Cross-posted from The Neuroethics Blog (Emory Center for Ethics)

As Neuroethics Scholars Program Fellows, Cyd Cipolla and I designed an interactive discussion-based undergraduate course “Feminism, Sexuality, and Neuroethics,” which we are currently teaching this semester at Emory. In developing our course, we decided to devote one week to examining neuroscientific research on “sex addiction.” In recent years, neuroscientists have started to use imaging technology to explore the neurobiology of “out of control” sexual behavior (sometimes called sex addiction). In addition, some researchers and mental health professionals have argued that the neurobiology of sex addiction is the same as the neurobiology of drug addiction. However, a number of scholars have critiqued the category of sex addiction, arguing that it is a reflection of our cultural anxieties about high rates of sexual activity (Irvine 1995, Moser 2001). We are fortunate to have an engaged and intellectually diverse group of students and our discussions have proven thought-provoking for us and our students. After our in-class discussions, I was still left wondering whether it is appropriate to view “excessive” sexual interest as an addiction (and, specifically, as a “brain disease” or a “mental illness”) or as a socio-cultural construct dependent on sex-negative cultural values.

Thus, I was very excited by Dr. Steve Hyman’s visit to Emory, as Dr. Hyman is a leader in thinking about the neurobiology of drug addiction and in thinking through the ethical implications of neuroscientific research on drug addiction. During his visit, I took advantage of the opportunity to ask Dr. Hyman to share his thoughts about sex addiction. This blog is a “report back” on both his answer and on my further reflections about whether it is appropriate to use a disease model to understand sex addiction.

The neurobiology of drug addiction: implications for voluntary control of behavior

First, some background on Dr. Hyman’s work on drug addiction: Hyman argues that drugs addiction is better understood as a disease than as a moral failing. According to Hyman, addictive drugs activate dopamine pathways, leading the individual to imbue “reward-associated cues” (e.g. drug paraphernalia) with “motivational salience.” In turn, encountering these salient cues leads the individual to engage in (nearly) automatic drug-seeking behavior. Hyman sees two primary ethical implications of this view of drug addiction: first, it is wrong to see a drug-addicted individual as entirely in control of, and thus entirely morally responsible for, his or her behavior; second, the fact that drug-addicted individuals are not entirely in control of their behavior may lead us to realize that, in general, humans are not nearly as “in control” of their behavior as they often think (Hyman 2007).

I see some tension in Dr. Hyman’s work between embracing a disease model of drug addiction (which suggests that drug-addicted individuals are categorically different from non-drug addicted individuals) and arguing that drug addiction reveals the extent to which we are all on “mental autopilot” most of the time. For me this tension was highlighted when, during an informal lunchtime presentation, Dr. Hyman expressed significant reservations about using a disease model for mental illness. As David Nicholson discusses in his blog post, Dr. Hyman described the diagnostic categories used by psychiatric researchers as “fictive categories,” not “natural kinds.” Hyman went on to argue that complex psychopathologies like autism are not “categorical” disorders (in other words, there is not one group of people that has autism and a separate group of people that does not) and suggested that the definitions of mental disorders are culturally and historically-dependent.

Does sex addiction equal drug addiction?

Some background on sex addiction: Over the years, many different terms have been used to describe “out-of-control” sexual behavior. In the 1980s, the term “sex addiction” was popularized in the U.S. to describe this behavior, but there remains a great deal of controversy in the mental health field over whether sex addiction should be considered a distinct mental disorder and, if so, how it should be defined and labeled (other terms in current usage include hypersexuality, compulsive sexual behavior, and impulsive sexual behavior) (Giugliano 2009; Irvine 1995).

In our class, we read a brain-imaging study about “compulsive sexual behavior” and a case study about the use of naltrexone to treat “sex addiction.” The later article is particularly interesting because the authors draw heavily on Dr. Hyman’s writings to argue that the same neurobiological processes that underlie drug addiction must underlie sex addiction, and therefore it makes sense to treat sex addiction with a drug like naltrexone (naltrexone is an opioid antagonist that is approved for the treatment of opioid and alcohol dependence).

