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How Do You Cure A Sex Addict?

Published: November 19, 2000

Once, sex addicts were treated with pillories and guillotines and gleaming clamps, but what used to be a moral problem is now a medical one, and this is no surprise. Our understanding of sexual compulsion has followed the same trajectory as our understanding of melancholy and moodiness. It's all in the brain. Goodbye heart, goodbye groin, and voil rumpled, slick organ crammed in its sheath of skull. New scientific theories are shedding an interesting light on the biochemistry of perversion and maybe, by extension, on the chemistry of ordinary kinkiness -- what you and I do, volitionally and consensually, behind bedroom doors.

His name, in all seriousness, is Dr. Kafka. No relation, he says. Martin Kafka treats and studies paraphiliacs at McLean Hospital in Belmont, Mass. Paraphilias are disorders characterized by persistent deviant sexual arousal -- think exhibitionism, fetishism and pedophilia. Closely related to the paraphilias are what Kafka calls the paraphilia-related disorders (P.R.D.'s). Those suffering from P.R.D.'s are, in common vernacular, sex addicts, who may not be breaking the law but are driven by libidos so excessive that they are pinned beneath their weight.

Kafka, senior attending psychiatrist at McLean Hospital and a clinical assistant professor at Harvard Medical School, where he lectures to residents on hypersexuality, is a nationally renowned expert in his field. He has published 14 papers on his subject. He comes to work each day in a serious suit, but he likes to laugh, and he likes to eat, insisting, always, that I meet him in the cafeteria at McLean, where he dines on Otis Spunkmeyer chocolate-chip cookies. ''My father was a dentist,'' he says, biting into a bit of chocolate goo, ''and I did two years in dental school before I realized it wasn't for me. I like to say I went from dental to mental.''

In his practice he sees about 40 patients a week, more than three-quarters of whom have what by current cultural standards at least are perversely heightened libidos. His most serious cases are sexual predators; his ''lite'' cases include the old standbys of masculine misery: compulsive porn-watchers, compulsive clients of prostitutes, men incapable of monogamy. The middle range is composed of guys we call creeps, the ones who peer in your bedroom window, the guy in the red raincoat parting the slicker's flaps.

Kafka started out at McLean in 1983 as the medical director of the cognitive-behavior therapy unit, which is a fairly grand beginning, given that McLean is to mental hospitals what Harvard is to colleges. In fact, McLean is affiliated with Harvard, and its gracious grounds reflect that. Originally, Kafka worked with women who had eating disorders, women so thin that the bones rose in ridges under their skin. ''One day, a sex offender was admitted,'' Kafka says. ''There were no other beds in the hospital, maybe, so they put this guy on my unit, with all the eating disorders, and that's when I had my eureka moment. I began to see that the sex offenders were just like the bulimics. Both groups were suffering from a disregulation of appetite. I began to think that paraphilias and the P.R.D.'s are to men what eating disorders are to women. I was so excited by this breakthrough, I didn't sleep for two nights.''

In fact, there are interesting inverse relationships between eating disorders and sexual-impulse disorders. The sex distribution of paraphilias and related disorders is about 95 percent male, 5 percent female, whereas the sex distribution for eating disorders is the opposite. Both disorders involve difficulty experiencing satiation, as well as a general disregulation of appetite drives.

''T.S.O.,'' Kafka says. ''Total sexual outlet.'' We are sitting in his damp basement office.

''So you have to look at total sexual outlet as one way of diagnosing a paraphiliac or a P.R.D.,'' he says. ''How many times does he masturbate a week? What are the number of orgasms he has per week. Anything over six and my ears perk up.''

''Six?'' I say. By this definition, my husband may be in trouble.

''What's the average amount a man masturbates?'' I ask.

''Three,'' he says. ''It varies.''

''There must be a lot of paraphiliacs out there that we don't know about,'' I say.

''There probably are,'' he says.

In one study, 33 percent of normal men admitted to having rape fantasies. In another study, penile tumescence was measured for both normal men and convicted pedophiles when both groups were shown deviant stimuli. Twenty-eight percent of those in the normal group were sexually aroused, some of them by pedophiliac images.

