Working as a therapist at Del Amo Hospital in Torrance back in the early 1980s, Patrick Carnes had a lot of patients whose sexual behavior reminded him of alcoholism and drug dependency: Though it disrupted or ruined their lives, they just could not control it.
So he came up with a new concept, one that would jolt the staid practice of sex therapy, rock mainstream psychiatry, make Carnes a leader of the burgeoning recovery movement, and splashily enter American slang.
He called it "sex addiction."
Fifteen years after he popularized the term in a self-help book, groups such as Sexaholics Anonymous and Sex Addicts Anonymous steer thousands through 12-step therapy programs. Advice books on sex addiction sell briskly. The National Council on Sexual Addiction/Compulsivity, an 11-year-old information clearinghouse that publishes a professional journal, promotes "acceptance and diagnosis of sexual addiction."
Few ideas have leapt from therapeutic circles into popular thinking so quickly. What therapists and patients appreciated was that it removed the shame and stigma from some behaviors long regarded as willful perversions. Classifying them instead as clinical conditions encouraged more people to admit the problem and seek treatment, therapists say.
It was perhaps inevitable that the phrase caught on, given that a lot of people are fairly hooked on the activity to begin with. But its very catchiness has created something of a public-relations crisis, inspiring more snickers than sympathy.
Ironically, a term invented to convey an agonizing, life-destroying compulsion connotes the opposite to non-experts, who cannot really be blamed for thinking that a sex addict--like a "chocolate addict" or a "Jerry Lewis addict" or "golf addict"--suffers from nothing but a naughty and vaguely comical resistance to common sense.
In addition, some psychiatrists and social scientists say that a self-destructive behavior cannot be "addictive" the way a drug can be, no matter how often the behavior happens and how much havoc it causes. Accordingly, to apply the label of addiction to sex--an instinctual drive, after all--is to invite unending debate over where to draw the line between the pathological and the merely excessive.
Nor have researchers established the basis for sex addiction in body and brain chemistry, as they have done for drug addictions. For that reason, the American Society of Addiction Medicine, a group of health professionals that lobbies Congress on drug-dependence and alcoholism issues, staunchly refuses to recognize any compulsive behavior as an addiction.
The American Medical Assn. and the American Psychiatric Assn. also do not accept the concept of sex addiction as a distinct entity.
Reflecting the controversy, the current, 886-page diagnostic manual of psychiatry does not include an entry on "sex addiction," despite efforts by Carnes and others over the years to get the concept included.
The debate also feeds into a larger cultural soul-searching over personal responsibility. Granted, sometimes the term "sex addict" is just shorthand for people who engage in more sex than is probably good for them. But even then it can seem to exalt or excuse behavior that is "fairly common and probably not pathological," said Stuart Kirk, a UCLA social welfare expert and coauthor of a 1996 book critical of rampant psychiatric diagnoses, "Making Us Crazy."
Whatever it is called, the problem known as sex addiction encompasses more than a dalliance outside marriage.
According to the National Council on Sexual Addiction and Compulsion, some behaviors that "may represent an addictive disorder" are multiple extramarital affairs; using a position of power to gain access to multiple partners; excessive use of prostitutes; indecent telephone calls; excessive time and money spent on pornography, Internet sex, and phone sex; multiple anonymous sexual encounters; touching others without their permission.
Carnes, who is now clinical director at the Meadows, a private recovery center in Wickenberg, Ariz., laces his books with case histories. He tells of a married woman whose many anonymous affairs led her to a stranger who brutally beat her in a motel room; a male therapist who structured his day around masturbating every few hours; and a physician who had unprotected sex with 200 partners in four months despite his knowledge that he carried the AIDS virus.
The key elements of a sex addiction, according to experts, are a lasting preoccupation with engaging in the behavior; loss of control over it; continuation despite adverse consequences; and denial of the problem.
Carnes has defined "sexual addiction" as a "compulsive" behavior that "dominates the addict's life," becoming "more important than family, friends and work."
In a survey of more than 1,000 sex addiction patients, Carnes found that many had another addiction or compulsion, including drug or alcohol dependency (42%), an eating disorder (38%) and compulsive working (28%) or gambling (5%). Also, more than two out of three people that he found to be afflicted with sex addiction had endured emotional, sexual or physical abuse as a child.
Estimates vary widely on the number of people who have a problem with compulsive or addictive sex, from 3% to 10% of the U.S. adult population, depending on the source. But those figures are extrapolations of unscientific surveys of people in recovery programs, researchers say.
