I had a surprising experience on a peak-hour train one morning. I was sitting directly behind a man who had his mobile phone held up at eye level, and I could see the moving image of what he was watching reflected in the window. I couldn’t figure out what it was for a while, then suddenly recognised a graphic close-up of genitals in full swing! He was watching pornography, on his morning commute, completely oblivious to the passengers around him. I was more curious than offended, and watched the reflection in amazement, wondering how long he would persist. Then I started wondering about what was going on in his brain. Was he born with an appetite for porn, or did his apparently prolific and blatant consumption change his brain to want or need more of it?
As I contemplated these questions and watched the reflection bouncing around on the window, the train carriage started filling up with other passengers. A woman sat next to me, and it wasn’t long before she noticed what our fellow commuter was up to. She gasped and we exchanged wide-eyed glances. She commented that her partner was a police officer and that she should call him, then sighed and muttered, ‘Disgusting.’ Suddenly she leaned forward over the top of his seat and slapped his mobile phone down, telling him, ‘You’re a nut short of a fruitcake, mate!’ He tucked his phone away and sat quietly until the train’s next stop, when he scurried out of the carriage without a glance or a word. It was certainly one of the most interesting train trips I have ever experienced.
The internet has revolutionised the porn industry, and it has been estimated that 50 per cent of all internet traffic is related to sex. The three As that make internet porn such a mass phenomenon are its accessibility, affordability and anonymity. Are we really so blasé about porn now that people feel they can watch it openly on their daily commute? Was the train passenger who sat in front of me that day a typical porn viewer, or was he an anomaly, a ‘high porn consumer’ who had lost all inhibitions, his brain ‘hijacked by porn’?
Is it really possible to become addicted to porn, and can it actually change our brains? These are highly controversial, challenging and complex topics. I want to preface this discussion by saying that as a clinical neuropsychologist, I don’t have any experience in treating or even meeting people with so-called porn or sex addictions. I’m raising these topics here because I was curious after my ‘porn on the train’ experience to understand more about the issue, and what we know (or as I found out, don’t know) about ‘porn on the brain’. So here I’ll focus on what some neuroscientific studies on this topic actually show.
It turns out that the brains of people who are considered ‘high porn consumers’ are different in both structure and function from the brains of those who watch porn only occasionally or not at all. The first study to explore this issue was published in 2014 by Simone Kühn and Jürgen Gallinat; they scanned the brains of 64 men who had reported their hours of porn consumption. (The average was 4 hours a week, but consumption ranged from 0 to 19 hours a week.) The researchers found an association between the number of hours that pornography was viewed, and the size and activity of certain brain structures. Specifically, high porn consumers had smaller volumes of the right caudate, part of the striatum – a ‘deep brain’ structure that is part of the basal ganglia and is known to be involved in reward processing (as discussed in Chapter 6). High porn consumers also showed less activity in the left putamen (also part of the basal ganglia) when viewing explicit sexual images, and less functional connectivity between the right caudate and left dorsolateral prefrontal cortex (in the frontal lobe) when compared with low porn consumers.
The dorsolateral prefrontal area is interconnected with other parts of the prefrontal cortex that mediate an incredible array of social, emotional and cognitive functions. The authors consider the dorsolateral prefrontal cortex to be ‘a key area for the integration of sensory information with behavioural intentions, rules and rewards’. The ‘frontostriatal’ network (which refers to the connections between the frontal regions and basal ganglia) is thought to help us choose the most relevant motor action in response to stimuli. Dysfunctions in this network have been related to inappropriate behavioural choices, such as drug seeking, which occur regardless of negative outcomes. So the functions of the brain regions in which differences were found are relevant to porn viewing, an activity that involves reward and motor actions, and engages social and emotional processes.
Although there were clear differences between the brains of men who viewed a lot of porn and those who viewed a little, what these findings do not tell us is whether viewing pornography actually caused those changes. It could be that these brain differences are pre-existing in men who watch a lot of porn, and predispose them to this behaviour. In other words, having a smaller right caudate and a less active left putamen could make you desire porn more than other people, and mean that you need more external visual stimulation to experience pleasure; you would therefore find porn more rewarding than other people might, leading to higher levels of consumption. Rather than being a consequence of frequent pornography consumption, these brain differences might actually be a precondition for it. The research done so far cannot answer this question of what causes what; it only tells us that the brains of high porn consumers are different. Interestingly, the high porn consumers were more likely to be depressed and have an alcohol use disorder; both these conditions are known to cause brain changes, so this adds another layer of complexity that needs to be addressed by future research.
