Nassir Ghaemi, MD, Psychiatry/Mental Health, 03:17PM Feb 6, 2010 - http://boards.medscape.com/forums?128@915.MLfhaTppmiq@.29fa173d!comment=1
Everyone is writing about Tiger Woods, and I am not at all inclined to join in - but I suppose I will. The casual use of the concept of "sexual addiction" in relation to his recent diagnosis and treatment may warrant some internal dialogue among psychiatrists. I write these notes not to persuade but to raise questions and see if other colleagues are not wondering similarly.
What is sex addiction all about? I understand hypersexuality, and I understand addiction, but I am not sure I understand sex addiction.
As a psychiatrist, I would first want to apply here the concept of a hierarchy of diagnoses. So a high amount of sexual activity could certainly occur with many conditions, and the concept of a sex addiction, if valid, would have to be the last thing one would diagnose - a diagnosis of exclusion since it could happen with so many other things. First on everyone's list of causes of high sexual activity, I would think, should be mania, or bipolar disorder. Next, or right with it, would be obsessive compulsive disorder (OCD), with sexual content; this is quite common. Then perhaps PTSD with sexual trauma (with later hypersexuality in some people), substance abuse (e.g., amphetamine, steroid, or testosterone abuse), and frontal lobe syndrome. Some depressed individuals also appear to engage in sexual activity, not because of aroused libido, but out of a wish to come out of their isolation and engage with others, even if only physically.
Sexual addiction, as a concept, though, would seem to represent nothing but sex: no mania, nor PTSD, nor substance use, nor other causes. Addiction, as a concept, implies an intense feeling of acute pleasure, followed by a wish to repeat, and, often, tolerance and withdrawal. In this context, tolerance would mean that the more one experienced sex, the less pleasurable it would be; and withdrawal would mean that when abstinence occurred, one experienced painful psychological or physical symptoms (perhaps depression and anxiety). Addiction also implies something that perhaps begins as an experiment, later becomes a habit, and then becomes autonomous. Neurobiologically, addictions tend to involve, we think, activation of the dopaminergic pleasure centers of the brain. Can lots of sex take on this pattern?
It seems difficult to me to distinguish OCD from so-called sexual addiction; perhaps the main difference would be that the individual is bothered by his behavior in one case (OCD) and not the other (addiction); yet this single minor subjective difference would seem to be a small feature upon which to base an entire diagnostic entity. Indeed, there appear to exist many cases of OCD without insight, that is, OCD in which the patient is not much bothered by his or her symptoms. OCD is not, traditional teaching notwithstanding, uniformly characterized by presence of insight (better phrasing than the old ego-dystonic term, in my view). One reputable website defines sexual addiction as "a progressive intimacy disorder characterized by compulsive sexual thoughts and acts." DSM's definition, under paraphilias, as sexual disorders NOS includes the following ideas: "compulsive searching for multiple partners, compulsive fixation on an unattainable partner, compulsive masturbation, compulsive love relationships and compulsive sexuality in a relationship." This kind of definition seems quite hard to distinguish from OCD with sexual content.
The difference in terminology is important; the idea of sexual addiction would seem to imply analogies to substance abuse: 12 step programs, a limited role for medications, Malibu resorts. The OCD concept would put medications central to the treatment, and make the problem more biological in origin and pathogenesis, rather than simply habit gone awry.
Where we are uncertain, I would prefer the term sexual paraphilia, so as to remain neutral as to the addiction versus OCD dichotomy. Dr. Martin Kafka, a specialist in paraphilias, with whom I have shared patients and whose expertise is large, recently suggested a new DSM category of "Hypersexual disorder", which presumes carefully first ruling out other conditions like OCD and bipolar disorder hierarchically. Though I know he practices this way, I fear that the public at large, and the average clinician, will be too democratic, and too little hierarchical, and forget that such a diagnosis, though perhaps not useless, is one of exclusion, and last resort.
If individuals like Tiger Woods have a variety of OCD, it could be that enough serotonergic antidepressant would knock out their libido or their OCD, or both, to keep them from ruining their lives. But 12 step programs might be tenuously utile.
