ArticlePDF Available

Abstract

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 conse
1 23
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
1 23
Your article is protected by copyright and all
rights are held exclusively by Springer Science
+Business Media New York. This e-offprint is
for personal use only and shall not be self-
archived in electronic repositories. If you wish
to self-archive your article, please use the
accepted manuscript version for posting on
your own website. You may further deposit
the accepted manuscript version in any
repository, provided it is only made publicly
available 12 months after official publication
or later and provided acknowledgement is
given to the original source of publication
and a link is inserted to the published article
on Springer's website. The link must be
accompanied by the following text: "The final
publication is available at link.springer.com”.
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 (&)
22 Mill St., Suite #306, Arlington, MA 02476, USA
e-mail: mpkafka@rcn.com
123
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
123
Author's personal copy
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.
References
American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders (5th ed.). Arlington, VA: Author.
Andrews, G., Brugha, T., Thase, M. E., Duffy, F. F., Rucci, P., & Slade,
T. (2008). Dimensionality and the category of major depressive
episode. In J. E. Helzer, H. C. Kraemer, H. Wittchen, P. J. Sirovatka,
&D.A.Regier(Eds.),Dimensional approaches in diagnostic classi-
fication: Refining the research agenda forDSM-V (pp. 35–51). Arling-
ton, VA: American Psychiatric Association.
Bancroft, J., & Vukadinovic, Z. (2004). Sexual addiction, sexual compul-
sivity, sexual impulsivity or what? Toward a theoretical model. Jour-
nalofSexResearch,41, 225–234.
Briken, P., Habermann, N., Kafka, M. P., Berner, W., & Hill, A. (2006).
Paraphilia-related disorders: An investigation of the relevance of
the concept in sexual murderers. Journal of Forensic Science, 51,
683–688.
Frances, A. (2010). DSM-5 sexual disorders make no sense. Retrieved
from http://www.psychologytoday.com/blog/dsm5-in-distress/201003/
dsm201005-sexual-disorders-make-no-sense. Accessed 25 Aug 2013.
Halpern, A. L. (2011). The proposed diagnosis of Hypersexual Disorder
for inclusion in DSM-5: Unnecessary and harmful [Letter to the
Editor]. Archives of Sexual Behavior, 40, 487–488.
Hanson, R. K., & Morton-Bourgon, K. (2004). Predictors of sexual
recidivism: An updated meta-analysis 19962004. Retrieved from
http://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/prdctrs-sxl-ffnd/
index-eng.aspx. Accessed 10 Sept 2013.
Kafka, M. P. (1997). Hypersexual desire in males: An operational defi-
nition and clinical implications for men with paraphilias and par-
aphilia-related disorders. Archives of Sexual Behavior, 26, 505–
526.
Kafka, M. P. (2010). Hypersexual Disorder: A proposed diagnosis for
DSM-V. Archives of Sexual Behavior, 39, 377–400.
Kafka, M. P., & Hennen, J. (1999). The paraphilia-related disorders: An
empirical investigation of nonparaphilic hypersexuality disorders
in 206 outpatient males. Journal of Sex and Marital Therapy, 25,
305–319.
Kafka, M. P., & Krueger, R. K. (2011). Response to Moser’s critique of
Hypersexual Disorder for DSM-5 [Letter to the Editor]. Archives of
Sexual Behavior, 40, 231–232.
Kalichman, S. C., & Rompa, D. (1995). Sexual sensation seeking and
sexual compulsivity scales: Reliability, validity and HIV risk behav-
ior. Journal of Personality Assessment, 65, 586–601.
Kingston, D. A., & Bradford, J. M. (2013). Hypersexuality and recidi-
vism among sexual offenders. Sexual Addiction & Compulsivity,
20, 91–105.
Marcus, D. K., & Barry, T. D. (2011). Does attention-deficit/hyperactivity
disorder have a dimensional latent structure? A taxometric analysis.
Journal of Abnormal Psychology, 120, 427–442.
Moser, C. (2010). Hypersexual Disorder: Just more muddled thinking
[Letter to the Editor]. Archives of Sexual Behavior, 40, 227–229.
Prentky, R. A., Janus, E., Barbaree, H., Schwartz, B. K., & Kafka, M. P.
(2006). Sexually violent predators in the courtroom: Science on
trial. Psychology, Public Policy, and Law, 12, 357–393.
