Author’s Note: This post is part of a larger sequence on addiction, and sampled from an appendix post of mine. For more background on the appendix format I used, read this.
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Image from painting “Autumnal Cannibalism” by Salvador Dali
While working on this other post, one of my favorite bloggers released a quite relevant blog post! Unfortunately, I thought it was not great. Blogger Ozy Brennan of “Thing of Things” wrote a post on sex addiction that was largely, but not entirely a book review. I don’t want to really comment on the book review part, I haven’t read the book and most of Brennan’s points look good to me (I can think of a couple exceptions but they feel nit-picky), but the more conciliatory early sections that basically argue sex addiction isn’t real seem to me to make quite bad points about addiction itself.
Much of the piece looks like it is just alternating between dismissing bad definitions of sex addiction that “sex addictionologists” have given, and showing that “sex addiction” doesn’t fit bad definitions of addiction that Ozy has given. Closer, and more charitable readings of this make it seem more like these are all swipes Ozy is taking at the idea of sex addiction from the edges of it rather than definitions they are actually considering, sort of weakening the concept through a million papercuts. The trouble with these elements is that I think the swipes are all rather lame if you are trying to undermine the idea of “sex addiction” in a stronger sense, rather than merely dispelling myths about it.
Some prominent “sex addictionologists” are traditionalist Christians who think a wide range of sexual behavior is problematic. Crucially to some of Brennan’s other arguments, many use definitions that set thresholds that are too low. Seven orgasms per week is sex addiction? Using orgasms as a way to let off steam after stress at work makes you a sex addict? Not being able to easily cut back from masturbating several times a week makes you a sex addict? The trouble with many of these points is that they are treated as straightforward boxes to check, rather than thresholds set too low. Addictive behaviors do typically only differ by degrees from normal behaviors. Indeed, addiction screening starts with questionnaires that ask you to put your frequency or severity of behavior in degrees (and final diagnosis ranges by degrees as well, from mild to severe. I’ve been diagnosed with “moderate” AUD for instance). “Wait, being unable to cut back from masturbating six times a day, including at times when you need to be elsewhere, or in situations where it is clearly inappropriate, makes you a sex addict? Well…come on, that only differs by degrees from the normal behavior these evangelical wackos are trying to stigmatize.”
I think there is an implicit appeal here to the idea that these “sex addictionologists” have all been highly influential on treatments and writings about sex addiction, and continue to be prevalent in the field, but I don’t consider this a great point against the existence of sex addiction. Addiction has historically been viewed in many narrow ways by people with religious agendas. Even if this is currently true of sex addiction, alcoholism was still a real addiction back when it was more widely misunderstood. I say that Brennan implicitly appeals to this rather than arguing it, because I think this is pretty clear and damning when you try to view the “argument from bad old definitions and hokey institutions” explicitly.
The clearly relevant question to sex addiction is whether, if we used definitions of sex addiction comparable to those that separate other addictions from non-addictive use, we find a sizable pool of people who check these boxes. This is where Brennan’s own bad criteria are employed. I say criteria because, again, I think it is too uncharitable to call them “definitions”. For example they cite withdrawal as an aspect of addiction, which I have already ranted quite a bit against in Appendix C, but to Brennan’s credit, they concede that withdrawal isn’t present in all addictions, and specifically give weed as an example in footnote 1.
I think even this is too little concession, not just because withdrawal can be a relatively small part of addiction proper, even for the addictions that come with it, but also because this is a behavioral addiction. Brennan seems willing to list gambling as a real behavioral addiction in the beginning, and that clearly doesn’t involve physical withdrawal symptoms either. This is just one example, but if we are entertaining the possible existence of a behavioral addiction, which is bound to have different properties from substance addictions, and your one example of a valid behavioral addiction doesn’t involve withdrawal either, then bringing it up is a rather unimpressive point.
Tolerance is one I haven’t even heard cited as part of the definition for addiction, though it at least makes sense why it would be a risk factor. Here I think Brennan mostly makes good points – there is something like tolerance, but only in a fairly mundane sense – though these points mostly have relevance to speculating about sex addiction, not bringing direct evidence against it.
Finally, Brennan points out that much “sex addiction” comes linked with other mental health disorders, and (somewhat more boldly) suggests that the correct treatment for these cases is treatment of the co-occurring disorder, and not the methods most associated with addiction treatment. The first, less bold point, seems to me less than irrelevant. Co-occurring mental health problems are incredibly common in addiction, to the point of being basically assumed in treatment. There are also groups dedicated to them, called “dual diagnosis”, though it is somewhat telling how similar their content often is to other therapist-guided groups. Brennan mentions manic episodes for instance; bipolar is such a common dual diagnosis it was literally the original model for the dual diagnosis program used at my rehab.
