How To Treat Sex Addiction When You Don’t Think It Exists
Sex addiction is a recurring theme in movie plots and TV series, in the real lives of movie and TV actors, even in discussions about whether this politician or that one may suffer from some form of the disorder. All of this presupposes that sex addiction is real. But experts are at odds about whether it is actually a medical phenomenon they can diagnose and treat in their patients.
“I will unequivocally say that sex addiction does not exist,” sex therapist and licensed marriage and family therapist Ian Kerner, Ph.D., author of She Comes First, tells SELF. “There was a big attempt by the addictionology community to get sex addiction into the most recent version of the Diagnostic and Statistical Manual, [released in 2013], under the category of hypersexuality,” he adds. “It was rejected by the American Psychological Association for lack of enough research and empirical data.”
On the other hand, the 2017 version of the International Classification of Diseases, compiled by the World Health Organization, includes excessive sexual desire and nymphomania under “Other sexual dysfunction not due to a substance or known physiological condition.”
In Kerner’s corner is the American Academy of Sexuality Educators, Counselors, and Therapists, which in December 2016 released a statement emphasizing their belief that sex addiction isn’t real. “[AASECT] does not find sufficient empirical evidence to support the classification of sex addiction or porn addiction as a mental health disorder and does not find the sexual addiction training, treatment methods, and educational pedagogies to be adequately informed by accurate human sexuality knowledge,” the statement reads in part.
Michael Aaron, Ph.D., a sex therapist in New York City and author of Modern Sexuality, helped write that statement. “Sex addiction is this nebulous umbrella term, and it’s problematic,” he tells SELF.
The fundamental problem is that experts can’t nail down a definition for what “sex addiction” really is, and therefore disagree on whether it is even a diagnosable disorder.
According to the American Society of Addiction Medicine, “Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations….Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”
When you’re addicted to something, you pursue it “pathologically,” ASAM notes. “Impulsivity turns to compulsivity, you have an inability to stop, and there’s preoccupation: You can only think about the thing itself,” certified sex therapist and certified sex addiction therapist and supervisor Alexandra Katehakis, Ph.D.(c), M.F.T., clinical director of the Center for Healthy Sex, tells SELF. As someone who believes in sex addiction but is an AASECT-certified sex therapist, she can see both sides of the debate, she says.
“Certainly, sex can become out of control. But when you use the word ‘addiction,’ you’re using a comparison to the way the brain is affected by drugs and alcohol,” Kerner says.
While some experts say sex doesn’t lead to comparable neurological effects, many sex addiction therapists disagree. “With drugs and alcohol, an external substance alters the neurochemistry of the body. With things like compulsive sex, internal mechanisms are creating neurobiological and neurochemical [changes],” Katehakis says.
That’s fundamentally true, as seen during the normal sexual response cycle. When you’re excited, physiological changes, like the release of the neurotransmitter dopamine, abound. According to Katehakis, people can get hooked on the rush, whether that’s due to sex or drugs: “[These actions] form deeper neural pathways as they become habituated. Humans have very malleable brains, so these become adaptive patterns.”
She believes that true sex addiction happens because the person needs that flood of feel-good feelings. “Classic sex addiction is based in trauma, like emotional or physical abuse or neglect in childhood,” Katehakis says, adding that a person who has been traumatized may feel “dead inside” and look to different vices in an effort to feel something. “The use of sex creates a dopaminergic [dopamine-related] rush.”
Research on the subject is mixed. In a small 2013 study out of UCLA, published in Socioaffective Neuroscience & Psychology, researchers showed sexual images to people who believed they were hypersexual versus a control group. The study subjects’ brain response wasn’t tied to whether they identified as hypersexual, only their level of sexual desire. “Hypersexuality does not appear to explain brain responses to sexual images any more than just having a high libido,” senior study author Nicole Prause, Ph.D., said in a statement. But a small 2014 University of Cambridge study published in PLOS ONE found that when people with compulsive sexual behavior watched pornography, their brain activity was similar to that of drug addicts viewing drug stimuli. “There are clear differences in brain activity between patients who have compulsive sexual behavior and healthy volunteers,” Valerie Voon, M.D., Ph.D., said. However, she said, “Whilst these findings are interesting, it’s important to note that they could not be used to diagnose [sex addiction].”
That’s basically AASECT’s stance. “The AASECT Position Statement is an assertion that the best scientific studies do not currently support the theory that sex can be an addiction directly analogous to cocaine, heroin, alcohol, or nicotine,” the statement reads. “That similar neural pathways may sometimes be shared by sexuality and other sources of pleasure and reward, including those involved in true addictions, reflects correlation but does not establish causation.”
