Dismantling the “group position” paper opposing porn and sex addiction (November, 2017)

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Introduction

In early November, 2017 three non-profit kink organizations (Center for Positive Sexuality, National Coalition for Sexual Freedom, and The Alternative Sexualities Health Research Alliance) released a group position paper "opposing the addiction model in relation to frequent sexual behavior and pornography viewing." The groups' press release, Position statement opposing sex/porn addiction model, explained their motivations:

"These organizations cite AASECT's statement as one of the reasons for their joint statement, as well as citing many scientific studies that reject the addiction model in relation to these sexual behaviors."

Contrary to this PR statement, there are no "scientific studies that reject the addiction model," and ASSECT's proclamation provided no studies to support its own assertions. As for the 3 kink organizations' proclamation, all their "evidence" (which we examine below) is packed into this handy PDF: Addiction to Porn/Sex Position Statement.

We suspect the primary reason for yet another public relations push (as it was with AASECT) is that the World Health Organization's upcoming edition of its diagnostic manual, the ICD-11, includes a diagnosis for “Compulsive Sexual Behavior Disorder.”  Due out in 2018, "Compulsive Sexual Behavior Disorder" (CSB) will function as an umbrella to diagnose both sex addiction and pornography addiction. And some sexual communities incorrectly perceive this as an attack on their behavior. It isn't.

Like the other items now being pushed out as part of this campaign to manufacture "astroturf" resistance to porn/sex addiction, the current proclamation relies primarily on a single flawed study to support its bald assertions, while simultaneously disregarding 3 dozen neurological studies that support the addiction model. For more, see this article: How to Recognize Biased Articles: They Cite Prause et al 2015 (falsely claiming it debunks porn addiction), While Omitting Over 35 Neurological Studies Supporting Porn Addiction.

The opening paragraph of the proclamation

Let’s start with the proclamation’s opening paragraph, which omitted some 50 relevant neurological studies and reviews of the literature, while misrepresenting many of the studies it did cite.

"Although some academic and professional reports have supported the application of an addiction model to frequent sexual behavior and/or pornography viewing (i.e., Hilton & Watts, 2011; Kafka, 2010), others point out serious potential or actual problems with applying an addiction model to sexual behavior and pornography viewing (Ley, 2012; Ley, Prause, & Finn, 2014; Reid & Kafka, 2014; Giugliano, 2009; Hall, 2014; Karila et al., 2014; Moser, 2013; Kor, Fogel, Reid, & Potenza, 2013; Ley et al., 2014; Prause & Fong, 2015; Prause, Steele, Staley, Sabatinelli, & Hajcak, 2015)."

What this proclamation purposely omitted: 

Next, let’s look at the proclamation’s scientific support for its statement that “others point out serious potential or actual problems with applying an addiction model to sexual behavior and pornography viewing”:

1) Ley, 2012: Not peer-reviewed. It's a book: The Myth of Sex Addiction by David Ley.

2) Ley, Prause, & Finn, 2014: An opinion piece commissioned by a minor journal (Current Sexual Health Reports). The lead author has never published any original research, yet was asked to give his opinion of pornography addiction and addiction in general. Virtually nothing in the opinion piece is backed up by the studies it cited. This extensive critique dismantles Ley et al., 2014 - claim by claim and documents dozens of misrepresentations of the research the authors cited. The most shocking aspect of the Ley paper is that it omitted ALL the many studies that reported negative effects related to porn use or found porn addiction. Also know that Current Sexual Health Reports has a short and rocky history. It started publishing in 2004, and then went on hiatus in 2008, only to be resurrected in 2014, just in time to feature Ley et al.'s "review."

3) Reid & Kafka, 2014: This paper hypothesizes why hypersexuality didn’t make it into the DSM-5 (Diagnostic and Statistical Manual). However, both Reid & Kafka favored hypersexuality for inclusion in the DSM. See this 2012 UCLA press release by Rory Reid: Science supports sex addiction as a legitimate disorder.