I look to my left. On a small table, Kafka, a jokester at heart, has his own fake pharmacy. There are medicine bottles -- red, green, piglet pink. One is labeled ''Virginity Restorer'' in frilly script. There's another bottle called ''Will Power,'' a third labeled ''Passion Control Pills.'' Kafka sees me staring. ''You have to have some humor in my line of work,'' he says. I nod. I try to imagine the porn addict, the rapist, sitting in the seat I occupy now, confessing. I wonder if they think the pills are funny. I wonder if they ever take them -- desperation, desire, the wish for an easy cure -- and feel the sweet sugar in their mouths.

''Sex,'' Kafka says, ''can be a curse.''

We have heard, of late, so much about sex and hormones; testosterone shot slowly into layered, striated muscle; estrogen rubbed on labial skin. One of Kafka's most significant contributions to the chemistry of perversity may be that he has been able to look beyond the obvious culprits -- our grease-based sex steroids -- to the more nuanced chemical messengers and the complex roles they play in mediating our desires.

In a 1969 study published in Science, a scientist shoots up some rats with parachlorophenylalanine, a compound that lowers serotonin levels in both blood and brain. Within minutes of its administration there's a veritable drought of serotonin. What happens to the rats? They become sexually aroused. They mount each other compulsively. Conversely, feed rats a serotonin-laced snack, thereby raising their levels, and almost all sexual appetite disappears. ''In other words, this isn't just about testosterone,'' Kafka says. ''It used to be thought sexual deviants had just testosterone abnormalities, but they may really have serotonin abnormalities. It may be that the lower the serotonin, the higher the sex drive, or it may be something much more complex, that sexual deviance is linked to an as-yet-unidentified disregulation affecting the serotonin system.''

Other studies on male animals bear this hypothesis out: before copulation, there is an increase in dopamine and a decrease in serotonin. Post-copulation, the opposite occurs. If this proves to be the case in the human species as well, afterward, when the man is smoking his cigarette or snoring as if he had chowed down a turkey dinner, he may be experiencing a serotonin surge. In a culture in love with the idea of ''high'' serotonin, it might surprise us to know that passion, and its distant cousin lewdness, may lie not in the dosed-up but in the dosed-down version of being.

Kafka calls his theory of sexual-impulse disorders ''the monoamine hypothesis'' because he is looking at the central role our monoamines -- dopamine, norepinephrine and, specifically, serotonin -- play in mediating desire. One of the more interesting studies he cites involves castrated rats that are injected with parachlorophenylalanine, which depletes central nervous system serotonin, and are subsequently able to resume normal mounting behavior with little or no testosterone additives. In other words, at least as far as animal analogues go, serotonin deprivation and its hypothesized partner, depression, appear to be powerful aphrodisiacs.

After hearing Kafka talk about this, after hearing, yet again, about serotonin grabbing the star role in still another psychiatric drama, I asked my husband, a chemist, to bring some of this chemical home so I could finally wrap my hands around it. He did, presenting this molecular media slut in a tiny glass tube with ''Warning'' written all over the label. ''Central Nervous System Irritant. For RD Use Only.'' I cupped the tiny tube in my palm. I uncapped the pink plug and peered inside. I had always imagined that a neurotransmitter would be wet. How else does it spurt from one ravenous cell to the next? But the serotonin was crystallized, like salt or snowflakes. Beneath our microscope, it pulsed into view, six-pronged, simple as a star; you could cap your Christmas tree with it. Seeing it there, magnified and crude, I found it difficult to believe that its presence or absence could cause such a ruckus in our heads.

''The brain is such an incredibly complex organ, so largely beyond our understanding,'' says Dr. Laurence Kirmayer, professor of psychiatry at McGill University. ''It's ridiculous to think that any one chemical causes, or is responsible for, this or that. It's patently reductive.''

But Kafka isn't so sure. ''Of course it's complex,'' he says. ''All of these systems are interrelated. But because these men respond so well to drugs like Prozac or other S.S.R.I.'s'' -- selective serotonin reuptake inhibitors -- which alter serotonin transmission in the brain, it's reasonable to point to that monoamine as central in sexual-impulse disorders.''

