I have been asked by the SPAA community to provide my reflections on the nature of compulsive, addictive use of sex, pornography, masturbation, and sexual fantasy (henceforward referred to simply as “sex”). As a physician and a psychiatrist who has spent the last two decades treating and researching patients with addiction, I am honored to do so.
Let me begin by rebutting the unfounded claims—often embraced by people with addiction themselves—that people cannot get addicted to sex. I refute these claims on the following grounds.
The patterns of behavior in sex addiction are the same as the patterns in addiction to substances like opioids, cocaine, and alcohol. That is, people start using drugs for pleasure or to solve a problem. If the drug works in the short term, then the individual returns to using it repeatedly. (I use drug to refer to all types of intoxicants, including sex.)
With repeated use over time, tolerance develops, that is, the drug loses efficacy and the individual needs more of the drug and/or more potent forms of the drug to get the same effect. With sex addiction, tolerance may manifest as: more energy and time spent in sexual behaviors; more deviant (culturally tabooed) forms of sex/pornography/fantasy; or riskier use that threatens health, wealth, and relationships.
In addition to tolerance, the individual experiences withdrawal when they cut back or stop using. The universal symptoms of withdrawal from any addictive substance are anxiety, irritability, insomnia, depression, and craving. These states are common in people with sex addiction. In some patients, I have also seen physical symptoms of withdrawal.
For the addicted individual, the disease eventually becomes “unmanageable.” They display the 4 C’s of addiction. Their use is out of control. They use compulsively. They experience craving for their drug. And they suffer significant life consequences yet struggle to stop.
Beyond shared patterns of behavior, all reinforcing drugs (including sex) work on the same reward pathway and involve the same reward neurotransmitter—namely, dopamine. All reinforcing drugs cause a spike in dopamine. With repeated use of any reinforcing drug, the brain adapts to chronically elevated levels of dopamine by decreasing dopamine receptors, thus creating a dopamine-deficit state.
In this deficit state, we need more potent and larger amounts of our drug to compete with the brain’s neuroadaptations and feel pleasure. When we’re not using, we’re experiencing the universal symptoms of withdrawal. We’ve effectively changed our set point for experiencing pleasure and pain. That is, we’re addicted. The addicted brain doesn’t need a reason to keep using. The drive for homeostasis—a balanced setpoint—is sufficient to perpetuate the behaviors.
Sex addiction is a disease caused by the interaction between the brain, the person, and the environment. We are living in a time when the quantity, variety, and potency of highly reinforcing drugs has never been greater. The advent of the Internet, and in particular the smartphone with its 24/7 access to pornography and sex partners, has vastly contributed to the prevalence of sex addiction. Our cultural preoccupation with sex, along with cultural narratives that normalize casual sex and hook-ups, has in turn made it harder to identify sex addiction when it exists.
Further, sex addiction may carry with it an additional layer of shame. Sexual activity occurring outside the partnership is almost always accompanied by a sense of romantic betrayal and the erosion of basic trust. Ironically, sex addiction at its core is not about sex. It’s about maladaptive coping.
Which brings us to what we can do about it.
A growing body of scientific evidence shows that active participation in 12 Step programs gets people into recovery from addiction. I have seen examples in my own clinical practice of people with severe sex addiction getting into recovery with the help of 12 Step programs like SPAA.
Recovery from sex addiction begins with abstinence. SPAA defines abstinence as: “No sex with oneself (masturbation), no sex outside of a committed relationship and no viewing of pornography.”
From a neuroscience perspective, abstinence is necessary to allow enough time for dopamine homeostasis to be restored. Sufficient abstinence is also necessary to see true cause and effect: When we’re chasing dopamine, we lose sight of how our drug use is impacting our lives. Our attention becomes narrowly focused on obtaining and using our drug of choice and we become blind to other information. This is sometimes referred to as the hijacked brain. A period of abstinence restores our ability to make choices based on true information.
I have learned from my patients that they also need to abstain from triggers and cues that lead to their addictive behavior. In SPAA, edging is defined as behaviors that “give us a ‘hit’ of our drug and often lead to the loss of our sobriety.” This is literally true since we know that even reminders of our drug can release dopamine in the brain’s reward pathway. Importantly, the small increase in dopamine triggered by a drug cue is followed by a small dopamine-deficit state. This suggests that by exposing the brain to a mere reminder of the drug, the individual might be plunged into the crippling physiology that drives compulsive use. By abstaining from triggers/edging, including fantasy and euphoric recall, the individual is avoiding the pain of addiction.
Twelve-step programs help keep our attention on recovery in many different ways. They provide emotional support, a sober social network, and a safe harbor in times of distress. The fellowship also functions as a memory repository to compensate for the brain’s inability to remember negative consequences of drug use. That is, we remember the initial pleasure, but not the pain on its heels. The constant cycle of old and new stories in SPAA allows us to tap into our collective memory. By encouraging “rigorous honesty,” the 12 Steps hold members accountable while also providing acceptance and a path to recovery in the face of those behaviors.
Most importantly, 12 Step programs promise and produce a better life, a life in which the individual can experience authentic joy and connection and human flourishing. Members of SPAA had this to say about their journey of recovery in the fellowship: “I felt something change in me, a weight lifting off my shoulders,” “It allowed me to live the life I was intended to live and be happy and joyous,” “It gave me a clear head so I was able to be more present in the moment,” and “Things roll off my back more now, and I’m more resilient.”
It’s not just the giving up, it’s the gaining of something better. That is the promise of recovery.
Anna Lembke, MD
March 20, 2022