The Wages of Sexual-Addiction Politics

Did addiction politics leave us stranded on a slippery slope?

Ever wonder why the brains of pathological gamblers, food addicts and video-game addicts have been studied, yet no one has studied the brains of porn addicts? We’ve certainly wondered—especially as one often hears the claim that the absence of studies is “proof” that porn addiction/sex addiction is a myth (even though clients and patients are increasingly complaining of being hooked on both).

Recently, we learned why brain-science research on porn and sex addiction is practically nonexistent. This fascinating bit of history also revealed the origins of the familiar assertion that sex and porn can never become addictive—and suggests we’ve lost our way.

In 1992, a political skirmish took place in the field of medicine, which has discouraged deeper understanding of human sexuality. According to David E. Smith MD, past president of the American Society of Addiction Medicine (ASAM), doctors bartered away the recognition of sex addiction as a pathology in order to address a more immediate risk. Smith, by the way, founded the free Haight-Ashbury medical clinic in San Francisco during the Summer of Love (1967). He has worked tirelessly ever since both to educate the medical profession about the plastic brain changes behind addiction and recovery and to treat addicted patients. He is the author of numerous books and journal articles.

According to Smith, here’s what happened: Jess Browley and he were the Delegate and Alternate Delegate, respectively, to the American Medical Association’s House of Delegates in search of endorsement of a new specialty: addiction medicine. It became clear that the AMA wouldn’t agree to approve the new specialty unless sex was excluded from the list of possible addictions. So, they tossed ‘sex addiction’ under the bus.

This exclusion was not based on science or Smith’s own clinical experience—both of which suggested that sexual behaviors indeed have the potential to become addictions under some circumstances. This is hardly surprising, as sexual arousal is the most compelling of all natural rewards and it arises in the brain’s reward circuitry (seat of all addiction).

The  reason was strategic. Doctors were bent on snuffing out the tobacco manufacturers’ spin. Big Tobacco was pulling out all the stops to prolong the illusion that “smoking is not addictive.” It claimed that the addiction experts’ evidence should be ignored because, “the experts are saying everything’s addictive.”

Excluding sex demonstrated that doctors weren’t saying everything is addictive. Besides, sex addicts were rare, while smokers were everywhere and suffering unnecessarily. Moreover, behavioral addiction brain science hadn’t reached today’s levels of reliability and conclusiveness.

Unforeseen repercussions

Carving sexual behaviors out of the addiction field has had perilous repercussions. Nearly two decades after experts extinguished the Smoke Spin, beginning with the tobacco papers published in the Journal of the American Medical Association (1994), we’re still in the Dark Ages of understanding sexuality.

The ASAM-AMA deal inadvertently shielded sexual addiction from the inquisitive eyes of the very medical researchers who could have shed the most light on sexual excess: neurobiologists. Why study something which, by medical fiat, does not exist? Therefore, there has been almost no direct investigation into the neurobiology of sexual excess. (In contrast, many studies confirm the existence addiction-related brain changes in other behavioral addicts.)

Instead, medical research has focused almost entirely on hyposexuality (lack of sexual responsiveness). Accordingly, we have sexual enhancement drugs and medically-prescribed vibrators and erotica. Doctors are even testing orgasm-producing implants for women’s spines.

Yet if a patient complains of inability to control behavior, porn tastes morphing in unsettling ways, or the need for increasing sexual stimulation—many a therapist will assure him that hypersexuality doesn’t exist. This is true even if he self-identifies as an addict. One academic sexologist proudly recounted that he told a guy masturbating to Internet porn for six hours per day that he didn’t have an addiction, but rather a procrastination problem. It’s theoretically possible, but….

Therapists who courageously point out that hypersexuality can lead to addiction, and attempt to treat clients accordingly, are either dismissed or shamed by their more dogmatic peers. In keeping with this mindset, the authors of the upcoming DSM-5 intend to banish the section on hypersexuality to the appendix.

Such tunnel vision is due, in part, to the historic pact discussed above. A generation of textbooks claims that (1) sexual repression is the prime threat to healthy sexuality, and (2) sexual behaviors cannot cause addiction. Academic training has not yet caught up with the radical changes of highspeed Internet and brain research on behavioral addicts.

For example, we asked a psychology professor and sex researcher what he thought about news of an Italian survey ordered by urologists, which confirmed what we’ve seen reported in hundreds of forum threads across 25 countries—namely that young, heavy porn users are developing erectile dysfunction, which reverses itself within months of stopping porn use. He scoffed at the possibility of excessive consumption of porn causing desensitization (an addiction-related brain change):

Why are so many silly news stories generated on this topic?  Hmm, does it represent excessive concern about something that doesn’t exist, like excessive concern about unicorns?

His response is comprehensible. After all, he has probably been drilling into his students for years the unexamined assumption that sexual behaviors, including Internet porn use, can never cause addiction processes in the brain. Since this position is not supported by actual brain science, circular explanations are common: “Internet porn is a masturbation aid…and there can be no such thing as too much masturbation (because sex can never be an addiction)… so there can be no such thing as too much porn use.”

Medical doctors recently began to close the knowledge gap. In The Brain That Changes Itself, psychiatrist Norman Doidge explained the brain plasticity principles behind the decreased sexual responsiveness in his heavy porn-using patients (and its reversibility). Yet most doctors who are not neuroscience specialists still hark back to their days of Penthouse use and continue to view Internet porn use as a harmless extension. They seem unaware that today’s porn delivers far more addiction-producing neurochemical stimulation to the brain than static porn of the past, that brain scans of Internet addicts are already revealing standard addiction-related brain changes, or that today’s kids are using Internet porn extensively while their brains are uniquely plastic. The latter is particularly disturbing given recent research suggesting that starting sex during adolescence can have lasting negative effects on both body and mood well into adulthood.

Also underlying the dismissive attitude of many experts is the assumption that, “Sex can’t become an addiction because people will stop when they’ve had enough orgasm.” Experts once assumed that this was true of highly palatable food, too, but we Americans have proved them dead wrong. Human neural satiation mechanisms appear to be set up for the kinds of food and sexual stimuli we evolved with. Today’s superstimulating junk food and ever-novel cyber erotica are enticing enough to override natural satiety programming in many of us. Moreover, Internet porn use doesn’t require orgasm. Orgasm is a ten-second phenomenon; Internet porn watching often goes on for hours…at work, school, and other places where masturbation isn’t an option. Result? As with junk food, we can consume until we numb our responsiveness to normal pleasures—a hallmark of addiction.

