The Nether Reaches of the Sexual Addiction Paradigm

I'm Atlanta counselor and therapist Bill Herring LCSW, CSAT. and this is a 2011 guest editorial in the journal Sexual Addiction & Compulsivity written that attempts to describe the potential limits of sex addiction as an explanatory concept. It represents the ongoing development of my thinking at that time.

The Nether Reaches Of The Sexual Addiction Paradigm

I recently had a conversation with one of my colleagues just after the Justice Department announced that it had arrested over 70 members of “Dreamboard”, a particularly heinous global online child pornography ring. In the midst of this discussion my colleague asked, "I know that most sex addicts aren't pedophiles, but are most pedophiles sex addicts?"
I was initially tempted to point out that not all pedophiles molest children (even therapists have a tendency to mix up their terms) but this would have been a diversion, for the truth is that I didn't have a ready response.  One reason for my quandary was that this question represents one of the more difficult conceptual challenges within our field: how to negotiate the interface between diminished control and absence of moral constraints.
People repeatedly engage in sexual behavior that violates their commitments and leads to negative consequences for a variety of reasons other than sex addiction.  Some simply don’t fully appreciate the problematic nature of their behavior, perhaps due to some combination of ignorance and denial. Others are acting upon a comorbid psychiatric condition, since poorly restrained hypersexual behavior can be a way to manage a depressive or anxiety disorder, a manifestation of a bipolar spectrum disorder, a form of obsessive-compulsive disorder or a type of post-traumatic reaction.
This leaves two remaining reasons why people repetitively engage in unprincipled sexual behavior.  People are either truly sexually addicted or they are doing exactly what they want. One has lost control while the other doesn’t care. 
It’s important not to collapse all these categories into one diagnostic and treatment formulation. This can be difficult, since regardless of how a person enters into a highly reinforcing pattern of sexual behavior, once the process takes root an independent addictive/compulsive cycle often results.

Distinguishing the Line Between Between "Can't Control" and "Don't Care"

One conventional way to demarcate the boundary between “can’t control” and “don’t care” is to assess the degree of remorse a person demonstrates when a pattern of problematic sexual behavior is brought to light. It’s tempting to conceive the distinction pretty simplistically: we tend to label a person who lacks a sufficient level of empathy and remorse as either narcissistic or sociopathic, while someone simmering in shame and professing a profound sense of powerlessness more accurately fits the profile of what we typically call a sex addict.
But it's worth considering that a fair number of people who feel great remorse because of their absence of sexual self-control in essence  need to feel this way in order to obscure a darker potential truth to themselves: that they did it because they enjoy it on a purely carnal level. They're not consciously lying as much as engaging in a more pernicious form of self-deception.
It’s possible that a person who demonstrates self-loathing and despair for chronically engaging in unhealthy sexual behavior may be subtly minting a currency of emotional pain that in effect pays for the option of doing whatever his or her basest instincts desire for a prescribed period of time. In other words, an individual capable of repeatedly violating sexually healthy boundaries at least has the cold comfort of feeling really bad about it.  “I hate that I can’t control myself” is an effective way to cloak an antisocial personality disorder with the language of addiction.
For what if a person repeatedly engages in sexual behavior that involves secrecy and deception, outright violation of professed commitments, immense personal costs, and all the other typical hallmarks we use to assess for compulsivity/addiction, with the exception of remorse? I don't mean remorse for being caught and no longer being able to practice sexually nefarious activities, but the profound ego deflation some people experience when they fully realize the vast expanse between their highest intentions and their basest actions. I would have to think carefully over the course of my career to come up with many clients who stated that they only regretted they got caught or who totally blamed their behavior on another person or extenuating circumstance.  Some may think it, but few have the courage to admit it.

