Review: Sex Addiction as a Disease: Evidence for Assessment, Diagnosis, and Response to Critics (2015)

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Journal coverCOMMENTS: This is a new review published in the July 2015 issue of "Sexual Addiction & Compulsivity: The Journal of Treatment & Prevention." Although we cannot reproduce the entire paper, below is a table containing criticisms of sex addiction and the authors' responses with citations. Link to Full-text PDF.


The journey of addiction treatment is marked with significant societal, clinical, and scientific advances over the past few decades. Not too long ago, addiction was viewed as a moral failing and those suffering with addiction were treated harshly and with great prejudice and fear. One thing remains evident, significant change is difficult to come by is met with resistance, and it takes the perseverance and vision of a collective force of individuals to bring about the change. Addiction is one disease that has been maligned and misunderstood historically, as it presents in its myriad forms, yet clarity has emerged over the last 50 years to the recognition that it is a primary, chronic disease of brain reward, motivation, memory, and related circuitry, with manifestations along biological, psychological, social, and spiritual domains. The ongoing controversy over the acceptance of problem behaviors related to sex as part of addiction is very similar to the phenomenon which occurred with alcoholism and drug dependencies not that long ago however, when presented with the latest scientific advances the criticisms prove to be unfounded and outdated.


Bonnie Phillipsa*, Raju Hajelab & Donald L. Hilton JR.c

pages 167-192

Published online: 09 Jul 2015

DOI: 10.1080/10720162.2015.1036184


Table 1 Criticisms of Sex Addiction and Responses

Criticisms Response Reference
There is no scientific evidence for sex addiction. Research on addictive behaviors, such as food addiction, gambling addiction, and internet addiction, has continued to reveal that there are many common mechanisms. Sussman, S., Lisha, N., & Griffiths, M. (2011). Prevalence of the addictions: a problem of the majority or the minority? Evaluation & the Health Professions, 34, 3–56.
  Addiction also affects neurotransmission and interactions between cortical and hippocampal circuits and brain reward systems, such that the memory of previous exposures to rewards (such as food, sex, alcohol, and other drugs) leads to a biological and behavioral response to external cues, in turn triggering craving and/or engagement in addictive behaviors. Kelley, A. E., & Berridge, K. C. (2002). The neuroscience of natural rewards: relevance to addictive drugs. The Journal of Neuroscience, 22, 3306–3311.
  Virtually every study on addiction has demonstrated atrophy of multiple areas of the brain, particularly those associated with frontal volitional control and the reward-salience centers. This is true for drug addictions such as to cocaine, methamphetamine, and opioids, and also for behavioral conditions associated with pathological overconsumption of natural rewards and behaviors such as food, sex, and internet addiction. Hilton D. L. (2014). High desire, or “merely” an addiction? A response to Steele et al. Socioaffective Neuroscience and Psychology, 4, 23833.
  In a recent study, those who are addicted to pornography showed similar brain activity as alcoholics or drug addicts. Brain scans revealed that the reward centers in the brain reacted to seeing explicit material in the same way an alcoholics might on seeing a friend consume alcohol. Voon, V., Mole, T. B., Banca, P., Porter, L., Morris, L., Mitchell, S., … Irvine, M. (2014). Neural correlates of sexual cue reactivity in Individuals with and without compulsive sexual behaviours. PloS One, 9, e102419.
  Evidence supporting a broader conceptualization of addiction is emerging. For example, neurobiological research suggests that addictive disorders might not be independent: each outwardly unique addictive disorder might be a destructive expression of the same underlying addictive syndrome. Recent research pertaining to excessive eating, gambling, sexual behaviors, and shopping also suggests that the existing focus on addictive substances does not adequately capture the origin, nature, and processes of addiction. Shaffer, H. J., LaPlante, D. A., LaBrie, R. A., Kidman, R. C., Donato, A. N., & Stanton, M. V. (2004). Toward a syndrome model of addiction: Multiple expressions, common etiology. Harvard Review of Psychiatry, 12, 367–374.
  Attentional bias to sexually explicit cues was assessed, and revealed that those with compulsive sexual behavior as compared to healthy volunteers have enhanced attentional bias to sexually explicit cues. Attentional bias in substance-dependent individuals is the tendency to automatically direct attention to substance-related cues in the environment. This study provides another scientific link between process and chemical addiction. Mechelmans, D. J., Irvine, M., Banca, P., Porter, L., Mitchell, S., Mole, T. B., … Voon, V. (2014). Enhanced attentional bias towards sexually explicit cues in individuals with and without compulsive sexual behaviours. PloS One, 9, e105476.
Most scientists have rejected the concept of sex addiction. Ken Blum in an article in 1996 described a reward deficiency syndrome that included not only alcoholism and drug addiction but also other compulsive behaviors, including gambling, sexual compulsivity, and compulsive overeating. He later described sex addiction as being a pathological form of neuroplasticity which involved a cascade of neurochemical changes primarily in the reward circuitry. Blum, K., Cull, J. G., Braverman, E. R., & Comings, D. E. (1996). Reward deficiency syndrome. American Scientist, 132–145.
