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Tiger Woods has reportedly sought treatment for sex addiction. Given the tsunami of false reports about him, this rumor is highly suspect. Nevertheless, no one would be surprised if he joined the list of high-profile figures, usually men, who have been labeled sex addicts or actively sought treatment as such, e.g. David Duchovny, Charlie Sheen, Michael Douglas, Eliot Spitzer, Mark Foley and Ted Haggard, to name a few.
Whether applied earnestly or as a PR gloss for bad behavior, sex addiction is an increasingly common diagnosis. In my view, it's a problematic one. It's ambiguous, hard to define, blurry around the edges, and an excuse for not thinking. If a married man has a lot of extramarital sex, is he necessarily a sex addict? If a seemingly straight man frequents restrooms for casual sex, is he an addict? How much pornography does someone have to look at, how many hours spent in chat rooms, hookers hired, to go from "hound dog" to "sex addict?"
Current attempts at diagnosis focus on the extent to which sexual compulsions interfere with a person's good judgment or are pursued despite obvious risks to health, job and family. Anyone who has experienced such compulsions or has treated them knows what I mean -- the husband who spends untold hours cheating on his wife online or with hookers, spends money he doesn't have pursuing his sexual interests, engages in unsafe sex, etc. But how much risk does there have to be? If my lifestyle easily allows me to spend five hours a day surfing Internet porn or cruising for hookers, I may experience little risk but a high level of compulsion. If I feel too guilty to leave a terrible marriage and instead have a series of affairs, am I being compulsive or simply escaping a lonely existence? What about a priest who feels compelled to have sex, thereby risking his entire identity and belief-system; is he a sex addict or did he choose a ridiculously unhealthy lifestyle? Subjective experiences are clearly unreliable: Some people with very strict consciences and conservative backgrounds experience almost any sexual impulse as "out of control," while for others, living in a Fellini film would barely make the forbidden list.
Traditional addictions like those to alcohol or heroin always involve the presence of tolerance and withdrawal; that is, increasing amounts of the substance are required to achieve the same effect, and in its absence the addict suffers an increasingly painful psychophysiological state as the body and brain rebound. But when it comes to sex addiction, physiological tolerance and withdrawal are usually not present, and if they are, they don't govern the addict's life in the same way that, say, opiates do. Sex addicts get anxious when they can't get their "fix" -- they don't go into DTs.
Sexual compulsions are real and they harm the person in their grip as well as others. But they shouldn't be called addictions.
But why should we care, especially when labeling sexual compulsions as addictions can sometimes have clear benefits. By accepting their helplessness to control their behavior, people can take it out of the harsh "good versus bad" arena and into one deserving of treatment. Such treatment is always based on a 12-step model focused exclusively on stopping addictive behavior. It is usually supportive and accepting in its focus on maintaining sexual sobriety "one day at a time." I have several patients who have found such support to be very healing.
The problem is that in our culture once something becomes viewed as an addiction, any real inquiry about its meaning goes out the window. No one cares any more why a man spends so much time on the Internet or spends a ton of money seeking out dominatrices. His focus -- our focus -- naturally shifts to simply stopping his behavior, one day at a time. No one cares why I can't be faithful in a relationship. My problem is my compulsive behavior; my recovery is measured only by the cessation of that behavior. Everything else, like the meaning of my behavior, is either discounted as intellectualized psychobabble or viewed as an elaborate rationalization. When addiction is the problem, its whys and wherefores, its psychological origins and meanings, are superfluous.
Unfortunately, it is precisely because of this bias that the success rates of the 12-step treatment approach to sexual compulsions are so poor. Unlike alcohol, sex is a natural and normal part of human life. So is sexual fantasy. Unlike heroin, sex naturally engages issues of intimacy, power, autonomy, and love. Sexual arousal always has meaning. In fact, sexual excitement of any kind is impossible unless its mental and social context is specifically conducive to it. While the desire for sexual pleasure is natural, the how, where and why are not. Sexual desire actually begins in the mind and travels down. The "problem" of sexual addiction always involves the mind and the social world, never the desire itself.
In fact, by viewing someone's sexual desires as addictions, 12-step approaches can subtly reinforce someone's own pathological view of themselves. People struggling with sexual compulsions are already afraid of their sexuality, viewing it as an alien internal beast. To imply that the addict's sexual fantasies and sources of satisfaction are, like alcohol to the alcoholic, a loaded gun, reinforces this belief, when in fact it's simply another fantasy. The actual psychological reality is that the so-called addicts' desires and fantasies are perfectly understandable attempts to deal with anxiety and depression given the context of their personal histories, their painful and irrational views about themselves and about men and women, and their inability to imagine a healthier way of living. Once they're helped to become aware of these meanings, they actually increase their self-compassion and are freer to exercise self-control.
Let me present just a few clinical examples to illustrate what I mean. One guy I treated used sex as a way to ward off depression. He felt fundamentally disconnected and grim even though he was outwardly successful and gregarious. When he had sex he felt alive and momentarily connected. He was constantly seeking out sexual partners as a desperate escape from painful internal feelings.
Another patient felt chronically responsible for making everyone else happy, particularly women, and most particularly his wife. This sense of responsibility came from his childhood. The only place he felt he could selfishly "take" and be safely indulged was when he hired a woman to have sex. As his external life became burdened more and more with responsibility, he began to compulsively seek out escorts and sexual masseuses.
Another man felt so privately inadequate he couldn't approach "normal" women for fear of being shamed and rejected. He found solace in constantly exciting himself in Internet chat rooms where he could completely control the interaction and felt safe from the danger of rejection.
All of these guys felt driven, often obsessed, and sometimes took risks to fulfill their sexual desires. However, only one of them found a 12-step program even minimally helpful. All of them, however, found enormous benefit from gaining insight into their psyches. Only then could they make choices to restrain their behavior and face the anxieties that seemed to emerge in more "normal" relationships. The first patient was able to gradually risk facing his underlying depression. The second went into couples therapy with his wife where she was able to disconfirm his assumption that he was omnipotently responsible for her welfare, and the third took the risk of experimenting with a very low risk level of online dating. All of these shifts involved an appreciation of the meaning of compulsive sexual desire and behavior and none of them, in my view, would have been initiated if the addiction model were the only one used to approach the problem.
There's such an antipathy today to considering the psychological meaning of behavior that I'm sure my own attempt here will provoke scorn in some quarters where it will be seen as a Freudian cop-out. On the other hand, the "addiction made me do it" approach seems to me a peculiar alternative since it has become clear that confessing to an addiction and entering a 12-step residential treatment program has become the gold standard of rationalization and manipulation for public figures caught with their proverbial pants down.
Everywhere that sex enters the public arena, whether it be in education, gay marriage, Internet sex, or the hypocrisy of self-righteous politicians getting busted for their indiscretions, we see a worrisome refusal or inability to think about psychological meaning, and to instead reduce the conversation to either a morality play or a voyeuristic parade of gossip and speculation. Replacing the psychologically complex and intensely human drama of sexual behavior with two-dimensional labels like addiction is but one example of this trend.
