Sex addiction article retracted, republished

An open-access journal with a speedy peer review process has been having some issues with a retracted article on the biology of sex addiction.

Here’s the simple timeline of events: “Hypersexuality Addiction and Withdrawal: Phenomenology, Neurogenetics and Epigenetics,” a review article, was published by Cureus in July, following a two-day peer review. In the weeks that followed, the paper received a number of criticisms. So the journal quietly corrected it, then issued a formal correction, then retracted the paper — and now, finally, has republished it. The editor of the journal, Stanford professor emeritus John Adler, admitted the “decision was dumb” to initially fix the article without an alert, but it was ultimately doomed by “political” issues — namely, a larger debate over whether or not “sex addiction” exists at all.

We’ll start with the retraction. According to the note, it stems from the mistaken characterization of how sex addition — “hypersexuality” — is described in the current “bible” of psychiatry:

This article has been retracted by agreement between all of the authors, John R. Adler (Cureus Editor-in-Chief) and Cureus. The retraction has been agreed upon due to erroneous statements about the existence of sexual addiction and hypersexuality codes within the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). In an effort to unambiguously rectify all errors, the authors have agreed to submit a significantly revised manuscript for subsequent peer review and re-publication.

Hypersexuality is listed in the DSM-5 as a condition that needs more research. But the introduction of the retracted article suggests that it is a recognized DSM-5 disorder:

Hypersexuality can now be found in the DSM-V. This major accomplishment required intensive work by Kafka, Reid and associates, Bancroft, and even the World Health Organization, among others.

We briefly spoke to corresponding author Kenneth Blum, a psychiatrist at the University of Florida known for elucidating the link between a dopamine receptor gene and alcoholism, via phone. He gave us as strange explanation as to how the mistake occurred:

It was a grammatical mistake. We said the word “not” and it ended up being the word “now.”

Of course, swapping “now” for “not” in the introduction would not make sense with the sentence that follows. He then told us the real reason, in his opinion, on why the paper was retracted:

We upset people politically in the hypersexuality world.

In the article, Blum and his colleagues “hypothesize that based on a plethora of scientific support hypersexual activity is indeed like drugs, food, and music that activate brain mesolimbic reward circuitry.” The authors encourage researchers to look more deeply into the genetic changes that may trigger — and ultimately help treat — hypersexuality.

But according to some researchers — who, unlike Blum, specialize in sexology — sex addiction is not a genuine disorder. One such critic, James Pfaus, who studies the neuroscience of sex at Concordia University, told us he believes that sex addiction has “no basis in empirical science.” Pfaus contacted the journal about the article, and told us his issues with it:

Essentially the article made wild claims about hypersexuality and porn/sex “addiction” (the latter of which has absolutely NO evidence in favor of it) and posited what the authors claimed was a novel and original idea that these phenomena all involve epigenetic changes to mesolimbic dopamine transmission in the brain.  I would be the LAST person to argue that sexual behavior does not involve dopamine, and that dopamine systems do not sensitize to erotic cues, but they are talking about an “addiction” that has no basis in empirical science, much less any evidence in favor of sensitized dopamine causing it through excessive porn use.

The biggest error, said Adler, was the authors’ mistaken understanding of how hypersexuality fits into the DSM:

Although the authors are all psychiatrists, the focus of their research interests is in neuroscience and the basic brain circuitry that underlies addiction. As psychiatrists they have some innate understandings of the DSM, but in this case it was clearly faulty and they were careless in relying on such innate beliefs. Meanwhile, the pre-publication manuscript was reviewed by two European neuroscience reviewers, neither of whom is familiar with the US centric DSM-system, and therefore they were not in a position to detect the error.