I don't know the right answer, but it seems to me that this is yet another part of psychiatry where the lapidary use of popular phrases hardly clarifies.
| Nassir Ghaemi, MD, MPH, is Professor of Psychiatry at Tufts University School of Medicine and Director of the Mood Disorders and Psychopharmacology Programs at Tufts Medical Center |
http://www.woodhullfoundation.org/victoria.htm
Victoria Woodhull
Victoria Woodhull (1838-1927) was a progressive and outspoken nineteenth-century activist who introduced sex-positive values to America during the repressive Victorian era. Far ahead of her time, Woodhull spoke frankly on the topic of sexual freedom and advocated for women's equality in the home, workplace, and in the political arena.
Elderly Staying Sexually Active By Rob Stein Washington Post Staff Writer Thursday, August 23, 2007; A01
Many people maintain rich, active sex lives well into their 80s, according to the first detailed examination of sexuality among older Americans.The nationally representative survey of more than 3,000 U.S. adults ages 57 to 85 found that more than half to three-quarters of those questioned remain sexually active, with a significant proportion engaging in frequent and varied sexual behavior.Sexual problems do increase with age, and the rate of sexual activity fades somewhat, the survey found. But interest in sex remains high and the frequency remains surprisingly stable among the physically able who are lucky enough to still have partners."There's a popular perception that older people aren't as interested in sex as younger people," said Stacy Tessler Lindau of the University of Chicago, who led the study, being published today in the New England Journal of Medicine. "Our study shows that's simply not true. Older people value sexuality as an important part of life.""This study paints a portrait of this aspect of older Americans' lives that suggests a previously uncharacterized vitality and interest in sexuality," agreed Georgeanne E. Patmios of the National Institute on Aging, the primary funder of the study. "This has not perhaps been fully appreciated."The survey found a close link between sex and health, with healthier people reporting the highest rates of sexual activity. In addition to supporting the well-known idea that illness can interfere with sex, that finding suggests that a healthy sex life may itself help keep people vibrant, the researchers said."Individuals who remain sexually active gain the benefit of the physical exercise that comes with sex," Lindau said. "It's also possible the hormones -- the endorphins released by orgasms -- give a general sense of well-being that could be beneficial. The psychological benefits of being loved and cared for may also trickle over to physical health."Despite the intense focus on sex in popular culture, political sensitivities have severely limited funding for reliable, detailed studies of sexual activity among Americans of any age. Smaller, more limited studies have provided glimpses into the sex lives of the elderly, but no one had previously attempted an in-depth, nationally representative survey among this rapidly growing segment of the population."We just don't know very much about sexuality in the later years," said Robert N. Butler, president of the International Longevity Center in New York, a nonprofit think tank. "There's been a tremendous amount of resistance to such studies. That's what makes this so terrific."For the study, researchers conducted face-to-face interviews with a randomly selected sample of 3,005 Americans from July 2005 to March 2006."We found people to be grateful to have an opportunity to discuss these issues," said Lindau, noting that researchers achieved an unusually high 75 percent response rate from those they approached. "The topics we were asking about resonated with people. Many said they had never had a chance to talk to anyone about these issues, not even a spouse or their physicians."About 28 percent of men and about 14 percent of women said sex was very important, and about three-quarters of those with partners reported being sexually active, which is about equivalent to what previous research had found for people in their 40s and 50s. Being sexually active was defined as having had mutually voluntary sexual contact with another person within the past 12 months."Our findings indicate that when it comes to sexual activity, older people are really just younger people later in life," Lindau said "There's no reason to believe they give up the basic human desire for love and intimacy and the kind of pleasure that comes from intimate relationships."The proportion of those having sex did decline somewhat with age. By ages 75 to 85, it was down to 39 percent of men and 17 percent of women.Among those who remained sexually active, frequency also fell somewhat with age. But even among the oldest age group, 54 percent of those who were sexually active reported having sex at least two to three times per month and 23 percent reported having sex once a week or more."This just shows that the light doesn't go out. The flame doesn't go out," said Todd P. Semla, president of the American Geriatrics Society.The most common sexual activity was vaginal intercourse. But the survey found a significant proportion reported engaging in oral sex, both giving and receiving, as well as masturbation.Mirroring their younger counterparts, elderly men reported more sexual activity than women, but researchers said that was largely because women live longer than men, giving the surviving men more opportunities to have sex than women."This doesn't necessarily mean that women aren't necessarily interested in intimacy and sexuality," Lindau said. "A substantial number of women say the reason they are not having sex is they don't have a partner."Among those who remained sexually active, nearly half reported at least one sexual problem. Forty-three percent of women reported a lack of sexual desire, 39 percent of women reported vaginal dryness, and 37 percent of men reported problems achieving an erection.Given the availability of new medical treatments such as Viagra, those findings indicate that the elderly would benefit from more frank and open discussions about sex with their doctors."This should increase awareness among physicians to pay more attention to this," said John E. Morley, director of geriatrics at St. Louis University. "This is extraordinarily important, and we need to pay more attention to it."
