Book Review: The Myth of Sex Addiction

I.

David Ley’s The Myth of Sex Addiction is a stupid, wrong book saved only by the fact that the people it’s arguing with are stupider and wronger.

II.

“Sex addiction” is a proposed mental health condition, not recognized by the DSM or the ICD, where a person is addicted to sex in an analogous way to how some people are addicted to drugs. It is one of the “behavioral addictions”, which range from the reasonably evidence-based (gambling addiction) to the entirely made up (work addiction).

To be clear, no one on any side of the “does sex addiction exist?” argument disagrees with the observations that some people make sexual choices that they really shouldn’t, that sometimes they can’t stop even though they want to, or that therapy and medication can be helpful for many people making sexual choices they don’t want to make. The question is whether sex addiction is a useful framing.

It isn’t. The “sex addiction” concept is used to pathologize behavior that sex addictionologists happen to disapprove of. Even if a sexual behavior is genuinely unwated or compulsive, “addiction” isn’t a very useful framing.

The modern notion of sex addiction comes from Patrick Carnes's influential Out Of The Shadows. To Carnes, a behavior is sex addiction if it is SAFE: Secret, Abusive (harmful), used to avoid painful Feelings, and Empty (outside of a loving and committed relationship). The “Empty” criterion is blatantly pathologizing sexual decisions that Carnes happens not to like. But all four criteria are based on Carnes’s personal values and not on any sort of medical science.

The vast majority of people keep some of their sexual practices Secret: for example, they have sexual fantasies they don’t tell their partners about. Having a private sexual life (that fits within your relationship agreements) is not dysfunctional behavior but rather good boundaries. Members of marginalized groups, such as gay people, are particularly likely to keep some of their sexual practices Secret.

Carnes defines Abusive to include not only conventional abusive behavior but also BDSM, which he characterizes as "torture" and as incompatible with a loving relationship. Studies consistently show that BDSM practice has no effect on relationship satisfaction and that people who practice BDSM are, if anything, better-adjusted than people who don’t. Carnes just thinks BDSM is morally wrong, which is fine, but not a good basis for a medical diagnosis.

Many perfectly mentally healthy people sometimes use masturbation and sex to manage their negative Feelings. It’s quite normal to go “I’ve had a bad day, do you want to have sex to cheer me up?” It’s even more normal to masturbate when you’re stressed. Therapists actively recommend doing something fun when you’re in a bad mood. Sex and masturbation are no different from going on a walk, watching a favorite TV show, cooking dinner from scratch, or petting a dog.

The SAFE criterion implies you’re a sex addict if you have a stressful time at work, go to a BDSM party, get tied up and flogged by an acquaintance, and then on Monday morning respond to “what did you do this weekend?” with “oh, nothing” because you don’t want to tell your coworkers about your sex life. You’re a sex addict even if you enjoy it, are happy about doing it, can stop whenever you want, and experience no negative consequences of any sort.

Other proposed definitions are equally questionable. For example, one prominent sex addictionologist proposed that hypersexual disorder should be defined as having, on average, seven or more orgasms a week. Everyone who masturbates to get to sleep now has hypersexual disorder—and indeed, one study showed that 10-17% of the population has hypersexual disorder by this criterion.

There is no consensus among sex addictionologists about which behaviors are pathological. Some everyone agrees are harmful (rape, sexual harassment, nonconsensual voyeurism, affairs). Some are merely sexual behaviors that addictionologists don't like (group sex, anonymous sex, BDSM, sex work). Some are extremely common behaviors that many healthy people do (roleplaying in bed, enjoying the role of the seducer, using porn). The Myth of Sex Addiction has a list of proposed criteria for healthy sex:

• Fewer than seven orgasms a week.

• Sex only when in love.

• Sex only in the context of a monogamous relationship.

• Any alternative relationships or sexuality is suspect.

• Sex should serve the purpose of procreation, or supporting/building a relationship.

• Healthy sex doesn’t involve pain.

• Healthy sex is mutually pleasurable.

• Healthy sex is happy sex—if you’re sad, angry or lonely, it’s probably not a good idea to have sex.

• Masturbation may be normal, but it may involve literally “taking your life into your own hands.”

All these criteria pathologize the behavior of many happy people who would be very surprised to discover they have a sexual problem.

Many sex addictionologists are Christian. For example, the president of the American Association for Sex Addiction Therapy got his masters’ degree at the Southern Baptist Theological Seminary. Some of his books are Christian 12-step workbooks. Although he claims to be secular, I have... questions. Much of the discourse around “sex addiction” seems less like a mental health condition and more like pathologizing people who don’t care to follow Christian sexual ethics.

