(To the uninitiated, agonist therapy may seem irresponsible. You give people with a heroin problem massive doses of opioids? Yes, we do! And it is completely life changing. Methadone and buprenorphine–the most common medications–have saved untold lives [2]. But there’s much more to life than not dying; people on agonist therapy generally live healthy, happy, productive, normal lives. It doesn’t work for everyone, but it’s one of the most effective treatments for a chronic medical problem ever developed. It’s an uncontroversial intervention among addiction medicine doctors around the world. I’ve never encountered a philosophical or data-driven argument against this form of treatment that I find even marginally compelling.)

I’m excited to share with you an excerpt from “A Doctor Among the Addicts,” by Nat Hentoff [3]. This 1968 volume is now out of print, but it offers a rare glimpse into the life of one of my personal heroes, Dr. Marie Nyswander. Nyswander spent almost two decades developing a reluctant expertise in addiction before meeting a collaborator in Dr. Vincent Dole. Their work–which should have won a Nobel Prize [4]–ultimately resulted in the discovery and empirical validation of methadone as a profoundly effective treatment for people with opioid use disorder. In this passage, Hentoff and Nyswander describe the first two patients treated, and the insight that led to methadone.

—

To help prepare the hospital staff, including the nurses, for the new work, Dr. Nyswander brought addicts to the [Rockefeller] Institute during the month before the project was to begin. There were conversations with them, and afterward the nurses, for whom Dr. Nyswander has a deep admiration, did a good deal of reading about addiction on their one. It was then decided to admit two “hard-core criminal addicts.” Elaborate security precautions were taken in an isolated wing of the hospital. Safety glass protected hospital medication, additional locks were provided, the security personnel was aletrted, and an outside security agency was also hired.

In the January, 1967, issue of The Bulletin, a publication of the New York State District Branches of the American Psychiatric Association, Dr. Nyswander described the start of the research. “The first patient,” she wrote, “was a 34-year-old single male of Italian extraction, and the second, a 21-year-old single male of Irish background. Both had a history of drug use for eight years, had spent several years in prison for possession of drugs and theft, and had made numerous attempts to get off drugs by detoxification in voluntary hospitals and in the federal hospital in Lexington. One patient had gone to California in his desperation to remain drug-free. Both patients had tried psychotherapy. Both had dropped out of high school in the first year. The I.Q.’s of the patients, as measured on the Wechsler-Bellevue Intelligence Scale, were 120 and 124.”

These first two addicts came in, Dr. Nyswander later explained to me, “because they knew they’d get drugs and because they wanted to get off the street for awhile. We were given a free hand by the Institute, and I had the watchful, perceptive, analytical guidance of Dr. Dole. The best thing that ever happened in this field was his getting into it; the success of this project rests squarely on him, in my opinion. There were no problems with the Narcotics Bureau because we were working in a hospital. Dr. Dole told me, ‘Marie, nobody’s holding you back now. You can do anything you want to do.’ And I suddenly realized that I wasn’t at all sure that I knew what I wanted to do. I’d heard the term ‘legalized drugs’ all these years, and used it myself, too, but now I had to ask: What did it really mean? What medical procedure?

“Well, we started the addicts on morphine, a quarter of a grain four times a day. In three weeks, in order to keep them comfortable, we had to go up to eight shots a day of an increased dosage, a total of ten grains a day. Obviously, it was going to be impractical to devise a maintenance program on morphine. Also, on morphine the patients were rendered practically immobile. Much of the time they sat passively, in bathrobes, in front of a television set. They didn’t respond to any of the other activities offered them. They just sat there, waiting for the next shot. One thing I did find out was that there were no problems with the patients. They cooperated beautifully and honestly. They had no desire to go out and cop heroin, because they didn’t have to. They didn’t need any sense of adventure in connection with their addiction.

“But,” she continued, “there they sat, their interests ebbing and flowing in rhythm with the morphine injections. I was confronted with an abysmal lack of knowledge of what to do next. And then there was an accidental circumstance. We switched them to methadone, a drug that had been synthesized during the Second World War by German chemists looking for inexpensive morphine substitutes. At the end of the war, the American government seized the formula, along with thousands of others, to be turned over to American drug manufacturers as an ‘open patent.’ We knew that it was a very effective pain-killer, that it had long-acting properties and minimal withdrawal symptoms. We also knew that it could be substituted for any other kind of narcotic.

“The accident was this. We wanted to reduce the huge daily doses of morphine without subjecting the two patients to severe withdrawal symptoms. Methadone was a way to do that, but because they had been on such high dosages of morphine, we had to put them on equivalently high dosages of methadone, more than twice as large as is usually given when methadone is used to withdraw people from heroin. And to keep them comfortable during the next few days, we gave them bigger and bigger amounts of methadone. What we then discovered would probably not have been apparent if those dosages of methadone had been a lot less, as they have been in some other, not so successful experiments with methadone. From that point, my life changed, and the addicts’ lives changed.

“I was still staggering back from my failure with morphine, and it was Dr. Dole who realized what was happening in front of us. Striking alterations in behavior and appearance were taking place in the two patients. The older addict began to paint industriously and his paintings were good. The younger started urging us to let him get his high-school-equivalency diploma. We sent them both off to school, outside the hospital grounds, and they continued to live at the hospital. Neither of them–although both of them had every opportunity–copped heroin on the outside. From two slugabeds they turned into dynamos of activity. We gave them all kinds of tests while they were on methadone. We found out that methadone blocked out all other narcotics. They couldn’t feel the effect of another narcotic while they were on methadone. Accordingly, there was no craving for heroin. We found out that methadone could be given only once a day, and that sometimes the patients were so busy they actually forgot to take it. So, in addition to freeing a patient from the need to think about drugs for twenty-four hours a day, it appears that methadone gives him another eight-hour leeway. And whatever withdrawal symptoms occur during that leeway are very mild. We confirmed the fact that the drug could be taken orally and we first put it in orange juice. As for tolerance, there was no escalation problem. The dosage remained stable. In addition, we did endless medical studies–G.I. tests, bone marrow tests, blood studies, X-rays, motor-coordination tests, psychological tests. Methadone had no deleterious effects anywhere.

“And the behavioral changes continued to take place at a dazzling rate. One addict who later went on the program told a meeting of psychiatrists, ‘When you’ve got the craving, when you have to keep scuffling for drugs, you can never complete anything. And so you never know what you can do.’ That’s why all addicts tend to behave alike while they’re stealing and lying and figuring out ways to cop. But when they’re released from the craving and the scuffling, they begin to find out who they are, and so do we. It’s tremendously moving to watch them change.

“One example of the change in addicts’ behavior that has held up through the entire first three years of research has had to do with their staying in the hospital during the initial stage of the methadone treatment. Addicts have been notorious hospital dropouts, rarely staying long enough to finish most treatment plans. And often hospitals have dismissed them because of their antisocial behavior. Many of our patients had had such discharges, and few had finished earlier attempts at treatment, whatever they were. But under methadone, all our patients have remained in the hospital the full six weeks except for a few working men or women whose children were being cared for by relatives. In those cases we did give them an earlier discharge.

“As for our first two patients, both completed the requirements for their high-school-equivalency diplomas, but the younger one also wanted an unqualified high school diploma. In eighteen months he worked through three years of the high school curriculum, including mathematics, physics, English, history, and Spanish, with A grades. He went on to an engineering college on a full scholarship. The older patient completed a two-year course at horticulture school and is working in a greenhouse. They continue to take methadone and come to the hospital for weekly supplies.”