IT’S ALSO NOT POSSIBLE TO TALK ABOUT ‘ADDICTION’ to porn without raising a related proposed condition: ‘sex addiction’. Most of us know the term due to several famous people who have been labelled ‘sex addicts’ or have claimed the title themselves, such as former US president John F Kennedy, actor Billy Bob Thornton and rapper Kanye West. In the TV show Californication, David Duchovny’s character Hank Moody is considered a textbook case of a person with ‘sex addiction’; in real life, Duchovny actually checked into a rehabilitation centre specifically for this reason. Despite the availability of specialised private clinics, rehabilitation centres and therapists offering treatment for ‘sex addiction’, it is a highly controversial condition and there is ongoing debate about whether it really is a bona fide addiction, and whether it should actually be formally classified as a mental or behavioural disorder.
I spoke with David Ley, a practising clinical psychologist, author and sexuality expert who has written several books including The Myth of Sex Addiction (2012). ‘The field of porn addiction is a mess, littered with pseudoscience, moral biases, and conclusions drawn in advance of the data,’ David said to me. Fundamentally, he said, the ‘sex and porn addiction’ proponents argue that ‘there are universal, homogeneous effects’ of sex and porn consumption on people, but ‘this is far from true’. ‘There’s a wealth of data demonstrating that alleged effects of sex or porn are extremely individualised, sensitive to personal, social, cultural and environmental contexts,’ he argues.
So how did the concept of ‘porn addiction’ arise in the first place? David highlighted the cultural and religious factors that propelled the idea forward. Religious institutions in the 1980s first popularised the idea to promote and drive legislation against pornography access; this was also around the time of the AIDS crisis, when there was a lot of fear about sex causing death. He said conservative churches ‘latched onto the concept of porn and sex addiction to outsource moral management to a pseudo–health care industry. If it’s a disease and not a moral issue, the church doesn’t have to manage it – they just tell the person to go and get treatment.’
The first book on sex addiction was written in the early 1980s by Patrick Carnes; in it Carnes identified homosexuality as a disease and addiction (though he did not repeat the claim in his subsequent books). Carnes applied to sex a 12-step model of addiction treatment usually used for drug and alcohol addictions. ‘It’s a nice theory but where’s the data?’ David queried, adding that there are no published, peer-reviewed, empirical studies that show that this treatment model is effective.
In the early 2010s, anti-pornography religious groups began to promote porn addiction as a brain disease, and the notion of porn changing the brain became a hot topic of discussion. But for David, the whole concept and industry of porn/sex addiction is based on conservative moral values around sexuality that intrude into clinical practice: ‘These conditions have been rejected by scientific and medical groups for well over 40 years, but are clung to by dedicated folks who have deep moral issues around sex, or are financially dependent upon the concept.’ He also pointed out that ‘across most definitions of sex addiction, masturbation, promiscuity and forms of infidelity are consistently identified as symptoms, and within religious individuals, same-sex desires are perceived as “addictive”’.
I also found it fascinating when David described how the concepts of porn and sex ‘addiction’ were supported much more in the United States than anywhere else in the world: ‘Other countries do not have the huge, lucrative, entrenched industry that we do, which is, notably, clustered in highly religious states.’ He gave the example that the state of Utah has the highest number of conservative Mormons, the highest level of porn consumption, and the highest number of porn/sex addiction treatment centres. So what is it about the United States that is so special in regard to this phenomenon? David’s view is that ‘it emerges from the American conflict about sex. We are obsessed with it and afraid of it at the same time.’ The high numbers of religious conservatives in the United States is another factor, he argued.
In David’s experience, he said, many advocates for the sex or porn addiction concept are themselves self-identified ‘sex addicts’. ‘That raises serious concerns about the possible intrusion of confirmation bias,’ he noted. Another issue he raised is that most mental health professionals have little or no specific training in human sexuality. He quoted Alfred Kinsey, the famous American sex researcher with an institute that bears his name, who said that the definition of a nymphomaniac – or ‘sex addict’, in today’s language – is someone who’s having more sex, or different sex, from what the therapist is having.
