The Paradox of Sex Addiction
The paradox of sex addiction is hard to explain, but easy to state: there are people who engage in unwanted or excessive sexual behavior. But there is really no good reason to ever consider this behavior a sex addiction.
I will try to explain what I mean in a moment. However, I can see the pitchforks rising in the distance, and I need to address two important caveats before we go further:
First, I know many wonderful people who find the label "sex addiction” a positive, meaningful description of their experience. I honor their experience, and I am thankful for all that I’ve learned from them. At the same time, I’ve treated far too many completely normal people whose lives have been devastated by the beliefs implicit in “sex addiction” definitions [1]. Their distress and suicidality has been the core motivation for my study of this subject. In my mind, formulating these problems as sex addiction causes far more harm than good, and there may be approaches that can satisfy both camps.
Second, most modern definitions of sex addiction have been explicitly non-paraphilic. This means that atypical sexual desires like pedophilia and frotterism cannot be considered sex addiction. In today’s post, I will honor this tradition by writing only about non-paraphilic sexual activity [2].
My early drafts of this post contained tightly written, highly complex arguments about the meaning of addiction, proposed diagnostic criteria, and the limitations of current definitions. I loved where it was going, but ultimately found it too academic. I decided that those discussions–while possibly interesting to clinicians–distract from the main point I want to make. Instead, I’ve decided to address just a single point. Afterwards, I’ll describe a brief parable that begins to flesh out what I consider a much healthier approach.
The problem of abstinence
Abstinence–the complete cessation of addictive substance use–has traditionally been the core treatment target for most substance use disorders [3]. Durable abstinence completely eliminates the risk of new harms from ongoing substance use. Of course, abstinence is only one of the many potential outcomes that are considered positive in substance use disorder treatment [4]. But for the sake of this post, it is sufficient to point out that complete abstinence from drugs or alcohol is at least a theoretical possibility.
Sex is different. Complete abstinence from sex is rarely consistent with a whole life. We are sexual beings. Sex has physical, emotional, relational, cultural, and spiritual benefits. Our relationship with sex simply cannot be managed through abstinence. And because of that, each of us must learn to moderate our sexual behaviors.
It’s at this point that the objections usually start to fly: “sex addiction isn’t about prohibiting sex, it’s about stopping problematic sex.” Maybe so. But if that is the case, sex addiction criteria must be able to objectively define addiction-related sex in a way that is categorically different from normal sex. I’m not convinced that this is possible.
Most definitions of problematic sex are actually moral boundaries hidden behind medicalized language. For example, during the AIDS epidemic of the 1980s, many gay men were considered addicted to sex. This continues to be the case in Sexaholics Anonymous, where any sex that occurs outside of a heterosexual marriage disrupts that person’s “sobriety.”
Porn is the current target of sex addiction advocates. I will not argue that porn is an unalloyed good–it’s much more complicated than that. There are legitimate reasons to be concerned about consent, normalization of sexual violence, and porn’s place as the de facto source of sex education in the United States. At the same time, data about the impact of porn on individuals, relationships, and society are heavily swayed by preexisting moral beliefs. Concerningly, few people propose that people with “porn addiction” use their imagination when they masturbate–suggesting that porn is also a euphemism for other forms of morally non-preferred sexual behavior [5].
Some have argued that brain imaging studies have proven porn to be addictive. This is a misrepresentation of the data. Porn viewing does engage many of the same reward learning pathways found in substance use disorders. This is not a coincidence. Learning how to identify and interpret sexual stimuli is critical to the survival of our species. Our desire pathways evolved to assist us in obtaining food and sex. That’s what these brain structures are for! So does the brain change in response to repetitive sexual stimulation? Of course, it changes in response to all repetitive inputs. And yes, we can develop abnormal, unhealthy patterns of behavior around sex that correlate with changes to the brain in imaging studies. But this kind of research cannot tell us what it actually means for the person being studied.