4) Giugliano, 2009: This older paper, by a past president of SASH, set out to question sex addiction, but results didn’t support the author’s hypothesis. Nowhere does it suggest that sex addiction doesn’t exist. See the SASH position paper on sex and porn addiction.

5) Hall, 2014: This article by UK therapist Paula Hall supports the existence of sex addiction. See this TEDx talk by Paula Hall - We Need To Talk About Sex Addiction.

6) Karila et al., 2014: This paper supports the existence of sex addiction. From the abstract: "Sexual addiction, which is also known as hypersexual disorder, has largely been ignored by psychiatrists, even though the condition causes serious psychosocial problems for many people."

7) Moser, 2013: Charles Moser is a known “sex addiction” skeptic. In fact, as the Section Editor of Current Sexual Health Reports, he is the one who invited Ley, Prause and Finn to do their pseudo-review discussed above, Ley et al., 2014.  

8) Kor, Fogel, Reid, & Potenza, 2013: This paper supports the existence of sex addiction. From the conclusion: "Although many gaps exist in knowledge in our understanding of HD, available data suggest that considering hypersexuality disorder within an addiction framework may be appropriate and helpful."

9) Ley et al., 2014: Same citation as #2.

10) Prause & Fong, 2015: This item was not peer-reviewed. It’s a short opinion piece in a lay volume, much of which is devoted to chronicling the mythology of Prause's victimization.

11) Prause, Steele, Staley, Sabatinelli, & Hajcak, 2015: A single EEG study. No less than six peer-reviewed papers say that this paper, Prause et al., 2015, lends support to the addition model: 1, 2, 3, 4, 5, 6. The neuroscientists on these six papers state that Prause et al. actually found desensitization/habituation (consistent with the development of addiction), as less brain activation to vanilla porn (pictures) was related to greater porn use.

So, let's summarize the evidence for the campaign by these 3 organizations: Five of the eleven references explicitly support the addiction model, two references aren’t peer-reviewed, and one is a repeat of an earlier reference.

The three remaining references arise from 3 individuals who have often teamed up to "debunk" porn and sex addiction: David Ley, Nicole Prause and Charles Moser. Ley and Prause wrote Ley et al., 2014 (which Moser commissioned), and at least two Psychology Today blog posts. Charles Moser also teamed up with Ley and Prause to "debunk" porn addiction at the February 2015 ISSWSH conference. They presented a 2-hour symposium: "Porn Addiction, Sex Addiction, or just another OCD?" The lone neurological study out of the remaining three (Prause et al., 2015) is regarded by six peer-reviewed papers as consistent with the addiction model.

Why didn't the proclamation cite any of the 13 recent reviews of the literature by some of the top neuroscientists working at Yale University, Cambridge University, University of Duisburg-Essen or the Max Planck Institute? Because the reviews lend support to the addiction model, contradicting the claims of these organizations.

The proclamation divides the rest of its claims into five sections: A, B, C, D, E.

The proclamation’s first main assertion (A)

A) The American Psychiatric Association (APA) does not identify sex/porn addiction as mental disorders. Similarly, the American Association of Sexuality Educators, Counselors, and Therapists (AASECT) does not recognize sex/porn addiction as mental disorders and has concluded that an addiction model “cannot be advanced as a standard of practice for sexuality education delivery, counseling, or therapy”.

Re AASECT: First, AASECT is not a scientific organization and cited nothing to support the assertions in its own press release – rendering its support meaningless.

Most importantly AASECT’s proclamation was pushed through by Michael Aaron and a few other AASECT members using unethical “guerrilla tactics” as Aaron admitted in this Psychology Today blog post: Analysis: How the AASECT Sex Addiction Statement Was Created. An excerpt from this analysis Decoding AASECT's "Position on Sex Addiction, summarized Aaron’s blog post:

Finding AASECT's tolerance of the "sex addiction model" to be "deeply hypocritical", in 2014 Dr. Aaron set out to eradicate support for the concept of “sex addiction” from AASECT’s ranks. To accomplish his goal, Dr. Aaron claims to have deliberately sowed controversy among AASECT members in order to expose those with viewpoints that disagreed with his own, and then to have explicitly silenced those viewpoints while steering the organization toward its rejection of the “sex addiction model.” Dr. Aaron justified using these “renegade, guerilla [sic] tactics” by reasoning that he was up against a “lucrative industry” of adherents to the “sex addiction model” whose financial incentives would prevent him from bringing them over to his side with logic and reason. Instead, to effect a “quick change” in AASECT’s “messaging,” he sought to ensure that pro-sex addiction voices were not materially included in the discussion of AASECT’s course change.