Reid, R. C. (2007). Assessing readiness to change among clients seeking
help for hypersexual behavior. Sexual Addiction & Compulsivity,
14, 167–186.
Reid, R. C., Carpenter, B. N., Hook, J. N., Garos, S., Manning, J. C.,
Gilliland, R., et al. (2012). Report of findings from a DSM-5 field
trial for Hypersexual Disorder. Journal of Sexual Medicine, 9,
2868–2877.
Skegg, K., Nada-Raja, S., Dickson, N., & Paul, C. (2010). Perceived‘‘out
of control’’sexual behaviorin a cohort of young adults fromthe Dun-
edin Multidisciplinary Health and Development Study. Archives of
Sexual Behavior, 39, 968–978.
Slade, T., & Grisham, J. R. (2009). A taxometric investigation of agora-
phobia in a clinical and community sample. Journal of Anxiety
Disorders, 23, 799–805.
Wakefield, J. C. (2012). The DSM-5’s proposed new categories of
sexual disorder: The problem of false positives in sexual diagnosis.
Clinical Social Work Journal, 40, 213–223.
Winters, J. (2010). Hypersexual Disorder: A more cautious approach
[Letter to the Editor]. Archives of Sexual Behavior, 39, 594–596.
Winters, J., Christoff, K., & Gorzalka, B. B. (2010). Dysregulated sexuality
and heightened sexual desire: Distinct constructs? Archives of Sexual
Behavior, 39, 1029–1043.
Zander, T. K. (2008). Commentary: Inventing diagnosis for the civil
commitmentof rapists. Journal of the American Academy of Psychi-
atry & Law, 36, 459–469.
Arch Sex Behav
123
Author's personal copy
... The term sexual addiction was introduced in the revised third version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) (American Psychiatric Association 1987) and was then excluded from the DSM-IV (American Psychiatric Association 1994) due to a lack of empirical data. A diagnostic category for the phenomenon, named 'Hypersexual Disorder', was reintroduced in the developmental process of the DSM-5 (American Psychiatric Association 2013); however, it was excluded from the final version (Kafka 2014). In 2018, the World Health Organization's (WHO's) working group on Impulse Control Disorders proposed a new diagnosis of Compulsive Sexual Behaviour Disorder (CSBD) for consideration in the 11th revision of the International Classification of Diseases (ICD-11) . ...
... These criteria also specifically noted the excessive use of sexual behaviour to cope with stress or negative affective states as a symptom. Despite undergoing a successful field trial (Reid, Carpenter, et al. 2012), the diagnosis was ultimately excluded from the DSM-5 (Kafka 2014). Even so, a very notable increase in empirical literature related to excessive, addictive, or out-of-control sexual behaviours was generated by this consideration , ultimately culminating in a novel diagnosis proposed and included in the ICD-11, as we discuss below. ...
Article
Objectives The current guidelines aim to evaluate the role of pharmacological agents in the treatment of patients with compulsive sexual behaviour disorder (CSBD). They are intended for use in clinical practice by clinicians who treat patients with CSBD. Methods An extensive literature search was conducted using the English-language-literature indexed on PubMed and Google Scholar without time limit, supplemented by other sources, including published reviews. Results Each treatment recommendation was evaluated with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. Psychoeducation and psychotherapy are first-choice treatments and should always be conducted. The type of medication recommended depended mainly on the intensity of CSBD and comorbid sexual and psychiatric disorders. There are few randomised controlled trials. Although no medications carry formal indications for CSBD, selective-serotonin-reuptake-inhibitors and naltrexone currently constitute the most relevant pharmacological treatments for the treatment of CSBD. In cases of CSBD with comorbid paraphilic disorders, hormonal agents may be indicated, and one should refer to previously published guidelines on the treatment of adults with paraphilic disorders. Specific recommendations are also proposed in case of chemsex behaviour associated with CSBD. Conclusions An algorithm is proposed with different levels of treatment for different categories of patients with CSBD.
... As always, the condition should last for more than 6 months and be associated with distress. A similar category was rejected for inclusion in the DSM-5 (Kafka, 2014). It has, perhaps with good reasons, been argued that frequent sexual behavior or intense pornography use are rather inoffensive leisure activities without any need to be pathologized (Williams et al., 2020). ...