Even if someone uses a value-neutral definition—perhaps the condition of not being able to stop having sex you don’t approve of having—it’s not helpful to frame unwanted or compulsive sexual behavior as an addiction. The analogy to drug addiction is more misleading than it is helpful.

For example, physiologically, drug addiction generally involves tolerance (needing more and more of the drug to get high) and withdrawal (getting sick when you don’t have the drug in your system).¹ Some people have claimed that sex addiction involves both. But the evidence really isn’t there.

Drug tolerance is an actual biochemical process where your body, regularly exposed to a poison, learns to expel it more efficiently. So-called tolerance for sex doesn't involve, like, liver enzymes. It’s true that many people report that, after they’ve started consuming porn, it takes more intense sexual stimuli for them to get off. But most of the people who report this effect are quite young. If you’re a teenager with very little exposure to sex, you’ll get turned on by anything that seems remotely sexual. If you’re an adult who has a normal amount of sexual experience, it will take longer exposure to more specific things to turn you on.

Even if porn use causes the need for more intense sexual stimuli, it’s unclear that this is bad or different from any other media. As I’ve consumed more horror novels, it takes more and more extreme body horror to squick me out. While I need to bear this in mind when recommending fiction to others, it’s not a sign that I have a horror tolerance analogous to a drug tolerance. It’s normal for people to get jaded about fiction over time. To many people, it’s desirable: I like being able to read a wider variety of horror novels.

As for sex withdrawal: it’s true that if many people try to stop orgasming they’ll be irritable and think about sex a lot. If I don’t get to see my husband for a while, I’ll be irritable and think about my husband a lot. If I’m interrupted in the middle of a fantasy novel, I’ll be irritable and think about the novel a lot. I don’t think my husband and fantasy-novel withdrawal symptoms imply I have a dual husband and fantasy novel addiction that I need to check into rehab for. To the extent that sex is different from husbands or fantasy novels, it’s because there’s an obvious evolutionary reason for people to have strong urges to have orgasms regularly and be grumpy when they don’t.

Some evidence suggests that sex addiction has more to do with people’s moral beliefs around sexuality than with what their behaviors actually are. For example, a meta-analysis showed that the correlation between perceived compulsive use of porn and how much time someone spends using porn is small but real—while the correlation between perceived compulsive use of porn and a person’s moral opposition to using porn is large. One study comparing a religious and a non-religious university even found that students at the religious university used porn less, but reported higher rates of compulsive porn use.

Imagine a man who can whiteknuckle his way through a few weeks or even months without porn, but it’s hard. He’s constantly fighting cravings. He uses Covenant Eyes to send his best friend a list of every website he goes to. He schedules so many social events that he’s never alone and bored for an extended period of time. He doesn’t watch R-rated movies because they’ll turn him on too much. Sometimes all he can think about is porn. And eventually he always finds himself back on porn websites.

…But if he gave up and was like “I’ll just use porn whenever I want,” he wouldn’t escalate in his addiction until he’s masturbating for eight hours a day and watching porn at work and neglecting his family and running off to Las Vegas to pay porn stars for sex. He’ll wind up just jerking off four times a week for maybe twenty minutes at a time and otherwise not think about it much.

I think that something like this is very common. Probably more people than not are like this for masturbation without porn use. Many gay and lesbian people who underwent conversion therapy had this experience. More controversially, I think a number of kinky people, poly people, and people who like casual sex are in the same boat. A surprising number of serial cheaters just become poly and then everything’s fine!

Are people like our example man sex addicts? Well, I don’t know. On one hand, he’s certainly compulsively doing sexual behavior he doesn’t want to do, it’s causing him a lot of distress, and it might make his life worse in other ways (for example, if his partner views porn use as cheating). And I spent hundreds of words complaining about people imposing their sexual values on me, so it would be hypocritical to turn around and say that this man should just think using porn is okay and then everything would be fine.

On the other hand, it seems important that his behavior is not fundamentally out of control. He doesn’t have to worry (as some irresponsible sex addictionologists imply) that it’s going to escalate to adultery, rape, and pedophilia. He just has demanding moral values.

Similarly, I have demanding moral values about not eating eggs. For a long time I ate eggs regularly even though I thought it was wrong. That was a real problem for me that caused me a lot of distress, and I’m glad that my therapist strategized with me about how to avoid eggs instead of telling me I should stop trying to be lacto vegetarian.