It is so common, in fact, that one of many popular overreductionist views on addiction you will hear from many patients and providers is that the person’s real problem isn’t addiction, it’s just the underlying mental health issues the person already has, and addiction is just the symptom. Maybe even a beneficial one! Now you are finally getting treatment because of the addiction! (Speaking of grating religious influences in recovery settings, have I mentioned how irritatingly influential “belief in a just world” thinking is in recovery spaces?) In general, I disagree with how reductionist these approaches can be, but other mental health problems are often a necessary condition to someone becoming an addict, and getting substantial treatment for the other mental health conditions is often a necessary condition for recovery. This is widely recognized and a huge part of addiction treatment.
The reason to still treat addiction as well is that it is an additional problematic factor to someone’s life and mental health. It could be one that is easier to help with quickly than the underlying problems, and an important additional life ruining struggle while it’s around, whatever its causes. It could be that getting rid of the underlying problem isn’t enough on its own to treat it, even if it was enough to cause it to begin with. At the very least there is a lower bar for relapsing into addictions than initiating them, and relapse prevention is a huge part of addiction treatment. It could be that treating the addictive behavior is necessary to treat the underlying problem – if someone started drinking because they were so lonely, but can’t maintain new relationships while they are drinking out of control, then you can’t just say “the loneliness is the underlying problem, and what we really need to treat.”
The bolder part of this section suggests that addiction treatment is not what “sex addicts” really need. A patient named “Carlos” is given as an example of someone whose problem really was mostly sex related, and was treated without conventional addiction treatment. 12 steps is given as an example of a program that would not have helped him much. The anecdote is pretty thin evidence to start, but the 12 steps point is especially thin when you consider than, per footnote 3, Brennan doesn’t seem to much like the 12 steps for addiction in general. It also feels somewhat unfair to ask whether a program primarily geared towards abstinence would be helpful for sex addiction, considering that almost no-one is interested in abstinence from sex as a solution for their problem.
Does this mean 12 steps should butt its head out of things like sex addiction and eating disorders? Well, maybe. Contrary to Brennan’s categorization of 12 steps as a program for addiction, 12 step evangelists have a general bad habit of insisting that the 12 steps are relevant to just about everything, not just all addictions, and that indeed they are just the right life philosophy to adopt. I don’t think we need to give them the benefit of the doubt on either claim. I would be more interested to know whether moderation-based approaches to addiction can have relevance to cases like Carlos (or whether the approach his therapist ultimately suggested even fits in with moderation approaches already).
There are more arguments in this section that cast too wide a net and aren’t unique to sex addiction. At one point they argue that treating “sex addiction” might be counterproductive because sex is a healthier coping mechanism than possible alternatives. Part of me wants to scream at this for pragmatic reasons – we treat alcoholism even though someone might turn to heroin instead! But part of me doesn’t have too much of an opinion on the practical stuff. We don’t say this about alcoholism because treating alcoholism is usually good and doesn’t usually result in heroin addiction. If treating “sex addiction” happens to cause more harm than good on its own, then fine, treat it differently. Not much evidence is given for this, just offhand speculation, but we shouldn’t dismiss the question. A bigger concern might be that, well, even if treating alcoholism generally turned people into heroin addicts, we would still call alcoholism an addiction. We would try to treat it with these complications in mind, and treatments geared towards helping reduce the behavior directly would still be addiction treatment.
At another point, Brennan says that sex addictionologists have a lot to answer for, because now sex criminals can use sex addiction as a defense in court. This is just the standard complaint about the “insanity defense”. Unfortunately we might just live in a complicated world where justice is difficult and minds are both inscrutable and prone to malfunction. For what it’s worth the insanity defense usually doesn’t work anyway.
Despite all of the whinging I’ve done over Brennan’s points, I need to disclaim here at the end that I don’t know if sex addiction is “a thing”. I think the right question for sex addiction is whether people who relate to sex in similar highly excessive and problematic ways to well-studied addictions exist, and whether some of the tools relevant to retaining self-control and motivation that addicts use can be a useful part of many of their treatments. Little that Brennan says directly addresses this question, but instead most of it circles a bunch of outlying semi-related claims, that (at best) imply the disorder is overdiagnosed, misunderstood, and often treated poorly.
In a fairly trivial reading of my point, it is basically certain that sex addiction is “a thing”, because probably at least one person in the world fits my description. That’s not very useful. What is more important is whether this is a common enough phenomenon to, in our heads, graduate it from the class of TLC-relevant disorders to the class of DSM-relevant disorders. To my eyes Brennan cites two[1] studies that might be useful to this question, though they seem more relevant to the reliability of self-diagnosis to me. I can’t cite any studies, it seems possible to me that sex addiction is in fact not “a thing”. I will admit to some motivated thinking in the other direction. I know self-described sex addicts. I am participating in an outpatient program that treats sex addiction (it is not exclusively 12 step based, and since one of its specialties is LGBT individuals, it doesn’t seem to fit Brennan’s stereotypes well). I have been trying to get a meeting with one of the sex addiction specialists there to get a better informed opinion on this matter, but no meeting is materializing.
My sole point here is to take issue with the great majority of Brennan’s arguments, and in the process to hopefully dispel some general misunderstandings about what addiction is and isn’t.
I think this is the study cited, the link is broken. ↩︎