That Kafka treats male sexual-impulse disorders biologically is nothing new. ''Chemical castration,'' the administration of testosterone-suppressing compounds that eradicate desire, has been used legally in this country for some time. However, Kafka does not want to castrate his patients. What he aims to do is far nobler, complex and chemically questionable. He aims, through the use of serotonin-selective drugs, to whitewash deviance but somehow spare conventional sexuality.

Drugs like Prozac and Paxil specifically target the serotonin systems, thereby avoiding the widespread side effects of the older generations of antidepressants. But in Kafka's conceptualization, selectivity has reached new heights. Kafka claims that the drugs are capable of reducing or eradicating pathological desire while preserving or enhancing what are culturally considered ''normal'' sexual urges. How can this be? Does deviant lust reside in one part of the brain, affiliative, conventional lust in another? Is a man's erection when he fetishizes powered by, say, the pituitary, while some other, friendlier lobe raises the tumescent tissue when he makes love? Kafka is by no means claiming this as fact, but his statements imply that it is one of myriad possibilities.

''You give a man with sexual problems Prozac,'' I ask, ''and his deviance disappears while his affiliative sexuality emerges?''

''I've seen it happen, over and over again,'' he says.

Bill Morrill is not a handsome man. this is the first thing he says to me after he shakes my hand. ''I am not a handsome man,'' he says, lowering his bulky body into the seat across from me, fingers gripping the sides.

''I'm nervous,'' he says, ''and when I'm nervous, my nose twitches,'' which it is, twitching like a libidinous rabbit's while he snuffs and dabs with a huge hankie pulled from his pants pocket.

Morrill is 49. He has a jowly face and wears square glasses. There is something frankly appealing about him, his palpable anxiety, his willingness to talk. ''People need to know,'' he says. ''Go ahead, use my name. Use my story. This is a sickness, and people need to know, but God, I'm nervous to tell you.'' Twitch, twitch.

He touches his throat, as though to take measure of his pulse, which, I imagine, is bebopping at a rate too rapid for his comfort. ''All right,'' he says, ''this is what I did.''

Morrill is a carnival man. He sets up and then disassembles the gear of other people's pleasure: moonwalks, painted carousels, Ferris wheels that jingle and sway.

''I felt my first wave,'' Morrill says, ''when I was in my 30's.'' It came on slowly, a clenching in the stomach, ''and then I was totally out of control -- I had to have a woman.''

The waves, the waves. Morrill talks at length about the waves, a total corporeal takeover that resulted in picking up prostitutes, cruising for hours on end, woman after woman, in a Dionysian but dystonic frenzy. Ambers and Jo Jos and Mandys and Sunshines. ''Exhausting,'' Morrill says. ''And I was married.''

Morrill describes a life before treatment of crippling obsession, a life in which he was driven to repeated exhibitionistic bouts of intercourse in bus stations, in the back seats of Greyhounds, in elevators with the stop button engaged. He describes sitting at the dinner table with his wife and feeling himself jerked upward by a powerful, invisible hand, reeling out into the night, leaving behind him a thick trail of lies. ''I never got anything done,'' he says. ''I was totally unreliable. Sex was to me what sleep was to a narcoleptic. I was in horror of it. Desire would come on. I'd drop down and wake up and have lost a whole day. Who knows? I lost 20 years of my life.''

In the mornings, after getting up, he had to watch at least one hour of porn. ''But it was mostly the waves,'' he says. ''I could get them anywhere. I kept a mattress in the back of my van just so I could get a prostitute as quick as possible. My van has more mileage inside than out.''

At first, Morrill thought he was simply oversexed. ''But then I noticed that in my 40's the waves started coming more and more,'' he says. ''They were especially bad after rainstorms.''

''And did your wife know about this behavior?''

''Oh, no,'' he says.

''Did you have sex with your wife as well?''

''Sure,'' he says, adding: ''Married sex is vanilla. I needed something dangerous. Anne, though, my wife, she's a super person. A super person. She's a Sagittarius. I'm a Gemini. We just blend.''

Finally, at the age of 47, Morrill succumbed to what he says was the vilest deed, repeated sex with an 18-year-old.

''I was in a wave, which is why it happened,'' Morrill says. ''She was so young. You've gotta understand. In a wave, anything can be sexual to me.'' He points to the lamp on the desk. ''Like that lamp,'' he says. ''In a wave, that lamp could turn me on.''