Jacob M. AppelEmbracing Teenage Sexuality: Let's Rethink the Age of Consent
At the opening of America's iconic (albeit controversial) romance epic, Gone With the Wind, 16-year-old Scarlett O'Hara fends off flirtatious propositions from the 19-year-old Tarleton twins -- a moment rendered indelible in the subsequent film by the gifted actors Fred Crane and George Reeves. I suspect few of the countless high school students who read this novel each year reflect on the morality of the age difference between Scarlett and her suitors. The stark reality is that a consensual sexual relationship between a 16-year-old and a 19-year-old is a prison offense in many states, including New York and California. New York State goes even further: Two 16-year-olds enjoying a voluntary sexual relationship are legally committing crimes against each other, with both partners being "victims" and possibly even sex offenders. These draconian and puritanical laws are largely the product of a conservative political culture that has transformed the fight against child molestation into a full-blown war on teenage sexuality. We now live in a moral milieu so toxic and muddled that we lump together as "sex offenders" teenagers who send nude photos to each other with clergymen who rape toddlers. A first step toward reversing this madness -- and actually protecting the health and safety of teenagers -- would be to revise the age of consent downward to a threshold in accordance with those of other enlightened nations.
The widespread decriminalization of homosexual intercourse over the past two decades has led many Western nations to reexamine "age of consent" statutes for both same-sex and opposite-sex couples. Great Britain, after considerable national debate, chose 16 at its magic number in 2003, although a minority of liberal Britons, led by gay rights activist Peter Tatchell, continue to push for a cut-off at 14 years. In 2008, Canada has also settled upon 16. French law sets the age of majority, in matters of romance, at 15. Our other closest cultural and moral allies fall into a similar range: Belgium (16), Denmark (15), Germany (14-16), Greece (15), Holland (16), Italy (14), Norway (16) and Sweden (15). The outliers are even lower, not higher, such as Spain's threshold of 13. What these nations have accepted, and many in this country still refuse to acknowledge, is that teenagers do have sex -- lots of it -- and that criminal law is neither an effective or an ethical means of deterring their sexual desires. (The average age of first sexual intercourse remains well below 18 in the United States, including in those states with an 18-year-old age floor, suggesting that a majority of teens violate these laws with impunity.) Furthermore, when it comes to older teens, it is not at all clear why safe sexual relationships should be deterred. If a 16-year-old can enjoy sex responsibly -- using birth control, taking measures to prevent the spread of disease -- and he or she wishes to add sexual pleasure to the rich tapestry of adolescent life, why shouldn't we encourage that individual to do so? It seems a far less dangerous endeavor than hunting, which New York licenses at the age of 12 (versus 17 for intercourse) and California allows at 16 (versus 18 for sex). Driving, too, is far more dangerous than sex. Whether the age of consent should be 16 or 15, or even a year younger, is a complex question that our society needs to address. Keeping the age of consent at 18, as do 12 states, is no more reasonable that setting it at 10.
