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Archives of Sexual Behavior
The Official Publication of the
International Academy of Sex Research
ISSN 0004-0002
Arch Sex Behav
DOI 10.1007/s10508-014-0326-y
What Happened to Hypersexual Disorder?
Martin P.Kafka
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COMMENTARY ON DSM-5
What Happened to Hypersexual Disorder?
Martin P. Kafka
ÓSpringer Science+Business Media New York 2014
Hypersexual Disorder (HD) was a proposed diagnosis for
inclusion in DSM-5 and was conceptualized as a sexual
behavior disorder with an impulsivity component (Kafka,
2010).
Despite what was, arguably, a substantial body of clinical
information, an independent field trial in outpatients (Reid
et al., 2012) as well as field trials in sex offenders (see below),
HD was rejected for placement in Section 3 (Appendix:
Emerging Measures and Models) of the DSM-5 by the Board
of Trustees of the American Psychiatric Association. Why?
During the process of the development of DSM-5, there
were persisting general criticisms that the proposed revision
potentially would add many new diagnoses that pathologize
normal behaviors, including sexual behavior (Frances, 2010;
Wakefield, 2012; Winters, 2010) or provide a medicalized
excuse for immoral conduct (Halpern, 2011; Moser, 2010).
Any new diagnostic entity would require rigorous scientific
and epidemiological testing to reduce the risk of unintended
consequences, including an unacceptable rate of false posi-
tive diagnosis. Certainly, HD, whose diagnostic criteria and
behavioral specifiers were all‘‘normophilic,’’would be cast in
this light and therefore be subject to particularly scrupulous
examination before being considered as a distinct clinical
disorder.
Thereweretwoadditionaloverarchingthemesthatpredom-
inated the available justification for rejecting HD entirely from
DSM-5: there was insufficient scientific evidence that the
proposed criteria represented a distinct clinical syndrome and
the potential misuse of the HD diagnosis in forensic settings. I
will address some of the major criticisms attached to both of
these domains.
An important method to establish whether HD represe nted
a distinct clinical disorder would be to include its diagnostic
criteria in large or epidemiologically surveyed populations.
Indeed, to date, no such study has been reported. In addition, a
particular concern was whether the proposed criteria set
would cast a too broad net, especially misdiagnosing ado-
lescent males.
There have been large population studies examining prox-
ies of HD. For example, Skegg, Nada-Raja, Dickson, and Paul
(2010), in a representative sample population of young adults in
New Zealand (n=940; M age, 32 years), reported that 3.8 %
surveyed males (sample n=474) and 1.7 % of females (n=
466) reported‘‘any out of control sexual experience interfering
with life’’ in the past year. These were predominantly fantasies
and urges, however, not enacted sexual behavior. Those who
reported problematic enacted sexual behavior were a small frac-
tion of the entire sample (0.8 % of the men and 0.6 % of the
women. Help-seeking for ‘‘out of control’’ sexual behavior was
‘‘rare.’’A second study collected online data from a large sample
of men (n=5,834) and women (n=7,251) who completed a
variety of sexuality questionnaires to investigate differences
between sexually ‘‘dysregulated’’ behavior and high levels of
sexual desire (Winters, Christoff, & Gorzalka, 2010). That report
found that 1.83 % of men and 0.95 % of women had significantly
elevated scores on the Sexual Compulsivity Scale (Kalichman &
Rompa, 1995) as well as a history of having sought treatment for
sexual compulsivity, addiction or impulsivity. These data would
suggest that the prevalence of putative HD would be low, espe-
cially if one considers help-seeking as a clinical equivalent of
Criterion B.
The available data also indicated that individuals seeking
clinical treatment for problems conceptualized similarly to
HD were in their fourth decade (Bancroft & Vukadinovic,
2004; Kafka & Hennen, 1999; Reid, 2007). In response to
concerns about over-diagnosing adolescents, we added a
M. P. Kafka (&)
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e-mail: mpkafka@rcn.com
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Arch Sex Behav
DOI 10.1007/s10508-014-0326-y
Author's personal copy
minimum age of at least 18 years of age as an exclusionary
Criterion D.
In addition, we sought additional information about help-
seeking behavior for HD by examining data from three resi-
dential treatment centers for‘‘sexual addiction’’ in the United
States (D. Sack, personal communication, May 2012) as well
as reviewing the sample of 152 individuals diagnosed with
HD (male =144; female =8) from the UCLA field trial (Reid
et al., 2012). The results are illustrated in Table 1.
Thus, the available clinical data suggest that, although
hypersexual behavior can have its onset during adolescence
and early adulthood (Kafka, 1997), it does not typically
appear to produce sufficient distress and/or impairment to
precipitate help-seeking required for a psychiatric disorder
(Criterion B) until the fourth or fifth decade of life, a period of
adult development when long-term relationships and family
stability are significantly disrupted by continued or abruptly
discovered hypersexual impulsivity.
To elucidate a clearer boundary to distinguish a patho-
logical condition that included normophilic behaviors, the
Paraphilias subworkgroup considered a diagnostic threshold
of requiring at least four of five symptoms and a minimum
duration of 6 months. The original proposal for HD (Kafka,
2010) suggested three symptoms but this threshold was made
more stringent after the first phase of public feedback to the
DSM5.org website (April 2010). Requiring at least 80 % of
the behavioral description factors set an exceptionally high
standard for any proposed polythetic psychiatric diagnosis
included in prior editions of the DSM Appendix. In fact, we
were unable to identify any proposed polythetic diagnosis in
the DSM-IV-TR Appendix B (Criteria Sets and Axes Pro-
vided for Further Study) that required at least 80 % of
behavioral A Criteria to be present simultaneously. While
there may be no single pathognomic sign or symptom
indicative of HD, it was the stringent threshold of concur-
rently requiring at least four of five symptoms for a minimum
duration of 6 months that set a high threshold for a proposed
new sexual disorder (Kafka & Krueger, 2011).