Dr. Peter R. Martin of the Addiction Center at Vanderbilt University elucidates. Using M.R.I.'s, Martin, along with his colleague Dr. Mitchell Parks, has begun studying the parts of the brain involved in arousal. ''If we can classify what parts of the brain are involved in normal arousal,'' he says, ''then maybe we can see if these parts are different in normal volunteers versus men with sexual addictions or paraphilias.'' He has a hunch that ''sex addicts'' may show activation in a larger -- or smaller -- portion of the brain in response to a stimulus than a normal volunteer. On an M.R.I. color-coded image, the aroused paraphiliac brain might look like a lobe of scarlet activity, whereas the aroused normal brain might look like, well, a normal brain. If this proves to be true, then in men like Morrill sex may bleed into the brain's more general geography, and thus such brains may be more capable of turning everyday events, and even objects, into erotic tools. Morrill's brain, perhaps, can make an aluminum lamp from Staples into some fluid fantasy object.

I reach over and switch off the lamp. Morrill laughs. ''I like you,'' he says. ''I feel you're on my side. Now, before treatment, if I had feelings of liking you, they'd go elsewhere. I'm not a handsome man, but before treatment I was so out of control, and I could get any woman.''

Morrill is the seventh man I interviewed for this article. All claimed to be more or less cured, but all spiked their conversation with troublesome kinds of come-ons, which at first made me uncomfortable but now engender little response. Say ''sex'' enough times, and it starts to sound like ''xxx,'' which is nothing. Nowhere. Dead.

''I tried to kill myself,'' Morrill says. ''I lit my trailer on fire, with me in it. When that didn't work, I decided to jump off the crane in the Quincy shipyard. It's called a Goliath Crane, 384 feet tall.'' He stood at the top of the crane for some time before deciding maybe he could kill a part of himself instead of the whole package. ''I went to a doctor and told them to take care of it.'' He points to his groin. ''Cut it off. Kill it. No doc would touch me.''

Morrill finally found his way to Kafka. ''Kafka is a great man. He knew just what questions to ask. I filled out a million questionnaires. He looked at them and said: 'I think I know what's wrong with you. You are a sexual compulsive.'''

Common wisdom has it that the sexually compulsive or the sexually deviant were often themselves victims of abuse. ''The fact is,'' Kafka says, ''only one-quarter to one-third of my patient population suffered physical or sexual abuse, and many of them had unremarkable childhoods, as far as I can see.'' Which is why Kafka, who acknowledges the need for a multimodal approach and does refer men for psychotherapy, treats his patients with medication. In Morrill's case, the pill was Celexa, a newer version of Prozac.

CONTINUED

Morrill went home and swallowed a pill. The next day he swallowed a second pill. Kaboom. Morrill No. 1 melted away, and Morrill No. 2 stepped forward, the only live wire his twitching nose. ''On these pills, I am a different man,'' Morrill says. ''My head is clear as a bell. But the weirdest thing is,'' and here his voice drops in wonder, ''the weirdest thing is how huggy I am now. I hug people left and right.''

For one moment I think he is going to hug me, but he collapses back, exhaling out his astonishment. ''Really, it's quite amazing,'' he says.

''What about your wife?'' I ask. ''How's sex with her?'' I've been waiting to get here, to see how ''affiliative sex'' perseveres or, in Morrill's case, is enhanced in the face of this chemical assault, as Kafka has described it to me.

''Listen, sex is dead,'' he says, patting his crotch as if it were a pet. ''It's gone.''

''So you don't have sex with your wife either?''

''Only when she insists,'' he says. ''And then, I'm good for maybe a minute, if at all.''

Prozac and its chemical cousins have been hailed as many things: antidepressants, PMS drugs, better-than-well drugs. Here's a new use for them, as far as I can tell -- chemical castrators. This idea flies directly in the face of Kafka's pioneering efforts, which are meant to restore normal sex drive while wiping out deviance. But Morrill's case points to another possibility. The

ramses (imported) wrote: Wed Jan 09, 2008 2:48 pm selective serotonin reuptake inhibitors

work in the treatment of paraphiliacs and sex addicts because they dampen if not destroy all libido, along with all sorts of other excessive behaviors. It makes sense that one day Prozac may be approved for chemical castration. After all, many say that S.S.R.I.'s cause sexual dysfunction in 80 percent of users, so why not use them to, well, dysfunction an overly functioning man?