Cultural and religious values also play a major role in perceived sex addiction. People from more conservative religious traditions are more likely to describe their sexual activity as an addiction–even if they engage in less sex than the average person. I sometimes call this the “one drink a day problem” of sex addiction. You cannot describe drinking a single, standard glass of wine every day as an alcohol use disorder. It’s simply not possible using our current diagnostic criteria. But this is often the case in people “diagnosed” with sex addiction. Libido and behaviors often fall within the normal range, while shame about sex may be extraordinary. Even the most significant, up-to-date, well-honed, “official” criteria fails when asked a single question. If you agree that “my sexual fantasies, urges, and behavior have often caused significant personal distress in my life,” there is a 72% chance that you qualify for a diagnosis of Compulsive Sexual Behavior Disorder [6]. This is absurd, and is roughly 72% higher than what I have seen in my clinical experience. This question is a marker for moral incongruence–engaging in actions that don’t align with your values–and not a sign of clinical pathology.
Now to be clear, I’m not advocating that you should accept anyone else’s sexual ethic as your own. At the same time, ethical concerns need to be approached with an eye towards flexibility and growth. If you want to avoid porn, that’s great. Abstain from masturbation if you’d like (so long as it’s possible for you and not the result of a misguided belief that it is harmful or evil [7]). By all means, please be faithful to your partner! But if you fail to meet these goals, I’m still not convinced that treating your sexual behavior as an addiction is the right approach.
[This is a critical side note about sexual ethics which is so important that I’m excluding it from my always excessive footnotes. If you are not heterosexual and worry about your sexuality: just be yourself. There is nothing unnatural, evil, or wrong about you. You may be completely out and generally comfortable, or you may be trying to live a life aligned with values that don’t allow for homosexuality. There can be deep conflicts between values and desires, and I would hate to oversimplify this complexity. I will say, however, that as as a man of faith who has a complicated relationship with my own tradition, I am convinced that anti-gay beliefs are not required elements of any religion. No sacred text interprets itself. We read our biases into scripture; supporting elements which align with our views while dismissing commands that don’t. The bible, for example, supports many practices that most modern people consider deeply immoral, while the few passages that reference gay sex can be readily interpreted in ways that allow for moral, same-sex relationships. I believe there are otherwise good people who truly believe they are doing God’s work by preaching against homosexuality. And if there is a God, I hope that God helps them change their minds. Until then, I don’t have a lot of time for the opinions of people who remain married while preaching that others don’t need romantic companionship in their lives. Traditions with celebate clergy don’t count; the scandals speak for themselves.]
In short, effectively defining sex addiction requires us to grapple with some important realities. We are sexual beings who engage in a wide range of largely normal sexual experiences. We evolved to experience sex as an incredibly reinforcing, species-critical behavior. Culture and religion play large roles in how we interpret the meaning of sex. And even if we are able to identify true pathology, it is critical that we don’t cause harm by pathologizing normal human behavior. It is not yet clear how we do this.
An Alternative Approach
What if we developed a different perspective? Instead of trying to control all the possible ways that sex might become maladaptive, we could focus on ways we can better honor our sexuality. Like so many things in life, the way we approach a problem is just as important as our desire to solve it.
A simple parable may help to explain what I mean.
There was a young man who was hired to manage the plumbing in an old apartment building. Each day, he arrived at work and attempted to fix problems as quickly as they arrived. He was prompt and smart; determined to do good work. But it was his first real job, and it was understaffed. The pipes in the basement leaked and occasionally burst. He developed a plan to replace these old pipes, but found himself so pre-occupied by calls to tenant rooms that he was unable to make any meaningful progress. And so he’d return again and again to a basement full of intermittent spills. He beat himself up, day after day for his failures. Every plumber he knew must manage their work with ease. How could he be so terrible at his job?
One day, this young man went hiking and came across a beautiful mountain stream. This water could not be contained. It had a life and beauty all its own. It was not defined by its leaks, but by its power. The flow had majesty that could be respected, but not easily controlled. He sat with it, learned from it, and got his feet wet. He dug small trenches and built dams, but the water always rose until it found a new way down the hill. He made mistakes in caring for it, but found it resilient. He was patient as he learned how the stream worked–not judgmental about his lack of control. He learned to care for it.