Dr. Aaron’s boast comes across as a little unseemly. People rarely take pride in, much less publicize, suppressing academic and scientific debate. And it seems odd that Dr. Aaron spent the time and money to become CST certified by an organization he deemed “deeply hypocritical" barely a year after joining it (if not before). If anything, it is Dr. Aaron who appears hypocritical when he criticizes pro-“sex addiction” therapists for having a financial investment in the "sex addiction model", when, quite obviously, he has a similar investment in promoting his opposing viewpoint

Several commentaries and critiques expose AASECT’s proclamation for what it truly is:

Re DSM-5 and ICD-11: Second, when the APA last updated its diagnostic manual in 2013 (DSM-5), it didn’t formally consider “internet porn addiction,” opting instead to debate “hypersexual disorder.” The latter umbrella term for problematic sexual behavior was recommended for inclusion by the DSM-5’s own Sexuality Work Group after years of review. However, in an eleventh-hour “star chamber” session (according to a Work Group member), other DSM-5 officials unilaterally rejected hypersexuality, citing reasons that have been described as illogical.

Moreover, just prior to the DSM-5’s publication in 2013, Thomas Insel, then Director of the National Institute of Mental Health, warned that it was time for the mental health field to stop relying on the DSM. Its "weakness is its lack of validity," he explained, and "we cannot succeed if we use DSM categories as the "gold standard." He added, "That is why NIMH will be re-orienting its research away from DSM categories." In other words, the NIMH planned to stop funding research based on DSM labels (and their absence).

Major medical organizations are moving ahead of the APA. The medical doctors and addiction researchers of the American Society of Addiction Medicine (ASAM) hammered what should have been the final nail in the porn-addiction debate coffin in August, 2011 based on decades of addiction research. Top addiction experts at ASAM released their carefully crafted definition of addiction. Foremost, behavioral addictions affect the brain in the same fundamental ways as drugs do. In other words, addiction is essentially one disease (condition), not many. ASAM explicitly stated that "sexual behavior addiction" exists and must necessarily be caused by the same fundamental brain changes found in substance addictions.

In any event, the World Health Organization appears poised to set right the APA’s excessive caution. The next edition of its diagnostic manual, the ICD, is due out in 2018. The beta draft of the new ICD-11 includes a diagnosis for “Compulsive sexual behavior disorder,” as well as one for “Disorders due to addictive behaviors.” Why aren't the 3 organizations mentioning this important development?

The proclamation’s second main assertion (B)

B) "Existing studies supporting an addiction model lack precise definitions and methodological rigor, and rely on correlational data. Pre-existing psychological issues that could account for changes in sexual behavior and/or pornography viewing have not been considered. Studies are needed that utilize experimental designs and account for a range of potential extraneous variables (Ley et al., 2014). Although some people may incorrectly assume that increased dopaminergic activity during sex or pornography viewing (which is to be expected) is evidence for addiction, Prause, Steele, Staley, Sabatinelli, and Hajcak (2015) found in their controlled study that participants reporting hypersexual problems did not show the same neural response patterns consistent with other known addictions. There are many diverse reasons why people may engage in pornography viewing, and frequent and diverse sexual activities, which must be considered when assessing behavior (Ley, 2012; Ley et al., 2014)."

The neurological studies on sex and porn addiction are very rigorous, and many of them are done by some of the top addiction neuroscientists in the world. Here they are: 3 dozen neuroscience-based studies.