Diagnostic dissonance

Meanwhile, scientific research on other behavioral addictions has marched on unhindered by the compromise that helped hog-tie tobacco lobbyists. Brain scans of the obese, as well as scans of gambling and video-gaming addicts, reveal genuine addiction-related brain changes.

The symptoms that correlate with brain changes in these addictions are the very symptoms that many of today’s porn users have in abundance: inability to control use, severe cravings, tolerance (escalation), decreasing sexual responsiveness, concentration problems, depression, unhealthy desire to isolate, anxiety, severe withdrawal symptoms upon quitting, and so forth. Many of them also report that these symptoms reverse themselves within months of quitting Internet porn.

Meanwhile, what happens if a patient can’t stop self-destructive sexual behaviors, and seeks professional help? In many cases, the patient is presumed to suffer from some illness other than a sexual addiction. That’s right. The healthcare practitioner selects a different primary, or causal, illness—and refers him for counseling, psychotropic drugs, or both.

The assumption that sexual-behavior addiction is strictly a symptom of some other primary illness produces misleading diagnoses for those wrestling with addiction-related brain changes. These include performance anxiety, ADHD, OCD, depression, severe social anxiety, erectile dysfunction, performance anxiety (with one’s hand?), and so forth. Worse yet, the addicted patient is not informed that he may be able to reverse his symptoms by enduring withdrawal and changing behavior. Brain plasticity works both ways.

Researchers know from other behavioral addictions that the symptoms on which such other diagnoses rest can often be a function of addiction itself (anhedonia, concentration problems, severe anxiety, etc.). Seizing upon another diagnosis instead of educating the client/patient about addiction is the equivalent telling a patient with a broken leg to take pain pills instead of prescribing immobilization of the leg and use of crutches.

Of course, some patients do actually have these other illnesses and conditions in lieu of, or in addition to, self-destructive sexual behavior. But if they do not, and sexual addiction itself is the prime cause of their woes, the doctor often ignores that fact. S/he has been trained not to consider sexual-behavior addiction as a possible primary illness.

Alas, the assumption that other addictions can be primary, but sexual-behavior addiction cannot, is a biological impossibility. Only by excluding sex from the field of addiction research for decades could we fool ourselves into believing otherwise.

In any case, the presence of other conditions do not make an addiction less of an addiction. An alcoholic with social anxiety still has to deal with alcoholism, and an obese person still has to deal with compulsive eating…and that extra 200 pounds. Both need help changing their behavior to rewire their brains.

A new era for human sexuality

In August of this year (2011) a mighty sea-change began. The omission of sexual behavior as a possible addiction was corrected—not by the AMA, but by ASAM. In the FAQs relating to its recent public announcement, ASAM explains that,

We all have the brain reward circuitry that makes food and sex rewarding. In fact, this is a survival mechanism. In a healthy brain, these rewards have feedback mechanisms for satiety or ‘enough.’ In someone with addiction, the circuitry becomes dysfunctional such that the message to the individual becomes ‘more’, which leads to the pathological pursuit of rewards and/or relief through the use of substances and behaviors.

Thanks to advancements in behavioral addiction research, addiction experts and neurobiologists are now confident that sexual-behavior addictions are fundamentally the same as other addictions. It’s time to empower healthcare professionals to align with the reality that Internet porn/sex addicts may be suffering from the brain changes seen in other addicts. By bringing textbooks and protocols up to date, we free healthcare providers to steer us more directly toward healthy sexuality, and avert lawsuits brought by misdiagnosed porn addicts.

RethinkASAM’s statement is a great leap forward, but there’s a lot of catching up to do. Thanks to decades of blinders, researchers still have little idea what the brain chemistry of sexual balance looks like, or why it promotes wellbeing. The meme that excess is both normal and risk-free lingers, despite warning signs for men, women and adolescents.

Signs that the brain is developing addiction-related changes could soon be common knowledge, but as scientists study sex’s effects on the brain with more open minds, other interesting insights into human sexuality may come to light. For example, are changes associated with excess, even in milder forms, impairing our ability to enjoy long-term intimate relationships by speeding habituation between partners? What is the effect of regular attachment cues on partners’ brains?

Are we missing some important essentials about orgasm itself? For example, there’s evidence of hormonal and neurochemical ripples following orgasm, which would be well worth investigating further. Are men’s, women’s and adolescents‘ brains different in this regard? Do intercourse and masturbation produce different effects on the brain?

Neuroscience research could conceivably shed a lot more light on questions like these—now that the study of physiology of sexual excess is back in play.

The emperor isn’t wearing his thong

The historical ASAM-AMA pact inadvertently fostered an unhealthy meme:  “When it comes to sexual behaviors, including Internet porn use, there’s no such thing as too much or abnormal because sexual addiction is impossible.” It’s time to uproot this wishful thinking—without allowing the discussion to be polarized in superficial ways: “sex positive vs. sex negative,” “free speech vs. commandment” or “sexual diversity vs. heteronormative.” It’s not “sex positive” to discourage hard science on sex.

Instead of condemning or defending sexual behavior (promiscuity, porn content, sexual orientation, etc.), let’s focus on brain physiology: neurochemicals, receptors, frontal cortex alterations, striatal gray matter volume, and changes in limbic white matter, as has been done in Internet addiction, gambling and food addiction research.

Other countries are already hard at work investigating Internet addiction (which includes porn use in some countries). One group of researchers recently found that 18 percent of university students were hooked. Incidentally, the risk of Internet addiction in men was about three times that of women. They concluded:

A great percentage of youths in the population suffer from the adverse effects of Internet addiction. It is necessary for psychiatrists and psychologists to be aware of the mental problems caused by Internet addiction [such as OCD, anxiety, and depression].

Physiologically speaking, abnormal has nothing to do with the desirability or undesirability of a given behavior. It is strictly a function of brain/body imbalance. Some people can engage in lots of sexual (or other) stimulation with no harmful brain changes. Others cannot, and such behavior causes symptoms they find unsettling or intolerable. It’s really that simple.

