All About Sex Addiction

by Brian Dunning
December 31, 2019

You can virtually set your watch by it: whenever a celebrity is caught in a well-publicized infidelity or sexual harassment case, you can count the seconds until their press agent announces they are seeking treatment for sex addiction. While it's a handy get-out-of-jail-free card that suggests a medical problem is the true perpetrator, it's one that hardly has universal recognition. It appears that for just about every case of an expert acknowledging the problem as a true addiction, there is another equal and opposite expert dismissing the notion. Today we're going to have a look a sex addiction, to find out what about it is real, what may be misrepresented, and learn just how much of it — if any — is complete fiction.

One of the first things you learn when you study this subject is that there are many different names for the idea of excessive sexual behavior: not just sex addiction, but also hypersexuality, hypersexual disorder, erotomania, sexual dependence, compulsive sexual behavior, nymphomania, and even a masculine version of nymphomania called satyriasis. If the idea is to define a situation where sexual behavior is both problematic and out of the person's control — to whatever degree — then the definition is usually given as compulsive engagement in rewarding sexual stimuli, despite adverse social, occupational, or other types of consequences. In broad strokes, any type of behavior that becomes incompatible with the desired normal, healthy lifestyle is one that warrants clinical intervention. Thus, if a person goes around having inappropriate sexual contact that cost them their jobs, their spouses, whatever, but they still continue the activity, then we can start to say that something is wrong that's not necessarily their fault. And it's this loophole that can apparently justify inappropriate and excessive sex that has turned sex addiction into a profitable industry.

However, once we start to get into medical terms — like addiction — we cross into the territory of specific, falsifiable claims. To be classified as an addiction, the compulsive behavior must be a disorder of the brain's reward system that involves a biological pathology regardless of any psychosocial factors. One of the main ways this is determined has to do with a protein called ΔFosB, which is part of the reward pathway that's activated whenever any person engages in any pleasurable activity, whether it's sexual or even just eating chocolate. However, when a person becomes addicted to something (anything), ΔFosB can become overexpressed; and this abnormally high level results in a sort of neuroplasticity throughout the reward system. It is widely accepted — though not universally — that ΔFosB overexpression is an addiction biomarker. In simple terms, it's a flag that tells us whether a person is addicted or not.

And the verdict for sex addicts? Yes. We do find that people identified with compulsive sexual behavior do have this addiction biomarker. And so — stressing that this is somewhat contentious and not universal — it is generally and widely accepted that sex addiction does indeed meet the medical definition of an addiction.

However, that's hardly the final summation of the issue. To the contrary, it's where all the controversy starts. And the short reason for this is that the fact that compulsive sex can be medically addictive is not sufficient to prove that a person is not accountable for their own actions. For that we would need to turn to the psychiatric literature. The current state of the art for what's what in psychiatry is codified in the United States in the DSM (the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association), and for much of the rest of the world in the ICD (International Statistical Classification of Diseases and Related Health Problems published by the World Health Organization). As of now, the DSM-5 and the ICD-11 are the current editions. Let's turn to their sections on sex addiction.

And guess what we find: They don't exist. Neither the DSM nor the ICD recognize sex addiction as a clinical diagnosis.

In 2010, a proposal to include it in the DSM-5 was put forth as "hypersexual disorder", but was ultimately not approved. That name was chosen instead of sex addiction because of the baggage included with the term addiction which implies a specific cause. Hypersexual disorder was proposed to be a valid diagnosis if the behavior had persisted for at least six months, and the patient had made multiple failed attempts to stop the behavior. The reasons that it was ultimately rejected are not completely clear; what's always cited is the lack of evidence that it is truly addictive behavior. Critics of this decision point to the fact that both the DSM and the ICD include "gambling disorder", and it's listed under substance-related and addictive disorders. It would seem that hypersexual disorder checks most of the same boxes — inability to stop on one's own, continuing the behavior despite increasingly adverse consequences — however, the governing bodies have made the decision that compulsive sexual behavior does not meet the clinical standards of addictive behavior. The ICD-11 did add "compulsive sexual behavior disorder", though only as an impulse control disorder and not as a true addiction. This has left sex addiction in a sort of diagnostic no man's land: medically, it's an addiction; but psychiatrically, it's not.

And yet, while psychiatrists continue to debate this, there is a large industry — worldwide — of sex addiction therapy. There are countless inpatient and outpatient addiction counseling and treatment centers, and some of these have specialists in treating sex addiction. This raises an obvious question, something of an elephant in the room: How can there be such a thing as a sex addiction specialist, if sex addiction is not a recognized psychiatric condition?

