Drug Addiction and Sex Addiction: Are they “real” (brain) diseases?

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). 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!

Want to cite this post?


Gupta, K. (2012). Drug Addiction and Sex Addiction: Are they “real” (brain) diseases? The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2012/04/drug-addiction-and-sex-addiction-are_24.html