It’s not what we do in the bedroom, in front of our computers, or in the bathhouse that matters. It’s how it affects our plastic brains. If someone’s brain happens to adapt quickly to intense stimulation, such that she needs more and more stimulation, or she shows other addiction-related symptoms, then the problem behavior is excessive for her. She has choices to make. This is no different from a man who doesn’t metabolize carbohydrates well. He must learn the effects of different diets on health.

When it comes to sexual behavior, there is such a thing as too much, and there is such a thing as abnormal. We can’t figure it out from any moral code, but our healthcare professionals can help us figure it out using the four Cs that indicate addiction-related brain changes:

  1. Loss of Control
  2. Compulsion
  3. Continued use despite adverse Consequences
  4. Cravings  – both psychological/physical

Never has humanity been better poised to understand its capacity for sexual balance and excess. The sexual-freedom genii has escaped the bottle for good. We can take a hard look at the effects of hypersexuality on the brain without fear of prudish reprisals. Let’s banish prior assumptions, sexual politics and slogans from sex research, and use all the new tools at our disposal to reveal a more complete understanding of human sexuality—its glories and its weak points.

Greater knowledge will empower those of us who love sex to steer for the results we choose while respecting our individual limitations. The alternative of continuing to underplay the peril of sexual-behavior addiction leaves us at risk for drowning in a sea of pharmaceuticals prescribed for secondary symptoms—while the primary cause of woe worsens, unacknowledged.

Decades ago we didn’t understand the science of addiction, but there’s no excuse for ignorance of addiction now.—David E. Smith, MD

Are You Hooked on Porn? Ask ASAM

AddictionLast month, 3000 doctors of the American Society for Addiction Medicine released a public statement bringing the definition of addiction into line with decades of addiction research. “[Addiction] is about brains…. It’s about underlying neurology, not outward actions,” explains ASAM’s Dr. Michael Miller.

ASAM’s definition captures the key elements of addiction described by NIDA head Nora Volkow, MD and her team in the review Addiction: Decreased Reward Sensitivity and Increased Expectation Sensitivity Conspire to Overwhelm the Brain’s Control Circuit Addiction behaviors are the consequence of measurable brain changes—and recovery entails reversing these changes. The telltale changes center around the reward circuitry of the brain: a numbed pleasure response, extreme sensitivity to addiction-related cues, and decrease in frontal-cortex function.

ASAM also affirms that sexual behaviors can be addictive:

We all have the brain reward circuitry that makes food and sex rewarding. In fact, this is a survival mechanism. In a healthy brain, these rewards have feedback mechanisms for satiety or ‘enough.’ In someone with addiction, the circuitry becomes dysfunctional such that the message to the individual becomes ‘more’, which leads to the pathological pursuit of rewards and/or relief through the use of substances and behaviors.

If you view porn, are you an addict or merely a user?

This question used to be a silly one for most porn users. Prior to the Internet, porn use (if any) bore some relation to authentic libido. When one had had enough, the magazine went back under the mattress. Internet porn, however, has the power to override natural satiety mechanisms in many brains. This increases the risk of the addiction-related brain changes ASAM addressed.

With respect to porn, it’s not time spent viewing or what you’re looking at that determines whether your brain has changed. Instead, watch for these signs:

  • Inability to abstain;
  • Impaired impulse control;
  • Cravings;
  • Diminished grasp of one’s problems; and
  • Problematic emotional responses. (Detailed ASAM list)

Curious how these telltale symptoms might show up in today’s porn users? We’ve culled the following questions from actual reports of self-identified porn addicts. Many users do not make the connection between their symptoms and their porn use until they abstain from porn for weeks, but these questions, and the remarks below them, may help you determine whether you need to seek help to reverse unwanted changes and restore your brain to balance.

  • Have you tried to stop using porn and failed? Did you notice withdrawal symptoms?
  • Do you experience intense cravings when you have no access to porn for several days?
  • When you use again do you notice rapid escalation to more extreme material?
  • Have you noticed changes in your sexual tastes?
    • Have you explored new types of porn in order to attain earlier levels of excitement?
    • Are you viewing things that never turned you on?
    • Are you using porn that does not match your sexual orientation?
  • Is porn viewing the most exciting thing in your life? Does life seem dull otherwise?
  • Do you feel powerless to stop yourself from using porn if you see or experience something you associate with porn use, such as:
    • being alone in the house,
    • seeing a TV show with your favorite fetish hinted at or portrayed,
    • seeing news about a favorite porn star?
  • Do you see potential mates differently—more as body parts than as people?
  • Since using Internet porn, do you feel more tongue-tied, unsafe, awkward or anxious around other people—especially potential mates?
  • Is it harder to connect with others? Do you feel lonelier? Are you more worried about what others think about you?
  • Have you (or those who care about you) noticed you:
    • procrastinate more than before using, have lower motivation (don’t care), chronic fatigue, brain-fog, or difficulty concentrating or remembering things?
    • have become more anxious, restless, impulsive, stressed, irritable, unhappy, pessimistic, emotionally numb, or depressed?
    • have become more secretive, or isolate more?
  • Have you noticed declines in your sexual function during sex: more rapid ejaculation (PE), inability to maintain an erection without self-stimulation, porn or porn fantasy (even if you can get rock-hard to porn), delayed ejaculation (or inability to orgasm), less satisfying orgasm, need the lights on during sex to get aroused, not turned on by attractive partner, no desire for sex?
  • Have you noticed declines in your sexual function during masturbation: unable to masturbate without porn or porn fantasy, need for more vigorous masturbation (“death grip,” faster strokes), weaker (or rapidly fading) erections, climaxing with a semi-erection, more frequent urination?
  • Since using Internet porn, do you feel like you’ve lost your “mojo,” or sex appeal? Do you doubt your attractiveness or feel more anxious about the dimensions/appearance of your genitals?
  • Does your voice feel more nervous, shallow, tight, or unnaturally high? Shallow breathing?
  • Have you masturbated to the point of abrasions or other physical damage?
  • Can you fall asleep without using porn? Do you have more trouble sleeping soundly through the night?
  • When under stress do you use more porn?
  • Do you have intrusive porn flashbacks?
  • Are you risking your job, education or relationship to watch porn, or spending too much money on it?
  • Have you lost a relationship or job, or dropped out of school due to your porn use (or symptoms related to it)?
  • After climaxing, do you notice more intense mood swings (irritability, depression, anxiety)?