The proclamation’s suggestion that “correlation” renders research useless, reveals remarkable ignorance (or spin), as it would be unethical to induce addiction of any type in human subjects. Besides, it is silly to suggest that porn addicts were all born with all the major addiction-caused brain changes that are showing up in rigorous brain research on porn/sex-addicted subjects. What are the odds? Zero. For example, the core addiction-caused brain change is sensitization, which can only occur with continuous and prolonged use.

The proclamation statement's mischaracterizing the neurological research as investigations of “dopaminergic activity during sex or pornography viewing” reveal that the authors of this proclamation haven’t read any of the studies in question. None of the neurological studies assessed dopamine activity! Instead, the 3 dozen studies assessed the presence of one or more of the four major brain changes involved with both drug and behavioral addictions: 1) Sensitization, 2) Desensitization, 3) Dysfunctional prefrontal circuits (poorer exceutive functioning), and 4) Dysfunctional stress circuits. All 4 of these brain changes have been identified among the 3 dozen neuroscience-based studies on frequent porn users & sex addicts:

  1. Sensitization (cue-reactivity or cravings). Studies reporting sensitization or cue-reactivity in porn users/sex addicts: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20.
  2. Desensitization (decreased reward sensitivity & tolerance). Studies reporting desensitization or habituation in porn users/sex addicts: 1, 2, 3, 4, 5, 6.
  3. Dysfunctional prefrontal circuits (poorer executive function + hyper-reactivity to cues). Studies reporting poorer executive functioning (hypofrontality) or altered prefrontal activity in porn users/sex addicts: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13.
  4. Malfunctional stress system (greater cravings & withdrawal symptoms). Studies indicating a dysfunctional stress system in porn users/sex addicts: 1, 2, 3.

What about the proclamation's claim concerning Prause et al., 2015?

"Prause, Steele, Staley, Sabatinelli, and Hajcak (2015) found in their controlled study that participants reporting hypersexual problems did not show the same neural response patterns consistent with other known addictions."

“Neural response patterns” means “cue-reactivity,” which reveals the core addiction brain change – sensitization. As you can see above, there are now 20 studies on porn users/sex addicts reporting findings consistent with cue-reactivity, attentional bias, or cravings. Even if the proclamation were correct that Prause et al., 2015’s findings actually contradicted the existence of cue-reactivity (it doesn't), it would take more than one anomalous (and flawed) study to “debunk” decades of behavioral addiction research!

And what were the actual results of Prause et al., 2015? Compared to controls "individuals experiencing problems regulating their porn viewing" had lower brain responses to one-second exposure to photos of vanilla porn. The authors claim these results "debunk porn addiction." Yet, in reality, the findings of Prause et al. 2015 align perfectly with Kühn & Gallinat (2014), which found that more porn use correlated with less brain activation in response to pictures of vanilla porn - an addiction-related brain change.

Prause et al. findings also align with Banca et al. 2015. Lower EEG readings mean that subjects are paying less attention to the pictures. Put simply, frequent porn users were desensitized to static images of vanilla porn, compared to a control group. They were bored (habituated or desensitized), which can be evidence of an addiction process at work. See this extensive YBOP critique. Six peer-reviewed papers agree that this study actually found desensitization/habituation in frequent porn users (consistent with addiction): 1, 2, 3, 4, 5, 6.

The proclamation’s third main assertion (C)

C) "The sex/porn addiction model reflects significant sociocultural biases (Klein, 2002; Williams, 2016), including specific measures of clinical assessment Joannides, 2012). Socio-cultural biases include assumptions concerning normal sex drive, relationship styles, and erotic interests and practices. Thus, people with alternative sexual identities are likely to face further marginalization and discrimination by those who support a sex/porn addiction model."

Only one of the above citations is peer-reviewed: Williams, 2016. It is in a minor social work journal that is not PubMed indexed. The only neurological study Williams cited was, you guessed it, Prause et al. 2015. Williams, 2016 is a biased opinion piece that depends on Prause et al. 2015 and David Ley’s books and articles for its empirical support. It ignores the 36 other neurological studies on porn users, 13 recent reviews, and 80 studies linking porn to sexual problems and less sexual & relationship satisfaction. Wiiliams, 2016 is nothing more than empty rhetoric.

