Monday, Feb. 28, 2011
The Truth about Sex Addiction
By John Cloud / Malibu
A difference between an addict and a recovering addict is that one hides his behavior, while the other can’t stop talking about it. Self-revelation is an important part of recovery, but it can lead to awkward moments when you meet a person who identifies as a sex addict.
For instance, within a half-hour of my first meeting Neil Melinkovich, a 59-year-old life coach, sometime writer and former model who has been in Sex Addicts Anonymous for more than 20 years, he told me about the time in 1987 that he made a quick detour from picking up his girlfriend at the Los Angeles airport so he could purchase a service from a prostitute. Afterward, he noticed what he thought was red lipstick on himself. It turned out to be blood from the woman’s mouth. He washed in a gas-station bathroom, met his girlfriend at the airport and then, in the grip of his insatiability, had unprotected sex with her as soon as they got home — in the same bed he said he had used to entertain three other women in the days before.(See how addiction affects the brain.)
Is this a man with colossally bad judgment or one with a blameless addictive disorder? In the past year, this question has presented itself with dependable regularity. Most famously, Tiger Woods received sex-addiction treatment last winter after he admitted to infidelities; at least a dozen women came forward to claim they’d had sex with him. The chronically undisciplined Charlie Sheen recently sought help in controlling a variety of runaway appetites, including a fondness for the company of porn actresses. Earlier this month, Republican Congressmen Christopher Lee resigned after he was caught e-mailing a shirtless photo of himself to entice a woman he met on Craigslist. And then there is Silvio Berlusconi, the uninhibited Prime Minister of Italy, where prosecutors want him to face trial for accusations that he paid an underage girl to have sex with him. Berlusconi has never hidden his partiality to beautiful women, but he has called the allegations — and reports of louche parties at his villa — politically motivated. All these cases differ in scope, but a central question remains: Why would these men risk everything to satisfy their urges?
When it comes to addiction, the line between morality and disease has always been blurry. But only in the past 25 years have we come to regard excesses in necessary cravings — hunger for food, lust for sex — as possible disease states. In 1983, when Melinkovich was continuously cheating on his then wife (an actress from Planet of the Apes), a Minnesota-based addiction-treatment organization called the Hazelden Foundation published a foundational book called Out of the Shadows: Understanding Sexual Addiction. The book, which is still in publication, helped create the field of sex-addiction treatment. Its author, Patrick Carnes, is now executive director of Gentle Path, the sex-addict program Woods is said to have entered last year in Hattiesburg, Miss. (See a brief history of the Tiger Woods scandal.)
The American Psychiatric Association (APA) is debating whether sex addiction should be added to its Diagnostic and Statistical Manual of Mental Disorders. The addition of what the APA is calling “hypersexual disorder” would legitimize sex addiction in a way that was unthinkable just a few years ago, when Bill Clinton’s philandering was regarded as a moral failing or a joke — but not, in the main, as an illness.
APA recognition of sex addiction would create huge revenue streams in the mental-health business. Some wives who know their husbands are porn enthusiasts would force them into treatment. Some husbands who have serial affairs would start to think of themselves not as rakes but as patients.
This is already happening. In the year since Woods made sex addiction famous, rehab facilities accustomed to dealing with alcoholics and drug addicts have found themselves swamped with requests for sex-addiction treatment. The privately held company Elements Behavioral Health, which operates high-priced rehab centers around the U.S. — including a celebrity-friendly one on a breathtaking mountainside in Malibu, Calif. — recently acquired the Sexual Recovery Institute, a Los Angeles center for sex addicts. The institute’s revenues grew 50% in 2010.
But the legitimacy now being granted to sex addiction requires a closer look. In the 20th century, we changed our thinking about alcoholism: what was once a moral weakness came to be understood as an illness resulting in large part from genetics. Sexual acting out seems different, though. Is excessive lust really just another biochemical accident?
See more about what happens in sex rehab.