The notion of excessive sexual behaviour has been around for hundreds of years. American physician Benjamin Rush (1745–1813) described various mental disorders he believed arose from ‘indulgence of the sexual appetite’, while nineteenth-century sexologists Richard von Krafft-Ebing, Havelock Ellis and Magnus Hirschfeld all reported cases of both men and women who displayed excessive and ‘maladaptive’ sexual appetites and compulsive masturbation. In the twentieth century, the terms ‘Don Juanism’ or ‘satyriasis’ were adopted for males and ‘nymphomania’ for females who showed such behaviours. In the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) in 1987, sexual addiction was defined as ‘distress about a pattern of repeated sexual conquests or other forms of nonparaphilic sexual addiction, involving a succession of people who exist only as things to be used’. Later versions of the DSM dropped the terms ‘non-paraphilic’ and ‘sexual addiction’ as there was not enough research and no agreement about whether sexual behaviours could constitute an addiction.
In addition to ‘sex addiction’, excessive sexual behaviour has also been labelled ‘hypersexual disorder’, ‘problematic hypersexual behaviour’ and ‘compulsive sexual behaviours’. More recently, the term ‘compulsive sexual behaviour disorder’ has been adopted in the first formal recognition of this phenomenon as a diagnostic entity, appearing in the most recent and eleventh version of the World Health Organization’s International Classification of Disease (ICD-11) in late 2018. ‘Compulsive sexual behaviour disorder’ is listed as an ‘impulse control’ disorder rather than being grouped with substance abuse disorders and other addiction-type conditions. The World Health Organization took a cautious approach, acknowledging that ‘we do not yet have definitive information on whether the processes involved in the development and maintenance of the disorder are equivalent to those observed in substance disorders, gambling and gaming’.
The concepts of ‘porn addiction’ and ‘sex addiction’ are not currently recognised by the major sex therapy organisations and associations in the United States; in fact, the American Association of Sexuality Educators, Counselors and Therapists (AASECT) put out an official statement saying that (1) it did not find ‘sufficient empirical evidence to support the classification of sex addiction or porn addiction as a mental health disorder’; and (2) that it found that sex addiction ‘training and treatment methods’, and the theory behind them, was not ‘adequately informed by accurate human sexuality knowledge’.
I asked David about the commonly expressed notion that porn use shared similarities with other types of addictions, like substance use. There’s a stark difference in physical effects and the process of ‘withdrawal’, for one, David noted: ‘No one in the history of the world has ever died from blue balls, or not getting to have sex when they want to. But removing alcohol from a long-term alcoholic can and does result in seizure and death.’ What about similarities in relation to porn use for things such as ‘habituation’ – the brain becoming less responsive to a stimulus over time, and needing more and more of it to feel the same reward – and the related notion of ‘escalation’ (the progression from ‘vanilla’ porn to more extreme porn)? ‘There is no evidence that porn results in a habituation or desensitisation effect that is distinguishable from normal changes in sexual development,’ David said to me. ‘A great deal of research on porn consumption actually demonstrates that people on average watch the same kind of porn over and over, and there is no evidence of a slippery slope leading to more “extreme” types of porn over time.’
David said that in most studies on porn use, ‘extreme’ use is typically categorised as only 17 minutes to one hour per day, while the ‘average’ use is 10–15 minutes a week. ‘Is it really changing brains at that level of use?’ David asked, ‘especially when the average US citizen watches five hours of TV a day’. ‘Why is it that pornography is considered to have this wild brain effect? Either it’s because it’s sexual, or because people are masturbating while watching it.’ In his opinion, masturbation frequency is a big issue that has not been adequately addressed in current neuroimaging studies of porn use.
SEX, RELIGION, POLITICS AND MONEY: AREN’T THESE all the things we shouldn’t discuss if we want to avoid trouble? And here I am talking about all of them! David told me trouble has indeed come his way, simply for being outspoken and challenging the validity of the concept of porn/sex addiction. He gets fairly regular hate mail and death threats from hardcore advocates of the concept. He is not the only one to have received such threats. This has also happened to sex researcher Dr Nicole Prause (see Chapter 5). She studied genital physiology for years, and it was only when she started doing research on porn use and reporting her findings that challenged some of the notions of the porn addiction concept that the threats began. ‘It’s a tough area. There are so many minefields,’ she said to me. When I commented that she must have been brave to embark on this research topic, she laughed and said, ‘Yes – and a little stupid!’