Footnotes

[1] In the United States, we sometimes use the terminology “dispense” instead of “prescribe.” Dispensing usually describes the direct provision of opioid doses through a methadone clinic, while prescribing typically means a set number of doses from a pharmacy. There is endless regulatory minutia around these terms, but “prescription” is much easier for most people to understand, so I’ll use it here.

[2] It’s hard to estimate the actual number of lives saved by agonist therapy, but it’s easy to estimate at least a 6-figure number for the United States alone.

[3] I hate the term “addict,” but it was normal to use in the time period. Modern guidelines for language in medicine wisely recommend that people not be defined by a problem they experience. “Correct” language can sometimes put us on a euphemistic treadmill or lead to pedantic bullshit, but I like this particular change.

[4] Nominees for the Nobel Prize are kept private for 50 years. However, the prize in physiology or medicine doesn’t have published data after 1953–so we’re actually missing 72 years of data at this point. I hope we’ll find Nyswander and Dole among the nominees when we have data!

I will try to explain what I mean in a moment. However, I can see the pitchforks rising in the distance, and I need to address two important caveats before we go further:

First, I know many wonderful people who find the label "sex addiction” a positive, meaningful description of their experience. I honor their experience, and I am thankful for all that I’ve learned from them. At the same time, I’ve treated far too many completely normal people whose lives have been devastated by the beliefs implicit in “sex addiction” definitions [1]. Their distress and suicidality has been the core motivation for my study of this subject. In my mind, formulating these problems as sex addiction causes far more harm than good, and there may be approaches that can satisfy both camps.

Second, most modern definitions of sex addiction have been explicitly non-paraphilic. This means that atypical sexual desires like pedophilia and frotterism cannot be considered sex addiction. In today’s post, I will honor this tradition by writing only about non-paraphilic sexual activity [2].

My early drafts of this post contained tightly written, highly complex arguments about the meaning of addiction, proposed diagnostic criteria, and the limitations of current definitions. I loved where it was going, but ultimately found it too academic. I decided that those discussions–while possibly interesting to clinicians–distract from the main point I want to make. Instead, I’ve decided to address just a single point. Afterwards, I’ll describe a brief parable that begins to flesh out what I consider a much healthier approach.

The problem of abstinence

Abstinence–the complete cessation of addictive substance use–has traditionally been the core treatment target for most substance use disorders [3]. Durable abstinence completely eliminates the risk of new harms from ongoing substance use. Of course, abstinence is only one of the many potential outcomes that are considered positive in substance use disorder treatment [4]. But for the sake of this post, it is sufficient to point out that complete abstinence from drugs or alcohol is at least a theoretical possibility.

Sex is different. Complete abstinence from sex is rarely consistent with a whole life. We are sexual beings. Sex has physical, emotional, relational, cultural, and spiritual benefits. Our relationship with sex simply cannot be managed through abstinence. And because of that, each of us must learn to moderate our sexual behaviors.

It’s at this point that the objections usually start to fly: “sex addiction isn’t about prohibiting sex, it’s about stopping problematic sex.” Maybe so. But if that is the case, sex addiction criteria must be able to objectively define addiction-related sex in a way that is categorically different from normal sex. I’m not convinced that this is possible. 

Most definitions of problematic sex are actually moral boundaries hidden behind medicalized language. For example, during the AIDS epidemic of the 1980s, many gay men were considered addicted to sex. This continues to be the case in Sexaholics Anonymous, where any sex that occurs outside of a heterosexual marriage disrupts that person’s “sobriety.”

Porn is the current target of sex addiction advocates. I will not argue that porn is an unalloyed good–it’s much more complicated than that. There are legitimate reasons to be concerned about consent, normalization of sexual violence, and porn’s place as the de facto source of sex education in the United States. At the same time, data about the impact of porn on individuals, relationships, and society are heavily swayed by preexisting moral beliefs. Concerningly, few people propose that people with “porn addiction” use their imagination when they masturbate–suggesting that porn is also a euphemism for other forms of morally non-preferred sexual behavior [5].

Some have argued that brain imaging studies have proven porn to be addictive. This is a misrepresentation of the data. Porn viewing does engage many of the same reward learning pathways found in substance use disorders. This is not a coincidence. Learning how to identify and interpret sexual stimuli is critical to the survival of our species. Our desire pathways evolved to assist us in obtaining food and sex. That’s what these brain structures are for! So does the brain change in response to repetitive sexual stimulation? Of course, it changes in response to all repetitive inputs. And yes, we can develop abnormal, unhealthy patterns of behavior around sex that correlate with changes to the brain in imaging studies. But this kind of research cannot tell us what it actually means for the person being studied.

Cultural and religious values also play a major role in perceived sex addiction. People from more conservative religious traditions are more likely to describe their sexual activity as an addiction–even if they engage in less sex than the average person. I sometimes call this the “one drink a day problem” of sex addiction. You cannot describe drinking a single, standard glass of wine every day as an alcohol use disorder. It’s simply not possible using our current diagnostic criteria. But this is often the case in people “diagnosed” with sex addiction. Libido and behaviors often fall within the normal range, while shame about sex may be extraordinary. Even the most significant, up-to-date, well-honed, “official” criteria fails when asked a single question. If you agree that “my sexual fantasies, urges, and behavior have often caused significant personal distress in my life,” there is a 72% chance that you qualify for a diagnosis of Compulsive Sexual Behavior Disorder [6]. This is absurd, and is roughly 72% higher than what I have seen in my clinical experience. This question is a marker for moral incongruence–engaging in actions that don’t align with your values–and not a sign of clinical pathology.

Now to be clear, I’m not advocating that you should accept anyone else’s sexual ethic as your own. At the same time, ethical concerns need to be approached with an eye towards flexibility and growth. If you want to avoid porn, that’s great. Abstain from masturbation if you’d like (so long as it’s possible for you and not the result of a misguided belief that it is harmful or evil [7]). By all means, please be faithful to your partner! But if you fail to meet these goals, I’m still not convinced that treating your sexual behavior as an addiction is the right approach.

[This is a critical side note about sexual ethics which is so important that I’m excluding it from my always excessive footnotes. If you are not heterosexual and worry about your sexuality: just be yourself. There is nothing unnatural, evil, or wrong about you. You may be completely out and generally comfortable, or you may be trying to live a life aligned with values that don’t allow for homosexuality. There can be deep conflicts between values and desires, and I would hate to oversimplify this complexity. I will say, however, that as as a man of faith who has a complicated relationship with my own tradition, I am convinced that anti-gay beliefs are not required elements of any religion. No sacred text interprets itself. We read our biases into scripture; supporting elements which align with our views while dismissing commands that don’t. The bible, for example, supports many practices that most modern people consider deeply immoral, while the few passages that reference gay sex can be readily interpreted in ways that allow for moral, same-sex relationships. I believe there are otherwise good people who truly believe they are doing God’s work by preaching against homosexuality. And if there is a God, I hope that God helps them change their minds. Until then, I don’t have a lot of time for the opinions of people who remain married while preaching that others don’t need romantic companionship in their lives. Traditions with celebate clergy don’t count; the scandals speak for themselves.]