''Sexual dysfunction is not the same as chemical castration,'' Kafka says. ''These men can function sexually -- it's just sometimes difficult. Furthermore, chemical castration came out of a need to punish these guys, whereas my aim is to help and value these men.''

Apparently, then, pharmacology, like crime, can be judged not only by outcome but also by intent. If you did not intend to murder the person, then it's manslaughter. If you don't intend to castrate the person, then it's . . . what? But Kafka has a point. You cannot easily tease apart the cure from the cure giver; medicine is an amalgam of hopes, intentions and observable results. The placebo effect underscores this. The drug is inextricably bound up with the patient's expectations. In Kafka's scheme, the doctor's expectations get thrown into the mix, as well they should. A drug is as much a wish as a fact.

All philosophizing aside, Morrill is happy with his outcome. ''It's dead, and I love it,'' he says. He is not the first man to bow down in gratitude to his ruined sexuality. Many sex addicts and sex offenders hate their sexuality. They see it as ''the Devil.'' It is horrific to the humane sides of their personality, which are everywhere in evidence. Morrill holds hands with his wife and walks on the beach. Jim, a convicted sex offender, designs dahlia gardens with his daughter. Bob, an exhibitionist, who, like Jim, requested anonymity, takes pride in his brand-new Hyundai, polishing its black armor until it shines like onyx. Kind men. Careful men. ''Sick men we are,'' Morrill says.

Why or how Prozac blunts sexuality is open to speculation. Animal studies clearly show a correlation between raised or altered serotonin and diminished sexual appetite. In addition, both serotonin and dopamine do an intricate dance with our hormones, priming neural pathways so that they can respond to testosterone. ''I don't think that the S.S.R.I.'s are really capable of restoring a normal sex drive,'' Peter Martin says. ''We all know that the S.S.R.I.'s cause sexual dysfunction. The sex addict, or the 'overly sexed' man, may have such a large portion of his brain dedicated to arousal that a blunted sex drive just looks like a normal sex drive, which is much different from the idea of two separate sexual systems, one for deviance, one for affiliation. The S.S.R.I.'s really need to be studied.''

Vince, who requested that his last name not be used, is one of Kafka's star patients. Kafka urges me to call him. ''Vince is evidence of how a paraphiliac can take medication and become sexually normal,'' he says. ''He is fully functional.''

''But why is he functional?'' I ask. ''Is he blunted, or has something been restored?''

This distinction is important. If the S.S.R.I.'s cure a man by inducing sexual dysfunction, then they are in some essential sense not normalizing eroticism but just transmogrifying it in yet a new way. Is this the role of good medicine -- to cure one illness by inducing another? Is this medicine or doctor-induced injury? Maybe, especially in the case of dangerous predators, a little injury is healing. But replacing one dysfunction with another is a problematic practice and is certainly different from treating a person with drugs that restore the flesh to its rightful homeostasis.

When I meet Vince, he is definitive, sure of himself, free of Morrill's twitches and tics. He works in accounting. His nails are nacreous, buffed pale crescents below trimmed cuticles, each knuckle a well-defined walnut. His dress is impeccable -- pressed chinos, a red designer shirt.

Vince's diagnosis: transvestic fetishism. He grew up in an Italian household, dark curtains hanging on the windows, red gravy bubbling on the black-topped stove. ''My grandmother was a seamstress,'' he says, ''and we visited her every weekend.'' There, Vince learned the luxury of textiles, the silky material pedaled in and out of the Singer sewing machine, the pearl-topped pins jabbed into crushed-velvet hearts, rhinestones, tiny and numerous as caviar eggs, sewn into the collars of cocktail dresses.

He was 8 years old when his fetish emerged. He started trying on his mother's clothes, and this gave him such a soothing thrill, ''the silky parts against my privates,'' that it developed into a full-blown compulsion culminating each time by masturbating while wearing his mother's underwear. He engaged in this repetitive behavior until he was 26, always with his mother's garments first and foremost. ''I liked her thigh-high stockings,'' he says. ''I liked her black silk panties and her slips and her teddies.''

