages people to be honest about their problems and to ask for help. Participants are led to understand that sex addiction, like any addiction, is a disease that robs them of agency. Their “allergy to selfish sexual behaviour” – according to a script read at meetings – means their bodies react “abnormally to the chemicals [their] brain produces” when they act out. In the face of this powerlessness, addicts are taught to seek strength in a higher power; faith in God features prominently throughout. A recent Sex Addiction Anonymous meeting in a church basement in Harlem began with a moment of silence to “meditate and invite God to our meeting”. Redemption requires identifying as an addict, taking a temporary pledge of abstinence, swearing off most forms of sexual selfishness (such as pornography and masturbation if they were problems) and experiencing a spiritual awakening. “It’s a disease that only a spiritual experience will conquer,” says Joe, a 40-something personal trainer in Dallas, Texas, who is recovering from his “unmanageable obsessions with women”.
This narrative of powerlessness is popular among self-described sex addicts. “A lot of people can look at porn and look away, but we get high from it and need more. It’s chemical,” explains Arthur. Stefanie Carnes, Patrick Carnes’s daughter and head of the International Institute for Trauma and Addiction Professionals (IITAP), the leading body for educating and certifying sex-addiction therapists, says that internet porn is fuelling a sharp rise in addiction. “The percentage of people who are starting to have problems because of this has grown exponentially.” The diagnosis, she says, is backed by neuroscience. “We are seeing the exact same response as substance-abuse disorders,” she says. “We look at this as a brain disease.” She compares efforts to discredit this research with early views of alcoholism, which dismissed the addiction as a moral failing, a problem of willpower.
But a closer look at the evidence yields little proof that an unhealthy obsession with sex is comparable to an addiction to drugs or alcohol. Sex-addiction therapists argue that their patients experience symptoms of withdrawal and risk-taking, and they persist in their often-destructive pursuits despite dire consequences, much like substance addicts. “I have patients who can lose everything in their lives, their jobs and relationships, yet they still continue to compulsively engage in that behaviour,” says Anna Lembke, a psychiatrist at Stanford University.
Yet these reports are largely anecdotal. Studies have yet to prove that people who feel they have a problem with sex or porn regularly increase the time they spend consuming it, or move on to more “extreme” stuff. As for withdrawal symptoms, people sometimes feel anxious or distressed when they abstain from this behaviour, but these are not analogous to the symptoms of substance addicts, which are often physiologically profound and medically serious.
Advocates of the sex-addiction model also point to functional magnetic-resonance imaging (fMRI) brain scans conducted by Valerie Voon, a neuroscientist at Cambridge University. She has found that the brains of sexually compulsive people seem to resemble those of drug addicts when they are presented with relevant cues, in this case sexually explicit videos. “People who don’t say this is an addiction, how do they explain those brain changes?” asks Stefanie Carnes.
Yet Voon is quick to caution against using her studies to leap to conclusions about the addictiveness of sex or porn. “Much more research is required,” she explains. Meanwhile, a study from Nicole Prause at the University of California, Los Angeles, used electroencephalography (EEG) to measure the brain waves of people presented with sexual images and found something different. She observed that volunteers who believed they had a problem with porn reacted to the pictures with low levels of excitement in the brain, unlike other addicts faced with triggering cues. “These people may be having problems, but of some other type,” says Prause. “Addiction is not a good way of understanding it.”
Keith Humphreys, a Stanford psychiatrist who helps run the NeuroChoice lab at the Stanford Neurosciences Institute, which studies the neuroscience of choice and addiction, is sceptical of the idea that you can be addicted to things – like food and sex – that we are hard-wired to consume in order to survive. “You don’t need to invoke an unusual pathological explanation for why human beings eat and why they have sex, because if they didn’t they wouldn’t be here,” says Humphreys. Substances like heroin, by contrast, not only more dramatically hijack our brain’s pleasure pathways but also inspire behaviour that threatens people’s survival, so an addictive process is necessary to explain our attachment to them.
“People can say, ‘I’m addicted to my smartphone, I’m addicted to chocolate, I’m addicted to line-dancing – believe it or not there’s quite a literature on line-dancing addiction,” says Nancy Petry, a psychiatrist at the University of Connecticut and the chairwoman of the American Psychiatric Association’s subcommittee on behavioural addictions for the latest “Diagnostic and Statistical Manual of Mental Disorders” (DSM-5), a clinical handbook. “But scientists and clinicians have to draw a line. Something may be causing people distress in their lives, but that doesn’t make it a unique and classifiable mental disorder.” The only so-called behavioural addiction to be included in the DSM-5 is gambling disorder. Sex addiction did not make the cut, owing to insufficient evidence. “The data aren’t there yet,” says Petry.