These users have noticed symptoms that may indicate brain changes:

Juan: I’m 23. My family told me on numerous occasions I was a shell of myself compared to when I was 18 (in a loving way). My friends weren’t as direct with me, but it was clear. I wasn’t close to the same person. In only a few years of heavy porn use, I developed debilitating social anxiety, depression, lack of drive, physical exhaustion, mental exhaustion, couldn’t hold a job, couldn’t even walk down the university halls without feeling scared to death of people, felt creepy around females from young to old etc.

Greg: Every relapse to transsexual porn was my last one. (I’m straight.) Why was this material suddenly so enticing, in such a short time period? I was masturbating to material that disgusted me before, and would still disgust me after I orgasmed.

Ryan: I am afraid of binging if I use porn. I know from my recent experience that if I masturbate while watching porn, I do it continuously for days.

Davy: I had no concept that I was suffering from porn withdrawal. I had simply given up porn, as was my custom when dating a new girl. Apparently, I had never before reached this level of addiction. 90% of these symptoms were things I have NEVER experienced in my life. ALL of them have either been alleviated, or are significantly improved, by this point (13 days no porn/masturbation/orgasm).

  • Anxiety, chest tightness, panic attacks, high heart rate and blood pressure
  • Feelings of impending doom. Depression to the point of suicidal thoughts
  • Chronic Fatigue symptoms
  • Inability to take pleasure in anything whatsoever: eating, reading, watching a movie, playing music or creating artwork (I am a musician and an artist.)
  • Strange enjoyment of physical pain
  • Severe insomnia: total of about 18 hours of sleep over the course of three weeks
  • Increased urge to masturbate—up to 10 times in a day
  • Sexual fatigue, loss of libido, loss of interest in life, testicular and groin pain, but still a strong urge to masturbate (figure that one out)
  • ADD
  • Incoherent speech
  • Digestive problems
  • Headaches

Adrian: I never really knew how bad I was addicted until I tried to quit. I realize I can only get aroused with porn.

Tyrone: I have felt so emotionally numb for years now that I really feel like I have lost who I am. I don’t know what I feel about things. Nothing makes me happy/sad.

Ben: Had no idea I was addicted, which is funny considering I would spend hours a day in front of the computer watching increasingly novel video after video. If my Internet was running slowly and I couldn’t watch, I would go into rages and fits. I could do nothing else but wait until the video started again.

Tim: For about a month after giving up porn, I really couldn’t get hard enough to masturbate, and when I “forced” it my orgasms were pretty unsatisfying.

Will: I go all night until I’m exhausted, and then I go some more. I feel so tired the next day it’s unbelievable. I feel physically sick with body aches, a sore throat, red eyes, etc. It is very hard to focus on work. I stare at the computer screen, and forget what I am doing. Social anxiety is high after a relapse. I don’t want to be around anyone, and get irritated very easily. My body is extremely exhausted after a binge, but it is hard to fall asleep because my mind is worked up with anxiety. It’s like I’m only half there, just a shell of the man I could be. My voice is higher pitched, and sounds somewhat frail. I don’t even like looking in the mirror. Last time, there were a couple of girls interested in hanging out with me, but I got horribly stressed out at the thought of hanging out with them. I have zero libido after my masturbation marathon, and no desire to be around real women. All I feel is anxiety.

Kyle: I kinda just felt separate from everyone, and as a result would drink to excess in hopes of appearing more confident… Didn’t work LOL. Thing is, I used to be so confident and popular. I even saw a counselor about my ED, lack of confidence and social anxiety etc., but never was I asked about porn use.

Andrew: For a while at least, I always went back to the “tame” stuff in order to get off. There seemed to me something unseemly about getting off to something I was watching only out of a car crash rubber-necking, morbid curiosity. But then one day, I actually started masturbating to these kinds of videos. That’s when I knew I’d crossed the line. I was getting off to something I found repellant, not sexually arousing in the conventional sense. I could easily become aroused and orgasm via masturbation, but not when having sex with my wife. When you have difficulty being aroused or ejaculating with real partners, you know you’ve got an addiction. When you find yourself asking your spouse to put a live eel in her p—- while you f— her a–, and she says “No,” and you say, “You’d do it if you loved me. This is my fantasy.” That’s how you know you’re addicted.

Brains are plastic. That’s what makes them vulnerable to addiction, but it’s also what makes recovery possible. If you want to make a change, get support. Change is entirely possible. See additional self-reports of symptoms, escalation and withdrawal distress. Also see self-reports of effects reversing themselves after stopping.

Doctors Redefine Sexual Behavior Addictions

Logo: American Society of Addiction MedicineA major event has occurred in the realm of addiction science and treatment. America’s top addiction experts at The American Society of Addiction Medicine (ASAM) have just released their sweeping new definition of addiction. This new definition ends the debate over whether sex and porn addictions are “real addictions.” They are.

From the ASAM press release:

The new definition resulted from an intensive, four‐year process with more than 80 experts actively working on it, including top addiction authorities, addiction medicine clinicians and leading neuroscience researchers from across the country. … Two decades of advancements in neurosciences convinced ASAM that addiction needed to be redefined by what’s going on in the brain.

It’s likely ASAM acted, in part, because the psychiatrists who are revising the DSM (the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders) have been dragging their feet in bringing the upcoming DSM-5 into alignment with advances in behavioral addiction research. Traditionally, the DSM offers diagnoses based not on underlying disease, but on lists of behaviors. Since DSM authors can’t agree on a list of sexual behaviors that constitute “Hypersexuality Disorder” (which addresses compulsive porn use), they are hamstrung. In fact, they may banish the disorder to the appendix—right as Internet porn use among adolescent boys is becoming nearly universal.

In contrast, the ASAM definition, “looks at the role of the brain in the etiology of addiction—what is happening with brain functioning and specific brain circuitry that can explain the outward behaviors seen in addiction.” It is an acknowledgement that a sexual behavior (e.g., viewing Internet porn daily) may be evidence of pathology in one person’s brain without reflecting pathology in another’s.

