We’ve come a long way since addiction as a ‘chronic brain disease’ was the general consensus, and in 2024, research is continuing to look at the broader picture and acknowledge that addiction is far more complex than a biological illness. However, the disease model of addiction is still prevalent and particularly in the US. Whilst there is no doubt that addiction changes the brain (copious research papers now indicate this is simply a fact), there is also a wider acceptance that psychological and sociological factors play a crucial role, as well as biology. So why are we still hung up on this idea of addiction being a disease and why is this debate so important to sex and porn addiction?
The controversy of sex and porn addiction and the disease model
Now we’ve spoken many times about the controversy surrounding sex and porn addiction, and regrettably, it still very much exists today. However, the reason for addressing it again here is because of how closely this ongoing debate connects to and relies upon the assumption that addiction is a disease.
When ‘sex addiction’ as a term came on the scene in the early 1980’s, led by the work of Patrick Carnes, there were, broadly speaking, two main areas of criticism. The first lies primarily in the notion that calling compulsive sexual behaviours an addiction would effectively remove responsibility from the individual and become an excuse for bad behaviour. Sex addiction was viewed as an invented diagnosis to exonerate those wealthy, famous men who had checked into luxury rehabs after their infidelity was revealed in the media. The other line of criticism came from those who felt the label could be used to pass moral judgement on those whose sex lives do not align with societally prescribed norms. In other words, it could pathologise and stigmatise perfectly healthy sexual behaviour and indeed, some people did (and still do) use the sex addiction label to bolster their anti-porn agendas and attack sexual liberalism. There is also a third, lesser-known, middle ground on the issue where researchers and professionals do not refute the addiction label entirely but urge caution in using it until there is a higher volume of conclusive research.
Compulsivity or addiction?
When Compulsive Sexual Behaviour Disorder (CSBD) was included in ICD-11, both sides of the debate declared this as a victory. For those who supported sex addiction, they believed this was a positive indication that things were moving in the right direction and sex addiction could follow the same trajectory as gambling by being first considered an impulse control disorder, and then a behavioural addiction. For the critics of sex addiction, they saw this as conclusive proof that compulsive sexual behaviours could NOT be considered an addiction and therefore, we should not be using the label at all. Therefore, instead of finally putting this debate to rest, if anything, the inclusion of CSBD in ICD-11 exacerbated it.
The problem with many of these arguments is that they all assume a disease model of addiction. But if we move away from a purely medical disease model, it not only eases and resolves some of these tensions, it also relates more closely with the client’s individual experience and produces greater rates of recovery.
A history of the disease model of addiction and why it is outdated
In the first half of the 20th century, addiction, in all its forms, was widely perceived as a moral failing by the individual. Those struggling with addiction would suffer in silence and when their behaviour could not remain a secret, they would be shamed and punished for their perceived weakness. Fortunately, nowadays no one (or at least very few) would view people struggling with addiction in this light and for all its flaws, we have the disease model of addiction to thank for that. Arguably, when this perspective of addiction became widely accepted in the latter half of the 20th century, it was indeed good news for the addict. Firstly, because it helped to de-stigmatise addiction as they could now say, “I have a disease,” and shift at least some of the burden of responsibility. The public became more empathetic and understanding of those who were struggling, and the growing impact of AA (Alcoholics Anonymous) in the 1950’s can also be seen as spearheading this more inclusive and compassionate perspective. Secondly, it also meant healthcare professionals and policymakers would pay attention to the issue, conduct more research, provide more funding and more treatment facilities. Furthermore, it would make it difficult for medical insurance companies to deny claims based on alcohol and drug problems. For this reason, there is a very real fear that if we abandon the notion that addiction is a disease, we may lose important funding, treatment opportunities and ultimately, the client will suffer. In short, the disease model of addiction ensured that addicts got professional help, but was it the right help? What if this ‘means-to-an-end’ actually harms the client as well?
