Guest Blog – Stefanie Carnes PhD, LMFT, CSAT-S

The Question Sex Addiction Critics Don’t Want You to AskOver the years I have developed a tremendous amount of respect for Dr. Stefanie Carnes and her work as both a clinician and a trainer of clinicians. Currently, she serves as President of the International Institute for Trauma and Addiction Professionals and as a National Clinical Consultant for Elements Behavioral Health. She is also the author of numerous well-regarded research articles and several books, including Mending a Shattered Heart: A Guide for Partners of Sex Addicts and Facing Heartbreak: Steps to Recovery for Partners of Sex Addicts.

Recently, Dr. Carnes wrote the following article addressing the mistaken belief (in certain parts of the psychotherapeutic community) that sex addiction is a “made up” diagnosis. This misconception is a prejudice that certified sex addiction therapists have battled for decades. In truth, sex can be every bit as addictive as alcohol and drugs – and a great deal of research backs this assertion up.

Please read what Dr. Carnes has to say, printed below.

* In recent months a small cadre of clinicians has leveled an ongoing criticism against the sex addiction treatment field, mostly arguing that all sex addiction treatment specialists are moralistic, ultra-conservative, narrow-minded therapists who unnecessarily pathologize their clients’ behaviors. Why these critics choose to attack sex addiction treatment clinicians in this way is not clear. Perhaps they find it easier to attack the practitioners treating sexual addiction than to look at and comment upon the growing body of scientific research that both confirms and supports the idea that sex, for some people, can be addictive in the same way that drugs, alcohol, cigarettes, gambling, and other pleasure-inducing substances and behaviors can be addictive.

The simple reality is that neuroscientists all over the globe are studying the actions and brain responses of sex addicts, comparing those reactions and responses to what occurs with other addicts (usually substance abusers). And the results are indisputable: Sex addiction manifests in the brain in much the same way as any other addiction – the only real difference being the substance/behavior of choice.

For instance, Ji-Woo Seok and Jin-Hun Sohn of the Brain Research Institute at Chungnam National University in South Korea recently published sex addiction research that parallels the findings of earlier sex addiction studies – conducted by Dr. Valerie Voon (University of Cambridge, UK) and an array of highly regarded colleagues – on attentional bias and neurological response. Other recent sex addiction research led by Paula Banca (University of Coimbra, Portugal) looks at sex and porn addicts’ preference for novelty.

Taken together, these studies reveal the following:

  • Sex addicts focus a higher-than-normal share of their attention on addiction related cues (i.e., pornography), doing so in the same basic ways and to the same basic degree as other addicts.
  • The brain response of sex addicts exposed to sexual stimuli (i.e., pornography) mirrors the brain response of drug addicts when exposed to drug-related stimuli. For example, the dorsal orbital prefrontal cortex lights up just as it does with substance addicts. Equally important is the fact that this region goes below baseline for neutral stimuli, the same as with substance abusers. In other words, the dorsal orbital prefrontal cortex overreacts to addiction cues and underreacts to neutral cues in all forms of addiction, including sexual addiction.
  • Compulsive porn users crave porn (greater “wanting”) but they do not have higher sexual desire (greater “liking”) than non-addicts. These findings are in complete alignment with our current understanding of substance addictions and other behavioral addictions.
  • Sex addicts have a greater preference for sexual novelty than a control group. Because of this, usage escalates (more of the same activity and/or more intense activity), just as it does with alcoholism, drug addiction, etc. In other words, sex addicts habituate to previous use and seek out “more and different,” just like other addicts. (Think about intravenous drug addicts, for instance, who typically start out with things like marijuana and prescription pills but, in time, end up with a needle in their arm, shooting heroin, methamphetamine, or some other hard drug.)

About their research, Seok and Sohn write: “In particular, these studies have identified the disrupted function of [the dorsal orbital prefrontal cortex] as an impairment in salience attribution, which results in symptoms such as the abnormally increased sensitivity to an addictive cue as in substance and addicted behaviors and decreased interest to normal-rewarding stimuli.”

Voon and her colleagues write: “Our findings of enhanced attentional bias in [sex addicts] suggest possible overlaps with enhanced attentional bias observed in studies of drug cues in disorders of addictions. These findings converge with recent findings of neural reactivity to sexually explicit cues in [sex addicts] in a network similar to that implicated in drug cue reactivity….”

Banca and her colleagues write: “We show experimentally what is [often] observed clinically, that [sexual addiction] is characterized by novelty-seeking, conditioning, and habituation to sexual stimuli….”

Other research, conducted in Berlin by Simone Kühn of the Max Planck Institute and Jürgen Gallinat of the Clinic for Psychiatry and Psychotherapy at Charité University, looked at the effects of porn use on the brain in a slightly different way, with the following findings:

  • Increased porn viewing is directly correlated with a reduction in gray matter in parts of the brain that house the rewards circuitry. Essentially, the brain’s rewards circuitry grows sluggish with compulsive porn use, resulting in a numbed pleasure response – i.e., desensitization.
  • Increased porn use is correlated with decreased functional connectivity between the prefrontal cortex and the rewards circuitry.

About their study, Kühn and Gallinat write: “That could mean that regular consumption of pornography more or less wears out your reward system. … We assume that subjects with a high porn consumption need increasing stimulation to receive the same amount of reward. … Dysfunction of this circuitry has [also] been related to inappropriate behavioral choices, such as drug seeking, regardless of the potential negative outcome.” Essentially, Kühn and Gallinat are discussing the same desensitization of the rewards circuitry (and the escalation response) that we see with substance addictions and other addictive behaviors.

So the question for sex addiction critics – the question that they don’t want anyone to ask – is this: How do you explain these addiction related brain changes? If this is not addiction, what is it?

The simple truth of the matter is that all of the latest high-end research aligns sexual addiction with substance addiction and other behavioral addictions. There just isn’t any credible research pointing to the contrary. Yes, there are fewer studies looking at sexual addiction than we might like. However, the studies that we have align perfectly with the hundreds of studies that we have on substance abuse, compulsive gambling, binge eating, and other behavioral addictions.

There just isn’t an alternative theory that fits as well as the addiction theory. Some have attempted to explain sex addiction as “high sexual desire.” But high sexual desire does not account for the types of neurological changes that we see in compulsively sexual clients. Nevertheless, critics of the sex addiction model choose to attack the clinicians who utilize it by calling them conservative moralizers. In so doing they minimize a very real disorder. Unfortunately, this further stigmatizes and isolates a group of individuals who already feel completely misunderstood and are reluctant to seek treatment.