Research shows that both behavioral and chemical addictions entail the same major alterations in brain anatomy and physiology. An ASAM spokesman explained:

The new definition leaves no doubt that all addictions—whether to alcohol, heroin or sex, say—are fundamentally the same. Dr. Raju Haleja, former president of the Canadian Society for Addiction Medicine and the chair of the ASAM committee that crafted the new definition, told The Fix, “We are looking at addiction as one disease, as opposed to those who see them as separate diseases. Addiction is addiction. It doesn’t matter what cranks your brain in that direction, once it has changed direction, you’re vulnerable to all addiction.” …Sex or gambling or food addiction [are] every bit as medically valid as addiction to alcohol or heroin or crystal meth.

Here is a brief summary of ASAM’s major points:

  1. Addiction reflects the same brain changes whether it arises in response to chemicals or behaviors.
  2. Addiction is a primary illness. It’s not necessarily caused by mental health issues such as mood or personality disorders. This puts to rest the popular notion that addictive behaviors are always a form of “self-medication” to ease other disorders.
  3. Both behavioral and substance addictions cause the same major changes in the same neural circuitry: Hypofrontality, sensitization, and desensitization.
  4. Engagement in chronic “addictive behaviors” indicates the above brain changes have occurred. Addictive behaviors then become unconscious and habitual.
  5. The new definition eradicates the old “addiction vs. compulsion” distinction, which was often used to deny the existence of behavioral addictions, including Internet porn addiction.

Unlike the brains of gambling, food, videogame addicts, the brains of sex/porn addicts have not yet been scanned. Yet the brain mechanics of behavioral addiction are already so well defined, that experts can say with confidence that sexual behaviors are also potentially addictive. In other words, it’s not the form or quantity of a stimulus, but rather the resulting brain changes, which matter. These excerpts from ASAM’s FAQs explain the science common to all addiction:

QUESTION: What’s different about this new definition?

ANSWER: The focus in the past has been generally on substances associated with addiction, such as alcohol, heroin, marijuana, or cocaine. This new definition makes clear that addiction is not about drugs, it’s about brains. It is not the substances a person uses that make them an addict; it is not even the quantity or frequency of use. Addiction is about what happens in a person’s brain when they are exposed to rewarding substances or rewarding behaviors, and it is more about reward circuitry in the brain and related brain structures than it is about the external chemicals or behavior that “turn on” that reward circuitry.(Emphasis added.)

Addicts share common brain changes, which show up in behavior as unsuccessful attempts to control use, cravings during abstinence periods, and withdrawal symptoms. To date, the underlying brain changes seen in all addicts (desensitization, sensitization, and hypofrontality) have already been observed in the brains of compulsive gamblers, overeaters, videogamers. It’s likely they are present in today’s compulsive porn users as well. If it walks, talks and acts like a duck, it’s a duck.

Another implication of ASAM’s statement is that one cannot define “porn addiction” by time spent viewing or genres watched. Porn addiction exists only if the relevant brain changes have occurred in the viewer. Since brain scans are impractical, ASAM has created a 5-part assessment to help people figure out if their brains have changed. This is similar to assessing diabetes markers in patients complaining of telltale symptoms.

These next two questions from ASAM address sex and food addictions specifically:

QUESTION: This new definition of addiction refers to addiction involving gambling, food, and sexual behaviors. Does ASAM really believe that food and sex are addicting?

ANSWER: Addiction to gambling has been well described in the scientific literature for several decades. In fact, the latest edition of the DSM (DSM-5) will list gambling disorder in the same section with substance use disorders.

The new ASAM definition makes a departure from equating addiction with just substance dependence, by describing how addiction is also related to behaviors that are rewarding. This the first time that ASAM has taken an official position that addiction is not solely “substance dependence.”

This definition says that addiction is about functioning and brain circuitry and how the structure and function of the brains of persons with addiction differ from the structure and function of the brains of persons who do not have addiction. It talks about reward circuitry in the brain and related circuitry, but the emphasis is not on the external rewards that act on the reward system. Food and sexual behaviors and gambling behaviors can be associated with the “pathological pursuit of rewards” described in this new definition of addiction. (Emphasis added.)

QUESTION: Who has food addiction or sex addiction?

ANSWER: We all have the brain reward circuitry that makes food and sex rewarding. In fact, this is a survival mechanism. In a healthy brain, these rewards have feedback mechanisms for satiety or ‘enough.’ In someone with addiction, the circuitry becomes dysfunctional such that the message to the individual becomes ‘more’, which leads to the pathological pursuit of rewards and/or relief through the use of substances and behaviors.

In short, sex addiction exists, and it is caused by the same basic alterations in brain structure and physiology as drug addictions. This makes perfect sense. After all, addictive drugs do nothing but increase or decrease normal biological functions. They hijack neural circuits for natural rewards, so it should be evident that extreme versions of natural rewards (junk food, Internet porn) can also hijack those circuits.

What about porn addicts?

Today’s healthcare providers and popular advice columnists are often misled about the risks of Internet porn use—in part because they know that masturbation (without porn) seldom results in addiction. Trouble is, Internet porn is not mere masturbation. The belief that masturbation and Internet porn are the same demonstrates a lack of understanding of the potential brain effects of constant novelty. Normally, masturbation leads to feelings of satiety. In contrast, Internet porn can override natural satiety. In some brains, overriding natural satiety with extreme stimulation is the slippery slope to addiction-related brain changes. This misunderstanding results in poor advice to patients/clients/readers.

When researchers someday look into the brains of Internet porn addicts, they are sure to see the changes already observed in other kinds of Internet addicts. Alas, porn-addiction research faces daunting challenges:

1.      Control groups of male, non-Internet porn users can no longer be found, and even if they could, review boards would certainly not approve protocols that call for them to watch the kinds of porn for as many hours a day as many of today’s young guys are watching.

2.      Vague questionnaires (unlike brain scans) make it tough for porn users to connect sexual performance problems (or social anxiety, depression or concentration problems) with Internet porn use. After all, porn seems like the world’s most reliable aphrodisiac, and users always feel better while using. How could it be causing the very problems it temporarily cures?

Only with broader knowledge of addiction, its symptoms, and its etiology can researchers and their subjects correctly connect cause with effect. The ASAM statement supports researchers in investigating porn use through the lens of brain changes.

Therapists have new responsibilities

ASAM’s declaration is a step forward in helping to reeducate therapists and their clients. Many were erroneously taught that sexual behavior addictions could not arise from overstimulation of the brain via behavior. Instead, they were trained to assure clients that addiction to sexual behavior was never a risk—unless the client had other (often genetic) disorders.