A common concern you’ll hear is that if you watch a lot of porn, you’ll eventually become unresponsive to your partner, and develop difficulties in responding sexually. But Nicole’s work on female orgasms doesn’t support this. She has found empirical evidence that porn use in women does not diminish sexual pleasure at all. In fact, it appears to do the reverse and actually enhance it. The women in her female orgasm study who reported the most porn use also reported experiencing the most intense orgasms. ‘Orgasm is a reflex – the physiology is what it is. So there’s no reason to think porn should alter it. This is really interesting.’ She also found, in a recent study of couples, that those who watched more porn reported a stronger sexual urge just before their partnered sexual interactions in the lab, and that their porn use didn’t impact at all on their sexual physiological responses; they showed no differences in their responses from those couples who didn’t watch porn.
Nicole argues that people who watch a lot of porn have high sex drives. ‘They engage with a lot of porn because they engage in a lot of sex. If they are distressed by this, there is typically a moral conflict,’ she said. In her work she has found a lot of ‘mixed affect’ – that is, positive and negative emotions – associated with porn use. ‘When people are asked about how they feel after watching porn alone, they report feeling sexually aroused, happy and excited, but also guilty, sad and anxious. But if they are watching it with a partner, they report the same positive emotions, in addition to feeling less sad and anxious.’ She also points out that ‘no one just watches porn – they masturbate to it’. This means that masturbation and orgasm are what are called the ‘primary reinforcers’, while porn is a ‘secondary reinforcer’. ‘There is some evidence that these two types of rewards/reinforcers have overlapping but distinct neural representations,’ Nicole said to me. This may be the reason why porn viewing habits alone have not been found to cause difficulties in sexual arousal or response with a partner. Masturbation habits, though, may generalise to sex with a partner, Nicole suggested. The conflation of masturbation habits with porn use will be discussed a little later.
FOR NOW, LET’S HEAD BACK TO THAT NEWLY PROPOSED ICD-11 diagnosis of ‘compulsive sexual behaviour disorder’ – what exactly is it, and what symptoms do you need to be given this diagnosis? As outlined by psychologist Shane Kraus and colleagues, it is characterised by a ‘persistent pattern of failure to control intense, repetitive sexual impulse or urges, resulting in repetitive sexual behaviour over an extended period (e.g., six months or more) that causes marked distress or impairment in personal, family, social, educational, occupational or other important areas of functioning’. A diagnosis of compulsive sexual behaviour disorder can only be made if the repetitive sexual behaviours consume all aspects of a person’s life, so that they neglect everything else – their work, health and personal care. They have to have made attempts to control it, and continue to engage in it despite consequences such as repeated relationship breakdowns. So, you can’t be diagnosed with compulsive sexual behaviour disorder if you have a high sex drive that you can control and that causes you no distress or impairment in everyday functioning. The diagnosis also can’t be given to people with high levels of sexual interest and behaviour (for example, masturbation) that are common in adolescents, even if the person suffers psychological distress. If the psychological distress is related to moral judgments or social disapproval about sexual impulses or behaviours, no diagnosis can be made. It’s difficult to know the prevalence of this disorder given the inconsistent definitions and absence of community-based data, but it is estimated at somewhere around 3–6 per cent in adults. Interestingly, David argued that most people currently diagnosed as sex/porn addicts would not qualify (for this diagnosis). He also noted that the World Health Organization has not yet formally approved the proposed diagnosis, and even if it does, it’s unlikely to have any effect in the United States, the sex/porn addiction centre of the world, as they use the DSM and not the ICD for psychiatric diagnoses.
I wondered if people identified as having ‘compulsive sexual behaviour disorder’ have different brains. Would their brains display similarities to those of high porn consumers? This question has recently been addressed by neuroimaging research. Heterosexual males with ‘problematic hypersexual behaviour’ were recruited via meetings for ‘sex addicts’ and treatment facilities for ‘sex addiction’. The men studied had each had an average number of 20 sexual partners in the previous six months, had sex on average three times a week, masturbated on average five times a week and viewed pornography five times per week. They were compared with a control group of males with the same level of education and income who did not report ‘hypersexual’ behaviours on screening tests. Men in the control group had an average number of two sexual partners in the previous six months, had sex on average less than once a week, masturbated on average once a week and viewed pornography twice a week.
