By Robert Weiss LCSW, CSAT-S and Stefanie Carnes PhD, CSAT-S
July 24, 2013
In a nationally distributed study published last week, a group of researchers argued that what is often termed as “sexual addiction” could be better understood as a pathological variation of “high sexual desire.” After the publication of this article, a multitude of media outlets suggested that the conclusions of this study demonstrate that there is no scientific basis for the diagnosis of sexual addiction. This has occurred despite the study being the first of its kind, riddled with methodological errors, and at best inconclusive with its findings. Nevertheless, it continues to get a lot of media attention, most likely because it addresses problematic human sexual behavior, which is always a media attention-getter.
In the study, researchers monitored the brain activity (using EEG technology) of 52 men and women who self-reported as having “problems controlling their viewing of sexual images.” The researchers then asked these individuals to look at more than 225 still photos - pictures of everything from violence to people skiing to men and women being sexual together - while the EEG measured their brain activity. Participants also completed several questionnaires about their sexual desire and activity. Essentially, researchers were looking for a correlation between EEG readings and the participants’ scores on the various questionnaires, thinking that any correlations might shed light on whether problematicporn use is caused by addiction (which is in essence a neurobiological dysfunction) or merely a high libido.
Since the study’s release, critics have cited numerous flaws in it, including concerns that the sample group differed significantly from treatment-seeking sex addicts and that the individual test subjects were not screened for other possible co-morbid conditions that could have interfered with the results. Additionally, there are serious questions about the strategy used to score one of the instruments in the study, which likely invalidated the measure and distorted the statistics. Basically, the researchers’ determination of a subject’s hypersexuality was primarily based on that individual’s responses to questions about having sex with a partner, whereas the brain scans were used to monitor solo sexual activity. As any sex addict can tell you, there is a huge difference in how most of them feel about and respond to in-the-flesh sex versus on-the-screen activity. The most readily apparent methodological error was the research team’s misuse of the Sexual Desire Inventory (SDI). Oddly, the researchers decided to use only part of this comprehensive questionnaire - inexplicably ignoring the questions about solo sexual activity, which, once again, was the exact activity they were monitoring with the brain scans.
Feeling confused? So are we.
Furthermore, the pre-screening of test subjects was wildly inadequate. The study lumped anyone who reported “issues with porn” into the same category. This means that some of the subjects were not likely porn addicts, while others may have been severely addicted. Adding to the quagmire is the fact that the researchers chose vastly different test subjects - men, women, heterosexuals, and homosexuals - and then showed them all the same heterosexually oriented sexual images (when clearly a gay participant would not respond to heterosexual images in the same way). In addition, the test subjects were shown only still images - hardly the streaming HD videos and live webcam shows that most were likely used to using.
Another criticism is the authors’ reliance on EEGs to measure subjects’ brain activity. Yes, EEGs are a useful scientific tool, but only to a certain extent. The simple truth is EEGs measure brain activity from the outside of the skull, making them the neurological equivalent of a blunt instrument. This is hardly definitive when looking at the complicated interplay of the numerous brain regions involved in the creation and expression of sexual desire (rewards, mood, memory, decision-making, etc.)
So, in a nutshell, this study is inconclusive at best, with conclusions drawn by the authors that don’t correlate to the data.
At least the researchers are not overtly indicating that the issue doesn’t exist. Instead, they argue that the problem is not an addiction and that conceptualizing it as “high sexual desire” would be more accurate. However, these researchers did not study the same areas of the brain or use the same technologies that have been utilized in previous research looking at process (behavioral) addictions. In an article released in the journal Socioaffective Neuroscience and Psychology, Dr. Donald Hilton summarizes much of the brain research that does lead scientists to believe that sex (and other natural processes) can be addictions. For a thorough review of this scientific literature see his article here. None of the brain regions looked at in Dr. Hilton’s work or the studies he cited were discussed or examined in the recently released study.
Amazingly, despite the study’s poor design, bad execution, and obvious limitations, the authors chose to formulate misguided conclusions and publish, even sending out an international press release touting their “achievement.”