When Lust Becomes a Compulsion
It was in the 1960s that the notion of sex addiction entered popular consciousness. Two men — Albert Ellis, one of the most esteemed psychologists of the late 20th century, and Edward Sagarin, a closeted gay sociologist who helped launch the gay-rights movement — wrote a book published in New York in 1964 as Nymphomania: A Study of the Oversexed Woman. The book was titillating and influential. It helped popularize the locution nymphomaniac as a slur against unreserved women, and it inspired a 1975 follow-up by a UCLA psychoanalyst, Dr. Robert Stoller, who introduced the clumsy companion term Don Juanism to describe unbridled male promiscuity.
Today the proposed APA definition of hypersexual disorder says you have an illness if you spend so much time pursuing intercourse or masturbation as to interfere with your job or other important activities. According to the working language of the diagnosis, “repetitively engaging” in sexual behaviors when you are anxious, depressed or stressed would be considered a major warning sign for the disorder.(See how we get addicted.)
But when it comes to sex, what could possibly be too much? The proposed definition of hypersexual disorder draws no distinction between masturbation and intercourse. Many studies, however, have shown that regular intercourse with a committed partner (up to once a day) is a sign of a good relationship. So at what point do partners in a healthy relationship become too focused on sex? And what constitutes too little sex?
In the late 1940s, the sex-research team led by biologist Alfred Kinsey said only 3% of college-age men reported a “total sexual outlet” of seven or more per week. Total sexual outlet was a euphemism for the number of orgasms. Although Kinsey’s data set was famously flawed — he used a largely self-selected sample that included some prison inmates — seven orgasms a week (either alone or with someone) is still considered by many experts to be a threshold for possible disorder. In a November 2009 Archives of Sexual Behavior paper, Dr. Martin Kafka, a Harvard Medical School professor and a prominent member of the APA work group on sex disorders, defined “hypersexual desire” among men as having seven or more orgasms per week for at least six months after age 15. Never mind that by Kafka’s definition, virtually every human male undergoes a period of sex addiction in his life. It’s called high school.
Kafka has also reported that the average man says he has three orgasms per week — but because some men are inclined to overestimate and others to underestimate, we have little idea what the accurate average is. The data on women’s sexual habits are even more meager. (See why men and women kiss differently.)
Because the definition of sex addiction is unclear, it’s impossible to know how many people have it, although professionals sometimes use Kinsey’s data to estimate prevalence at 3% to 10% of the population. That range is too wide to be of much use, but we do know that the arrival of Internet porn in the 1990s led many into unhealthy behaviors and extreme desires that eventually spurred them to seek treatment.
Their misfortune created a challenge for psychologists, who had little idea how to help those who called themselves sex addicts. Over the past half-century, Hazelden, Alcoholics Anonymous and most other anti-substance-abuse organizations have defined recovery as 100% abstinence. But the desire to procreate is powerfully encoded in our DNA. Total abstinence isn’t impossible, but it is usually unrealistic. As Melinkovich, the L.A. sex addict, told me, “When it comes to drinking, you can put the plug back in the jug. But you can’t totally turn off sexual desire.”
No one has figured out how to solve the conundrum of an addiction that must be mitigated but not eradicated. (A good analogy is to those who chronically binge on food and must be taught to eat moderately.) Doctors have one reliable way to stop people from having sex: give them antihormone drugs that result in what is known as “chemical castration.” But because of side effects — for instance, the feminization of men who take them — the drugs are recommended only for recalcitrant sex offenders. Someone who rents too many adult films is surely different from a child molester.
So what can be done for those spending thousands on porn or seeing six prostitutes a week? According to Robert Weiss, who runs the Sexual Recovery Institute, the most seriously affected patients must enter a facility where they have no access to porn or sex workers. They start individual and group therapy that is, ideally, grounded in a cognitive-behavioral model designed to help them find rewarding activities other than sex — and consider the consequences of, say, looking at porn at work. But Weiss admits there is no simple way to teach sex addicts how to have healthy romantic relationships.
See how rehab has the potential to create addiction.