At 27, Vince married. His wife knew nothing of his behavior. ''Now it was really terrible, because we had this two-bedroom apartment, and I bought all these clothes from Frederick's of Hollywood catalogs, and I had to hide them in this really small space,'' he says. ''And I spent too much money at Shoe Town buying thigh-high boots. I was so afraid she'd find out. Still, I'd cross-dress whenever I got the chance -- when she was in the shower, when she was at work, when she was asleep. And I began, also, to be aggressive. I'd push her into sex acts. This put a damper between us.''

Vince describes a life of silk swathes and nylon netting, a life that he saw as sordid, partly for cultural reasons. (''Look, I'm not gay,'' he hastens to assure me. ''I never wore makeup. O.K.?'') If the culture condoned this kind of behavior, I ask, would it have been so problematic for you? Was it the shame that made it a problem?

''No,'' Vince says swiftly, dicing my words right up. ''With free rein, my problem would have gotten worse and worse until my whole self was lost. I would have been nothing but cloth.''

One night after a particularly compulsive day of cross-dressing that left him exhausted and demoralized, Vince had a dream. His car crashed and flew over a cliff with him inside. He was not, in the dream, afraid of dying, but afraid of what would happen when his wife went through his possessions, when she found his secret stash of sling-back pumps and monstrous teddies.

He woke up soaked in sweat, resolved to change. His wife lay curled on her side. ''An object,'' he says, ''but I always loved her anyway.''

He started treatment with Carol Ball at New England Forensic Associates in Arlington, Mass. Behavioral treatment with paraphiliacs follows a fairly predictable pattern, including, among other things, what is called aversive reconditioning. Men are instructed to masturbate to their deviant fantasies and just prior to climax to take a deep breath of ammonia, meaning that they ejaculate in a clutch of coughs and cramps. Behavioral therapy can be highly successful. Two months after Vince started at the institute, Ball referred him to Kafka for a medication consult.

Vince credits Kafka, not Ball, with the bulk of his success. ''I love Carol Ball,'' he says. ''But it was the medication, definitely the medication, that really changed things for me.''

Kafka put Vince on Celexa. ''Within three months I felt totally different,'' Vince says. ''All my cross-dressing urges were gone. I put the teddies, the Frederick's of Hollywood stuff, the panties, the thigh-highs, I put it all in a duffel bag and threw it away. It was just closing a door.''

Vince reports that he has no more urges to cross-dress, no more consuming fetishes, no more desires to coerce his wife into sex. He has not masturbated since drug treatment began. ''My life in the past 11 months has been better than it's been in the past 28 years,'' he says. ''I have possibilities.''

The difference between Vince and Bill Morrill is that Vince enjoys what sounds like a very ''normal'' sex life with his wife. ''Three times a week,'' he says. ''I have no trouble. My orgasms are actually better on the Celexa than they were off. It's because on the Celexa I can really concentrate on my wife's body and not on the fantasies and fetishes. My wife is gorgeous. She's petite, five-three, 110 pounds. We take our time.''

He goes on to describe his recovery in still more detail. ''The fetishisms were like all this static,'' he says. ''Now the static's cleared away, and what's left is my real desire. My head feels like a whole new thing. My real desire is not for my mother or for a man, but for my wife.''

Vince is a model for successful treatment outcomes -- living proof that at least some men experience not a preferable form of dysfunction but an erotic restoration under Kafka's care. If, in fact, drugs like Prozac and Celexa can selectively wipe out deviance while restoring or even enhancing ''normal'' sexuality, what might this mean about the way our brains are built?

In 1985, a group of scientists reported on a brain-damaged subject who could recall everything but the names of fruits and vegetables. This case, among others, has raised the possibility that our brains are modular and store information in category-specific locales. And this modular notion of brain function appears to expand beyond the domain of language recall. Other scientists have written extensively about separate memory systems, short term versus long term, declarative versus implicit.