Dr. Hilton argues that we are on the brink of a paradigm shift in our conceptualization of process addictions. He states, “During the shift, crisis and tension predominate, clouding the significance of the shift in the present. Nevertheless, the new combined paradigm that amalgamates addictions to both substances and processes is beginning to assert itself.” This assertion is evidenced by the fact that in the PubMed literature database the term “sexual addiction” is used almost three times as often as any other term that describes the disease. So is this current media frenzy simply part of the “crisis and tension” clouding our view during the midst of a shift?
Why is it that when two excellent articles come out, one supporting the addiction framework and one questioning it, that the media hones in on one and distorts its conclusions for shock value? What are the resulting repercussions for the tens of thousands of patients whose reality is denied and invalidated? In the 1980s sex addicts were told by mental health practitioners that their problem didn’t exist. Well, it did exist, and because therapists didn’t help them they created their own support groups, and now that network of “S-fellowships” provides critical, free care to tens of thousands of people daily. So while we as clinicians can continue to argue whether this is an addiction, a compulsion, an impulse control problem, or high sexual desire, we should not be arguing that the problem doesn’t exist. And the media shouldn’t either.
A similar phenomenon occurred with alcoholism at the turn of the century. Alcohol addiction was seen as a “moral failing” brought on by a “lack of willpower.” It wasn’t until many years later, when we began to fully understand the disease concept of addiction, that it became better understood. So why is it that society would rather call sex addicts “womanizers” and “schmucks” than use a paradigm that is helpful?
So, let’s consider the repercussions of our labels… So far we have sex addiction, sexual compulsion, impulse control disorder, hypersexual behavior disorder, out-of-control sexual behavior, problematic sexual behavior, and now a new one: high sexual desire. Using the label “sex addiction” rather than the others has a multitude of advantages. First, it is the language that the clients speak. Clients do not come to therapybecause they think they have “hypersexual behavior disorder,” they come because they are “sex addicts.” Second, it is the term most often used by physicians. Third, by using an addiction perspective you can reduce the shame, normalize the behavior, provide lots of ancillary resources and materials, and immerse the client in a community of support that involves accountability and taking responsibility for one’s behavior. In contrast, how are we as therapists to effectively help a patient with his or her “high sexual desire”?
And when did high sexual desire and sexual addiction become mutually exclusive concepts? Simply put, diagnosing a person as having a high sexual desire does not rule out sexual addiction. In fact, the research discussed above does nothing to refute the concept of sexual addiction and the growing body of literature that supports that idea. Either way, until a definitive ruling is out, let’s stick to the label that’s clinically useful (especially since it looks like the majority of the existing research supports that paradigm).
Robert Weiss LCSW, CSAT-S is Senior Vice President of Clinical Development with Elements Behavioral Health. A licensed UCLA MSW graduate and personal trainee of Dr. Patrick Carnes, he founded The Sexual Recovery Institute in Los Angeles in 1995. He has developed clinical programs for The Ranch in Nunnelly, Tennessee, Promises Treatment Centers in Malibu, and the aforementioned Sexual Recovery Institute in Los Angeles.He has also provided clinical multi-addiction training and behavioral health program development for the US military and numerous other treatment centers throughout the United States, Europe, and Asia.
Dr. Stefanie Carnes, Ph.D. is a licensed marriage and family therapist and an AAMFT approved supervisor. Her area of expertise includes working with patients and families struggling with multiple addictions such as sexual addiction, eating disorders and chemical dependency. Dr. Carnes is also a certified sex addiction therapist and supervisor, specializing in therapy for couples and families struggling with sexual addiction. Currently, she is the president of the International Institute for Trauma and Addiction Professionals. She is also the author of numerous research articles and publications including her books, Mending a Shattered Heart: A Guide for Partners of Sex Addicts, Facing Addiction: Starting Recovery from Alcohol and Drugs, and Facing Heartbreak: Steps to Recovery for Partners of Sex Addicts.