The purpose of "age of consent" statues is presumably to prevent the exploitation of children who are not yet mature enough to make wise decisions or who do not understand the implications and consequences of sex. (Of course, one could apply that same reasoning to many other potentially-corrupting activities -- attending church or synagogue, for example. Yet nobody argues we should shield children from religion until they reach 18 and are thus old enough to understand the implications and consequences of religious practice.) Another justification for age-of-consent laws is that the sort of adults who prey upon young children sexually are also likely to harm them in other ways, including violently -- to cover up their deeds, if for no other reason. These concerns for the safety and welfare of minors justify legal regulation, but only up to a point. A college freshman who asks a high school junior on a date poses little threat to the commonweal -- even if that date ends in bed. Statutes criminalizing such behavior are far more likely to harm teenagers than to help them -- whether by denying them access to necessary information, deterring them from sharing their experiences with teachers and counselors for fear that they or their partners will be reported to authorities, or driving them to have sex in parked cars and dark alleys rather than safe, warm bedrooms. In fact, in many states the responsible and sexuality-aware parent who creates a safe environment for a teenager to explore his or her sexuality with peers can face prosecution and even loss of custody for contributing to the corruption of a minor.
The Christian right and its political allies have similarly co-opted efforts to crack down on child pornography as part of their drive to suppress teenage sexuality. Child pornography statues, which were initially designed to prevent predators from exploiting children, are now increasingly being used to prosecute or intimidate teenagers who receive sexually explicit photos of their boyfriends or girlfriends. Some of these teens have even been charged under child pornography statues themselves -- including a 17-year-old Ohio girl who was prosecuted for "sexting" her own partially-clad photograph to an ex-boyfriend who was over 18. The problem is not with these teenagers. The problem is with the statutes. While sexual images of 16- and 17 year olds may of course be used inappropriately -- as may those of adults, for that matter -- the individuals who should be punished are those offenders who misuse these images, not the teenagers who take them or the romantic partners who savor them. Exploitation is wrong. Neither sex nor nudity are inherently wrong or inherently exploitative. Alas, we appear to have forgotten how to tell the difference. The media all too often focuses on cases where sexual relations are non-consensual (such as Roman Polanski's encounter with Samantha Geimer) or where authority figures, such as teachers and coaches, seduced young charges in their care. But many teenagers are prosecuted for consensual encounters with their peers or partners only a few years younger than themselves. Some of these cases prove truly Kafkaesque. In Florida, for example, a 15-year-old girl recently had consensual sex with four 17-year-old football players -- and then, by her own admission, allegedly fabricated rape charges against them. The boys, who are the actual victims in this case, now await trial on charges of "lewd and lascivious battery of a minor," a serious felony. In Georgia, the widely-publicized tragedy of 17-year-old Genarlow Wilson -- sentenced to 10 years in prison for consensual oral sex with a 15-year-old girl -- nearly ruined the life of a promising young man without in any way protecting the welfare of other teens. These are merely the tip of the forensic iceberg. On a regular basis, morally blameless young adults are prosecuted, forced to register as sex offenders, and even deported for consensual sex-acts with 16- and 17-year olds that would be legal in Canada and often in neighboring states. What is a loving relationship in Newark or Las Vegas is the worst of all crimes in New York City and Los Angeles.
Teenagers are smart. They understand that sex can be pleasurable and that it can enhance the intimacy of their relationships. Telling them otherwise -- by insisting, for example, that "sex is for adults only" -- defies their lived reality. We should instead be emphasizing safe sex practices, open communication, and gender equality. We should not tolerate, for example, any double standard that winks at teenage boys for having multiple partners but disparages girls who do so. We should take a warning from the old joke: What do you call teenagers who receive abstinence-only sex education? Anwers: Mothers and fathers. I look forward to the day when those adults who preach an anti-sex philosophy to teenagers become as unpopular as the teens who embrace it.
That is not to say that some teenagers won't choose to remain celibate. I cannot imagine why they would, by I respect their right to do so. However, those 16- and 17-year-olds who want to indulge in one of life's great pleasures should not have to worry about the long arm of the law coming after them or their partners. Even more important, our society needs an open debate on this question. For far too long, those progressive voices who would bring common sense to the issues of teenage sexuality have been afraid to speak out for fear of being branded sympathetic to pedophiles and sex predators. The reality is that a reasonably lower age of consent, and a frank national discussion of adolescent sexuality, would serve the interests of the very minors that current laws are supposedly trying to protect. Pro-sex is Pro-safety. Conservative parents are certainly entitled to encourage their teenage daughters to keep their legs crossed, much as they may tell their sons that masturbation causes blindness. What they do not have have a right to do is to lock the rest of our society in a chastity belt by fighting a war on under the specious guise of protecting teens from themselves.
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