Why, then, might not forms of sexual appetite, or desire, be divided as well? There has been one reported case of a patient with a right thalmic-hypothalmic infarction that led to hypersexuality and another of a midbrain hypothalmic glioma leading to pedophilia. Women who develop seizure disorders, which are often linked to lesions in a specific part of the brain, may also display exhibitionistic behavior. There is a very rare disorder called Kluver Bucy syndrome, in which the amygdala is damaged and the patient may experience intense sexual desire for objects -- pins, cups, maybe even lamps. Does Vince's brain look different in the act of making love to his wife than in masturbating in thigh-highs?

Kafka doesn't know, and he isn't afraid to say so. ''But it is interesting to speculate that normal male sexual arousal resides in one area of the brain, deviant sexual arousal in another, and that the S.S.R.I.'s work by targeting one arousal system while sparing another,'' he says. ''That's an interesting, plausible hypothesis, and one that wouldn't surprise me.''

Another possibility is this: the higher the intensity of any drive, the more polymorphous its manifestations. The S.S.R.I.'s may work in paraphilias and sexual addiction not by deleting but by pruning, so that the person's core sexuality is finally free to emerge. This hypothesis lies close to the idea some psychiatrists hold that the paraphilias are simply another form of obsessive compulsive disorder (O.C.D.) and that the S.S.R.I.'s work not because they target sexual arousal but because they reduce ruminative thoughts and repetitive behaviors in all kinds of conditions.

''I hate that idea,'' Kafka says. ''The paraphilias and P.R.D.'s are not a form of O.C.D. People who have O.C.D. do not have an appetite-disregulation disorder. O.C.D. is not about appetite. Sexual-impulse disorders are all about appetite.''

In the end, we have these men and their appetites. We have just a few facts. That these men feel better is a fact. That Prozac and its chemical cousins appear to have yet another use is a fact. That its uses are so widespread as to present us with a boggling contradiction is a fact; here we have a drug celebrated for its specificity but employed for every nook and cranny of our multiple miseries -- that, surely, is a fact. That, when we think of sex, or brains, we are sometimes reductive is also a troublesome fact.

However, reductive or not, Kafka is doing something right. He appears to have ''cured,'' or restored to better balance, hundreds of men, many of whom are dangerous, all of whom are, by their own standards at least, terribly twisted. Kafka's patients love him. ''He is the guy,'' Jim says. ''He saved my life,'' Bob says. But where, I wonder, is the history, the culture in this story? Is this just one more tale of the brain?

Kafka practices neurospeak, but strangely enough, if you're looking for culture you'll find it right where he dwells, in that basement office, above the Passion Control Pills. On my last visit to Kafka, I notice what I have oddly not noticed in all my visits before: large and very beautiful photographs on almost every inch of wall space. ''I took these pictures myself,'' Kafka says. He has traveled all over the world. Here, above me, a Peruvian boy holds his little naked brother -- fat, dimpled buttocks, a sweet grin. Across the way, Italian women play cards beneath flags of laundry on a line, the photo shot in saturated yellow light, the fabric as human as flesh, vivid, living. I walk around the room, staring. There is a photo of a zebra, an extreme closeup of the animal's face, the dark, dilated eye.

''I took this picture at the Kenya zoo,'' Kafka says. ''The zebra was wounded, in a cage, so I could get real close to him, put the camera right up next to his face, and I got this shot of his eye.''

The eye, of course, is a part of our brains, a little bit of the visual cortex poking through our flesh. Now Kafka seems to forget that I'm here. He pulls into himself. I recall how he told me, over lunch a few days ago, that in this line of work he has seen the Devil, and that the Devil has neural substrates, but something more, as well. ''I have become theistic,'' he said, looking troubled. And then he said: ''You know, my patients are my boys. They're all my boys.''

Kafka reaches out and touches his photograph, the eye, this bit of animal brain exposed, unknowable. I think of how he says ''my boys,'' and into my mind comes the old tale of Pinocchio, and the island of bad little boys, those spectral males becoming part donkey, hard hoof, the horror of that. He touches the zebra's eye tenderly, almost sadly, and watching him do this, I have to wonder if it's the proffered pill, or his hand held out, that, for these men, finally does the trick.

Lauren Slater is a psychologist and the director of AfterCare Services, a mental health and substance-abuse clinic in Boston. Her most recent book is ''Lying: A Metaphorical Memoir.''

Very interesting article. Thanks for posting it.