The proclamation’s fourth main assertion (D)

D) "Research has shown that religiosity and moral disapproval have a strong influence on perceived sex/porn addiction. For example, Grubbs and colleagues (2010, 2015) found that religiosity and moral disapproval were strong predictors of perceived pornography addiction, even when actual pornography use was controlled. Other researchers have reported similar findings (Abell, Steenbergh, & Boivin, 2006; Kwee, Dominguez, & Ferrell, 2007; Leonhardt, Willoughby, & Young-Petersen, 2017). Regarding pornography use, Thomas (2013, 2016) applied archival analysis to trace the creation and deployment of the addiction framework among evangelical Christians. Other scholars have reported that the concept of sex addiction emerged in the 1980s as a socially conservative response to cultural anxieties, and has gained acceptance through its reliance on medicalization and popular culture visibility (Reay, Attwood, & Gooder, 2013;Voros, 2009)."

Actually sex/porn addiction is not related to religiosity in men. First, the preponderance of studies report lower rates of compulsive sexual behavior and porn use in religious individuals (study 1, study 2, study 3, study 4, study 5, study 6, study 7, study 8, study 9, study 10, study 11, study 12, study 13, study 14, study 15, study 16, study 17, study 18, study 19).

Second, two studies that assessed treatment-seeking male sex addicts found no relationship with religiosity. For example, this 2016 study on treatment-seeking porn addicts found that religiosity did not correlate with negative symptoms or scores on a sex addiction questionnaire. This 2016 study on treatment-seeking hypersexuals found no relationship between religious commitment and self-reported levels of hypersexual behavior and related consequences.

As for the claims concerning morality and “perceived addiction” (almost all the studies listed in the proclamation’s excerpt), a new study suggests they are unsupported: Do Cyber Pornography Use Inventory-9 Scores Reflect Actual Compulsivity in Internet Pornography Use? Exploring the Role of Abstinence Effort. This new study says that the instrument Grubbs uses in all his studies, CPUI-9, is flawed.

The CPUI-9 includes 3 extraneous questions assessing guilt and shame, such that religious porn users' CPUI-9 scores tend to be skewed upward. The existence of higher CPUI-9 scores for religious porn users was then fed to the media as the claim that, "religious people falsely believe they are addicted to porn." This was followed by several studies correlating moral disapproval with CPUI-9 scores. Since religious people as a group score higher on moral disapproval, and (thus) the total CPUI-9, it was pronounced (without actual support) that religious-based moral disapproval is the true cause of pornography addiction. That's quite a leap, and unjustified as a matter of science.

In addition, the conclusions and claims spawned by the CPUI-9 are simply invalid. Grubbs created a questionnaire that cannot, and was never validated for, sorting "perceived" from actual addiction: the CPUI-9. With zero scientific justification he re-labeled his CPUI-9 as a "perceived pornography addiction" questionnaire. For much, much more see “New study invalidates the Grubbs CPUI-9 as an instrument to assess either “perceived pornography addiction” or actual pornography addiction (2017).”

Finally, religious shame doesn't induce brain changes that mirror those found in drug addicts. Thus groups pushing the “sex/porn addiction is just religious shame” assertion still need to explain more than 3 dozen neurological studies reporting addiction-related brain changes in compulsive porn users/sex addicts. In light of 24 studies linking porn use/addiction to sexual problems and lower arousal, they also need to explain a nearly 1000% rise in youthful erectile dysfunction since the advent of porn tube sites.

The proclamation’s fifth main assertion (E)

Finally, this proclamation assertion combines 2 specious “straw man” arguments:

E) The sex/porn addiction model assumes that sexual behaviors as a coping mechanism are an indicator of addiction, but it does not consider the possibility that sex may be a positive coping mechanism.

The sex/porn addiction model makes no such assumption. It is concerned with people who cannot control their behavior despite serious negative consequences. This is the very opposite of “coping.”