Article
Full-text available
Sexual motivation (desire) requires the simultaneous presence of an active central motive state and a stimulus with sexual significance. Once activated, sexual motivation leads to visceral responses and approach behaviors directed toward the emitter of the sexual stimulus. In humans, such behaviors follow cognitive evaluation of the context, including predictions of the approached individual’s response. After successful approach and establishment of physical contact, manifest sexual activities may be initiated. Sexual interaction is associated with and followed by a state of positive affect in most animals, whereas aversive consequences may be experienced by humans. The affective reactions may become associated with stimuli present during sexual interaction, and these stimuli may thereby alter their incentive properties. Here we show how the incentive motivation model can be used to explain the origins and possible treatments of sexual dysfunctions, notably disorders of desire. We propose that associations formed between negative outcomes of sexual interaction and the salient stimuli, for example, the partner, underlies hypoactive desire disorder. Highly positive outcomes of sexual interaction enhance the incentive value of the stimuli present, and eventually lead to hyperactive sexual desire. Treatments aim to alter the impact of sexual incentives, mainly by modifying cognitive processes.
... In particular, gonad hormones, are involved in compulsive sexual behavior, and anti-androgenetic medicines have been associated with decreased sexual motivation and compulsion . It is consistent with the notion that sexual excitation is a disordered basic appetite drive (12). ICSBs may also be caused by cognitive dysfunction, such as attention and inhibition. ...
Article
Full-text available
Background and Aim:Compulsive sexual behavior disorder is characterized by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behavior. The aim of this study was to standardize the Impulsive-compulsive Sexual Behaviors (ICSB) Questionnaire and to present and test an experimental model to explain impulsive-compulsive sexual behaviors. Materials and Methods:The sample consisted of 257 individuals who referred to counseling centers in Tehran with complaints of sexual hyperactivity, sexual addiction and high-risk sexual behaviors. The Compulsive-Impulsive Sexual Behavior Questionnaire, the Persian version of Jackson-5 Scales Questionnaire, Attachment Style Questionnaire, Marital Intimacy Scale, Hulbert Index of Sexual Assertiveness (HISA) Questionnaire,Sexual Knowledge and Attitude Scale, and Emotion and Self-Regulation Questionnaire were used in this study. Using LISREL software, structural equation method was used to test the model and using SPSS statistical software, exploratory factor analysis was performed to standardize the questionnaire. Results:The research findings showed that, among the three components of personality: BAS (SC=-0.109), BIS (SC:-0.357) and FFFS (SC=0.617), have a direct effect on secure attachment style. BIS SC: (0.2) and FFFS (SC=0.219) have a direct effect on the avoidant attachment style. The FFFS (SC=0.416) has a direct effect on anxious attachment style. Among the attachment styles, avoidant style (SC=-0.135) and anxious style (SC=-0.415) have a direct effect on emotion regulation. Sexual motivation (SC=0.174) on intimacy, (SC=0.386) on sexual knowledge and attitude, (SC=-0.225) on the emotion regulation and (SC=-0.405) on ICSBs, had a direct effect. There was a direct effect between intimacy (SC=0.291) on emotion regulation and (SC=-0.207) on ICSBs. There was a direct effect between intimacy, (SC=0.291) on emotion regulation and (SC=-0.207) on ICSBs. Also there was a direct effect between sexual knowledge and attitude (SC=-0.616) on ICSBs. Regulating emotion does not affect ICSBs. Conclusion:The proposed model can explain the relationships between the occurrence of CISBs and ten effective factors (directly and indirectly) including: personality (BAS, BI S, FFFS), attachment style (secure, avoidant, Anxious), sexual motivation, intimacy, knowledge, and sexual attitude and emotion regulation.
... This symptomology was classified in the DSM III through DSM IV-TR under the "Sexual Disorder Not Otherwise Specified" category, rather than a more specific diagnostic entity (American Psychiatric Association, 1980, 1987, 1994, 2000. Although Hypersexual Disorder was proposed during the development of the DSM-5, the proposal was ultimately rejected (Kafka, 2014). Additionally, the mention of compulsive, impulsive, or addictive sexual behavior was dropped from the Other Sexual Disorder category in the DSM-5, leaving no official classification of these symptoms in this nosology (American Psychiatric Association, 2013). ...