Comparing Competing Disgnostic Criteria

Viewed through the lens of the proposed DSM-V diagnosis of hypersexuality, two people engaging in the same behavior can be viewed very differently. It’s possible for a person to have recurrent and intense sexual fantasies, urges or behaviors that don’t interfere with any goals, activities or obligations and are not a response to dysphoric mood states, stressful life events or substances. Additionally a person could have little to no regard for any physical or emotional harm caused to others, and have no desire or attempt to control, reduce or stop what he or she is doing.
Compare this to the current DSM-IV classification in which a person meets the criteria for an antisocial personality disorder by repeatedly performing acts that are grounds for arrest; lying, using aliases or conning others for personal pleasure; demonstrating impulsive behavior; disregarding the safety of others; and demonstrating consistent irresponsibility. How many people meeting such criteria occupy a sex addiction therapist’s caseload?
The essential conundrum continues to circle around considerations of conscience. We hope that a person who doesn’t feel bad about repeated acts of sexual duplicity and betrayal is so dissociative or otherwise disconnected from his or her feelings that a requisite sense of conscience is in effect anesthetized. But an often under-appreciated possibility is that we may be witnessing a person who is essentially untouched by moral constraints. The first category is the realm of addiction, while the second is that of evil.
I almost cringe writing that word, because it seems like such an archaic and moralistic concept. I typically fall back to the word 'unethical' when distinguishing these two fundamental categories. This raises a variant syllogism to the one my colleague queried: not all addictively driven sexual behavior is evil, and not all evil sexual behavior is addictively driven. But sometimes both are true.

Defining the Ethical Limits of the Term "Sex Addiction"

Past a certain point the ethical component of sexually inappropriate behavior simply exceeds the explanatory ability of the word "addictive", and a primary area in which the definition starts to break down is non-consensual behavior. When dealing with people who have committed certain sexual offenses, some therapists attempt a sort of diagnostic alchemy that attempts to transform behavior that is essentially sociopathic into a more tolerable addictive construct. This can be a crucial mistake for our profession, for our clients and for their past and potential victims.
In my clinical practice I am more likely to refer a client to a colleague who specializes in treating sexual offenders to the degree that the legal rights of another person have been criminally violated. While I work with an increasing number of clients who have criminal charges stemming from internet child pornography, I don't have serial rapists in my caseload. Am I saying that there aren't people who commit criminal sexual offenses who meet every criteria typically used when assessing for sexual addiction/compulsivity? Not at all: it's just that a functional definition of sexual addiction is insufficient to adequately account for the immensity of such egregious behavior.
This brings the conversation full circle to the Dreamboard child pornography ring. This vile organization offered membership incentives based on ever-increasing degrees of child sexual exploitation, all the way up to a "Super Hardcore" category reserved for those who submitted videos of themselves violently sexual assaulting very young children, including infants. The amount of video imagery that was created in response to this offer is staggering: the equivalent of over 16,000 DVDs.
So, back to my colleague's question: are any/some/most/all of these people sex addicts? The answer depends in large measure on who is doing the labeling.
Since by the very nature of this ring a person had to continually upload child pornography, every one of them repeatedly engaged in behavior that violated societal norms. I would bet that all of them knew that what they were doing was wrong and that the consequences of their behavior could be devastating to themselves if they were discovered.  
It’s also fair to presume that some of these men (no females were arrested) had periods in which they felt truly terrible about what they were doing and tried to stop their behavior, perhaps many times, and were unsuccessful despite everything that they tried.  This leaves others who had few if any moral scruples and consequently never made much effort to cease their behavior. The behavior of the first group therefore begins to somewhat more closely approach terms like addictive or compulsive, while those in the second group are not eligible for such a construct because they were not bothered by what they did and consequently never tried to stop.
This leads to the consideration that there may be a fairly narrow bandwidth for the concept of sex addiction. On one extreme it is an inappropriate term to use to pathologize nothing more than a socially marginalized fetish carried underground due to an acculturated sense of shame and a consequent fear of relational rejection. 
On the other extreme “sex addiction” seems to be a woefully inadequate term to describe some of the nether reaches of sexual behavior where distinctions between ill and evil begin to cloud.  It would be the equivalent of claiming that a car careening through a crowd of children at 100 miles per hour simply lacked sufficient brakes. Even if it’s true, the explanation hardly matters.
So can a person be both sexually addicted and sociopathic? They seem to be mutually exclusive contexts for describing behavior that may appear to be exactly the same, down to the very last whimper of an innocent victim. So what’s a self-reflective, ever-developing, diverse, responsible field of sexual health supposed to do about such conceptual dilemmas?  One answer is that the questions that are difficult to answer are the ones that we must continually ask.