On the heels of the controversial Myth of Sex Addiction comes a new just released book entitled Sex Addiction: A Critical History by Reay, Attwood and Gooder. My colleague, Dr. David Ley, a therapist and author of several book including Insatiable Wives and the aforementioned The Myth of Sex Addiction had an extra copy laying about and I said I would be happy to receive it in exchange for an honest review of the book. Putting that piece of full disclosure out of the way, I should also mention that this is a version of a fuller review I have written that will appear in an upcoming issue of the Journal of Sex and Marital Therapy, in which I have a standing outlet for book reviews.  On to the review.

For those unfamiliar with the sex addiction debate, this book is as thorough of an introduction and analysis of the key concepts as one could find anywhere. Even for those like myself, who is up on the latest in sex research, reads all the journals and is keyed in to dialogue with all of the thought leaders, there is still a significant amount of new information to be learned. Typically, when reading a new sexological book, I find myself thoroughly reading the first few chapters and then skimming the rest because either I already know most of what is being presented or the rest of the book simply repeats the ideas from the beginning but in a variety of different ways. Not the case here. The book is strong from beginning to end, and is as much a referendum on our culture and media as it is a sexological casebook on a sexual malady that exists without historical precedent.

Just as an aside, this book doesn’t argue against the existence of people who experience their sexual behavior as out of control or who struggle with immense negative consequences due to the results of these behaviors. We all know they exist, and I work successfully with these kinds of individuals regularly. Rather, the debate here is how do we conceptualize these constellations of difficulties. Are they a separate diagnosis, such as hypersexuality, which was just recently denied inclusion into the DSM 5, or are they merely symptomatic of other mental health issues? Indeed, as the authors clearly point out, research indicates that an exceedingly large majority of those who struggle with sexual compulsivity have some other co-morbid mental health diagnosis, such as major depression, generalized anxiety disorder or bipolar disorder.

The book is at its strongest when it surveys the history of sexological thinking on hypersexuality. Indeed, terms such as satyriasis and nymphomania have existed for centuries, but as the authors point out, these terms derived from different contexts than modern-day sex addiction. Pioneering sexologist Wilhelm Stekel, who coined the term paraphilia, for example did focus entire sections of his studies on Don Juanism, but for him, this form of hypersexuality was exceedingly rare and more tied in to a counterphobia of homosexual desire; for Stekel, we were all born bisexual, so a desire to bed numerous women was seen by him as an antidote to escape inborn homosexual impulses. According to him, “… the greater my opportunity to study the ‘woman chaser’ the stronger my conviction becomes that, back of the ceaseless hunt, stands the longing after the male” (p. 21). Not quite the antecedent to modern sex addiction.

As the authors analyze media’s unquestioning acceptance of the sex addiction premise, we are struck by one of the overarching narratives of this book– the intense ambivalence our society experiences around sexuality. On one hand, we have the recent movies such as Shame and I Am a Sex Addict, which luridly portray the negative effects of the condition, while at the same time using sexuality to attract viewers. Even the tell-all memoirs that warn us of this terrible disease read more like pornography than pornographic novels themselves. So, on one hand we get the message that sex is bad, yet we must also act on our sexual impulses in order to consume more of this kind of media content. In a most powerful paradox, it is the media surrounding sex addiction which is most preoccupied with sexuality.

Then we have the dangers of the encroachment of the DSM (psychiatry and the pharmaceutical industry), the attempts of the sex addiction industry to legitimize itself, and the resulting smorgasbord of muddied thinking. Really, no one, not even the sex addiction pioneers such as Patrick Carnes can agree on what is the correct and concise definition of sex addiction. As a result, we have a diagnostic creep in which just about anyone for any reason can be labeled a sex addict for behaviors that are disapproved of by someone. In a more comical turn, the authors describe an absurd case in which a psychotherapist described having “a case of a man who was sex addicted to his wife. It was a problem because it was depersonalising– he turned her into an object rather than treating her as his wife” (p. 114).

This is a must-have book for the library of any scholar interested in the fields of sexology, culture, media studies, the history of psychiatry and mental illness, and sociology. Lay readers will also enjoy it, although some parts do bog down when the authors go through a laundry list of items, such as the variety of sex addiction psychological instruments out there in existence. Although I’m not sure that anyone who is an addictionologist will be swayed, I do think that those who are on the fence will have more context to make an informed opinion and those in the sexological and sex positive camps will have more ammunition for their views.

In the end, the main thesis of the book is neatly summarized by several quotes. The first by researchers Bancroft and Vukadinovic on p. 118, states:

While acknowledging the importance to both the individual and society of patterns of sexual behavior that are out of control and have problematic consequences, we think it likely that such patterns are varied in both their etiological determinants and how they are best treated. For that reason, we consider it to be premature to attempt some overriding definition relevant to clinical management until we have a better understanding of the various patterns and their likely determinants. The concepts of compulsivity and addiction may prove to have explanatory value in some cases, but are not helpful when used as general terms for this class of behavior problem.

Finally, Professor Allen Frances, who worked on prior DSM work groups, weighs in:

The fundamental problem with ‘hypersexuality’ is that it represents a half baked, poorly conceptualized medicalization of the expected variability of sexual behavior. The authors have not thought through how difficult it is to distinguish between ordinary recreational sexual misbehavior (which is very common) and sexual compulsion (which is very rare)… The authors are trying to provide a diagnosis for the small group whose sexual behaviors are compulsive– but their label would quickly expand to provide a psychiatric excuse for the very large group whose misbehaviors are pleasure-driven, recreational, and impulsive. The offloading of personal responsibility in this way has already captured the public and media fancy and would spread like wildfire” (p. 127-128).