Participants’ brains were scanned while they viewed sexual images of naked women and sexual activities, and while they viewed ‘non-sexual’ images of water sport activities. Compared with the controls, the hypersexual men expressed greater sexual desire when viewing the sexual images and also showed greater activation in certain brain regions, including many that have been mentioned in this book already, such as the right frontal region (specifically the dorsolateral prefrontal cortex), and subcortical regions including the right dorsal anterior cingulate cortex, left caudate nucleus and right thalamus. These brain regions are known to be involved in motivation, reward processing and physiological responses – in other words, getting ready for sexual activity. The authors reported that the level of activation in frontal regions and the thalamus were directly correlated with the severity of the participants’ sex ‘addiction’. In other words, there was more brain activation in men who had higher scores on a hypersexual behaviour questionnaire. The authors of the study also reported that the functional brain changes observed were similar to those in people with substance addictions, so it is clear that these researchers are coming from the ‘sex addiction is a true addiction’ camp.
These same researchers did another study looking at structural brain differences in hypersexual men. They found that the temporal lobes of men who displayed ‘problematic hypersexual behaviours’ were reduced in volume (yes, once again, there is no doubting the temporal lobe’s status as central to the sexual neural network), and also found reduced connectivity between these smaller temporal regions and other brain areas, including the left precuneus (involved in attention shifting) and the right caudate (involved in reward processing). The authors point out that people with addiction problems have trouble with shifting their attention and with reward-based behavioural learning; these relate to the maintenance of addictive behaviours. I was surprised to see they referred to my own PhD studies in their discussion of the role of the temporal lobes in human sexual behaviour. They argue that the temporal regions are related to inhibition of the development of sexual arousal – in other words, they put the brakes on your sex drive. If there is damage or dysfunction in the temporal lobes (and as we know from earlier discussions, specifically the amygdalae within the temporal lobes), then these brakes become faulty and there is an alleviation of the inhibition which can potentially lead to hypersexuality (see Chapter 1).
Nevertheless, just like the neuroimaging research on frequent consumers of pornography, these studies are correlational. That means they only show a mutual relationship between two things. They don’t tell us the cause. So we don’t know if these brain differences predispose people to compulsive sexual disorder or are actually the result of it – or are actually related to something else altogether! Like high porn consumers, people with hypersexual disorders have been found to have high rates of depression and anxiety. They can also have features of attention deficit and hyperactivity disorder (ADHD) and obsessive-compulsive disorder. All these conditions are associated with changes to brain structure and function, so disentangling all of this is extremely complex.
David Ley also highlighted that none of the neuroimaging studies addressing this issue (of brain differences in so-called sex or porn addicts) have considered critical issues such as libido, frequency of masturbation and differences in sensation seeking – a personality trait involving the tendency to seek out new and intense sensations or experiences, even if they are risky, which in itself is associated with brain differences. There is still a lot more research to be done to disentangle all of these factors and determine how they might impact on brain structure and function. In a nutshell: just because brain differences are found in people with a high frequency of sex or porn use, it doesn’t mean these differences are definitely the cause or the result of their sexual behaviours. There is much more research that needs to be done before it will be possible to answer the question ‘can porn change your brain?’
ALTHOUGH THE RESEARCH IS NOT CONCLUSIVE, I wanted to talk to some people working on the frontline of providing treatments for people with excessive sexual behaviours to find out their opinions. Dr Vanessa Thompson is a sex therapist who has worked in private practice in Australia for a decade and sees a diverse range of people, including ‘mainstream’ clients, people with intellectual disability, and people who have committed sexual offences. She told me there is no ‘typical’ sex therapy client. She sees an equal number of males and females, ranging in age from school-aged children who have suffered sexual abuse to men in their eighties who need help with erectile problems.
I asked her about people with so-called ‘sex addiction’. ‘I’ve seen so many people who just love sex a lot – mainly men who definitely struggle to control their sexual urges,’ she said, but she is not in the addiction camp. ‘I don’t work from an addiction perspective,’ she clarified. ‘When you treat an addiction you try to stop the behaviour. With sex addiction, you don’t want them to leave therapy nonsexual. They don’t want this, and neither do their partners.’ She follows what she calls a ‘sexual control’ model, ‘to teach them to understand their thoughts and behaviours and get some control over them’. ‘Sexual control’, she explained, was different for everyone; for example, what is acceptable for a single guy in his twenties may not be for a married guy in his thirties. ‘It’s about them being in control of what they’re doing. Not me telling them what’s wrong with what they’re doing or saying, “You can’t do this or that.”’
