It seems that one either loves or hates this book. Of the comments on Amazon USA, almost all reviewers either give it a maximum 5 stars or a minimum 1 star, the `loves' strongly outweighing the `hates'. The 3 UK reviewers were less generous. If possible, I would have given it 4.5 but, not being allowed this, I opted for 5 stars. I did this, not because I agree with its central premise that sex addiction is a myth - I don't - but because of how well written it is and because of the obvious help that it has brought to many people who presumably have been falsely diagnosed. Dr Ley's scholarship in assembling fascinating and highly relevant case studies is nothing short of amazing. If the book were reframed as, say, `Uses and Abuses of Sex Addiction', I would unhesitatingly give it 5 stars. I must confess that, if I had read it before submitting my own book `How Sexual Desire Works: The Enigmatic Urge' to the publishers, I might well have added a question mark after the chapter heading `Sexual addiction'.
Three fundamental issues seem to run through the debate, as follows.
First, is a moral agenda driving much of the discussion, forcing some people to see their perfectly healthy consensual activity as wrong, thereby causing much unnecessary distress and the seeking of expensive therapy? The answer that Dr Ley gives is a very convincing `yes'. However, does everyone who claims, or appears, to have an addiction fit this category? I would say `no'.
Secondly, do (so-called) sexually-addicted people have free will and agency over their behaviour or have they lost control? Here Dr Ley sails into rather treacherous waters, since the issue of free-will and determinism is one that has eluded philosophers from at least the time of the ancient Greeks. There is simply no answer to it. However, there are answers to the related question - does what you believe about free-will and determinism make a difference to how you behave? It appears that it does, so a belief in free-will might give some people a realistic sense of agency.
Dr Ley appears to recognize the limits of the notions of free will, when he writes (page 173) "When these chemicals are raging in our brain, we can often do nothing but think about our new lover...". Can sexually-addicted people restrain their behaviour and thereby show themselves in one sense to be in control? Yes, Dr Ley and I agree here - they can, as indicated by, say, their controlled use of a car in finding their next sexual outlet or their restraint in the face of, say, a potential police raid on a brothel. But so can heroin addicts show great skill and control in, say, house-breaking or forging checks. The compulsive hand-washer can show restraint under some conditions as can even to a very limited degree the sufferer from Tourette's syndrome. The issue is surely that in all such cases there is (i) the imposition of a goal that arises outside the conscious mind and against the will and (ii) distress is involved in resisting its pull. How much stress is involved to define an addiction or compulsion is surely not something for which a scientific answer can be given.
Thirdly, the issue of whether sex can be classified as a potential addiction is equally elusive and not open to absolute scientific arbitration. It all hinges on first articulating the properties of an unambiguous addiction, such as to heroin. Then we need to see how many of these defining features are shared with sex. It depends upon your cut-off point for how many boxes and which boxes need to be ticked in order to include sex as being usefully classified as potentially an addiction. I recall that the tobacco industry tried desperately to convince us that nicotine was not addictive, whereas addiction researchers know otherwise. As the researcher Donald L. Hinton argues, consider two people spending hours on the Internet, wishing that they could quit but finding it impossible. According to DSM-5, the first is gambling for money and would be classified as an addict, whereas the second is gambling for the perfect porno image and would not be classified as an addict. This makes no sense to me.
Evidence published since this book appeared shows changes in the dopaminergic regions of the brain of sexually addicted people, somewhat comparable to that of chemical addiction (see Donald L. Hinton, amongst others). Is this a box to tick? I would say so.
On page 79, Dr. Ley argues: "One hundred percent of the people who seek sex addiction treatment have some other major mental illness, including alcohol and drug addictions, mood disorders, and personality disorders." He does not give a citation for this claim. R.C. Reid and B.N. Carpenter give the figure of 38% as those patients with no other disorder apart from hypersexuality. We do not know how many, if any, of the parallel disorders were the consequence of the hypersexuality, as opposed to the assumption that they lie in its causation. Although I am not a clinician, I would suggest that someone presenting with combined sex and cocaine addiction (both engaging brain dopaminergic systems) would need to have both activities addressed.
On page 101, Dr. Ley writes: "What are the environmental and personal factors that lead some individuals to choose sex, or alcohol, or drugs, or gambling in response to their brain's functioning, and what are the things that lead other people with that same type of brain chemistry to be able to overcome those predispositions, and not engage in such addictive or destructive behaviors?" A good question and I would suggest an early potent exposure to the object of the later addiction plus run-away dopamine sensitization as a positive feedback system (see recent studies by Marco Leyton and Paul Vezina).
In short a very good read, best done with some caution.
Frederick Toates, Emeritus Professor of Biological Psychology, Open University, UK.