Detractors believe that a sex addiction diagnosis may occlude deeper issues with sex or mental health.
Some people may think they’re addicted to sex—or even have an expert diagnose them as such—because they’re doing things outside their comfort zone or acting in a way that feels out of control.
“In my experience, the majority of people [who identify as sex addicts] are not really compulsive at all,” Aaron says. “They may have a fetish they feel is unhealthy or impure, or come from a religious, sex-negative, or sex-shaming background.”
Kerner agrees. “There’s a number of people who are alarmed at some aspect of their sexuality, like masturbating to gay porn or liking kinky sex, and want to eliminate it. Because they cannot, they identify as sex addicts,” he says, noting that men are far more likely than women to present with problematic sexual issues.
Many experts also posit that focusing on someone’s so-called sex addiction can mask their mental health issues. “When I’m working with someone who says they’re a sex addict, I try to look at what’s underneath that,” Kerner says. It could be that they use masturbation as a balm for crushing anxiety, for example. And when it comes to people whose compulsive sexual habits wreak havoc on their day-to-day lives—financial downward spirals, losing their partners or jobs—sometimes they qualify for a diagnosis like bipolar disorder or obsessive compulsive disorder, Aaron says.
Katehakis isn’t opposed to this idea, saying that only “a small fraction of the population is actually sexually addicted.” Definitive numbers are hard to come by, but estimates put about 3 to 5 percent of the adult American population in this category, if it does in fact exist.
With that said, no matter whether experts agree on sex addiction as a classification, they have to treat their patients.
Some, like Aaron, who doubt the legitimacy of sex as an addiction, focus on harm reduction therapy, which has two basic tenets. “It’s humanistic, meaning it privileges the subjective experience of a person and doesn’t try to apply some external model on what they’re describing, and it’s culturally libertarian, meaning as long as they’re not hurting anyone, you allow people to behave the way that they want and give them the space to do it,” he explains.
This method can work for people troubled by their sexual urges and those with compulsive sexual behavior. “Rather than trying to change something, we need to acknowledge it and embrace it,” Aaron says. He offers the example of someone who has fantasies of traumatizing children sexually or being sexually violent toward women: “The harm reduction approach asks, can you play out some of these themes with a consenting partner?” The aim is to satisfy these desires with a willing partner instead of suppressing them, which can just make them stronger, he explains.
As another example, when treating a man who would go on pornography-watching marathons from around 8:00 P.M. to 3:00 A.M. every night, Aaron sussed out that his patient had 10 extra minutes in the morning before he had to leave for work and suggested masturbating in that window instead. “You treat it with a utilitarian approach: He masturbated in the morning, taking only a short time because he knew he’d be late for work, and when he got home, he wasn’t that horny as a result,” Aaron says.
Sex addiction therapists often take a different approach, at least in the beginning. They might say, “Let’s stop all sexual behavior for 30 days and get a read on what’s going on,” Katehakis explains. Some experts take issue with this abstinence-based model, but the idea isn’t to say someone who experiences compulsive sexual behavior should never have sex again—it’s to figure out how going without their vice affects them, then work from there, Katehakis explains.
Another major divergence between the two groups is the subject of shame. Many harm reduction proponents attempt to diminish it, especially when it comes to taboo and/or illegal subjects. “If they have a rape fantasy, they feel like rapist. If they have child fantasy, they feel like child molester. There’s all this guilt and shame about something they’ve never done, and guilt and shame are big drivers of compulsive behavior,” Aaron says. By explaining that although these thoughts would be harmful if acted out, thinking about them isn’t the same thing, harm reduction therapists like Aaron actively work to reduce people’s shame.
Other therapists work to stoke it. “Sex addicts need to feel some shame about what they’re doing, because they are shameless. When people are shameless, they rape and murder and steal and pillage and get into politics,” Katehakis says. But this is different from shaming someone, she says. “Shaming in an unprincipled way is out of bounds [for a mental health professional],” she explains. That would include saying or even implying that someone is disgusting based on what they’re doing. Rather, she asks questions designed to make someone reflect on what their actions have wrought, like, “What do you think that feels like for your partner?” It’s helpful, not damaging, she explains, because, “It challenges them to see what they’re doing, and it brings them into the reality of their behavior.”
No matter the treatment method, experts all want one thing: To help people resume a healthy sex life.
“We’re looking to restore people’s sexuality to something positive,” Katehakis says. “Maybe the initial assessment might be different [from that of people who don’t believe in sex addiction], but in the end, if both parties are getting good results, what difference does it make? We’re all in agreement that we want people to have vital, healthy sex lives.”