Yet ASAM authors estimate that genetics only make up about half the cause of addiction. This means that addiction can develop in the absence of pre-existing conditions. In other words, porn-related symptoms such as depression, social anxiety, youthful sexual performance issues and concentration problems need to be viewed as possible consequences of addiction, instead of being presumed always to be their cause.

The new statement thus places responsibility on therapists to help sex and porn-addicted clients make fundamental changes to their behavior. At the moment, many counselors simply refer clients to a doctor for psychotropic and sexual-enhancement drugs—while assuring them that their sexual behavior is typical and harmless.

The ASAM statement is a big step in a sound direction. In the following post, we consider specific symptoms porn users report, which may indicate addiction-related brain changes.

Ominous News for Porn Users: Internet Addiction Atrophies Brains

"Game Over" button

Here’s some headline news for anyone who has been trained that Internet porn use is harmless: Physical evidence of addiction processes is showing up in the brains of avid Internet video-gamers. What’s more, use of online erotica has greater potential for becoming compulsive than online gaming according to Dutch researchers.

According to NIDA head Nora Volkow, MD, and her team these three physical changes define addiction: desensitization (numbing of the brain’s pleasure response), sensitization, and hypofrontality. These same brain changes (which are now showing up in Internet addicts) also show up in pathological gamblers and drug abusers.

For example, cocaine use floods the brain’s reward circuitry with dopamine. Nerve cells respond, more or less quickly, by decreasing their responsiveness to dopamine. As a result, some users feel “off” (desensitization). They crave more intense stimulation (tolerance), and tend to neglect interests, stimuli, and behaviors that were once important to them.

At the same time, because their brains have recorded that cocaine use feels good, they grow hypersensitive to anything they associate with cocaine. White powder, the word “snow,” the neighborhood where they smoked, or friends with whom they used will all trigger spurts of high dopamine in the reward circuitry, driving them to use (sensitization). Also, ΔFosB, a protein that helps preserve intense memories and promotes relapse, accumulates in key brain regions. Incidentally, ΔFosB also rises with sexual activity.

If heavy cocaine use continues, the desensitization of the reward circuitry decreases corresponding activity in the frontal lobes of their brains. Now, the users’ abilities to control impulses and make sound choices weaken, and their frontal cortex may atrophy (hypofrontality). Taken together, decreased pleasure response, marked cravings to use, and compromised impulse control fuel the vicious cycle of addiction.

Behavioral addictions

The study of non-drug addictions is still quite new. Yet already experts have uncovered decisive physical evidence that today’s extreme versions of natural rewards can change the brain in ways that drugs do. “Natural rewards” are activities/substances that entice us because they enhanced our ancestors’ survival, or the survival of their genes.

Moreover, it’s not just a tiny minority with pre-existing disorders who are at risk. Normal, healthy brains can also change. Said a healthy 37-year old, “When I first watched porn online at age 35, I felt like I was going to have an orgasm without an erection. That’s how powerful an effect the it had on me.”

So far, here’s the research scorecard. (Dates indicate when brain-scan research turned up evidence of the last of the three key addiction-related brain changes.)

  • Pathological gambling – studied for 10 years, and added to the upcoming DSM-5 as an addiction (2010)
  • Food addiction – (2010)
  • Internet video-gaming addiction – (2011)
  • Internet porn addiction – still not studied via brain scans

Incidentally, the reason the Internet addiction studies address addiction to gaming, not porn, is that they were done in countries that block access to porn sites—and have for years (China, 2006 and Korea, 2007). Unlike other countries, they don’t have a lot of heavy porn users.

Here are studies showing the three critical, physical changes in the brains of Internet addicts (two just released in June, 2011):

A reduction of striatal D2 dopamine receptors is the main marker for desensitization of the reward circuitry, a hallmark of all addictions. In this study PET scans of men with and without Internet addiction were compared.

“An increasing amount of research has suggested that Internet addiction is associated with abnormalities in the dopaminergic brain system… [In this study] individuals with Internet addiction showed reduced levels of dopamine D2 receptor availability.”

In this study, college students played Internet video games for 6 weeks. Measures were done before and after. Those subjects with the highest cravings also had the most changes in their brains that indicate early addiction process. The control group, which played a less stimulating game, had no such brain changes.

These changes in frontal-lobe activity with extended video-game play may be similar to those observed during the early stages of addiction.”

In this study, researchers found a 10-20% reduction in frontal cortex gray matter in adolescents with Internet addiction. Research on other addictions has already established that decreases in frontal-lobe gray matter and functioning reduce both impulse control and the ability to foresee consequences.

“The presence of relatively immature cognitive control, makes [adolescence] a time of vulnerability and adjustment, and may lead to a higher incidence of affective disorders and addiction among adolescents. As one of the common mental health problems amongst Chinese adolescents, internet addiction disorder (IAD) is currently becoming more and more serious. … The incidence rate of internet addiction among Chinese urban youths is about 14%. … These results demonstrated that as internet addiction persisted, brain atrophy … was more serious.” (Also see this earlier Chinese study.) 

Online porn and video gaming stimulate the brain in comparable ways

Compare these two quotations. Which is about porn addiction and which is about gaming addiction?

We don’t have sex anymore. We don’t go on date nights or anything together. I feel so guilty because I just can’t take it anymore. Ever since 2 weeks into our marriage I was threatening to divorce him.

Three of my friends did realize they had a problem, but 2 of them said they’ve made attempts to quit, and they literally think there’s nothing they can do about it. *

The characteristics that make Internet porn and video gaming so popular are the same characteristics that give both the power to dysregulate dopamine in some brains. Novelty and ‘stimuli that violate expectations‘ both release dopamine, sending the brain the message that the activity is more valuable than it is. Successful video games deliver a rapid-fire of both novelty and surprise. Each new generation of games exceeds the last in these respects.

Today’s porn also delivers both, and constantly ratchets them up. There’s unending novelty and something more startling always beckoning just beyond the next click. There’s also the dopamine released by the “hunt” for the perfect shot. Novelty, shock and hunting absorb the user’s attention because they raise dopamine levels. Intense focus allows users to override their natural satiety mechanisms and, often, to rewire their brains in ways that take a lot of effort to undo. Addiction is “pathological learning.”