Sharon Nathan, a clinical psychologist and epidemiologist specializing in sexual compulsions at the Cornell University Medical Center in New York City, said she was not aware of any "reliable" scientific data on the extent of the problem and the effectiveness of treatments.
In any event, therapists agree that people with the problem are not having fun. For them, "the sex act is more about fantasy and friction than love and intimacy," said Alvin Cooper, a Stanford University psychologist and clinical director of the San Jose Marital and Sexuality Centre.
He speaks informally of his patients' "addiction" but says he prefers the less absolute term "compulsion." In his view, the behavior ultimately reflects what he calls an "intimacy disorder."
Many of his patients are highly successful professionals, he said, "who have very superficial social skills. They don't know how to relate to people on a deep level."
The National Council on Sexual Addiction and Compulsivity concurs, saying in a recent statement that "isolation and superficiality" are hallmarks of the disorder.
Defending its position in the debate, the council, which is based in Marietta, Ga., says that "in many cases of repetitive, problem sexual behaviors, the addiction model readily explains apparently irrational behavior, is easily understood by patients and family members, and leads to effective treatment."
Treatment generally entails counseling a patient to realize the problem and its consequences; group therapy to diminish the shame; enlisting family members to help; and maintaining abstinence or control through support programs like those pioneered for alcoholism. Some therapists also prescribe medications like Prozac, which have been found to ease compulsions in some patients.
Dr. Jennifer Schneider, an internal medicine specialist and sex therapist in Tucson, agreed that the addiction "treatment model has helped thousands of people whose lives were falling apart." In fact, she said, the success of the addiction approach in treating people with sexual compulsion is one of the main arguments for viewing the behavior as an addiction as powerful as the smoker's craving for nicotine.
"Most recovering sex addicts are not interested in what you call their condition," said Jerry B., office manager of the Houston chapter of Sex Addicts Anonymous. "All they know is that it was ruining their lives, they really wanted to stop," and the program helped them succeed "where before they had failed."
He said people in recovery programs tend to stay out of the debate itself, if only because the 10th step in the 12-step program states that the group "has no opinion on outside issues" and should "never be drawn into public controversy."
The addiction dispute is about more than just a word. Social norms, important policies and perhaps even a good deal of money are at stake.
If the nation officially embraced the sex addiction concept, that might cut into funds for treating people with drug dependencies and alcoholism, said James Callahan, executive vice president of the American Society of Addiction Medicine. Scarce resources for treating and researching chemical addictions would suddenly have to cover people seeking treatment for troubles ranging from workaholism to compulsive gambling and shopping.
"It's obvious that there can never be enough health-care funding to take care of everyone's compulsions," he said.
Also, he said, it would diminish the significance of labeling addictive drugs as such. If sex and shopping become potentially addictive, then nicotine no longer seems quite so dangerous. Indeed, the tobacco industry has long argued that because many behaviors are potentially addictive, nicotine is hardly special and, therefore, not subject to government regulation.
"Tobacco companies would like to see behaviors regarded as addictions so the focus would go off the physical properties of nicotine," he said.
The addiction medicine society, the AMA and other professional medical groups do not consider behaviors as potential addictions because there is little data showing how the behaviors affect body and brain chemistry in ways consistent with chemical addictions.
"We know exactly what's going on in the brain when someone ingests a drug like cocaine or heroin or nicotine, how it triggers the craving and compulsion and drug-seeking," Callahan said. "We don't have that kind of evidence for sexual activity."
Schneider criticizes that view as simplistic, pointing out that even chemical addictions involve more than the drug being abused. There are heroin addicts who will inject water into their veins if they're out of the drug, just to simulate the high, she said.
"The drug addict is addicted not so much to a drug itself as to a set of behaviors connected with the drug use, and it is these behaviors that reinforce the drug use," she recently wrote in a defense of the addiction concept.
Still, she conceded that interpretation of addiction may be too radical to convince skeptics.
"It took quite a few years before alcoholism was considered a disease," she said. "In just 15 years you can't expect to persuade thousands of psychiatrists and addiction medicine specialists about this."
The controversy is not entirely polarized. Among those in the middle is Cornell's Nathan, who refers to sex patients as having a "compulsion" or "addiction."
She finds it useful to think of those who might benefit from abstinence and 12-step programs as "addicted," while those who might benefit from medication like Prozac to help control their behavior as "compulsive."
"I'm not doctrinaire about it," she said. "It's useful to think about it either way."