Stanton reviews a new medical tome on sexual addiction, by psychoanalyst Aviel Goodman. Yes, people become addicted to sex; no, it is not a medical disease best treated by the 12 steps.

Review of Sexual Addiction: An Integrated Approach, by Aviel Goodman

Stanton Peele
Morristown, NJ

Sex can be addictive. Addictive sex and love are culture bound, and are especially prevalent in the United States and some other Western societies. Sexual addiction is not a disease. Addictive sex occurs on a continuum, with a large part of the population displaying some degree of sex addiction over their life spans. Sexual addiction is resolved when people believe they can—and have the resources to—achieve sufficient gratification from activities inconsistent with compulsive sex.

One who wishes to deal with addictions other than drugs or alcohol can either approach the topic phenomenologically or behaviorally (cf. Marlatt & Gordon, 1985; Peele & Brodsky, 1975/1991; Peele, 1985/1998) or else claim that somehow the observed behavior implicates biological systems that can be linked to addiction (see Peele, 1981). Today, the National Institute of Mental Health, National Institute on Drug Abuse, and National Institute on Alcohol Abuse and Alcoholism are all committed to uncovering a fundamental neurobiological "cause of addiction" (Hyman, 1996).

The most common and influential current of thought about addiction in the United States has grown from the 12-step philosophy originally developed and presented by Alcoholics Anonymous (AA). AA is a folk movement that adopted the symbolic position that alcoholism is a disease. But the 12 steps' constant reference to a higher power and AA's use of group sessions resembling religious confessionals have created a peculiarly American system of hospital and auxiliary chemical dependence treatment based almost exclusively on a spiritually oriented approach to behavior change. To the extent that the 12 steps are practiced as a systematic treatment, they comprise a behavioral-experiential therapy. Opportunistically, however, many 12-step advocates claim that alcoholism is completely biological in its genesis. Meanwhile, the 12-step approach has been applied to a host of behaviors, including compulsive gambling, shopping, sexuality, and so on.

Aviel Goodman, a psychoanalytically oriented psychiatrist, is by experience, personal orientation, and treatment approach in the experiential and behavioral realm. Yet he seeks to justify the reality of his clients' experiences of intense suffering brought on by compulsive sexual behavior by claiming its source is biological. Goodman also identifies as his direct predecessor in labeling sexual addiction Patrick Carnes (1983), someone steeped in AA and the so-called "Minnesota Model" of 12-step treatment.

Goodman discursively cites a large body of research he believes demonstrates a biological etiology for compulsive masturbation, promiscuous sexual encounters, and resorting to prostitutes for sex. Nonetheless, Goodman does not sacrifice his independent perspective—he argues that psychological and biological perspectives are equally valid. In this light, his encyclopedic references represent an effort to give credit to and to learn from the entire range of professional orientations and bodies of research that contribute to addiction theory.

Of course, even many who follow the 12-step ideology or who search for medical cures for most human maladies might view sexual addiction as falling outside their purview, particularly given the ironclad 12-step, disease-treatment requirement of abstinence. Cases like food or sex, in which the problem behavior cannot totally be eliminated from a person's repertoire, seemingly demand transcendence of 12-step boundaries. Goodman does so easily and sensibly, for instance by directing his clients to confront internal conflicts that he believes underlie their compulsive sexual behavior. He also understands the concept makes the most sense in its adverbial form:

Any behavior that can function both to produce pleasure and to relieve painful effects can be used addictively; and the more effective a behavior is at producing pleasure or at relieving painful effects for a particular individual who is predisposed to use behaviors addictively, the more likely is the individual to engage addictively in that behavior. (p. 19)

However, Goodman's success at integrating all factors contributing to addiction is questionable. Goodman asserts that addicts are neurobiologically predisposed to addiction—or, indeed, to affective, anxiety, personality, and attention-deficit disorders as well as every possible kind of addiction, from gambling to drugs to bulimia, and, underlying all these, to obsessive-compulsive and affective-spectrum disorders. (From an evolutionary genetics standpoint, how did such a genotype survive?) The particular outlet for this predisposition is then determined by experience—"In the presence of these underlying vulnerabilities, bulimics seem to select the eating of food as their prosthetic self-regulatory behavior primarily because food is unconsciously identified with the mother" (p. 167). Goodman's resolution of the biological and psychological, although hopeful—"We can see that the psychological formulation of the addictive process and the neurobiological formulation of the addictive process are consistent with each other; that they are moreover, to a great extent, isomorphic with each other" (p. 219)—includes a lot of unexamined philosophical turf.

Goodman makes more sense in combining two more closely-related areas of theory—psychoanalytic and social learning: "Impaired internal regulation of their subjective states leads individuals to depend on external actions to regulate their subjective states and to cope with the subjective consequences of internal dysregulation" (p. 175). His citation of cognitive-behavioral alcohol and other addiction research is sound, but the theorists with whom Goodman is most inward are psychoanalytic thinkers not central to addiction theory—Leon Wurmser, Otto Fenichel, Robert A. Prentky, Eric Hollander, Ismond Rosen—and one who is, Edward Khantzian.

Goodman is not forceful enough in confronting the inherent conflicts between his own perceptions and treatment approach and medical and biological perspectives (as in his fatuous repetition of the claim that "psychotherapy is a biological treatment"). The universality of sex gainsays deterministic addictive models that entail the stimulation of neuroreceptors and endorphins to explain how daily activities implicate fundamental addictive mechanisms. The obvious question is always, Why then does not everyone who engages in the activity become addicted to it? The idea of "born addicts" ordained by genes to react addictively to narcotics (or something or everything else) is quickly refuted by standard epidemiological surveys showing tremendous variability in the individual's tendency to be addicted over time and in different settings. Neurochemical and genetic theories are not economical ways to explain how it was that so many heroin addicts in Vietnam came home to use narcotics nonaddictively in the United States (Robins, Davis, & Goodwin, 1974).