We are fortunate to have an engaged and intellectually diverse group of students and our discussions have proven thought-provoking for us and our students. In class, we discussed the cultural assumptions influencing the scientific research on “sex addiction” and the ethical implications of this research for society. We debated the following questions:

• To what extent does the definition of “sex addiction” reflect our cultural ambivalence about or even distaste for high levels of sexual activity?
• Will an individual seek treatment if he or she is distressed primarily because of our society’s stigmatization of “promiscuity?”
• Will individuals be pressured to seek treatment by partners who have different levels of sexual interest?
• Is a person with a sex addiction morally responsible if he or she puts a partner at risk for contracting a sexually transmitted infection (STI)?
• Is sex addiction defined and/or experienced differently for women than for men?
• Are the neurobiological processes underlying sex addiction the same as the neurobiological processes underlying drug addiction?
• Is it ethically acceptable for doctors to prescribe naltrexone to individuals with a sex addiction based on the theory that sex addiction and drug addiction involve the same neurobiological processes?
• Does conceptualizing “out of control” sexual behavior as an addiction or a brain disease or a mental illness reduce stigma against people with a sex addiction?
• To what extent does our society make access to treatment, legal protection, social support, and respect dependent on taking up a disease label?

Dr. Hyman’s take on the issue

As you can imagine, class discussion about these issues was lively. So, when the opportunity arose, I jumped at the chance to ask Dr. Hyman whether he thought it was appropriate to describe “out of control” sexual behavior as an addiction or to treat sex addiction with naltrexone. He offered what I thought was a thoughtful response to my question, making six main points:

1. On the one hand, behavioral addictions (like sex addiction) do seem to share phenomenological and phenotypic similarities to drug addiction.
2. It may make sense to make treatment and policy decisions about behavioral addictions based on the knowledge that people with these addictions are not fully in control of their behavior.
3. As in the case of drug addiction, our society has the tendency to over-attribute agency and moral responsibility to individuals with behavioral addictions.
4. However, we do not understand the neurobiological mechanisms involved in behavioral addictions; we do not know if they are the same as the mechanisms involved in drug addictions.
5. It is probably premature (he used the word “faddish”) to treat sex addiction with naltrexone without further research.
6. (As in the case of drug addiction?) it is very tempting for afflicted individuals, their families, and health care professionals to call something a disease or an addiction.

So, is sex addiction a “real” (brain) disease?

It’s important to clarify what we mean when we ask whether sex addiction is a “real” disease. If we are asking, are people consciously faking it, then the answer is usually no, although it may be the case that some celebrities or politicians cynically claim to have a sex addiction in order to re-ingratiate themselves with the public after their sexual misdeeds are exposed. Still, in the vast majority of cases, people who consider themselves to be “sex addicts” are genuinely distressed by sexual thoughts, desires, or behaviors that are experienced phenomenologically as “out of control,” and these people may benefit from psychological and/or physiological treatments. In addition, although the neurobiological processes involved in out-of-control sexual behavior may not yet be well-understand, I am certain that neuroscientists will be able to shed light on these processes in the near future.

However, if by “is it real” we are asking whether sex addiction should be conceptualized as a distinct mental illness around which a clear line can be drawn separating sex addiction both from other mental illnesses and from “normal” sexual behavior, the answer is probably no. The placement of any line we draw between sex addiction and “normal” sexual behavior (and between “sex addicted brains” and “normal brains”) will be heavily influenced by historically contingent sociocultural norms about what is a “proper” level of sexual interest. Thus, I believe it would behoove us all to tread carefully in order to avoid reifying sex addiction as a “natural kind.”

So, for me, the real ethical questions are: can we respect the phenomenological and (possibly) neurobiological “validity” of diagnoses like sex addiction while also simultaneously recognizing the extent to which they are sociocultural constructs (in other words, can we see sex addiction as both a real and a fictive category)? Can we develop effective treatments for sex addiction while also working to challenge our society’s stigmatization of promiscuity and obsession with achieving “normalcy”? Can we accord respect to people who consider themselves to be “sex addicts” while simultaneously undermining the pressure our society places on people to take up disease labels?

I look forward to hearing your thoughts!