Did addiction politics leave us stranded on a slippery slope?
Ever wonder why the brains of pathological gamblers, food addicts and video-game addicts have been studied, yet no one has studied the brains of porn addicts? We've certainly wondered—especially as one often hears the claim that the absence of studies is "proof" that porn addiction/sex addiction is a myth (even though clients and patients are increasingly complaining of being hooked on both).
Recently, we learned why brain-science research on porn and sex addiction is practically nonexistent.
This fascinating bit of history also revealed the origins of the familiar assertion that sex and porn can never become addictive—and suggests we've lost our way.
In 1992, a political skirmish took place in the field of medicine, which has discouraged deeper understanding of human sexuality. According to David E. Smith MD, past president of the American Society of Addiction Medicine (ASAM), doctors bartered away the recognition of sex addiction as a pathology in order to address a more immediate risk. Smith, by the way, founded the free Haight-Ashbury medical clinic in San Francisco during the Summer of Love (1967). He has worked tirelessly ever since both to educate the medical profession about the plastic brain changes behind addiction and recovery and to treat addicted patients. He is the author of numerous books and journal articles.
According to Smith, here's what happened: Jess Browley and he were the Delegate and Alternate Delegate, respectively, to the American Medical Association's House of Delegates in search of endorsement of a new specialty: addiction medicine. It became clear that the AMA wouldn't agree to approve the new specialty unless sex was excluded from the list of possible addictions. So, they tossed 'sex addiction' under the bus.
This exclusion was not based on science or Smith's own clinical experience—both of which suggested that sexual behaviors indeed have the potential to become addictions under some circumstances. This is hardly surprising, as sexual arousal is the most compelling of all natural rewards and it arises in the brain's reward circuitry (seat of all addiction).
The reason was strategic. Doctors were bent on snuffing out the tobacco manufacturers' spin. Big Tobacco was pulling out all the stops to prolong the illusion that "smoking is not addictive." It claimed that the addiction experts' evidence should be ignored because, "the experts are saying everything's addictive."
Excluding sex demonstrated that doctors weren't saying everything is addictive. Besides, sex addicts were rare, while smokers were everywhere and suffering unnecessarily. Moreover, behavioral addiction brain science hadn't reached today's levels of reliability and conclusiveness.
Carving sexual behaviors out of the addiction field has had perilous repercussions. Nearly two decades after experts extinguished the Smoke Spin, beginning with the tobacco papers published in the Journal of the American Medical Association (1994), we're still in the Dark Ages of understanding sexuality.
The ASAM-AMA deal inadvertently shielded sexual addiction from the inquisitive eyes of the very medical researchers who could have shed the most light on sexual excess: neurobiologists. Why study something which, by medical fiat, does not exist? Therefore, there has been almost no direct investigation into the neurobiology of sexual excess. (In contrast, many studies confirm the existence addiction-related brain changes in other behavioral addicts.)
Instead, medical research has focused almost entirely on hyposexuality (lack of sexual responsiveness). Accordingly, we have sexual enhancement drugs and medically-prescribed vibrators and erotica. Doctors are even testing orgasm-producing implants for women's spines.
Yet if a patient complains of inability to control behavior, porn tastes morphing in unsettling ways, or the need for increasing sexual stimulation—many a therapist will assure him that hypersexuality doesn't exist. This is true even if he self-identifies as an addict. One academic sexologist proudly recounted that he told a guy masturbating to Internet porn for six hours per day that he didn't have an addiction, but rather a procrastination problem. It's theoretically possible, but....
Therapists who courageously point out that hypersexuality can lead to addiction, and attempt to treat clients accordingly, are either dismissed or shamed by their more dogmatic peers. In keeping with this mindset, the authors of the upcoming DSM-5 intend to banish the section on hypersexuality to the appendix.
Such tunnel vision is due, in part, to the historic pact discussed above. A generation of textbooks claims that (1) sexual repression is the prime threat to healthy sexuality, and (2) sexual behaviors cannot cause addiction. Academic training has not yet caught up with the radical changes of highspeed Internet and brain research on behavioral addicts.
For example, we asked a psychology professor and sex researcher what he thought about news of an Italian survey ordered by urologists, which confirmed what we've seen reported in hundreds of forum threads across 25 countries—namely that young, heavy porn users are developing erectile dysfunction, which reverses itself within months of stopping porn use. He scoffed at the possibility of excessive consumption of porn causing desensitization (an addiction-related brain change):
Why are so many silly news stories generated on this topic? Hmm, does it represent excessive concern about something that doesn't exist, like excessive concern about unicorns?