In short, effectively defining sex addiction requires us to grapple with some important realities. We are sexual beings who engage in a wide range of largely normal sexual experiences. We evolved to experience sex as an incredibly reinforcing, species-critical behavior. Culture and religion play large roles in how we interpret the meaning of sex. And even if we are able to identify true pathology, it is critical that we don’t cause harm by pathologizing normal human behavior. It is not yet clear how we do this.

An Alternative Approach

What if we developed a different perspective? Instead of trying to control all the possible ways that sex might become maladaptive, we could focus on ways we can better honor our sexuality. Like so many things in life, the way we approach a problem is just as important as our desire to solve it.

A simple parable may help to explain what I mean.

There was a young man who was hired to manage the plumbing in an old apartment building. Each day, he arrived at work and attempted to fix problems as quickly as they arrived. He was prompt and smart; determined to do good work. But it was his first real job, and it was understaffed. The pipes in the basement leaked and occasionally burst. He developed a plan to replace these old pipes, but found himself so pre-occupied by calls to tenant rooms that he was unable to make any meaningful progress. And so he’d return again and again to a basement full of intermittent spills. He beat himself up, day after day for his failures. Every plumber he knew must manage their work with ease. How could he be so terrible at his job?

One day, this young man went hiking and came across a beautiful mountain stream. This water could not be contained. It had a life and beauty all its own. It was not defined by its leaks, but by its power. The flow had majesty that could be respected, but not easily controlled. He sat with it, learned from it, and got his feet wet. He dug small trenches and built dams, but the water always rose until it found a new way down the hill. He made mistakes in caring for it, but found it resilient. He was patient as he learned how the stream worked–not judgmental about his lack of control. He learned to care for it.

This “Parable of the Pipes” is, of course, a gross oversimplification. But there’s a major kernel of truth here. The almost universal insight shared by “sex addicts in recovery” is a recognition that their sexual desires and behaviors do not define them. Before this occurs, they often grasp at every possible way to control their actions with very little traction. It is the act of acceptance that finally leads to freedom. Why not start there instead?

This parable also speaks to a developmental trajectory around sex. It would be absurd to imagine that anyone makes it through puberty with a fully formed, permanent, and complete understanding of their sexual nature that just so happens to align with the values of their culture. This is never the case. Consequently, if we consider sex a dirty, dark part of ourselves that must be scrupulously controlled, we give it far more power than it deserves. But if we teach that sex is something we honor, appreciate, and treat with respect, we eventually learn to develop appropriate values and restraint around our sexual behavior.

Maybe that is too simple. Maybe there is a need for a diagnostic framework to better explain some forms of non-paraphilic, consensual sexual activity. But for now, I’d rather focus my efforts on helping people accept a joyful, accepting path towards healthy sexuality.

Footnotes

[1]: Although formal acceptance of a diagnosis does not make it beyond criticism, it’s still important to note that sex addiction is not an accepted medical diagnosis. The committee in charge of The Diagnostic and Statistical Manual of Mental Disorders (DSM) was exploring the diagnosis of Hypersexual Disorder for DSM-5, but ultimately chose not to include it in the manual (Kafka 2014, What happened to hypersexual disorder?). The World Health Organization’s International Classification of Diseases has adopted an adjacent diagnosis called Compulsive Sexual Behavior Disorder. This definition is much more helpful than others, but I still find it fundamentally broken. For simplicity, I will lump Hypersexual Disorder, Compulsive Sexual Behavior Disorder, and all other major variants with the older term “sex addiction” in this post. This isn’t entirely fair, as I am convinced that the folks behind Compulsive Sexual Behavior Disorder are really trying hard to create a useful construct. But in my view, the core problems are conserved across all diagnostic frameworks.

[2] I’ve described what I perceive to be some of the weaknesses of current definitions of paraphilias in a previous post. But for the purposes of this article, we will consider paraphilias as presently constituted an absolute exclusion criteria for “sex addiction.”  

[3] “Addiction” is not a well-defined word, and it is not used in any current medical diagnosis. Instead we have defined “substance use disorders.” I find that terminology much more expansive and useful. But for the sake of simplicity in this post, my arguments against sex addiction would also apply to a “sex use disorder.”

[4] People with opioid use disorder, for example, do much better when treated appropriately with long-term, stable doses of opioids. This effect is so profound that many in my profession consider failure to offer effective treatment of this form a profound moral tragedy. You’ll hear more from me on this subject in the future!

[5] If we can’t establish that masturbation is medically and psychologically normal, then we really can’t have a productive conversation at all. Even if you believe that sex with the person you love is the best kind of sex–and I concur–it’s a hot take to assume that everyone who doesn’t currently have this partner must be either completely celebate or a raging sex addict. There probably is a point where too much private masturbation becomes a problem, but I’ve always found an alternative explanation long before I even needed to consider sex addiction. Neurodevelopmental disorders, severe mental illness, stimulant intoxication, and several other medical disorders have always been better explanations to me than sex addiction. Of course, I haven’t seen every case, but I believe that clearly excessive masturbation without any medical or psychiatric comorbidity is extraordinarily rare. I’m open to considering studies that can better describe this population if they exist, but I haven’t seen them yet.

[6] (Grubbs et al. 2023, Assessing compulsive sexual behavior disorder: The development and international validation of the compulsive sexual behavior disorder diagnostic inventory (CSBD-DI)). I added italics around “personal distress” for emphasis in this post; they are not in the paper. 

[7] In the United States, the belief that masturbation is a sin tends to come from Christian traditions (although some sects of Judaism and Islam espouse a similar belief). However, this belief is not found in the Bible or the Quran. Again, you may decide your own values. But it may be worth considering the assumptions required to make sweeping statements about the morality of masturbation.

Classification of sexual disorders carries an additional challenge: it is almost impossible to divorce morality from sexuality. Some diagnoses carry explicit moral biases—like the thankfully discarded disorder of homosexuality. Other labels carry more subtle moral judgments. For example, female orgasmic disorder assumes that a woman’s sexual function should be robust regardless of the efforts of her partner. An astute clinician will assess the ways that interpersonal and cultural factors modify sex, but there is nothing in the core criteria for female orgasmic disorder that would help a non-specialist understand this nuance.

In contrast to the sexual disorders, almost all other psychiatric diagnoses take a relatively soft stance towards moral considerations. Depression may result in impaired function, but there is no moral judgment around failure to perform necessary tasks. Psychosis may cause erratic and sometimes illegal actions, but social norms are not used as a benchmark for pathology. Opioid use disorder does not consider whether a person's behavior is morally right or wrong. We only assess whether symptoms are present and causing clinically significant distress and impairment. 

Before I go further, I want to be clear that I am not arguing that a moral perspective is wrong. There are implicit, generally inoffensive, moral judgments in the way we define all illnesses. I am suggesting that our attempts to define pathology need to come from a shared moral framework. Our failure to do this is most apparent in disorders related to human sexuality. 

I hope we can agree that explicit consent to sexual activity is a basic moral framework worth building around. You may have additional moral beliefs you would consider—and they may even be near globally shared. You may also want me to flesh out the meaning of phrases like “explicit consent” or “sexual activity,” which is beyond the scope of this post. My goal today is not to describe a perfect moral or diagnostic framework. Far from it. My goal isn’t even to talk about “weird” sex. What I really want to talk about is perceived sexual addiction—a deeply flawed but immensely interesting topic. But because almost every formal definition of sexual addiction is explicitly non-paraphilic, it makes sense to talk first about paraphilias.

