Is sex addiction a true addiction, a crime, or a made-up condition used by misbehaving VIPs to deflect blame or repair tarnished images?
A tide of high-profile sexual misconduct accusations against celebrities, politicians and media members has raised these questions -- and sowed confusion. Sex addiction is not an officially recognized psychiatric diagnosis, though even those who doubt it's a true addiction acknowledge that compulsive sexual behaviour can upend lives.
Either way, there is an important distinction, sometimes blurred, between a mental condition and a crime. Some men who have been accused of assault or other sexual crimes have sought treatment for sex addiction or other unspecified conditions. But compulsive behaviour is very different from a crime, and the vast majority of people who suffer from sexually compulsive behaviour do not harass or assault others.
There's "an extremely fine line between addict and offender" and sometimes the two overlap, said psychologist Leah Claire Bennett of Pine Grove Behavioral Health & Addiction Services, a rehab centre that offers sex addiction treatment in Hattiesburg, Mississippi.
Despite pressure from some therapists, sex addiction was not included in the most recent edition of the manual that psychiatrists use to diagnose mental illness. "The reason is very simple," said Dr. Charles O'Brien, a University of Pennsylvania psychiatry professor involved in the manual's 2013 update. There is no rigorous scientific proof that compulsive sexual behaviour affects the brain in the same ways that have been shown with addiction to drugs or alcohol, he said.
"There's an overuse of the word 'addiction,"' O'Brien said. "There are many treatment programs. That doesn't make it a disorder."
Still, some skeptics don't dispute that compulsive sexual behaviour can become a serious problem. The issue for some is whether it amounts to mental illness, or whether it might result from a different psychiatric condition, such as obsessive-compulsive disorder.
Robert Weiss, a California-based sex addiction therapist, said the condition involves unrestrained compulsive sexual behaviour without regard to consequences. Sometimes that leads to illegal behaviour.
The International Institute for Trauma and Addiction Professionals says sex addiction affects from 2 per cent to 5 per cent of the general population but that only 10 per cent of those with this addiction engage in criminal sexual behaviour. Most patients and sex offenders are men.
Some treatment programs won't admit patients accused of rape and other violent sex crimes, referring them to centres or therapists who specialize in treating sex offenders.
Addiction treatment at Pine Grove, The Meadows in Arizona and other high-profile residential rehab centres can cost tens of thousands of dollars. Despite country club-like settings, there's nothing cushy or indulgent about sex addiction therapy, Weiss said.
Pine Grove requires daylong sessions including group therapy daily for up to three months. Some centres use 12-step programs similar to Alcoholics Anonymous, but they don't require swearing off sex for good. Some use brain "retraining" exercises, or sharing stories about bad behaviour with a roomful of strangers.
Some centres use equine therapy. Weiss says that interacting with horses can help patients recognize problems sometimes associated with sex addiction, including overly aggressive, controlling behaviour.
The New York Post published a photograph last year that it said showed former New York Congressman Anthony Weiner riding a horse as part of treatment at a Tennessee sex addiction rehab centre. Weiner was sentenced in September for sexting with a teenager. He said at the time that he was undergoing therapy and had been "a very sick man for a very long time."
Weiss and other therapists say sex addicts are never cured, but they can learn to manage their behaviour and avoid triggers, including avoiding jobs and circumstances that could lead to a repeat of problem behaviour.
L.J. Schwartz, a former real estate adviser in Fort Lauderdale, Florida, says a nearly 30-year addiction to sex almost ruined his life.
Schwartz says his addiction included having sex with strangers at adult bookstores or masturbating there while watching porn nearly every chance he got; working as a stripper and phone sex. He was never arrested but says his behaviour endangered his job and marriage.
"There's no pleasure derived from sex addiction; it's pain," Schwartz said.
He says a 12-step program helped him resist his compulsions and he now works as a recovery coach for other patients.
But hard evidence that treatment works is lacking. "There's not a lot of data," Bennett acknowledged.
"We have a lot of anecdotal evidence. We can see the change in people," she said. She said Pine Grove plans a long-term study to measure the benefits.
Whether treatment can repair tarnished images is uncertain.
"The accusations levied against Harvey Weinstein, Kevin Spacey, Louis C.K. and others for sexual assault, harassment and abuse have created righteous outrage and concerns that 'sex addiction treatment' is being used to excuse their offensive behaviour," the addiction professionals institute said in a recent statement.
Whether any of these men have a diagnosed mental condition has not been publicized.
A representative for Weinstein confirmed that he is receiving treatment and has been taking his recovery and sessions seriously. But the representative declined to specify Weinstein's condition or the treatment he is receiving for it. A former publicist for Spacey said he also is seeking unspecified treatment.
Bennett said some people do use sex addiction as an excuse, "but that's not who we're treating here at Pine Grove. These peoples' lives are in shambles. They've been traumatized throughout their lives. They have huge psychological wounds and are using very maladaptive ways of coping."
Actor David Duchovny voluntarily sought rehab for sex addiction in 2008 while starring on Showtime's "Californication." Married to actress Tea Leoni at the time, he had been dogged by cheating rumours. His career never stalled. He returned to "Californication" for the remainder of its run and has continued to appear in high-profile roles.
When sex addiction may have contributed to criminal behaviour, a trip to rehab could bolster a defence attorney's argument that the accused person has changed, said Samuel Pillsbury, a professor at Loyola School of Law in Los Angeles. But it's a less effective strategy for violent crimes, he said.
"It's very difficult for me to imagine a prosecutor deciding, 'Oh, he's in rehab, I'll drop the charges or I'll reduce the charges significantly,"' Pillsbury said. "But it could have an effect on sentencing."