In the absence of clear diagnostic criteria, how does someone know if he or she is a sex addict? How much sex or porn is too much? Most of the literature defines sex addiction as a problem of compulsive, preoccupying, secretive behaviour, which leaves the addict feeling both depressed and ashamed. A six-question test that IITAP recommends physicians use to screen patients for this problem includes the questions, “Do you often find yourself preoccupied with sexual thoughts?” and “Do you hide some of your sexual behaviour from others?” Saying yes at least twice makes someone a candidate for further scrutiny. “We don’t determine addiction quantitatively, we determine it qualitatively,” explains Robert Weiss, a leading sex-addiction therapist based in Long Beach, California. “If your relationship with that substance or behaviour becomes so all-consuming that it has become detrimental to your life goals, then maybe there’s an addictive process in place.” This seems to mean that the problem is not the amount of sex you have, but how you feel about it. As Alexandra Katehakis, a sex-addiction therapist and the clinical director of the Centre for Healthy Sex in Los Angeles, explains: “People are not necessarily having more sex, they’re just obsessed with it.”
This elastic definition makes some intuitive sense. But it means that someone who is having lots of sex but doesn’t feel badly about it doesn’t qualify – like Warren Beatty, who is thought of as a lucky Lothario, not a sex addict, despite a recent biography that alleged he slept with nearly 13,000 women (Beatty claims the number is exaggerated). Such criteria for classifying addicts do, however, ensnare those who simply feel ashamed of their desires, perhaps because they sit uncomfortably with their partner or religion. Ian Kerner, a sex therapist in New York, notes that many of the people who come to him worried they are sex addicts are simply craving or engaging in behaviour that doesn’t conform to conventional, monogamous love-making. “I’ve had men come in who are kinky who describe themselves as sex addicts. I’ve had men who simply want more sex than their partners describe themselves as sex addicts. It’s the easiest place to go to not deal with the underlying issue. If you choose not to use the term ‘sex addiction’ what are you compelled to look at then?”
The term “addiction” here seems to describe a uniquely subjective phenomenon, a personal feeling of shame or of being out of control. Interestingly, this feeling often doesn’t align with actually having more sex or watching more pornography. Joshua Grubbs, a psychologist at Bowling Green University, has found that religious people are far more likely to believe they are addicted to porn than non-believers, regardless of how much they are watching. He has also discovered that people who worry they are addicted to porn tend to feel more stressed about their behaviour than others, yet they are not necessarily consuming more of it. “I don’t know any other substance or behavioural addiction where the people who are suffering don’t actually do the thing more,” observes Prause. Given the way culture and context inform our feelings about sex, this definition of addiction suggests an awkwardly fuzzy line between a sexual preference and a disease.
Andrew, the sex-addict-turned-therapist, noticed just how grey this area could be when he began seeing patients. “I kept having people come in and say, ‘I think I’m a sex addict. I need you to help me’,” he says. “I’d work with them, but from a gut level I would think this guy isn’t a sex addict in the way I think of sex addiction.” He recalls a married father who had been labelled a sex addict by a fellow therapist because of his cocaine and prostitute binges. A little digging revealed that his behaviour seemed to be linked to his intense shame over a secret fetish for gay pornography. This left Andrew wondering whether it made more sense to concentrate on the man’s shame, rather than simply addressing the way he was acting out.
Andrew also noted that most of the therapists pursuing certification either identified as sex addicts themselves or had a partner who struggled with the problem. This didn’t seem too strange at first, given his own history. But he soon wondered whether this bred loyalty to the treatment-model and a tendency to over-diagnose. Studies of recovering drug addicts who become counsellors show they are often guilty of both. “They’re so rooted in the model,” Andrew says. “So, if someone comes in and says, ‘I’m doing this and this, but I don’t think I’m a sex addict,’ they’ll think this person is in denial. You have to get on board or you’re in your disease.”
Not only do sex-addiction therapists tend to approach patients from this particular standpoint; less than 5% of nearly 1,600 certified sex-addiction therapists are trained in sex therapy. As a result, many have a limited understanding of sexual diversity, which may make them quicker to pathologise behaviour that doesn’t conform to a monogamous heterosexual standard. “Clinicians who are not trained in sexuality have a lot of the same myths and assumptions that the general public has, particularly about sexual diversity,” says D.J. Williams, director of research for the Centre for Positive Sexuality and a social scientist at Idaho State University.
It is worth noting just who is being labelled an addict. Studies on prevalence are limited, but researchers estimate the problem affects between 3% to 6% of the population, 80% of whom are men. This gender imbalance may be partly explained by male sexual privilege, argues David Ley, a psychologist in New Mexico and author of the book, “The Myth of Sex Addiction”. “Sex addiction has become a convenient excuse for men who get caught doing something they get in trouble for.” Men like Weinstein and Anthony Weiner, an American congressman renowned for his sexting, may hope to earn some compassion for their transgressions when they claim they are ill. Wives tend to be more tolerant of infidelity when they believe it is a product of a disease. The label usually invites less sympathy on the rare cases when it is applied to women.
But something else may also be at play. Men tend to desire more sex and more sexual partners than women. They also like pornography and strip clubs more than women do. This can lead to some tension on the home front. Couples often have conflicting or discrepant desires, and the needs of one – the man, usually – are occasionally labelled as sick. “Sometimes simply learning that their husband is masturbating rather than having sex with them exclusively is enough to make a wife see him as a sex addict,” says Coleman. A number of studies have found that women often find it “devastating” or “traumatic” when they learn that their male partner is masturbating to porn. A recent study of pornography-use among American men found that heterosexual men were more likely than gay men to report watching porn on a computer at work – perhaps in order to evade the judgmental eyes of a spouse.