Defining Paraphilias

A paraphilia is an abnormal sexual desire that is so significant that it causes distress or impairment in the person’s life [2]. But which sexual desires count as abnormal, and who gets to decide what normal means?

The DSM-5 is not particularly helpful. DSM-5 paraphilias are “intense and persistent sexual interest[s]” for anything other than “genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners.”

There is so much to unpack here. Reducing sexual activity to "preparatory fondling" and "genital stimulation" is only slightly more open-minded than “missionary position when attempting conception [3].” And why must our interest in partners be derived from them appearing "phenotypically normal?" Isn’t it healthy to be attracted to a partner’s unique characteristics [4]? While I agree with the DSM-5 committee that physical maturity is important in a sexual partner, why aren't emotional, intellectual, and spiritual maturity considered similarly important? Although “intense and persistent sexual interest” seems like a good bar for concern, these vague terms have major flaws. Every good clinician knows that many people who experience intense and persistent desires are perfectly normal, no matter how strange they may sound to others. At the same time, more than momentary pedophilic interests need to be assessed carefully—regardless of their intensity.

Even without all these caveats, the DSM-5 fails to consistently apply these principles. Paraphilic disorders are only included if they are 1) relatively common or 2) potentially criminal. The relative commonality criteria has an obvious problem: if a desire or behavior is common, why would we consider it abnormal? You might find a foot fetish unusual, but a large proportion of the population is really into feet. Maybe that means that foot people are normal. On the other hand, rare but clearly pathological paraphilias like necrophilia aren’t included as separate disorders.

Potential criminality is a flawed criteria for a different reason. Crimes are based upon legal definitions, and I don’t recommend that anyone pattern their sexuality around the whims of legislators. A better standard would be a strong desire for atypical, nonconsensual sexual contact with another person. Inadequate consent—not current legal definitions—is a much more reasonable line when considering pathology.

The Currently Accepted Paraphilias

As I describe the core arousal target in each of these paraphilias, please note that a simple desire to engage in these behaviors alone is insufficient for diagnosis. There are clear overlaps between some paraphilias and normal sexuality (e.g. BDSM play could be mischaracterized as masochism or sadism). It is also very common for these desires to be present in children and adolescents without persistence to adulthood. In addition, there are important rule-outs which must be considered when making the diagnosis. For example, behaviors that only occur during substance use or mania would not typically be considered paraphilic. Likewise, people with obsessive-compulsive disorder may experience thoughts that sound paraphilic to an untrained observer. Because of these complexities, a skilled clinician is needed to confirm the clinically significant features which are core to each diagnosis. 

The DSM-5 describes eight specific paraphilias alongside a waste basket category of “other specified paraphilias.”

Voyeuristic disorder describes arousal from watching unsuspecting people undress or have sex. It is not clear from the text whether this same disorder would apply to simulated situations, such as voyeur-related pornography viewing.

Exhibitionistic disorder describes arousal related to exposing your genitals to others without their consent. Please note that this disorder applies to the display of genitals only and not other body parts. This may be related to the fact that paraphilias are almost exclusively described in men. I suspect—but can’t support with data—that most unsolicited dick pics are misguided rather than paraphilic. (Fellas, does that ever actually work? Let’s be better than that.)

Frotteuristic disorder describes arousal from touching or rubbing up against nonconsenting people. This behavior typically occurs in public settings, such as a crowded subway.

Sexual masochism disorder describes arousal from being “humiliated, beaten, bound, or otherwise made to suffer.” Erotic asphyxiation would be included in this category. Again, this disorder—like sexual sadism below—is not designed for people who enjoy consensual BDSM. Most cases of sexual masochism disorder occur in situations where it limits flexibility around sex in a partnered relationship.

Sexual sadism disorder describes arousal from causing pain to others. There is an ocean of gray area in the diagnosis of this disorder, as serial rape alone is generally not considered sufficient to meet criteria for this diagnosis. It’s too complex to dig deeply into this today, but the general idea is that rape occurs for many different reasons. A desire for power over someone is not enough for sexual sadism; the diagnosis requires a core pattern of sexual arousal from deeply hurting other human beings. Not surprisingly, many other paraphilic behaviors are also related to power more than sex, and so there is common recognition among clinicians that someone who has sexually assaulted a child may not experience pedophilia.

Pedophilic disorder describes arousal from potential sexual activity with prepubescent children. This differs from the common usage of the word pedophilia, which typically means sex between an adult and anyone who is underage. DSM-5 and ICD-11 pedophilic disorder only describes attraction to prepubescent children.

Fetishistic disorder describes arousal specifically focused on non-genital body parts or objects. Specificity here is lacking. It is not clear to me why breasts, pecs, abs, and butts—which are not genitals—do not appear to count as fetishes, while arousal in response to ankles and hair—which are also not genitals—is considered abnormal. Not surprisingly, the use of devices like vibrators do not count as object fetishes. The plain language used in the description lacks specificity, and cultural norms around sexual attraction are heavily implied.

Transvestic disorder describes arousal from cross-dressing. It is critical to note that transvestic disorder and transgender identity are unrelated ideas. Trans people are not trans because they are turned on by their gender identity. There has been a longstanding, deeply misguided suggestion by some researchers that a subset of trans women experience autogynephilia—sexual arousal from imagining themselves as women. The DSM-5 propagates this absurd concern by including autogynephilia as a potential specifier for transvestic disorder. This simply does not matter. How many cisgender people are turned on simply by existing in the sex they were assigned at birth? No one suggests that autophallophilia in cisgender men is a problem, despite it being an extraordinarily common phenomenon [5].

Other specified paraphilic disorder describes a poorly defined wastebasket of disorders that includes necrophilia (arousal from corpses), zoophilia (arousal from animals), urophilia (arousal from urine), and coprophilia (arousal from feces) among others. 

Two Surprising Omissions from the Paraphilias 

Despite all these efforts to classify paraphilias, there are two especially notable omissions: hebephilia and ephebophilia.

Hebephilia describes attraction to children who are in the midst of puberty. In my opinion, this always constitutes a harmful attraction, as a child undergoing puberty is never able to provide consent for a sexual relationship with an adult. The decision to not include hebephilia as its own paraphilic disorder was likely made due to a lack of data, but the failure to specifically include hebephilia under the heading “other specified paraphilic disorder” is surprising.

Ephebophilia describes attraction to adolescents who have already completed puberty. In essence, ephebophilia is attraction to youth who have mature, physical sexual characteristics, but who have not yet reached emotional, cognitive, spiritual, or cultural maturity. There is a reasonable evolutionary argument that physical attraction to young, fertile humans is a normal human trait. At the same time, the age and power mismatch between a mature adult and an adolescent is a cause for concern. Proposed ephebophilia definitions acknowledge that adolescence persists much longer than the statutory age of consent in most jurisdictions. It’s not my business whether a consensual, legal, relationship is appropriate, but I also find that our whole-human attractions tend to age with us. The complexity of defining ephebophilia is a reasonable argument for excluding it from the DSM-5, but I mourn the implication that healthy sex is primarily connected to physical maturity.

Reimagining Paraphilias

As I said before, I’m not interested in creating an absolutely coherent, perfect definition of maladaptive sexuality. That may not even be possible. However, I do think that there is room for improvement in the way that we approach paraphilic desires.