His response is comprehensible. After all, he has probably been drilling into his students for years the unexamined assumption that sexual behaviors, including Internet porn use, can never cause addiction processes in the brain. Since this position is not supported by actual brain science, circular explanations are common: "Internet porn is a masturbation aid...and there can be no such thing as too much masturbation (because sex can never be an addiction)... so there can be no such thing as too much porn use."
Medical doctors recently began to close the knowledge gap. In The Brain That Changes Itself, psychiatrist Norman Doidge explained the brain plasticity principles behind the decreased sexual responsiveness in his heavy porn-using patients (and its reversibility). Yet most doctors who are not neuroscience specialists still hark back to their days of Penthouse use and continue to view Internet porn use as a harmless extension. They seem unaware that today's porn delivers far more addiction-producing neurochemical stimulation to the brain than static porn of the past, that brain scans of Internet addicts are already revealing standard addiction-related brain changes, or that today's kids are using Internet porn extensively while their brains are uniquely plastic. The latter is particularly disturbing given recent research suggesting that starting sex during adolescence can have lasting negative effects on both body and mood well into adulthood.
Also underlying the dismissive attitude of many experts is the assumption that, "Sex can't become an addiction because people will stop when they've had enough orgasm." Experts once assumed that this was true of highly palatable food, too, but we Americans have proved them dead wrong. Human neural satiation mechanisms appear to be set up for the kinds of food and sexual stimuli we evolved with. Today's superstimulating junk food and ever-novel cyber erotica are enticing enough to override natural satiety programming in many of us. Moreover, Internet porn use doesn't require orgasm. Orgasm is a ten-second phenomenon; Internet porn watching often goes on for hours...at work, school, and other places where masturbation isn't an option. Result? As with junk food, we can consume until we numb our responsiveness to normal pleasures—a hallmark of addiction.
Meanwhile, scientific research on other behavioral addictions has marched on unhindered by the compromise that helped hog-tie tobacco lobbyists. Brain scans of the obese, as well as scans of gambling and video-gaming addicts, reveal genuine addiction-related brain changes.
The symptoms that correlate with brain changes in these addictions are the very symptoms that many of today's porn users have in abundance: inability to control use, severe cravings, tolerance (escalation), decreasing sexual responsiveness, concentration problems, depression, unhealthy desire to isolate, anxiety, severe withdrawal symptoms upon quitting, and so forth. Many of them also report that these symptoms reverse themselves within months of quitting Internet porn.
Meanwhile, what happens if a patient can't stop self-destructive sexual behaviors, and seeks professional help? In many cases, the patient is presumed to suffer from some illness other than a sexual addiction. That's right. The healthcare practitioner selects a different primary, or causal, illness—and refers him for counseling, psychotropic drugs, or both.
The assumption that sexual-behavior addiction is strictly a symptom of some other primary illness produces misleading diagnoses for those wrestling with addiction-related brain changes. These include performance anxiety, ADHD, OCD, depression, severe social anxiety, erectile dysfunction, performance anxiety (with one's hand?), and so forth. Worse yet, the addicted patient is not informed that he may be able to reverse his symptoms by enduring withdrawal and changing behavior. Brain plasticity works both ways.
Researchers know from other behavioral addictions that the symptoms on which such other diagnoses rest can often be a function of addiction itself (anhedonia, concentration problems, severe anxiety, etc.). Seizing upon another diagnosis instead of educating the client/patient about addiction is the equivalent telling a patient with a broken leg to take pain pills instead of prescribing immobilization of the leg and use of crutches.
Of course, some patients do actually have these other illnesses and conditions in lieu of, or in addition to, self-destructive sexual behavior. But if they do not, and sexual addiction itself is the prime cause of their woes, the doctor often ignores that fact. S/he has been trained not to consider sexual-behavior addiction as a possible primary illness.
Alas, the assumption that other addictions can be primary, but sexual-behavior addiction cannot, is a biological impossibility. Only by excluding sex from the field of addiction research for decades could we fool ourselves into believing otherwise.
In any case, the presence of other conditions do not make an addiction less of an addiction. An alcoholic with social anxiety still has to deal with alcoholism, and an obese person still has to deal with compulsive eating...and that extra 200 pounds. Both need help changing their behavior to rewire their brains.
A new era for human sexuality
In August of this year (2011) a mighty sea-change began. The omission of sexual behavior as a possible addiction was corrected—not by the AMA, but by ASAM. In the FAQs relating to its recent public announcement, ASAM explains that,
We all have the brain reward circuitry that makes food and sex rewarding. In fact, this is a survival mechanism. In a healthy brain, these rewards have feedback mechanisms for satiety or 'enough.' In someone with addiction, the circuitry becomes dysfunctional such that the message to the individual becomes 'more', which leads to the pathological pursuit of rewards and/or relief through the use of substances and behaviors.