The journal didn’t leave much time to catch such errors during peer review. The review process, as University of Colorado Denver librarian as Jeffery Beall pointed out on his blog, was just two days:

We asked Adler about the fast review process, and he explained that it was very much on purpose. Part of the very “philosophy” of the journal, in fact:

Yes Cureus has an unusually fast review process, which is an important part of the journal’s philosophy. We believe that post publication peer review, a focus of our journal through commenting and our unique SIQ process, is potentially a more powerful way to discern truth. This idea is not unlike Faculty of 1000 or ArXiv (in physics), and may not be for everyone but it is who we are. We believe that our post publication review process enables us to support faster publication.

Indeed, it was this post-publication review process that caught the mistake, Adler noted:

After the review period ended and the paper was published, a third US-based reviewer submitted his review, and pointed out the DSM error in question.

But initially, the journal changed the text of the article, without an official errata. Beall’s blog post, published on August 20th — 22 days prior to the official correction — shows screenshots of the abstract, before and after the change. It shows that the original text said:

Hypersexuality is now part of the DSM-V and has been defined as abnormally increased sexual activity.

And here’s the changed text, prior to the correction notice:

Hypersexuality has been defined as abnormally increased sexual activity.

We asked Adler about the unofficial correction:

Jeff Beall is correct that the abstract of the published paper was changed post publication (i.e. the erroneous DSM statements) as a prelude to publishing of a formal erratum. This action was intitiated by the most junior member of the Cureus editorial team in response to a request by the author. Yes this decision was dumb……but also entirely remediated through the subsequent publication of an erratum. At the time this issue happened our online journal had the technology for neither the publication of erratums or retractions. FYI…..the Cureus website is a rather sophisticated piece of software and over the past 2 months software and software processes have now been developed to enable more seamless, and less embarrassing, publishing of errata and paper retractions going forward…..and yes my young editorial member was appropriately chastened.

Since some people — such as Beall — noticed the changes, the journal then published a formal correction notice. You can see it in full here. It indeed changed the “now” to “not” in the excerpt presented above, and modified the subsequent sentence:

Hypersexuality is not found in the DSM-5. This inclusion, which would be a major accomplishment, continues to require intensive work by Kafka, Reid and associates, Bancroft, and even the World Health Organization, among others.

Shortly after, the correction turned into a retraction. Adler told us that was done as a measure of damage control, so that errors in the authors’ understanding of hypersexuality in the DSM didn’t cloud the overall argument over the existence of sex addiction:

A simple errata was being prepared to be published when two sexologists, who are members of a community that vociferously disputes, oftentimes in rather political arenas, the mere existence of sexual addictions, started a social media campaign to  “out” the errors in the published article. As a result the challenge for me as, a Editor-in-Chief, changed from correcting a simple (and seemingly innocuous) error in a published article, to doing damage control in a more political environment. Hence my Co-Editor-in-Chief and I made the decision to retract and be as rigorous as possible in any decision to republish, soliciting additional reviews from 7 world class domain experts. Cureus has utter confidence in the veracity of the newly published article.

Adler declined to identify the two sexologists in question; we were unable to find more than a handful of tweets related to the retraction of this article.

Now, the article has been republished, with a few additions. Some of it is very similar to the original — you can see a comparison of the abstract text here (retracted text is on the left, and the new text is on the right).  Two sentences about how hypersexuality is defined have been added to the abstract. Here’s one:

It is a very controversial and political topic in terms of how best to categorize it as similar or not similar to addictive behaviors including substance abuse.

Pfaus tells us he is not satisfied with the final article:

It still makes ridiculous claims about dopamine and porn/sex addiction, and still misrepresents the entire literature on dopamine’s role in attention and reward.  I would not accept it as an undergaduate’s attempt at a term paper given the inaccuracies.  I cannot understand how an allegedly open-access, “peer-reviewed” journal could do so.

In a phone conversation, Adler acknowledged the critics of the paper:

Their argument is that sexual addition doesn’t exist. That is an intelligent criticism.

And according to him, one of the paper’s reviewers,

said, ‘yeah the paper’s not great.’

He told us why he published the paper anyway:

It is my responsibility to provide an open forum. I would invite the critics to write a paper rebutting [this one].

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