Rather than creating distinct categories of disorder, it may be more useful to think in shades of gray. We often call this form of measurement dimensional [6]. One example of a dimensional approach is the Kinsey Scale, which asks participants to rate their sexual attraction to the same or opposite sex on a scale of 0 to 6. A rating of 0 would correspond to someone who identifies as straight, while a 6 would be given by someone who is gay or lesbian. Scores between 1 and 5 represent variable levels of bisexuality. This score alone only describes one dimension of a person’s experience, and the measurement of additional dimensions (such as romantic attraction or libido) would help to describe a fuller picture of sexual orientation than gay, straight, or bisexual. Dimensional approaches do not claim to explain everything, but they can carry much more nuance than the DSM model of simple categorization.

What dimensions matter in describing paraphilias? I would like to suggest that two dimensions must be present to even consider an attraction pathological. First, a paraphilic desire must be atypical. Under this dimension, a belly button fetish might score so low as to be unremarkable, while hebephilia would be clearly atypical. Second, paraphilic desires must be for nonconsensual sexual activity. For the sake of clarity, I note that some paraphilic behaviors are always nonconsensual—as children and unsuspecting victims cannot consent to sex. When consent is impossible, this paraphilia always falls on the extreme end of this dimension. A more nuanced approach needs to be taken when behaviors can be either consensual or sexual assault. For example, private exhibitionism by a dancer in a club is consensual and should never be considered paraphilic, while it would not be appropriate to display your genitals publicly in most western cultures. In short, behaviors that are typical or always consensual should never be considered paraphilic—no matter how unusual they may sound to others.

There are two other dimensions that are worth exploring: enactment and exclusivity. These dimensions are not needed to determine the presence of pathology, but they give us critical information about how the paraphilia is manifest. Enactment measures how often an individual has engaged in paraphilic behavior. We all appreciate that someone who experiences pedophilia and has never harmed a child is very different from someone who has sexually assaulted children. The innocent person with maladaptive attractions deserves non-judgmental care and support, while a person who has perpetrated must be approached with an even sharper eye towards public safety. The stigma and legal risk to acknowledging a pedophilic desire has made it almost impossible to determine the prevalence of pedophilia, but I’d be willing to bet that the vast majority of people with pedophilia never assault a child. For those at risk of offending, it is critical that we develop preventative tools that help to manage pedophilia effectively. Legal consequences—while necessary when abuse happens—cannot reverse the consequences of childhood sexual assault.

Exclusivity measures whether someone experiences paraphilic desires alone or as part of a spectrum that also includes healthy sexual behaviors. Abstinence from sex is rarely consistent with a full life, and someone who cannot experience sex outside of atypical, nonconsensual behaviors is at high risk of harm to others. On the other hand, non-exclusive paraphilias may raise additional concerns. For example, someone who experiences attraction to both adults and children is more likely to have children of their own, placing them in close proximity to potential targets for sexual assault. The DSM-5 does attempt to describe exclusivity in the case of pedophilia, but this domain should be considered in the assessment of all paraphilias.

These dimensions are just a rough sketch. I’m well aware that there are additional dimensions that need to be explored, and that sexuality cannot be described with any real rigidity. I’m also aware that suggesting dimensions and obtaining accurate, validated measurements of these dimensions are entirely different processes. But without a dimensional approach, we end up with the thoroughly broken system we currently have.

Conclusion

Why do I care? It’s a fair question, and one I don’t have a complete answer to. Perhaps it is because I treat two distinct groups of people: those who desire or engage in normal sexual expression that is often stigmatized, and those who are at high risk of future offenses towards others. Our current descriptions of paraphilias label too many normal people as disordered, and fail to adequately address the very real struggles of people who experience dangerous paraphilias. Both groups deserve compassionate care and human dignity, but only people who engage in nonconsensual sexual behaviors as a result of atypical sexual desires require legal rehabilitation [7].

With this groundwork out of the way, we can begin talking about sex addiction—a construct which I will argue is much, much harder to define than paraphilias. Please consider subscribing to get my next post in your inbox.

Footnotes

[1]: The World Health Organization publishes a similar book of diagnoses called the International Classification of Diseases 11th Revision (ICD-11). The ICD-11 is more expansive than the DSM-5 as it includes both physical and mental health diagnoses. With regards to mental health, it is not necessarily better than the DSM-5. It has its own strengths and shortcomings, but the same general problems with diagnosis can be applied here. 

[2]: The DSM-5 distinguishes between paraphilia and paraphilic disorder by suggesting that a paraphilia only becomes a disorder when it is intense enough to cause harm to others or clinically significant distress or impairment. I will break tradition here by using both terms interchangeably, as I will disagree with some of the conclusions the DSM-5 makes about the pathology of many paraphilic disorders.

[3]: You don’t need to be a psychoanalyst to feel the repression in “genital stimulation or preparatory fondling.” It’s a phrase that makes the perpetual 14-year old in me giggle.

[4]: I am well aware of what the DSM-5 means here: it is fine to be attracted to your partner’s amputated limb, but it may be a problem when you are only attracted to people with amputations. I don’t think that matters. Even if it did, greater precision of language is necessary.

[5]: I’m aware that autoandrophilia is more congruent to autogynephilia than autophallophilia. Gyn- is a root suggestive of women, and so andro- (meaning men) would be more congruent. Many men mistakenly think that gyn- is primarily related to the vagina, and what kind of psychiatrist would I be if I walked by a good penis reference?

[6]: The dimensional perspective is not a unique viewpoint for mental health diagnosis, although I will confess that I intentionally chose not to deeply explore the literature on dimensionality in paraphilias before writing this post. This allows me to think out loud—right or wrong—without being overtly influenced by the predominant models that have been proposed. I’m also approaching this as a critic of both sex addiction models and paraphilias, which may not be the typical approach of paraphilia researchers.

[7]: I’m deeply aware of the brokenness of the legal system in the United States and much of the world. Our current system doesn’t usually result in rehabilitation. I’m remarking on what people need from our legal system, not what they currently get.

When I was growing up, no one was concerned that masturbation caused hairy palms, blindness, or epilepsy. But there was a common fear in the religious community of my youth that masturbation was addictive. Masturbation was frequently discussed and demonized; a vile sin that would take over lives and prevent healthy sexuality within marriage. “Of course masturbation is addictive!” we thought as we hung our heads in shame—not realizing that almost every other adolescent boy (and most of the girls) were doing exactly the same thing. My parents held the same beliefs, and schools in my state did not mention that masturbation is a natural process. President Clinton even forced his surgeon general to resign when she suggested that kids ought to know that masturbation is normal [1]. Masturbation addiction continues to carry some misguided cultural cachet, though this messaging doesn’t seem to be as relentless as it was in the past [2].

In my parent’s day, many people worried that masturbation would make boys gay. (Fellas, is it gay to touch a penis?) I’m endlessly fascinated by this idea. Were the men who invented and perpetuated this belief part of the rare few that had no personal experience with masturbation? Were they closeted gay and bisexual men who extrapolated their own sexual thoughts onto others? And why weren’t they worried that women were becoming gay through masturbation? This belief seems absurd to most modern Americans, but it still gets occasionally touted in other parts of the world.

My favorite myth is the belief that masturbation is prohibited in the scriptural canon of the Abrahamic religions. It is not. The Hebrew Bible, New Testament, and the Quran are completely silent on the matter. This near ubiquitous behavior was apparently never a great concern to the ancients. Masturbation is a relatively late addition to each of these traditions, and modern teachings within sects of all three major branches vary from full acceptance to complete prohibition.