Thanks to advancements in behavioral addiction research, addiction experts and neurobiologists are now confident that sexual-behavior addictions are fundamentally the same as other addictions. It's time to empower healthcare professionals to align with the reality that Internet porn/sex addicts may be suffering from the brain changes seen in other addicts. By bringing textbooks and protocols up to date, we free healthcare providers to steer us more directly toward healthy sexuality, and avert lawsuits brought by misdiagnosed porn addicts.
ASAM's statement is a great leap forward, but there's a lot of catching up to do. Thanks to decades of blinders, researchers still have little idea what the brain chemistry of sexual balance looks like, or why it promotes wellbeing. The meme that excess is both normal and risk-free lingers, despite warning signs for men, women and adolescents.
Signs that the brain is developing addiction-related changes could soon be common knowledge, but as scientists study sex's effects on the brain with more open minds, other interesting insights into human sexuality may come to light. For example, are changes associated with excess, even in milder forms, impairing our ability to enjoy long-term intimate relationships by speeding habituation between partners? What is the effect of regular attachment cues on partners' brains?
Are we missing some important essentials about orgasm itself? For example, there's evidence of hormonal and neurochemical ripples following orgasm, which would be well worth investigating further. Are men's, women's and adolescents' brains different in this regard? Do intercourse and masturbation produce different effects on the brain?
Neuroscience research could conceivably shed a lot more light on questions like these—now that the study of physiology of sexual excess is back in play.
The emperor isn't wearing his thong
The historical ASAM-AMA pact inadvertently fostered an unhealthy meme: "When it comes to sexual behaviors, including Internet porn use, there's no such thing as too much or abnormal because sexual addiction is impossible." It's time to uproot this wishful thinking—without allowing the discussion to be polarized in superficial ways: "sex positive vs. sex negative," "free speech vs. commandment" or "sexual diversity vs. heteronormative." It's not "sex positive" to discourage hard science on sex.
Instead of condemning or defending sexual behavior (promiscuity, porn content, sexual orientation, etc.), let's focus on brain physiology: neurochemicals, receptors, frontal cortex alterations, striatal gray matter volume, and changes in limbic white matter, as has been done in Internet addiction, gambling and food addiction research.
Other countries are already hard at work investigating Internet addiction (which includes porn use in some countries). One group of researchers recently found that 18 percent of university students were hooked. Incidentally, the risk of Internet addiction in men was about three times that of women. They concluded:
A great percentage of youths in the population suffer from the adverse effects of Internet addiction. It is necessary for psychiatrists and psychologists to be aware of the mental problems caused by Internet addiction [such as OCD, anxiety, and depression].
Physiologically speaking, abnormal has nothing to do with the desirability or undesirability of a given behavior. It is strictly a function of brain/body imbalance. Some people can engage in lots of sexual (or other) stimulation with no harmful brain changes. Others cannot, and such behavior causes symptoms they find unsettling or intolerable. It's really that simple.
It's not what we do in the bedroom, in front of our computers, or in the bathhouse that matters. It's how it affects our plastic brains. If someone's brain happens to adapt quickly to intense stimulation, such that she needs more and more stimulation, or she shows other addiction-related symptoms, then the problem behavior is excessive for her. She has choices to make. This is no different from a man who doesn't metabolize carbohydrates well. He must learn the effects of different diets on health.
When it comes to sexual behavior, there is such a thing as too much, and there is such a thing as abnormal. We can't figure it out from any moral code, but our healthcare professionals can help us figure it out using the four Cs that indicate addiction-related brain changes:
- Loss of Control
- Continued use despite adverse Consequences
- Cravings - both psychological/physical
Never has humanity been better poised to understand its capacity for sexual balance and excess. The sexual-freedom genii has escaped the bottle for good. We can take a hard look at the effects of hypersexuality on the brain without fear of prudish reprisals. Let's banish prior assumptions, sexual politics and slogans from sex research, and use all the new tools at our disposal to reveal a more complete understanding of human sexuality—its glories and its weak points.
Greater knowledge will empower those of us who love sex to steer for the results we choose while respecting our individual limitations. The alternative of continuing to underplay the peril of sexual-behavior addiction leaves us at risk for drowning in a sea of pharmaceuticals prescribed for secondary symptoms—while the primary cause of woe worsens, unacknowledged.
Decades ago we didn't understand the science of addiction, but there's no excuse for ignorance of addiction now.—David E. Smith, MD