  For many years, experts believed that only alcohol and powerful drugs could cause addiction. Neuroimaging technologies and more recent research, however, have shown that certain pleasurable activities, such as gambling, shopping, and sex, can also co-opt the brain. Goldstein, R. Z., & Volkow, N. D. (2011). Dysfunction of the prefrontal cortex in addiction: neuroimaging findings and clinical implications. Nature Reviews Neuroscience, 12, 652–669.25.
    Grant, J. E., Potenza, M. N., Weinstein, A., & Gorelick, D. A. (2010). Introduction to behavioral addictions. The American Journal of Drug and Alcohol Abuse, 36, 233–241.
  Whether in the service of food or heroin, love or gambling, dopamine forms a rut, a line of footprints in the neural flesh. And those footprints harden and become indelible, beating an intractable path to a highly specialized, and limited pot of gold. Lewis, M. (2011). Memoirs of an addicted brain: A neuroscientist examines his former life on drugs., New York, NY: Public Affairs.
    Shaffer, H. J., LaPlante, D. A., LaBrie, R. A., Kidman, R. C., Donato, A. N., & Stanton, M. V. (2004). Toward a syndrome model of addiction: Multiple expressions, common etiology. Harvard Review of Psychiatry, 12, 367–374.
  Dr. Eric Nestler, head of neuroscience research at Mount Sinai Medical Center in New York and one of the most respected addiction scientists in the world, published a paper in the Journal of Nature Neuroscience in 2005 titled, “Is there a common pathway for addiction?” In this paper, he stated that the dopamine reward systems. mediate not only drug addiction, but also “natural addictions” (that is, compulsive consumption of natural rewards) such as pathological overeating, pathological gambling, and sexual addiction. Nestler, E. J. (2005). Is there a common molecular pathway for addiction? Nature Neuroscience, 8, 1445–1449.
There is no unifying definition or diagnostic criteria for sex addiction. Although disagreement remains as to the nomenclature (sexual addiction, hypersexuality), researchers across several perspectives are relatively consistent with regards to the description of related phenomena. As the literature was otherwise congruent, we assert that reasonably accurate measurement of the construct of sexual addiction should be possible apart from any consideration of etiological theories. The high prevalence rates of diagnostic criteria found among treatment-seeking individuals presenting with elevations on the SAST-R suggest that the proposed criteria are highly applicable to individuals presenting for treatment for sex addiction. Carnes, P. J., Hopkins, T. A., & Green, B. A. (2014). Clinical relevance of the proposed sexual addiction diagnostic criteria: Relation to the Sexual Addiction Screening Test-Revised. Journal of Addiction Medicine, 8, 450–461.
  There are surprisingly congruent criteria in the literature when viewed from an atheoretical perspective. In other words, despite what you call it, there is consensus on the behaviors which present issues. Carnes, P. J., Hopkins, T. A., & Green, B. A. (2014). Clinical relevance of the proposed sexual addiction diagnostic criteria: Relation to the Sexual Addiction Screening Test-Revised. Journal of Addiction Medicine, 8, 450–461.
The issue is not sex addiction but rather underlying issues. This argument continues to focus on behaviors rather than the underlying disease processes. Some who focus on personality disorders as the cause of sex addiction are adding to the stigma and marginalization. Leshner, A. I. (1997). Addiction is a brain disease, and it matters. Science, 278, 45–47.
Sex addiction is a lucrative and unregulated industry. The sex industry is a lucrative and unregulated industry with more money being spent in the promotion of pornography and the sex industry for personal gain, in addition to the high cost to individuals and society in general, than what the treatment industry can afford to effectively educate people about healthy sexuality and problems with addiction that involve sex and pornography. Given the evidence that today's internet pornography fuels stereotypes of misogyny and aggression towards women, there is a fascinating schism here in these critics of sex addiction's wholehearted embrace of such material without even a whimper of protest or concern. Bridges, A. J., Wosnitzer, R., Scharrer, E., Sun, C., & Liberman, R. (2010). Aggression and sexual behavior in best-selling pornography videos: A content analysis update. Violence Against Women, 16, 1065–1085. Hilton Jr., D. L., & Watts, C. (2011). Pornography addiction: A neuroscience perspective. Surgical Neurology International, 2.
Calling sex addiction a disease serves as an excuse for bad behavior and takes away personal responsibility. Accepting the disease model of addiction does not take away personal responsibility rather it allows each person to understand the biological, emotional, spiritual, and relational impact of addiction and take appropriate action. It decreases our collective denial of the problem and allows us to advance effective treatment responses. What appears to be bad behavior is actually driven by the brain disease that has a genetic basis and results from dysfunction in brain reward, motivation, memory and related circuitry that is there for the natural rewards, primarily food and sex, as motivators for survival. Understanding the dysfunction that further impacts biological, psychological, social and spiritual domains actually encourages personal responsibility for being more responsible and accountable in recovery. Wilson, W. A., & Kuhn, C. M. (2005). How addiction hijacks our reward system. Cerebrum, 7, 53–66. Kauer, J. A., & Malenka, R. C. (2007). Synaptic plasticity and addiction. Nature Reviews Neuroscience, 8, 844–858.