Now frankly, I find the medicalization of masturbation much more interesting than the moral baggage it’s picked up throughout human history. And in my estimation, no medical connection is more interesting than the centuries-long link between masturbation and psychosis. 

Psychosis—the modern term we would use to describe most cases of “insanity”—is a phenomenon where people experience a severe disconnection from reality that is manifest through hallucinations, delusions, disorganized behavior, and disconnected thoughts [3]. Psychosis can occur for many different reasons, but the most common form of chronic psychosis is a disorder we now call schizophrenia [4].

Historical psychosis was often described in spiritual terms. Many ancient descriptions of demon possession appear to be psychosis, although a number of other disorders could also present with possession-like symptoms. Even today, it is not uncommon for people with psychosis to report a belief that they are possessed by demons. Attempted exorcism remains surprisingly common, though I haven’t seen a reliably documented case where this was successful. The medical connection between demonic possession and psychosis was discarded centuries ago, but the connection between sin and psychosis lived on much longer than many people would have expected.

The English psychiatrist Edward Henry Hare—who I now gratefully summarize from—has argued that masturbation was rarely more than a spiritual consideration before the early 1700s when a book known as Onania began to be widely published in Europe [5]. Onania was primarily concerned with the sin of masturbation, but it is also the first document connecting masturbation to serious medical illness. This document had profound effects on the general populace, (and likely drove impressive sales of the cure it promoted) but was generally ignored by most of the medical establishment of its time. It was only after the 1760 publication of Samuel Tissot’s “L’Onanisme” that the medical consequences of masturbation—including insanity—came into favor among physicians of the day.

Like most moral panics, “L’Onanisme” blamed masturbation for numerous medical conditions. One by one, scientific consensus began to rule out masturbation as the cause of almost all physical illnesses. Psychopathology was not so fortunate. The covert nature of masturbation and the complexity of mental health gave the masturbatory hypothesis a lasting appeal.

In exploring this, I am not attempting to put our modern understanding of chronic psychotic disorders on a pedestal. We currently think of schizophrenia as a brain disorder caused by interactions between biological, psychological, social, and cultural influences. But to this day, we still have no concrete explanation for why almost anyone develops psychosis. Few cases are caused by a single gene or a chromosomal abnormality. Identical twins are much more likely to share the diagnosis than non-identical siblings, but identical genes alone are not enough to predict a shared outcome. Early life experiences are absolutely important, but which experiences matter, and how do they produce these changes? Why is the presentation of psychosis so diverse? How many different illnesses are we actually observing? This is a wicked problem; the failure of any potential hypothesis reflects the complexity of the issue more than naivete alone.

Masturbatory insanity had a provocative logic to it. For example, people experiencing acute psychosis may engage in public masturbation while grossly disorganized or manic. This is an uncommon phenomenon in adults without psychosis, suggesting that masturbation may be contributing to the psychotic experience. Likewise, masturbation usually begins or dramatically increases during puberty. Psychosis is rare in childhood, but often emerges in adolescence.

We rightly look at these correlations and see them as just that: correlation, not causation. The common cause of public masturbation may have been the psychotic experience itself. Puberty precedes both masturbation and psychosis, and could cause both outcomes. But the suspicion of correlation alone is not enough to readily change beliefs. Concrete data must be produced to support an alternative explanation.

Skepticism of the masturbatory hypothesis was published alongside “L’Onanisme,” and thoughtful minds did significantly narrow the scope of the problem. But masturbatory insanity was an influential idea until the end of the 19th century, and continued in less potent forms until the medical link between masturbation and essentially all negative health outcomes died out for good around the time of World War II. Hare offers four observations for why the masturbatory hypothesis of insanity may have fallen out of favor.

First—and as we’ve observed above—observers noticed that mental illness itself may be causing masturbation, and not the other way around. I do not want to dismiss how subtle this idea is. Dualism was the philosophy of the day. Neither physicians nor the public broadly appreciated that consciousness arose from the brain. Thoughts and emotions were derived from the spirit, and sinful insults to the soul were bound to cause psychic problems. Even today, many people are uncomfortable with the idea that their experience is the product of a corporeal existence. We, like our forebears, are products of our time and culture.

Second, masturbation was discovered to be common within healthy communities. This was not a banal observation. No one actually knew how common masturbation was until the late 19th century, when researchers reported that more than 90% of boys and 60% of girls masturbated—findings that have been repeatedly replicated across western cultures over the last 150 years. If masturbation was such a common experience, then why did so few go on to develop psychosis?

Third, it was impossible to objectively know how often a patient masturbates. Self-report is inherently challenging, and becomes even more suspect when there is religious and medical stigma regarding a behavior. A patient with psychosis who reports frequent masturbation serves as confirmation bias. But what if that same person reports that they never masturbate? You can easily dismiss their report as a shame-driven lie. Your assumptions catch you in a loop you cannot escape without humility [6]. This fallacy is sometimes known as Morton’s fork: either observation leads to exactly the same conclusion.

Finally, the masturbatory hypothesis had a major physiological flaw. Why did people who primarily engaged in masturbation develop psychosis, but not people who participated solely in partnered sex? These physicians were not generally worried about the total number of orgasms that the patient experienced; they believed that there was something uniquely different about masturbation compared to all other forms of sexual activity. But how would these experiences differentially impact the development of the brain? Could my religiously scrupulous patient with psychosis who abstains from masturbation as often as possible be truly differentiated from the man on the pew next to me who has sex with his wife every night? Removal of the moral implications of masturbation revealed no significant physiological difference between the two acts. 

Like most advances in knowledge, reason and data alone was not enough to produce immediate impacts. It took generations to change the scientific consensus. Changes to our cultural understanding will take even more time. Because although we now recognize that masturbation is by and large a harmless act, there is still a push to add false medical risks to normal human behavior [7].

Footnotes:  

[1] Joycelyn Elders is a badass. Her words ring just as true today as they did almost 30 years ago: “I feel that we have tried ignorance for a very long time and it's time we try education.”

[2] Some communities—such as r/NoFap—explicitly attempt reductions in masturbation. Others say very little outwardly on the subject, and instead talk about addiction to porn. In reality, most “porn addiction” groups worry about both porn and masturbation. Few people are suggesting that “porn addicts” use their imagination when they masturbate, as shame about masturbation remains a core belief in “sex addiction” communities. (I don’t want to dismiss concerns about compulsive sexual behavior outright, but I’ve never found sex addiction to be a useful construct. Even among those who really believe they are addicted to sex, self-reported behavioral change tends to follow acceptance and anti-shame beliefs. This is an axe I plan to keep grinding. You’d better believe I’ll be talking about it more in the future.)

[3] Psychosis is actually a lot harder to define than this. For example, many people hear an occasional, non-bothersome voice talking to them. Or in a time of bereavement, they may see or feel the presence of a deceased loved one. These experiences alone are not signs of mental illness. Psychosis requires much more, and includes significant distress or gross impairment. This trips up a lot of my medical students, but they tend to accept that the phrase “non-psychotic hallucinations” is just another one of the nonsensical things that psychiatrists like to say.

[4] From here on out, I’m going to use schizophrenia and psychosis interchangeably. It’s actually much more complicated than this, but it’s a reasonable approximation for today.