Sex Addicts Anonymous
Our limitations in understanding the nature of sex addiction haven’t prevented practitioners from trying to profit from the surge in demand to cure it. The top inpatient programs — Carnes’ Gentle Path in Mississippi; the resort-like Promises facility in Malibu, Calif. (where Britney Spears and Sheen are reported to have sought addiction help); the swank AToN (Aide to Navigation) facility in La Jolla, Calif., which on a given afternoon might serve grilled halibut by the pool — can run you $2,000 a day or more, with a minimum stay of a week. Fifteen years ago, none of these programs existed.
Free community meetings based on the Alcoholics Anonymous model are also thriving. Melinkovich has not only undergone professional treatment at Promises; he also presides over a regular Los Angeles meeting of Sex Addicts Anonymous (SAA), one of the four major sex-addict 12-step groups in the U.S. (The others are Sexaholics Anonymous, Sex and Love Addicts Anonymous and Sexual Compulsives Anonymous.) Together, these four groups host 5 million to 10 million Americans per year. According to the official who took my call at SAA’s international headquarters in Houston — a man who requested that not even his first name be printed — the organization has grown approximately 10% per year for the past seven years. Founded by a group of men in Minnesota in the late 1970s, SAA now has roughly 1,200 meetings convening around the globe each week. Ninety percent of the meetings are in the U.S., but the SAA official told me there are regular meetings in Argentina, South Africa, the U.K. and other countries. (See the drug that could put an end to drug addiction.)
The SAA meeting that Melinkovich runs assembles in an L.A. church every weekday at noon. On the day I went, 38 people — only two of them women — gathered in a sun-flooded room on the ground floor. Like Alcoholics Anonymous and Cocaine Anonymous, the sex groups operate in a highly structured, almost liturgical fashion. People read aloud from manuals cum bibles — like AA’s Big Book, Sexaholics Anonymous has its White Book — that are filled with harrowing personal stories and vague generalities. (From the White Book: “sexual sobriety includes progressive victory over lust.”) About halfway through each meeting, a donation-collection plate is passed around, just like in church.
At the heart of every sex-addict meeting is the sharing portion, when addicts warring with longings spill stories. The need to share once hidden desires is so strong that those who run meetings designate a timer who asks attendees to stop talking after three or four minutes. One of the first speakers at Melinkovich’s meeting — I’ll call him Daniel — noted that when he started attending five or six years ago, only a half-dozen people regularly showed up. Now, Daniel said, approximately 40 go to each meeting, even on weekdays at noon.
Sex-addict meetings can be extraordinarily awkward. Some attendees barely look up from fingernails digging into cuticles. At one meeting I attended in New York City, I met a man in his late 40s who said he hunches over his laptop and masturbates with such intensity that he once gave himself a hernia for which he had to be hospitalized. Other sex addicts have lost spouses and jobs. (See “Does Suffering from Withdrawal Really Mean You’re Addicted?”)
The Promises facility in Malibu searches the possessions of entering clients (no matter how famous) in order to confiscate any porn. Computer access is tightly restricted. And as though they are boys at a midcentury parochial school, clients are instructed to not masturbate.
Contrarian therapists argue that asking adults to refrain from basic urges like the desire to masturbate goes against evolutionary psychology. “Almost all U.S. treatment programs tell the client to abstain, without consideration of what the client is motivated to do,” writes A. Thomas Horvath, a past director of the addiction bureau of the American Psychological Association and the author of Sex, Drugs, Gambling & Chocolate: A Workbook for Overcoming Addictions. (He is also the medical director of the AToN facility in La Jolla.) Instead, Horvath suggests that clients be given the choice of either abstinence or moderation. “You get the rewards; you pay the consequences; you decide,” he writes.
Unfortunately, science does little to settle this debate, because the brain chemistry of sex addiction is not well understood. Your sexuality — your orientation, your level of desire, what you consider romantic satisfaction (orgasm, love, validation, all of the above) — is a complex amalgam that involves your brain’s hormonal system, its frontal-lobe reward system and its limbic system, which controls mood. Genes regulate these neural pathways, meaning that sexuality is partly heritable, but the environment in which you develop sexually can affect how those genes are expressed.