So how did she end up being a sex therapist? Vanessa said she had always been interested in sexual health and during her undergraduate degree, her first assignment was interviewing people on the university campus about whether they used condoms. She then worked in behaviour intervention for people with intellectual disability and brain injury and described herself as ‘the only person in the team who could say “penis” without laughing’. She ended up seeing all the clients who had problematic ‘sexualised behaviours’, such as exposing their genitals or public masturbation. She admitted that initially she had no idea what she was doing, so she tried to learn all she could by attending different courses around the country; she ended up doing a Master of Health Science (Sexual Health), qualifying as a sex therapist and then completing her PhD on ‘sexual knowledge assessment tools for people with intellectual disability’.
Vanessa has provided therapy to people who have experienced a brain injury and resultant hyposexuality, hypersexuality or inability to orgasm. She couldn’t recall any clients with paraphilias after brain injury but commented that it was difficult to assess whether people affected in this way had had ‘unique interests’ before their injuries; some may have already had a tendency to be outside the ‘vanilla’ – the conventional – realm in their sexual behaviours or preferences, she suggested. She recalled one of her first private practice clients who was referred for hypersexuality after brain injury, and who arrived at her office and immediately dropped his pants, revealing his penis to her shocked receptionist. He was a single man desperately seeking partners, but ‘there was nowhere he could get his sexual needs met. Sex workers were too expensive for him.’ Their therapy sessions involved making rules and a ‘contract’ that they agreed on, setting up a plan and structure that he could follow, and giving him advice on the best ways to find a sexual partner (certainly not by immediately dropping your pants!).
Vanessa’s approach is very directive: she tells people what to try and gives them homework to do, then they report back to her what works or doesn’t work for them. There is ‘no touching or looking at bits’ in her sessions, she emphasised. ‘No Masters and Johnson here!’ – in other words, her therapy doesn’t include watching people have sex. At the core of her practice is an acknowledgment of individual differences. ‘Everyone is different. There’s no point me telling them they have to put their finger up their nose if they don’t want to do it,’ she said. Her favourite part of her work is ‘seeing people succeed and reach their goals’. Her least favourite part is when clients ‘divert away from talking about sex and start talking about who’s doing the dishes…Relationship dynamics definitely come into play, but I’d rather they see a couples counsellor and just let me deal with the sex.’
I also spoke with Brian Russman, an American psychotherapist who has worked in the addiction field for nearly two decades. He tells me he is a ‘Certified Sex Addiction Therapist’ under the training scheme founded by Patrick Carnes. I was curious to learn what a ‘certified sex addiction therapist’ actually does. Brian is the deputy chief clinical officer at a specialised addiction treatment centre in Thailand; its website offers views of lush grounds with people meditating, being massaged and exercising by a pool. The music that played while the images rolled across my screen sounded hopeful, like it was specifically composed to make people think, ‘This will fix me.’ It looked more like an expensive holiday resort than a treatment centre, and I wondered how the people who stayed there could afford it.
Brian estimated that in the six months that he had spent working in an outpatient clinic in Singapore, 50 per cent of his clients had presented for ‘primary sex addiction’. He reflected that this may be an environmental issue, as the penalties for illicit drug use in Singapore are severe, so there are more sex, gambling and cyber addictions. At his workplace in Thailand, he estimated that 10–15 per cent of the people in residential treatment have a primary sex or cyber addiction.
‘We’re starting to see a huge tidal wave of people with sex and cyber addictions,’ he said. ‘Ten years ago, I rarely saw people with primary sex addiction, and never saw gaming disorder. These two addictions are now presenting much more for treatment, and it’s the direct result of the internet. The vast majority of those with sex addiction have a component that is related to the internet, whether it’s using porn or seeking partners through sites such as Tinder or Grindr.’ He sees more males than females with sex addiction, at a ratio of about 4:1, and also mentioned that his patients often have paraphilias, typically exhibitionism or voyeurism, and more rarely fetishes for things like spectacles, feet or shoes.
People typically refer themselves to the Thai treatment centre where he works. ‘Nine times out of ten, if they think they have a sex addiction, they do,’ he said. He seemed genuinely excited about the recognition of ‘sex addiction’ in the ICD-11. He didn’t refer to its official diagnostic label of ‘compulsive sexual behaviour disorder’, but perhaps for him and some others working in the field, these terms refer to the same behaviours, and so they use them interchangeably. He believes that formal recognition of the disorder would make life easier for those who have it and pave the way for more research. ‘It’s a catch 22 because if it is not a bona fide disorder then there’s no money for research or treatment, which makes it hard to make the diagnosis official. There’s also a lot of shame and stigma if it is not a legitimate diagnosis.’