There are very few psychiatric disorders that have been
established as taxonic, i.e., making a clear categorical dis-
tinction from ‘‘normal.’’ Many common psychiatric disor-
ders, like HD, have dimensional latent structures, including
major depression (Andrews et al., 2008), agoraphobia (Slade
& Grisham, 2009), and attention deficit hyperactivity disor-
der (Marcus & Barry, 2011). In addition, none of the para-
philic disorders have been demonstrated to be taxonic despite
their being characterized by persistent and socially anoma-
lous sexual arousal.
There was significant concern expressed by forensic review-
ers that HD could be misused in court settings, especially in
sexually violent predator (SVP) civil commitment proceedings.
During the past 25 years, sexual crimes have been substantively
demonized, civil commitment proceedings for sexual crimes
have been reinstituted in 20 states in the U.S., and periods of
incarceration have increased as a result. During this time frame,
hypersexuality as a dimensional measure of sexual behavior
associated with paraphilias has been identified as an important
factor associated with recidivistic sexual offending (Hanson &
Morton-Bourgon, 2004).
The diagnostic criteria for HD were independently field
tested with both outpatient and incarcerated sexual offenders
in California, Florida, and Wisconsin. The three centers that
assessed HD in sexual offenders (n=447) utilized differing
assessment methodologies but their results were consistent
with the extant clinical literature. The ‘‘lifetime’’ occurrence
of probable HD was about 47 % (D. Thornton, personal
communication, Wisconsin Field Trial, August 29, 2011). A
high lifetime prevalence of paraphilia-related disorders (a
progenitor of HD) in paraphiliacs had been reported in prior
clinical studies (Briken, Habermann, Kafka, Berner, & Hill,
2006). When a field trial evaluated ‘‘current’’(past 6 months)
prevalence of HD, the prevalence rate dropped down to
11.7 % in outpatient sexual offenders (D. Thornton and D.
Dorazio, personal communication, California Field Trial,
August 29, 2011), similar to rates recently reported by
Kingston and Bradford (2013) in outpatients. About 2 % of
incarcerated sexual offenders (R. Wilson, personal commu-
nication, Florida Field Trial, September 5, 2011) met the
current diagnostic criteria for HD. The very low prevalence in
the incarcerated sample is very likely a reflection of their
incarcerated state, i.e., they were ‘‘in a controlled environ-
ment,’’one of the course speci fiers for HD and the Paraphilias.
Thus, for sexual offenders, the prevalence of HD depends on
the setting in which it is assessed: incarcerated SVP offenders
(in a controlled environment) have a low current incidence of
HD (1.8 %), suggesting that the consideration of a current
diagnosis of HD is unlikely to significantly influence the
assessment of sexual offenders who are being evaluated for
civil commitment.
The Paraphilias subworkgroup argued that the absence of
an operationalized diagnosis incorporating specific compo-
nents of dimensional hypersexuality into an associated
diagnostic category had significantly contributed to the
problematic misuse of ‘‘Not Otherwise Specified (NOS)’’
sexual diagnoses during civil commitment hearings (Zander,
2008). In other words, while some paraphilic sexual offenders
Table 1 Mean age of help-seeking behavior associated with putative
HD
Setting nAge (years)
HD outpatient multicenter field trial 152 41.1 ±13.1
CA residential ?OP tx center 129/year 45±13
TN residential 148/year 34±12
TN partial hospitalization 423/year 32±12
Arch Sex Behav
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may have some indicators of dimensional hypersexuality
(e.g., sexual preoccupation, using sex as a means of coping
with stressors, engaging in frequent sexual behavior), this is
not necessarily synonymous with the either the durational or
polythetic criteria of HD. The Paraphilias subworkgroup
contended that introducing an operationalized, polythetic,
and evidence-based ‘‘disorder’’ category would reduce the
misuse of ‘‘Sexual Disorder-Not Otherwise Specified’’ des-
ignations in both court and non-forensic clinical settings
(Prentky, Janus, Barbaree, Schwartz, & Kafka, 2006). It must
be emphasized that the great majority of persons who would
meet clinical criteria for HD are not paraphiliacs, are not
sexual offenders, and are not sexually violent predators. Any
psychiatric disorder, including HD, that has applicability in
forensic settings can expect it to be ‘‘misused.’’ Ultimately,
this is a legal matter that must be resolved by applied juris-
prudence as well as by refining psychiatric diagnostic criteria
when indicated.
The failure of HD to achieve any designated placement in
DSM-5 leaves clinicians with the quandary of how to ade-
quately diagnose or categorize persons who would otherwise
have been designated by Sexual Disorder Not Otherwise
Specified, a residual diagnostic category in prior DSM edi-
tions. HD is neither a sexual dysfunction nor a paraphilia, but
can be considered an impulsivity disorder and thus can be
diagnosed as ‘‘Other Specified Disruptive, Impulse-Control,
and Conduct Disorder: HD (ICD 312.89) (American Psy-
chiatric Association, 2013, p. 479).
Acknowledgments The author was a member of the Paraphilias
subworkgroup of the Sexual and Gender Identity Disorders Work Group
for DSM-5.
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