This “Parable of the Pipes” is, of course, a gross oversimplification. But there’s a major kernel of truth here. The almost universal insight shared by “sex addicts in recovery” is a recognition that their sexual desires and behaviors do not define them. Before this occurs, they often grasp at every possible way to control their actions with very little traction. It is the act of acceptance that finally leads to freedom. Why not start there instead?
This parable also speaks to a developmental trajectory around sex. It would be absurd to imagine that anyone makes it through puberty with a fully formed, permanent, and complete understanding of their sexual nature that just so happens to align with the values of their culture. This is never the case. Consequently, if we consider sex a dirty, dark part of ourselves that must be scrupulously controlled, we give it far more power than it deserves. But if we teach that sex is something we honor, appreciate, and treat with respect, we eventually learn to develop appropriate values and restraint around our sexual behavior.
Maybe that is too simple. Maybe there is a need for a diagnostic framework to better explain some forms of non-paraphilic, consensual sexual activity. But for now, I’d rather focus my efforts on helping people accept a joyful, accepting path towards healthy sexuality.
Footnotes
[1]: Although formal acceptance of a diagnosis does not make it beyond criticism, it’s still important to note that sex addiction is not an accepted medical diagnosis. The committee in charge of The Diagnostic and Statistical Manual of Mental Disorders (DSM) was exploring the diagnosis of Hypersexual Disorder for DSM-5, but ultimately chose not to include it in the manual (Kafka 2014, What happened to hypersexual disorder?). The World Health Organization’s International Classification of Diseases has adopted an adjacent diagnosis called Compulsive Sexual Behavior Disorder. This definition is much more helpful than others, but I still find it fundamentally broken. For simplicity, I will lump Hypersexual Disorder, Compulsive Sexual Behavior Disorder, and all other major variants with the older term “sex addiction” in this post. This isn’t entirely fair, as I am convinced that the folks behind Compulsive Sexual Behavior Disorder are really trying hard to create a useful construct. But in my view, the core problems are conserved across all diagnostic frameworks.
[2] I’ve described what I perceive to be some of the weaknesses of current definitions of paraphilias in a previous post. But for the purposes of this article, we will consider paraphilias as presently constituted an absolute exclusion criteria for “sex addiction.”
[3] “Addiction” is not a well-defined word, and it is not used in any current medical diagnosis. Instead we have defined “substance use disorders.” I find that terminology much more expansive and useful. But for the sake of simplicity in this post, my arguments against sex addiction would also apply to a “sex use disorder.”
[4] People with opioid use disorder, for example, do much better when treated appropriately with long-term, stable doses of opioids. This effect is so profound that many in my profession consider failure to offer effective treatment of this form a profound moral tragedy. You’ll hear more from me on this subject in the future!
[5] If we can’t establish that masturbation is medically and psychologically normal, then we really can’t have a productive conversation at all. Even if you believe that sex with the person you love is the best kind of sex–and I concur–it’s a hot take to assume that everyone who doesn’t currently have this partner must be either completely celebate or a raging sex addict. There probably is a point where too much private masturbation becomes a problem, but I’ve always found an alternative explanation long before I even needed to consider sex addiction. Neurodevelopmental disorders, severe mental illness, stimulant intoxication, and several other medical disorders have always been better explanations to me than sex addiction. Of course, I haven’t seen every case, but I believe that clearly excessive masturbation without any medical or psychiatric comorbidity is extraordinarily rare. I’m open to considering studies that can better describe this population if they exist, but I haven’t seen them yet.
[6] (Grubbs et al. 2023, Assessing compulsive sexual behavior disorder: The development and international validation of the compulsive sexual behavior disorder diagnostic inventory (CSBD-DI)). I added italics around “personal distress” for emphasis in this post; they are not in the paper.
[7] In the United States, the belief that masturbation is a sin tends to come from Christian traditions (although some sects of Judaism and Islam espouse a similar belief). However, this belief is not found in the Bible or the Quran. Again, you may decide your own values. But it may be worth considering the assumptions required to make sweeping statements about the morality of masturbation.