I asked Brian how he treats his clients with ‘sex addiction’. After his assessment, he makes an ‘abstinence contract’ with his client. ‘The rule of thumb is 90 days,’ he explained. ‘No masturbation [or] sex with any partner; no caffeine, sugar, nicotine or alcohol. The hedonic set point is at such a high level. The rationale is to reset the brain.’ This phrase, ‘resetting the brain’, came up several times in our conversation. It certainly is a powerful metaphor that is easy to comprehend, but I couldn’t help wondering if a carefully designed and rigorous neuroimaging study would actually show any brain changes in response to abstinence from porn or sex. The jury is still out on the question of whether porn changes the brain, or if some people are just born with brains wired for porn. You don’t really need to know the answer to this if you are just exploring if abstinence changes the brain. Brian acknowledged that for those who he sees as having ‘sex addiction’, complete abstinence for the rest of their lives is not the goal, although it would be for alcohol and drug addictions. He said that ‘healthy sexual behaviours’ are slowly reintroduced after the period of abstinence. ‘Having said that, porn is not an option,’ he clarified.
Coming as he does from the non-addiction camp, David Ley takes a different approach. He doesn’t believe that porn ‘changes’ the brain. ‘The brain is constantly changing,’ he said to me. ‘The crazy language about rebooting the brain after 90 days of abstinence? It’s wild stuff.’ In contrast to Brian’s idea that a formal diagnosis of ‘sex addiction’ as a mental disorder would destigmatise the condition, David argues that the sex/porn addiction model and portrayal of these conditions as emerging from a brain issue – the ‘brain-disease fallacy’ of addiction, as it has been called – actually increases stigma and leads to people believing that these behaviours cannot be changed.
His approach to treating people who have previously been diagnosed with a sex or porn ‘addiction’ is also very different:
If I walk into a doctor’s office sneezing, they don’t say to me, ‘You’ve got a sneezing addiction.’ They try to figure out what’s underlying it – is it a virus, an allergy, a bacterial infection? That’s what I do. I try to figure out what purpose or function the behaviour serves. Why is it a conflict?
He uses psychotherapy techniques including cognitive behavioural therapy, a thoroughly researched, empirically tested and effective psychological treatment for a variety of mental health conditions. He is firm in his view that ‘as clinicians, we have an absolute ethical obligation to not promote unproven experimental treatments without acknowledging their severe limitations’.
David also had an interesting point about treatment and recovery from sex addiction. He told me about research that had shown that 95 per cent of people who self-identify as addicted to sex or porn actually get better on their own, without any treatment, within a year. Being older and having better adjustment in life are protective factors from developing any so-called behavioural (as opposed to substance use) addictions. This suggests that these ‘behavioural addictions’ are not a disease, he said, but ‘reflect the need to adjust and accommodate to changes in life’.
THIS CHAPTER HAS BEEN A MERE INTRODUCTION TO the complexity of the highly controversial concept of porn and sex ‘addictions’. Given that there is ongoing debate among experts and clinicians in the field about whether these are bona fide ‘addictions’, it is no surprise that our understanding of the neural basis of excessive porn use or compulsive sexual behaviour disorder is currently limited. Pre-existing brain abnormalities such as differences in the size of certain brain structures might make you more likely to watch a lot of porn, or predispose you to developing compulsive sexual behaviour disorder – or these brain differences could actually be the result of frequent porn use or excessive sex, or even due to something else entirely, like differences in sensation seeking or associated mental health conditions. I would have loved to do a neuropsychological assessment on my fellow train commuter, just to contribute a tiny piece to the puzzle – to understand the cognitive profile of someone who appeared to see nothing unusual about openly watching porn on his peak-hour train ride.
Who knows what the future holds for research into the neural correlates of frequent porn use and compulsive sexual behaviour? Will there ever be agreement among clinicians, scientists and other experts in the field about whether there is such a thing as sex or porn ‘addiction’? What cultural factors are at play right now that impact on all of these issues? So many questions are raised, and it is only by conducting more methodologically rigorous scientific research that we will find answers. Hopefully some more researchers will be brave enough to take on the challenge.