This post is in response to Sex Addiction Is An Excuse For Not Thinking by Michael Bader

There's no shortage of doubt when it comes to Tiger Woods' recent stint at a well-known sex-addiction clinic. When celebrities seek help, it's difficult to know whether the plea is a promotional tool or an honest attempt at self-improvement. Still, trying to base one's mental-health opinions on celebrity mistrust seems too cynical for me.

There are psychological causes to behavior. There are also genetic, environmental, and interaction effects. Michael Bader's post, which focuses on the psychological, seems to suggest that sex-addiction is far more difficult to diagnose than other (specifically alcohol and heroin) addictions.Without getting into whether or not I believe in "sex addiction" being the correct term for an increaslingly common clinical presentation, in my opinion the basis for Dr. Bader's argument is a bit weak.

Here's why: In sex-, like in drug-addiction, no one criteria is enough for a diagnosis. Instead, 3 or more criteria from a list of 7 have to be present within a 12 month period. Addiction diagnosis is always somewhat subjective. Therefore the cheating husband and priest examples would require more information to allow for a diagnosis. I go through the criteria below, analyzing Dr. Bader's take along the way.

  1. Tolerance and Withdrawal - Despite Dr. Bader's assertion, substance dependence does not have to include tolerance or withdrawal. Those are two of the symptoms, so their presence would get you half-way there, but they aren't required. Additionally, tolerance and withdrawal do present in many sex-adddiction cases, though of course, the withdrawal looks nothing like opiate withdrawal. Then again, neither does methamphetamine withdrawal and I doubt anyone's questioning that drug's addictive potential.
  2. The substance is often taken in larger amounts or over a longer period than intended - Regardless of Dr. Bader's objection to it, intention, a subjective criteria, is the standard here. Still, if a sex addict watching porn for 8 hours straight doesn't qualify, I don't know what does. Maybe someone cruising for prostitutes 4-5 times a day taking up to 10 hours to do so...
  3. There is a persistent desire or unsuccessful efforts to cut down or control substance use - The Dr pointed out that some people are okay with cheating, prostitution, and porn marathons. Good for them! But most sex-addicts report a desire, and often unsuccesful efforts, to stop or reduce their behavior. Some go to therapists for years trying to manage their porn addiction or their repeated cheating.
  4. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects - See number 2.
  5. Important social, occupational, or recreational activities are given up or reduced because of substance use - Like the Dr. said, if it interferes with the patient's life, it might be an issue. Some sex-addicts isolate for hours watching porn, others forgoe, or lose, jobs because those would hinder their ability to act-out.
  6. The substance use is continued despite knowledge of having a persistent physical or psychological problem that is likely to have been caused or exacerbated by the substance - Close your eyes on this one. Masturbating for 8 hours will cause injury. Making regular stops at your local red-light district is dangerous for your health (HIV, STDs) and safety (these places are normally not in the ebst aprts of town). All of these qualify here.

As you can see, it's not very difficult to diagnose someone as an addict as long as they display enough symptoms over a long enough period of time. Still, if you try to apply the above to other behaviors, you'll find that most people fall short. Those who don't might just qualify as sex-addicts.

In regards to some other points brought up

The above was a simple clinical break-down of why sex-addiction is diagnosed currently. Still, Dr. Bader's post brought-up some other points I'd like to address:

While it's true that sex-addicts care primarily about stopping the behavior and not the underlying problem, the same is true of crack, heroin, meth, and alcohol dependent patients. Most end-up seeking help for the underlying issues that may have brought on their behavior, which I think is cruicial, but again, not in any way a requirement.

I think that arguing against the notion that the desire plays a role in sex-addiction is difficult when one encounters individuals who abstain from actual physical contact with others (the evolutionarily justified kind of desire) and resort to masturbation, voyeurism, and other, more fringe, sexual activities. Again, the notion that sexual desire is natural isn't the issue, it's the fact that the desire has somehow gone off-track.

While I certainly agree that patients' histories often understandably lead to their sexual acting-out, I fail to see how this is different than one's abnormal compulsion to drink to help with their justified anxiety, or, as the Dr. pointed out, depression. Addictions are complex and often include environmental, biological, and behavioral causes and consequences. The fact that they do doesn't make them an excuse.

The bottom line for me is this: People will use addictions as an excuse in the same way that they use depression, anxiety, or any other difficult to diagnose disorders. It's our job as clinicians and experts to do the best we can to seperate those from the rest. We're never going to do it perfectly, but robbing legitimate patients from an appropriate understanding of their condition won't help anyone.

Some people are addicts and some aren't. Let's not throw the baby out quite yet.

© 2010 Adi Jaffe, All Rights Reserved

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