The disease model of addiction undoubtedly had a positive influence on the way society views and treats addicts, but it also comes with its own problems. As already mentioned in the context of sex and porn addiction, calling addiction a disease arguably ignores the whole idea of choice and exonerates addicts for their behaviour as being completely out of their control. “It’s not my fault”, we might read in the papers or online, “I’m a sex addict and I can’t help it!” Another problem is that many argue that it simply creates a new kind of stigma and shame by paralysing addicts in their ‘incurable, chronic disease’, keeping them stuck with the burden that they have an inherent biological defect. A large part of the philosophy of AA which encapsulates the first step is that to get into recovery, you must ‘admit powerlessness’ over your addiction. Now, it’s important to highlight here that AA has helped an extraordinary number of people recover from alcohol addiction and indeed, it is certainly life-changing for some. But nowadays, there are many critics to the 12-step approach and a lot of this stems from the strong implication that there is an underlying sickness or ‘disease’ in those who struggle with alcohol. Furthermore, whilst in the 1950’s it may have been overwhelmingly novel and eye-opening for the archetypal white, cis man to ‘accept powerlessness’ over something to the point that it affected long-lasting change in their lives, this concept of powerlessness would have been (and still is) nothing new to more historically marginalised groups like ethnic minorities, the LGBTQ+ community or women. In fact, some research indicates that the common denominator in those who manage to achieve long-term recovery from addiction was actually a sense of feeling the complete opposite – empowered – not powerless. This notion of powerlessness and living with an incurable disease brings with it another form of stigma and shame, and when it comes to sexuality and sexual health, we’re already forced to wrestle with huge amounts of shame that, quite frankly, I don’t think we need any more!
The neuroscience of addiction
A big reason why many professionals claim that addiction is a disease is because of the overwhelming evidence of how much it impacts and changes brain structure. Neuroscience has come a long way since the late 20th century and there is now indisputable proof of these facts, but there is still the question of how it changes the brain and whether that equates to it being a disease. It was believed by many scientists that it was the actual substance that caused the brain to change but advances in research on the ‘desiring’ and ‘craving’ effects of dopamine suggest that this isn’t the case. Marc Lewis, a neuroscientist who writes about addiction, explains:
“The neural circuitry of desire governs anticipation, focused attention, and behaviour. So, the most attractive goals will be pursued repeatedly, while other goals lose their appeal, and that repetition (rather than the drugs, booze or gambling) will change the brain’s wiring.”
The idea that the consumed substance was the direct cause of brain change had been questioned prior to these new developments surrounding the impact of dopamine. As many have pointed out over the years, not everyone gets addicted. A famous example that bamboozled many a scientist at the time was the number of Vietnam War veterans returning home after regularly using heroin and having zero withdrawal symptoms and stopping without difficulty. There are many other examples, but the overall indication is that the substance itself is not central to the addiction.
Another problem with this focus on changing brain structure as evidence of a disease is that it seems to ignore the fact that our brains change all the time, with or without substances. With repetition and reward, as described by Marc Lewis above, many behaviours can change the brain, like the dopamine rush of falling in love and the way you can’t stop thinking about them, or even learning the piano or how to drive a car. In short, just because it changes the brain doesn’t mean it’s a disease.
Addiction is not a disease
Finally, and for me, the most convincing argument against the disease model is that problems with addiction are so clearly far more complex and nuanced than basic biology. Of course, there are crucial biological factors that must be considered when providing treatment but there is so, so much more to it.
Next time, we’re going to take a deeper dive into an alternative model of addiction – a biopsychosocial one – which considers all the other factors at play when it comes to addiction, and specifically, sex and porn addiction. But in the meantime, I would emphasize that just because a person uses the term ‘addiction’, it does not mean that they prescribe to disease-focused methods of understanding and treatment. The disease model of addiction is no longer the only school of thought and new, innovative and inclusive approaches to addiction treatment are available and effective.
If you’re a therapist or counsellor who is interested in training in CSBD and sex addiction and how to treat it without disease-based models, take a look at our diploma. Our next Tutor Tuesday, an online, open afternoon all about our diploma, takes place on 12th November from 1-2pm. If you’d like to join us, learn more and ask tutors some questions, sign up using the button below.