But it would have been very unhelpful if my therapist had been like “actually, you’re a food addict. You eat eggs because you have a fundamentally distorted and warped idea of food, which probably stems from childhood trauma. This shows that you’re scared of intimacy and vulnerability and that you have no skills for controlling your emotions other than egg consumption. You must turn your life over to a Higher Power and accept that you are powerless over eggs and make amends to all the chickens you have harmed. If you don’t, your eating will be entirely out of control, and soon you’ll be eating the brains of still-living monkeys and washing it down with the tears of adorable orphaned toddlers.”

There’s a middle ground: accepting that it’s okay for people to have demanding moral standards, and that it doesn’t make you evil or a failure or an addict to sometimes not live up to them.

III.

Some people have uncontroversially problematic sexual behavior: having unprotected sex, spending ten hours a day masturbating or having sex, flashing people. How do we handle these cases outside a sex addiction framework?

First, many sex addicts are mentally ill. One small study suggests that about 70% of sex addicts have a mood disorder, 40% have anxiety, and 40% have a substance use disorder. Problematic sexual behavior might be better understood holistically, as a manifestation of poor coping skills throughout a person’s life, rather than a uniquely sex-related problem.

The depressed person this meme describes doesn’t have separate cases of Porn Addiction, Self-Isolation Addiction, Gaming Addiction, Reddit Addiction, Crying Addiction, and Not Eating Addiction. She has a single problem: she’s miserable, so she reaches for anything that might distract her enough to numb the pain for a while, even though those actions don’t fix her real problems and might make things worse. An approach that focuses on porn use—blocking porn sites from her browser or joining a porn addiction support group—doesn’t address the root problem. It could even be counterproductive: porn may well be a better terrible coping skill than self-isolation, getting high, or not eating.

Other mental illnesses also cause problematic sexual behavior. For example, manic people often impulsively cheat on their partners or have unprotected sex. Borderlines might have dangerous sex or sex that they don’t enjoy, in order to keep their favorite person from leaving or to get attention. But the depressed person, the borderline, and the manic person have different problems with different solutions. The manic person might need mood stabilizers; the depressed person might need cognitive behavioral therapy and SSRIs; the borderline might need to learn to believe that her favorite person won’t suddenly hate her if she turns down sex. Classifying all three as “sex addicts” implies that they should be treated the same way, when they really shouldn’t.

But what if someone’s sexual problems really are just about sex?

In The Erotic Mind, therapist Jack Morin empathetically discusses his treatment of a voyeur, Carlos, who spied on other men while they were changing. Morin explored with Carlos how his shame and internalized homophobia had caused him to be attracted to unattainable, idealized masculine men that he felt inferior to—and to get an erotic thrill from taking revenge on them by upsetting them through his voyeurism. Morin encouraged Carlos to indulge his voyeuristic kinks in a safe, consensual fashion through going to a gay sex club. He also addressed the psychological issues behind Carlos’s behavior, without shaming him for his present sexuality. He and Carlos worked together to help Carlos cultivate an interest—in both fantasy and behavior—in attainable men to whom he was an equal and whom he didn’t resent. Carlos practiced accepting positive sexual attention from men who flirted with him, even if it was uncomfortable and even unerotic. Eventually, Carlos stopped his voyeuristic behavior and formed a romantic relationship with a man he loved.

Admittedly, the approach Morin used with Carlos can’t be used with all people with problematic sexual behavior. Sadly, it’s much easier for queer men to safely and consensually indulge voyeuristic fantasies than for people of any other gender and sexual orientation. But I think the overall principles are helpful for everyone with problematic sexual behavior: a sex-positive approach that considers sexuality—even deviant sexuality—to be fundamentally good; the commitment to find healthy ways to indulge sexual interests; curiosity about what lies behind an interest for a specific person, instead of assuming they’re the same as all other sex addicts; behavioral change strategies that are related to the person’s actual motivation for their behavior. I think a strategy like Morin’s will likely be far more compassionate and effective than, say, Sex Addicts Anonymous’s Twelve Steps.

Finally: not everyone who makes sexual decisions that hurt other people has a mental illness. Very often people cheat on their partners or sexually harass their employees or commit rape because they want to and they think they won’t get caught. While Harvey Weinstein’s defense team called him a sex addict, I think it’s most likely that he liked raping people and was powerful enough that, for a long time, he could do it without experiencing consequences. The use of sex addiction to excuse the behavior of powerful sexual predators is one of the most serious situations that sex addictionologists have to answer for.

IV.

If David Ley had written a book something like what I wrote above, I would have no complaints about him. Unfortunately, he didn’t.