“Teenagers generally grow up thinking there’s something shameful about porn and masturbation, that it’s something you have to hide,” says Tony Stiker, a psychotherapist in New York. This feeling, he explains, never really goes away. “Instead, you enter adulthood with this unspoken, shameful secret that you still use porn, that you still masturbate. All women know that men do it, but there seems to be this idea that once you get married that stops. But often it doesn’t stop. The key thing is no one is talking about it.” Many men find it easier to identify as a sex addict than to have a more difficult conversation with their partners about their needs and desires, particularly if they are ashamed of them.
We also tend to give boys and girls somewhat different messages about sex. Most parents teach their daughters that sex involves big risks and serious consequences, and that it is best to share it with someone you trust and, ideally, love. Sons, however, are often left to figure things out for themselves. “In our society, we’re less interested in the sexual health of men until they injure people,” observes Braun-Harvey. Few men are ever comfortable seeking guidance from other men, particularly about sex. Most end up learning what they feel they need to know from pornography.
Religion can exacerbate these problems. Mordechai Salzberg, a therapist who specialises in sexual disorders with mainly ultra-Orthodox Jews in New York, says the men who come to his office have real trouble regulating themselves. “We’re talking about wives literally banging on the bathroom door because they’ve been in there for four hours masturbating and their penis is bleeding.” He suggests this compulsion comes about because so many of his clients had lonely, traumatic, gender-segregated childhoods, during which they were encouraged to suppress their needs and feelings. They learned as children that they could make themselves feel better by masturbating, which ultimately becomes “a self-soothing exercise run amok”. It may be an overstatement to call this a disease, says Salzberg, yet many of his clients like the “sex addiction” label because it captures just how unmanageable their problem feels. It is also easier, initially, to address the behaviour than to unpack the emotional drama of their early childhood.
For Andrew, this sense of shame was a big part of what he later saw as his problem. His parents, who were raised Catholic, were too uncomfortable to ever talk about sex with him, and he never learned anything useful about it in school. He ultimately stumbled across pornography, which felt endlessly alluring and thoroughly shameful. “It was something I knew I could never talk about,” he recalls. As he grew older, the prospect of an emotionally intimate relationship with a woman made him increasingly nervous. “The whole shebang was terrifying for me. Porn…gave me a way to be sexual without taking any emotional risks.”
All of this can make the male-dominated environment of Sex Addiction Anonymous meetings especially comforting for participants. These are rare spaces where men are encouraged to be vulnerable and connect with others. “These meetings are the biggest men’s movement” in Los Angeles, says Katehakis. “These guys are directors, producers, financiers, bankers. There’s an SAA meeting in LA every day.”
Human sexuality is a complicated business. Not until Alfred Kinsey’s ground-breaking research in the mid-20th century was it publicly recognised just how common it is for men to have sex with other men, and that women even enjoy sex at all. Understanding the great variety of sexual desire and experience, Kinsey cautioned against pathologising what simply seemed different. The notion of normality is subjective, he argued, making such judgments more moral than scientific. “A nymphomaniac”, he said, “is someone who has more sex than you do.”
More than half a century on, we are still fairly squeamish about sex. It is everywhere and is used to sell everything, yet we rarely talk about it. Many of us avoid discussing our needs and desires even with the people we are having sex with. This seems especially true in America, where a reigning Puritanism ensures few adolescents are taught how to make healthy sexual choices. “The culture in general is kind of sex phobic,” says John Giugliano, a psychotherapist in Pennsylvania who specialises in out-of-control sexual behaviour. He notes that some people do have real trouble regulating their sexual conduct – just as some people struggle to regulate their eating or shopping – but he suggests it’s the shame around sex that turns these problems into a presumed pathology. “I don’t think the concept of sex addiction would be embraced if the culture was more accepting.”
America has a bad record of pathologising sexual behaviour. It wasn’t so long ago that leading therapists worked to “cure” masturbation, homosexuality and transgenderism. Yet many conditions we once ascribed to mental illness are now accepted as natural products of a healthy sexuality. Even sado-masochism between consenting adults seems far less alarming in the wake of “Fifty Shades of Grey”. It was only in 2010 that the American Psychiatric Association announced that it would exclude BDSM from the DSM.
Sex addiction may enjoy a similar fate. In the meantime, the term may not be as helpful as some may hope. For Andrew, the concept was useful initially because at the time “no one else was talking about this”. But he has come to see the label as an awkwardly simple way to describe what is often a more complicated set of problems. Some act out sexually because they never learned how to be intimate in a healthy way. Others were sexually abused as children. Many feel ashamed of a fetish. Quite a few more prefer the label to admitting that they no longer desire their spouse. And a number are suffering from other untreated mental problems, like obsessive-compulsive disorder or depression, which can hinder their ability to control their impulses. While the addiction model typically labels someone an “addict” for life, Andrew has found that addressing these underlying problems helps his clients put this behaviour behind them. “I no longer identify as a sex addict,” he says. “I don’t think it’s useful.”