Online gamers are sometimes called “adrenaline junkies.” However, adrenaline (which is released in the adrenal glands) appears to have little effect on addiction processes. Dopamine, not adrenaline, is at the heart of all addictions. Fear and anxiety can enhance addiction processes due to neurochemicals released in the brain (such as norepinephrine), but they don’t cause those processes.

Sexual cues can be more compelling than gaming activities

Mock warfare and risky quests were no doubt high priorities for our ancestors. That’s why we find play rewarding enough to get hooked. Yet reproduction is our genes’ top priority. Like food, sex is essential to genetic success.

In terms of effects on the brain, Internet porn use combines elements of consuming highly palatable food and video gaming’s constant stimulation. Like junk food, Internet erotica is a hyperstimulating version of something we evolved to value highly. Today’s erotica is also delivered via a rapid-fire, mesmerizing medium, very similar to online video games. A double whammy in terms of addictiveness.

It’s worth considering what brain researchers have learned about food. When rats had unlimited access to cafeteria food, nearly all of them showed a rapid drop in D2 (dopamine) receptors (numbed pleasure response), and then binged to obesity. The D2-receptor drop apparently motivates mammals to grab as much as possible while the getting is good—whether high-calorie foods or a willing harem.

Keep in mind that unlimited cafeteria-type food stimulation was not the norm during our evolution, until recently. That’s why unlimited access to junk food is risky to rats and humans. Clicking effortlessly to hundreds of hot, novel mates is also an evolutionary anomaly, and 9 out of 10 of college-age men were already using Internet porn three years ago. Risky, given its inherent addictiveness. Also, reversible. When heavy users give up porn, they report increased pleasure from all aspects of life (often after a miserable withdrawal).

Back to food. In recent years, brain researchers have also turned up evidence of all three key addiction processes in the brains of overeaters:

  • Numbed pleasure response: A 2010 study showed that overeating blunts the reward circuitry, increasing the risk for future weight gain. After 6 months, the brains of those who had eaten more “pleasurable” foods (i.e., more fattening) showed less response to pleasure than the others.
  • Sensitization: A 2011 study found that those who score high on a food addiction test (brain activation in response to pictures of food) show brain responses similar to drug addicts’ responses to drugs.
  • Hypofrontality: A 2006 study revealed that obese individuals have brain abnormalities in areas associated with taste, self-control, and reward—including a reduction of gray matter in the frontal lobes (atrophy). It’s likely that overeating causes these changes, as the study mentioned above confirmed brains changes from overeating.

If overstimulation via highly palatable food can cause brain changes in so many humans (30% of Americans are obese, and only about 10% due to metabolic abnormalities according to neuroscientist David Linden), how is it possible that over-stimulation via highly erotic online sexual activity could not change brains? Internet porn use/cybersex is surely no less stimulating than tempting food.

Is history repeating itself?

History is full of examples of “common knowledge” that turned out to be erroneous upon investigation. Consider margarine. Everyone “knew” it was better for you than butter. Experts were so confident of this “fact,” that they didn’t even test it for years, and regularly advised people to substitute margarine for butter.

Finally, experts did test the healthfulness of margarine. It turns out that trans-fatty acids (found in margarine) are among the most dangerous fats. They are far worse for humans than butter.

Critics may claim that it is “unscientific” to suggest that Internet porn can cause addiction processes in the brain just because Internet addiction clearly does. Actually, it’s unscientific to suggest the reverse. All addictions, including behavioral ones (gambling, food, video games) show hypofrontality (atrophy and lack of impulse control). Frankly, what critics now need to supply is solid, scientific evidence showing that Internet porn addiction is an exception to the rule. To suggest there’s still major doubt about its addictiveness is most unscientific, as it presumes there must be some other brain circuitry for porn use that has yet to be discovered.

Sex is healthy, but the assumption that Internet porn use is safe is increasingly tenuous.

* The first remarks are about gaming addiction, the second about porn addiction.

Is Today’s Ejaculation Advice Right for Our Species?

For the last half-century, Western sexologists have advised men to ejaculate as frequently as the urge arises, on a par with nose-blowing. At the same time, doctors assure guys that there’s no risk of excessive ejaculation because they’ll stop when they’ve had enough.

But what if this advice is not supported by the data biologists are turning up? We’ve been fascinated by a debate going on over on Amazon about the realities of primate sex and mating. This debate and the self-reports from young guys on a variety of forums are making us question the standard ejaculation advice.

Personally, we’re not enthused about increasing the world’s population, but it’s hard not to feel sorry for the men we’ve heard from who cannot consummate their marriages, let alone impregnate their wives, as a consequence of their heavy porn use. (Come to think of it, that suggests a strategy for population control. Simply give every guy on the planet an iPhone, and every woman a vibrator.)

Where are we now?

The predictable, though not necessarily intended, result of the standard ejaculation advice is that many younger men believe it is unhealthy not to ejaculate very frequently-at least once a day. (Indeed, authorities in England and Spain have actively campaigned to spread this notion in schools.) Many guys believe that if once is healthy, 2, 3 or 4 times must be even healthier.

In the under-thirty crowd, masturbation and Internet porn use are synonymous, so if 4 ejaculations per day are really healthy…well then, that many Internet-porn sessions are too. Indeed, even after their hormonal rush of puberty and sexual peak have passed, guys can use today’s superstimulating masturbation aids (Internet porn, cam-2-cam, sex toys) to remain veritable geysers of semen…at least until they hit a wall.

Now, many men, as early as age twenty, are complaining of delayed ejaculation, an inability to climax with mates who don’t look/act like their favorite fetish porn star, erectile dysfunction and a host of other symptoms. (Astonishingly, when they stop porn/masturbation for a couple of months, they report dramatic improvements  in confidence, mood, concentration, sexual chemistry and sexual performance.)

If you’re noticing unwanted symptoms, and you’re not sure you want to let your genes down, consider the following biological and anthropological information.

‘My sperm production keeps up with my daily ejaculation frequency.’