[5] Edward Henry Hare wrote “Masturbatory Insanity: The History of an Idea” in 1962. It’s a provocative article. Historical research has no doubt advanced since that time, but Hare’s writing is thoughtful and entertaining. For example, Zachar and Kendler provide an update to Hare’s treatise in a recent article. Although many of their points appear implied in my reading of the original article, I appreciate both their perspective and their accounting of more recent historical research. 

[6] Similar behaviors still occur today. Patients who test positive for amphetamines often report that they have not used anything in this class of drugs (e.g. methamphetamine, Adderall, and Vyvanse). Many well-meaning doctors will interpret this response as a lie, and the denial as proof that the person has a substance use disorder. The reality is much more complicated. This test is known to have many false positives, and cannot be considered accurate unless it is confirmed by patient report or a more specific test for the drug. Assuming lies in truthful patients is an age-old medical error. I’ll have to talk more about urine drug screens in the future, as their use and misuse is worth discussing.

[7] Where are the caveats to the statement that “masturbation is by and large a harmless act?” Well, I’m just pedantic enough to point out that there are some uncommon, but fairly obvious risks. The use of harmful physical implements and masturbation in the presence of non-consenting individuals would be top of the list. There is also understandable concern that masturbation to harmful stimuli (such as media portraying child sexual abuse) could result in the reinforcement of dangerous beliefs, emotions, and behaviors regarding children. Frequently choosing masturbation over sex with a partner may also be detrimental to a relationship—although that would also be true of any number of non-sexual activities that distract from connection.

This isn’t a criticism of the Rom-Com. The formula is part of the reason we enjoy them. (Have you read Pride and Prejudice? It’s fantastic, and I’m comfortable enough in my masculinity to say so. Fight me if you disagree.)

The central plot point in every Rom-Com–most dramas, really–is poor communication. If the characters would just talk openly and respectfully, most of their problems would evaporate. I get it. Being more transparent comes with a potential for both connection and pain. It requires confidence. It is hard, emotional work. 

At the same time, good communication is the central challenge in all of our lives. Does your boss really know you? When was the last time someone sat with you and just tried to understand your heart? How much better would your relationships be if you understood what the people in your life truly thought and felt?

Most communication skill education focuses on speaking effectively. And yes, people are more likely to respond favorably when you communicate your wishes clearly. But speaking effectively is only half of the challenge–and probably not the most important half. In my experience, learning to effectively listen does more to improve communication than anything else. Speaking well may get you what you want right now, but excellent listening will help you build powerful, collaborative relationships that support you over the long-term.

The best book I’ve read on the subject is Listening Well, by Dr. Bill Miller [1]. For those who may not know, Bill Miller is the co-founder of a practice called Motivational Interviewing. Motivational Interviewing is an evidence-based method therapists and doctors use to help people choose healthier habits. It isn’t a Jedi mind trick where we instill our values in someone else; it’s a skill we use to draw out intrinsic motivation for change. There is plenty of nuance to the approach, but all Motivational Interviewing is founded on principles of effective listening.

In Listening Well, Dr. Miller synthesizes decades of experience into one hundred focused pages. Each chapter is short, and most include a practical exercise to apply the skills taught. Listening Well is written for a general audience, but I’ve found it immensely helpful in my work and personal life. 

Listening Well is written to help you experience accurate empathy–a correct understanding of someone else’s feelings, beliefs, and thoughts. Empathy in this context is not intended to mean an innate shared feeling, nor is it short statements of sympathy like “I’m sorry that happened to you.” Accurate empathy is like obtaining API access to someone else’s mind (with read-only privileges, authentication, and rate-limiting in place, of course). Accurate empathy is a learnable process that allows you to repeatedly guess and confirm what someone else truly means while actively deepening the relationship.

In explaining accurate empathy, Miller summarizes the work of Thomas Gordon, who described a seemingly simple model of communication: the speaker translates what they mean into language, you hear spoken words, and then your brain intuitively interprets the meaning of those words. This process of encoding, transmitting, and decoding happens effortlessly. In addition to conversation, this process is foundational to literature, music, news, and entertainment. We would have not have created civilization without an ability to share our minds so through language [2].

A simplified diagram of Thomas Gordon’s model of communication. Adapted from Listening Well and Motivational Interviewing, 3rd Edition.

But the process of communication is marred by one tragic flaw: the listener often believes they understand what the speaker thinks, even though they cannot know with certainty what the speaker actually meant. This is not a failing of the listener or speaker. Language is ambiguous, complex, and lossy. My brain cannot stop itself from expanding upon what you said, and I’m often wrong. Even if you painstakingly construct seemingly perfect speech, I will misunderstand something you say [3].

You would be correct in reminding me that communication is a dialogue, and that one way speech will always be marked by misunderstanding. This is true, though I offer two important challenges that need to be overcome through dialogue.

First, listeners often assume that they understand what speakers mean. It takes practice, time, and emotional availability to counteract this habit. Even when an opportunity for dialogue arises, listeners may move on before they develop an accurate view of the speaker’s mind.

Second, effectively clarifying what someone means is inherently challenging. In the simplest case, repeating back what you heard can work. Miller calls this a simple reflection, and it is excellent for confirming that you heard what was said. With straightforward instructions, simple reflections are incredibly valuable. Almost every high-functioning system incorporates simple reflection into its communication structures, and it’s an easy way to improve ordering a burger or leading a surgery suite. But simple reflection doesn’t solve the first problem: it confirms what was said; it does not confirm what was meant.

Solving this dilemma is the crux of Listening Well. How do you actively listen in a way that helps you truly understand what is meant? You could focus on asking questions–and you will pick up some skills to create more effective questions in this book. At the same time, questions are emotionally expensive. Asking too many questions feels like an interrogation. Questions can also put you in the role of authority figure, which quickly shuts down open conversation. A great question can make all the difference in the world, but an overly eager questioner is terribly frustrating.

How do you clarify with fewer questions? One solution is the use of complex reflections. A complex reflection is a simple statement that guesses what the other person means. For example, someone might tell you about an unjust criticism they received. “Do you feel angry?” may be answered with a yes or a no. If you’re lucky, the speaker may spontaneously clarify what they meant. On the other hand, guessing “You must be angry” is an invitation for the speaker to clarify what they mean, continuing the conversation. “I’m not angry, I just feel like my efforts have been ignored…” Answering with a complex reflection also shows that you’ve taken efforts to walk in their shoes, deepening the relationship.

Closing the communication loop with complex reflections. Adapted from Listening Well and Motivational Interviewing, 3rd Edition.

A well-formed complex reflection is a nearly free API call. I’ve had people get incredibly angry at me after what I thought was a reasonable question (it’s expected from time to time in my work as an addiction psychiatrist). But I can’t recall any instances where trying to understand someone through a genuine, curious reflection caused more than momentary annoyance. Complex reflections have leveled up my communication abilities more than anything else I have ever practiced. (And I still suck at using them.)

I can’t emphasize the power of complex reflections enough. When I’ve trained novices in this basic skill, It’s not uncommon for them to walk away feeling like they were heard in a way they haven’t been in a long time. (And this comes after they listen to each other, not me!) Does it always work? No. But it is a great tool that will make you more effective.

I’m only giving you a taste of this phenomenal book–but it’s the part I find most insightful. Miller goes much further in expanding on this model, and provides helpful skills around roadblocks to effective listening, applying these skills in relationships, and even a few gems you can apply to speak more effectively.

Most non-fiction books contain 1-2 take-aways which are stretched to fill the 200+ page format. This is not that kind of book. It’s a dense, practical, rich book with timeless advice. I can’t recommend it enough.