It's a good question, and an important one. And the answer is something that regular Skeptoid listeners have heard time and time again. When there is a profession that's peripheral to accredited, board certified medical professions, but that is not itself recognized by the American Medical Association or the American Psychiatric Association as an actual medical or psychiatric field, it's common for practitioners to invent their own accreditations and self-certify their own practitioners. This is what has happened with sex addiction therapists.

The market in sex addiction therapy is quite the crowded place. There is IITAP (the International Institute for Trauma and Addiction Professionals) which offers the trademarked Certified Sex Addiction Therapist (CSAT®) program; there is AASAT (the American Association For Sex Addiction Therapy) which offers Recovery Therapist, Recovery Coaches, and Pastoral Counselor certifications for as low as $795. There are undoubtedly others. Usually, such a proliferation of institutes and academies and associations selling certifications is a sure red flag indicative of a fraudulent industry comprised of vultures swooping in to take advantage not only of patients but of hopeful practitioners who have some cash in their pockets. But in the case of sex addiction therapists, it is fair to draw a line of distinction from the sham industries with similar structures. Though it's not universal, most of the certifying groups have high standards, requiring their applicants to have advanced degrees in psychology, as well as a legal license to practice psychotherapy in their state. So, unlike certified naturopaths or nutritionists, a certified sex addiction therapist is likely to have an actual board certification and license in addition to their sex addiction therapy certification. Strictly speaking, a sex addiction therapy certification does not mean that the provider has a skill that is certified by any body accredited to provide such a certification; but at least you can be assured (in most cases) that the provider still has the relevant professional qualifications and background.

Treatment typically involves CBT (cognitive behavioral therapy) to seek other types of rewarding activity, and often requires keeping the patient in an environment with no access to porn, sex workers, and so forth. Twelve-step programs are also used; however, data show that these produce outcomes similar to no treatment at all.

So while the self-certifying industry on sex addiction treatment is there to fill a real hole in psychiatry that many believe shouldn't be a hole, the fact remains that the majority of the psychiatric profession — as represented by the APA and the WHO — believes that it's not a clinical diagnosis and is therefore outside of their scope of treatment.

However, this is not the whole story. There is a darker side of the industry outside of even this self-certifying segment. There exist numerous sex addiction treatment programs based on Christian fundamentalism that tend to regard virtually all sexual activity outside of monogamous marriage to be "sex addiction", including homosexuality, masturbation, paid sex, use of porn, and pretty much anything else. Such groups as AACC (the American Association of Christian Counselors), C-SASI (Christian Sex Addiction Specialists International), and APSATS (the Association of Partners of Sex Addicts Trauma Specialists) sell certifications as a sex addiction therapist with hardly any meaningful prerequisites at all; as little as four days of training, or in one case, just 10 hours of self-reported reading.

In some cases, people are forced into such counseling where they may spend years having it drilled into their heads that their behavior is abnormal and the result of a disorder — behavior which is in fact perfectly normal and healthy. Sex addiction treatment that exists entirely outside of the psychological and psychiatric professions should be regarded with extreme skepticism, and probably just avoided entirely.

This existence of an almost totally bogus industry alongside the unaccredited but reasonably well self-policing industry puts patients at substantial risk. The question of whether anyone should be seeking psychiatric treatment for sex addiction at all is still an unclear one; but for anyone who chooses to, insist on a degreed and licensed psychotherapist.

It is a murky and complicated situation. Consumers are faced with three levels of professionals: First, the mainstream psychiatric community that generally feels sex addiction is not a condition for which there is a psychiatric treatment; second, competent and conscientious professionals who combine legitimate psychotherapy with a minority view on sex addiction; and third, a sham industry of untrained proselytizers happy to show you their nicely laser printed certifications as sex addiction therapists.

I believe the most practical place for this episode to conclude is to give us all a better idea of how we should react when we hear a defense of "sex addiction" in some case of harassment or other inappropriate behavior. All we can know is that a medical addiction is possible, but we can't know that person's status due to privacy laws; and that a psychiatric diagnosis does not exist. We can also be mindful of the difference between real sex addiction and all the other behaviors that people often wrongly apply the label to: behaviors ranging from totally normal healthy sexual acts all the way to rape. Very few of those qualify, so be very skeptical of the application of the label. Beyond that, this is one place where we're going to have to leave the science and any potential treatment more or less unresolved, at least for now. Dissatisfying though that may be, it is often the most honest answer to difficult questions.

By Brian Dunning
Follow @BrianDunning