Even though Western males apparently masturbate to climax more than any other species, humans are not, in fact, built for prolific ejaculation. According to Promiscuity author Tim Birkhead:

The rate of human sperm production is lower than that of any other mammal so far investigated. The numbers of sperm stored in the epididymis are also low. … Men, in contrast [to chimpanzees] have a more limited capacity and six ejaculations in twenty-four hours is enough to deplete the epididymal sperm stores completely. [pp. 82,84]

Sperm collected via daily masturbation dropped from 150 million on day one, to 80 million on day two, and to 47 million on day three. It takes about 64 days for sperm to mature.

While figures vary across studies, and certainly between men, humans have a low sperm production rate, considering that a sperm count of around 100 million is usually considered necessary for a reasonable chance of fertilization. It is simple to see how habitual frequent ejaculation could lead to chronic depletion and decreased fertility.

Sperm production estimates vary, but it appears that ejaculation every third day would not overtax sperm supplies (assuming they have normalized after very frequent ejaculation). Ejaculation every third day is more than enough action to keep a mate “topped up” with viable sperm, so evolution is likely to have equipped us accordingly. Incidentally, too many sperm can increase miscarriages because fertilization by more than one sperm renders a zygote inviable. “Eject!”

‘If I’m horny, it means I need to ejaculate.’

Not necessarily. Even though human sperm production is low relative to other animals, human males still become aroused in response to promising genetic opportunities regardless of semen reserves (the Coolidge Effect). This reality is what makes possible a binge using Internet porn (with its parade of novel “mates”).

Male zeal for sex and the willingness to risk lives to access potential mates are common across species. After all, the male gender more often faces the potential of zero offspring because the struggle for fertilizations is normally demanding and failure common.

In short, you don’t have to have a mammoth libido, or be a pervert, to have trouble saying “no.” Healthy human brains respond to high-value sexual cues or novel mates. If they didn’t, you wouldn’t be here. In fact, you’re the product of those who wanted sex the most.

Yet what happens when limitless simulated and stimulating sex becomes available to these zealous males in the form of virtual sirens begging for semen from cyberspace?

Research shows that animals will prefer a supernormal stimulus to the natural one. Female birds prefer to brood an oversized wooden egg rather than their own real eggs. A male fish prefers to court a wooden oversized female (bigger size = more eggs) than a real female with real eggs. And humans can easily fall for superstimulating online charmers in lieu of real mates with whom they could potentially reproduce. An evolutionary-biologist friend, who specializes in sexual evolution and the sexes, remarked:

Now, we face the prospect that porn sex will make real sex a poor alternative or even impossible. Moreover, women have vibrators that can also make real sex a poor alternative—and even more so if men cannot achieve erections.

I can almost envision a future in which men and women will live separately, masturbating to porn or with sex toys. Reproduction, when desired, will be done with a turkey baster—assuming computer-illiterate donors can be found. We could even be the first species whose sex drive leads it to masturbating itself to extinction. LOL

Laughable, and yet a recent UK survey reported that among men looking at porn for at least 10 hours a week sixty-one per cent agreed it could make you less interested in sex with a partner (compared with 27 per cent of moderate users and 24 per cent of light users). 

 ‘Even if I overdo it, there are no lingering repercussions.’

We were startled to learn that exhausting semen supplies may have surprisingly long lasting repercussions for human-male fertility. In a study where men ejaculated an average of 2.4 times a day over ten days, their sperm output remained below pre-depletion levels for more than five months

There’s also the risk of long-lasting plastic brain changes in response to super-enticing stimuli. Brain changes can desensitize the individual’s pleasure response and leave him hyper-responsive to sexually explicit material indefinitely…much as an obese person continues to buy chips because his brain’s reward circuitry is shouting, “More!” even as his body is screaming, “Enough!”

Lingering brain changes increase the risk that today’s frequent ejaculators will not, in fact, “stop when they’ve had enough” as the medical profession claims. Binging on Internet porn in search of satisfaction is not unusual among users. One possible result is chronic sperm depletion.

 ‘The suggestion that there can be too much ejaculation is religious moralizing.’

Actually, many sex-positive cultures have taught moderation for millennia. As explained, men have not evolved to be able to have limitless sex without suffering physiological repercussions. Historically, male fervor was held in check by the reality of sexual opportunities with novel mates being rare. Later, when population density rose, male potency was protected by traditions that regulated sexual excess.

In fact, the last half-century’s decision to dismiss the possibility of biological limits represents a sweeping departure. Across the globe and over thousands of years mankind generated a broad array of traditions and taboos to protect male potency and vitality. For example, the ancient Chinese Daoists made a science of sexual health and relationship harmony, without a hint of moralizing.

They were not alone. Almost a century ago, anthropologist A. Ernest Crawley recorded that tribal cultures all over the world believed that temporary abstinence from sex was appropriate in connection with many activities (depending upon the culture). These included hunting, warfare, planting, fishing, harvesting, wine preparation, shamanic deeds, pilgrimage, the first days of marriage, pregnancy, lactation, menstruation, and so forth. Such advice was so widespread that Crawley characterized temporary chastity as an “infallible nostrum for all important undertakings and critical junctures.”

Periodic abstinence was believed to increase male invincibility and vigor. For the same reasons, numerous cultures have also evolved ways of making love that encourage frequent intercourse but infrequent ejaculation (unless conception is desired).

More recently, anthropologists studying cultures in Central Africa reported that the Aka and Ngandu peoples don’t masturbate. (They don’t even have a word for it.) These cultures also traditionally observe a moratorium on sex from the birth of a child until it is able to walk. Despite the fact that adults of both genders obviously relish sex, men’s interludes of frequent ejaculation tend to be limited. (Incidentally, no religious missionary influenced these traditions.)

Is the ejaculation advice of the last half-century suitable for humans?

Perhaps not. In the words of our evolutionary-biologist friend,

Cheering on multiple daily ejaculations as some sort of ‘natural’/ancestral behavior is mistaken. All-in-all the evidence suggests that human sperm production has not evolved for more than a moderate rate of ejaculation, and masturbation is possibly not something that is ‘normal’ on a daily basis, if at all.

It’s likely our false belief in ‘limitless’ human sperm production arose primarily because the brain’s evolved reward mechanism for sex is very strong. Especially for males, reproduction is uncertain. It’s the intensity of sexual pleasure that makes us assume frequent ejaculation is more beneficial than it is.

How could something that feels so great ever be a problem? Answer: Our sexual expression is occurring in an environment very different from the one in which it evolved.