Best wishes,

Jeff

Thank you for reading. If you found this post helpful, please consider sharing it.

Footnotes:

[1]: I am using Amazon affiliate links, and will receive a small commission from Amazon if you choose to buy a product from them.

[2]: It is impossible to overstate the physiological complexity underlying spoken communication–even if you take consciousness for granted (which I do not). Neurons somehow condense meaning into conscious language. The speaker then subconsciously coordinates muscle activity to force air across sound producing structures resulting in pressure waves corresponding to distinct phonemes. These waves then travel until they are directed by funnels of cartilage on the side of the listeners head into a tiny tunnel, where these minute pressure changes vibrate a membrane to mechanically conduct a signal into the inner ear. Distinct frequencies are parsed out by cochlear neurons, and these are then translated back into phonemes and language within the brain, where the process of meaning-making can begin to occur. We assume this is normal, but it is one of the most profound products of evolution. Why did I go through all of this? Probably not for you; I personally like to experience the wonder of neuroscience as often as I get the chance.

[3]: This is one of the many reasons why writing is so challenging. The writer tries to anticipate–in advance–the many different directions your brain may go when encountering language. Fiction uses the generative nature of language-based-meaning-making to stimulate emotions and imagery, while technical writing tries to limit your mind’s ability to wander. 

[4]: There is no [4] in the essay. But I’ve added this brief note because this is only my third post, and I’m sure someone is wondering what this has to do with sex, drugs, and suicide. First: this is my mental health blog, so I get to talk about whatever the hell I want to! 😊. (Of course, suggestions are always appreciated, and I’m currently writing about a sexually adjacent topic for next month.) Second, and more importantly: I’m a firm believer that our interpersonal relationships are major drivers of all human processes. If improving your ability to communicate doesn’t improve your sex life, I don’t know what to tell you. You simply cannot understand without discussing the interpersonal model of suicide, and as for drugs—well, you get the picture.

Every drug seems to have a “right” way to take it. You drink alcohol, smoke tobacco, snort powdered cocaine, inject heroin, and booty bump ecstasy [1]. There will always be exceptions, but the route of administration seems to heavily impact the experience of drug use. 

So I was surprised a few months ago when a patient told me about an experience he had with IV caffeine. 

I’d never heard of anyone intentionally mainlining caffeine–and that wasn’t the case for this patient either. He received IV caffeine as part of a medical procedure done under general anesthesia. People are usually completely asleep before they receive caffeine, but for reasons I cannot comprehend, the caffeine hit before he was fully sedated, causing an intense rush of anxiety; one of the worst experiences of his life.

Part of me was horrified. I’ve had anxiety provoking experiences with anesthesia before, and I can’t even imagine being hit with a stimulant right before going under.

The other side of me was curious. If caffeine is so great, why don’t people inject it? Does it always cause anxiety? Don’t get me wrong–I certainly see the downsides to IV caffeine: needles, infections, and the social stigma of taking a prolonged “bathroom break” at work instead of getting coffee for the team. I’m also aware that caffeine is quickly (and almost perfectly) absorbed by the gut. Plus, it’s dirt cheap when not taken in its artisanal forms, meaning nobody needs to squeeze every last drop of benefit out of the drug itself. But somebody must have tried shooting it before, right?

Thankfully, it’s easy to find information on questions like this. I usually turn to one of the many websites which curate the stories of drug users. But as I had heard about this in a medical procedure, I decided to do a literature review instead. And I found what may be one of the greatest scientific papers ever written.

In the study, Johns Hopkins researchers recruited 10 individuals with a history of significant cocaine use and told them “that the purpose of the study was to see how different drugs affect the mood and behavior of people.” They were given a list of IV drugs they might be given, which included–among other drugs–xanax, speed, and cocaine. They were then paid to stay in a research facility for 20 days to receive IV drugs.

Here’s where it gets interesting. The study was not designed to look at hard drugs–the scientists were only interested in IV caffeine. They held oral caffeine from research subjects for several days, and then gathered baseline data by testing whether escalating doses of IV caffeine caused physiological problems. After their initial tests, they randomized each subject to varying doses of placebo or IV caffeine. Doses ranged from 37.5 mg (a touch more than a can of Coca Cola) to 300 mg (which is 4-5 shots of espresso).

Immediately following caffeine injection, subjects were given a battery of questions. My favorites: rate from 0-100 the following: “Do you feel high?” “Have you felt any good effects?” “Have you felt any bad effects?” “Do you like the drug?” and “Have you had a desire for cocaine?” Simply beautiful.

Overall, higher doses of caffeine were associated with positive effects and a euphoric feeling. Negative effects weren’t quite as clear with small amounts of caffeine, but when given the maximum dose, one participant noted a “dull” or “bitter” taste, while most others experienced a scent that was “musty” or reminiscent of Clorox, ammonia, or burning rubber. Does IV caffeine make you want to use cocaine? Only a little, and only at the highest dose.

So what do we learn from this study? First, while I was wearing Red Ribbons and listening to ineffective D.A.R.E. propaganda in Elementary School, the National Institute on Drug Abuse was funding some really fascinating research on what happens when you take IV drugs. (This research group has some other fascinating work I may get around to one day.) Second, when taken in the right context, IV caffeine carries a brief, pleasurable high and a noxious scent. We can’t compare it to any other drug because it wasn’t tested head to head, but it seemed to be a positive experience overall. 

As someone who gets a little jittery when over-caffeinated, I’ll pass.

Footnote:

[1] Most people consume ecstasy by mouth, but I’ve heard from many that anal ecstasy is a more satisfying experience.

Now to be clear, this blog is not about my own mental health. My struggles with depression and anxiety are terribly boring, and thankfully, I’m doing pretty well. (That’s the truth, Mom, thank you for always asking!) My recovery isn’t built on perfect practice, so I’d hate to speak from my very narrow personal experience.

I’m writing as a student of mental health. I have professional qualifications as a board-certified general adult and addiction psychiatrist, but I think of my training as a broad foundation rather than a symbol of expertise. (For those who don’t know: a psychiatrist is a physician with an MD or DO, while a psychologist typically has a PhD or PsyD. More simply: as a psychiatrist I can prescribe medications, although that tends to be only a small part of my job.)

This blog won’t always be correct, and you should obviously never consider it personal medical advice. I’m also not speaking for my employer or any other third party. 

If the title isn’t clear, I’m writing to an adult audience about themes that are often considered adult. The adolescents you know are navigating these same topics, and the education they receive is poor. (Teenagers: I’m not requiring a birthdate to access this content, but I encourage you to connect with a compassionate, non-judgmental adult on your journey.)

So why this title? Sex, drugs, and suicide are among my major clinical interests. I think about these three topics frequently, and almost all of my patients are heavily impacted by problems with at least one of these subjects. I’ll explore mental health from many other angles, but these themes are the overarching focus.

I’m not planning on publishing articles at any particular pace or in any specific order. I’ve found that I do my best work when I’m initially driven by passion. (Like any other writer, I’m painfully aware that finishing a piece is drudgery, so I will be keeping my own internal deadlines.) I’ve tried weekly blogging and found that it’s hard to publish something with true substance every week. In lieu of consistency, I plan to offer something with a little more meaning. Perhaps you’ll find it useful, and perhaps you won’t. But I hope that you consider subscribing.

-Jeff