See “Does Men’s ‘Bond’ with Porn Ruin Them for Real-Life Sex?”
Sex addicts like to compare their habit to substance addiction, but scientists are only beginning to show proof of this connection. In December, scientists at Binghamton University in New York released the results of a study of 181 young adults showing that differences in their DNA were linked to differences in their sexual behavior. Those with a certain variant of the DRD4 gene were more likely to report having had one-night stands and adulterous affairs. The DRD4 gene helps control how much dopamine is released when you have sex. For some, sex seems to provide more of a dopamine high. Also, we know that having sex releases endorphins, which are peptides that activate opiate receptors. Heroin and other drugs activate opiate receptors as well. But no study has proved that sex is tied to opiate receptors, and the DRD4 study hasn’t been replicated.
What’s more, we know that desire is more than testosterone and peptides. When evolution programmed our urge to mate, it used all kinds of tricks to make sure sexual desire would be durable: we want others not just hormonally but emotionally — so deeply that we speak of being “madly” in love. That’s why the current models for treating sex addicts are so poor. As the prominent sex researcher Fred Berlin of Johns Hopkins University pointed out in a 2008 article in the journal Psychiatric Clinics of North America, “the notion that one can successfully choose to indefinitely resist an intense urge is often simply incorrect.” (See a brief history of sex on TV.)
The Future of Treatment
After Melinkovich and I had spent a few hours together in Los Angeles, he started showing me some of the messages that were pinging his BlackBerry. At least three women had called him while we were eating dinner. One of them he kept calling “the 16-year-old” and then correcting himself to say “the 19-year-old.” Once when his phone was ringing, Melinkovich turned the illuminated screen toward me. I saw that he had given the woman who was calling a special name — in honor of her favorite sexual position — which suggested that his treatment to date had not addressed a tendency to reduce women to sex objects.
“It’s true,” he told me later. “If you have this addiction, you objectify women. There’s a lot of skin, a lot of beauty in this town.” He said SAA has a three-second rule: you can check out an attractive person for a maximum of three seconds, “because after that, you start going into fantasy.”
Melinkovich checked himself into Promises five years ago. After a relationship fell apart and he lost a $1,000-a-day job as a sober coach for a wealthy young man with addiction problems, Melinkovich’s libido came roaring back. “It made me realize I was medicating depression with sexual activity,” he told me. “Also, I realized I hadn’t really been in love with that woman — I just had a complete sexual obsession with her.” (See “Texting Leads to Sex Sooner — and Easier Breakups Later.”)
Partly because of its proximity to Hollywood, where so many wealthy men and beautiful women can pursue their unhealthy sexual appetites ad libitum, Promises now has one of the most comprehensive and respected sex-addiction programs in the nation. But when Melinkovich arrived there, he found that he was the only one there for sex addiction and that the unit had little experience in treating sex addicts. That’s not surprising; even today, most addict-treatment centers are still trying to develop standards of care for hypersexual conditions.
And they are still trying to address very basic questions. Should we regard out-of-control sexual behavior as an extreme version of normal sexuality, or is it an illness completely separate from it? That question lies at the heart of the sex-addiction field, but right now it’s unanswerable. When I was with Melinkovich, I sometimes felt he was a normal guy who didn’t quite know how to deal with the many women who find him attractive. Other times, like when he got a lascivious look in his eyes while reading a text from a woman young enough to be his granddaughter, he seemed like a guy with a debilitating illness. “I’m kind of a work in progress,” he told me a few months after we first met. “I’m still trying to define a healthy sexuality that works for me.” The other day, he said, his impulses were so powerfully triggered by the sight of the singer Rihanna at the Grammys that he had to change the channel to a golf program. He is also trying to use his experience with sex addiction to help others. He is working on a sober-coaching site called getneiled.com and he wants to write a book.
It wasn’t clear to me whether these ventures would work out or whether Melinkovich would relapse yet again. For now, he tries to cope with his urges through simple behavioral strategies. When he sees a pretty woman, he tries to look away and then tell himself, “God bless her and her beauty.”
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