Article
Compulsive sexual behavior (CSB) is associated with religiosity and moral disapproval for sexual behaviors, and religiosity and moral disapproval are often used interchangeably in understanding moral incongruence. The present study expands prior research by examining relationships between several religious orientations and CSB and testing how moral disapproval contributes to these relationships via mediation analysis. Results indicated that religious orientations reflecting commitment to beliefs and rigidity in adhering to beliefs predicted greater CSB. Additionally, moral disapproval mediated relationships between several religiosity orientations and CSB. Overall, findings suggest that religiosity and moral disapproval are related constructs that aid in understanding CSB presentations.
... Some of these exclusionary criteria included ruling out the influences of substances and/or underlying mental health and physical health concerns on the individual's PH (Kafka, 2010). Ultimately, the DSM V task force decided to exclude HD from the DSM V, citing their reasons for this omission as a lack of empirical evidence supporting HD as a clinical disorder and the potential for this diagnosis to be misused in certain settings (e.g., the legal system; Kafka, 2014). Based on this information, the researchers will use the term PH for the remainder of this study to refer to the construct being measured by the PHS. ...
Article
The purpose of this investigation was to develop an instrument to screen for the presence of problematic hypersexuality (PH) in a non-clinical sample of 357 adults residing in the United States. The Problematic Hypersexuality Scale (PHS) was the product of this investigation and was designed to address the limitations of existing measures for this construct and gather psychometric evidence to support the intended uses of and claims drawn from this instrument. Empirical evidence for the use of the PHS as a screener was founded through factor analytic procedures, Rasch modeling and the use of Item Response Theory.
... In detail, HD was conceptualized as a nonparaphilic sexual behavior disorder, not caused by a direct effect of any exogenous substances, for which the most important symptoms were: (1) sexual behavior interfering with activities in other important spheres of life; (2) repetitive engagement in sexual behavior undertaken as a means of coping with dysphoric mood (3) or coping with stress; (4) numerous and unsuccessful attempts to stop or reduce sexual behavior; (5) engagement in sexual behavior despite the risk of physical and/or emotional harm as well as (6) sexual behavior causing significant distress or impairment in functioning (Kafka, 2010). HD was proposed for, but ultimately not included, in the final version of DSM-V (American Psychiatric Association [APA], 2013; Kafka, 2010Kafka, , 2013Kafka, , 2014. More recently, Compulsive Sexual Behavior Disorder was included in the ICD-11 classification (International Classification of Diseases, 11th revision, World Health Organization [WHO], 2020), which is in many ways related to HD. ...
Article
Full-text available
Previous studies have shown that specific attitudes related to moral convictions can have an important role in the development and maintenance of problematic sexual behavior symptoms. However, although other types of attitudes, like sexual attitudes, are potentially highly relevant, they have not yet been studied in this role. We investigated how four dimensions of sexual attitudes: Permissiveness, Birth Control, Communion and Instrumentality, contribute to problematic pornography use (PPU) and hypersexual disorder (HD) symptoms, controlling for religiosity, sex, age and relationship status. The study was administered through an online questionnaire and based on a representative sample of n = 1036 (Mage = 43.28, SD = 14.21; 50.3% women) Polish adult citizens. When adjusting for other variables, higher sexual Permissiveness positively predicted HD and PPU among both men (HD: β = .26, p < .001; PPU: β = .22, p < .001) and women (HD: β = .44, p < .001; PPU: β = .26; p < .001). Sexual Instrumentality positively, although weakly, contributed to HD severity among men (β = .11, p < .05). Attitudes reflecting higher support for responsible sexuality (Birth Control subscale) negatively and weakly predicted HD among women (β = – .11, p < .05). Permissiveness was also the only sexual attitude dimension that consistently predicted a higher frequency of sexual activity among men and women. Based on the cutoff criteria proposed by the authors of the used screening instruments (≥ 53 points for the Hypersexual Behavior Inventory and ≥ 4 points for the Brief Pornography Screen), the prevalence of being at risk for HD was 10.0% (men: 11.4%, women: 8.7%) and for PPU was 17.8% (men: 26.8%, women: 9.1%). Our results point to a significant contribution of sexual attitudes to problematic sexual behavior symptoms, which was not encapsulated by the previously studied influence of religious beliefs, although most of the obtained relationships were relatively weak. Particularly, a consistent link between permissive attitudes and both HD and PPU among men and women may indicate that permissive attitudes can potentially contribute to the development and maintenance of problematic sexual behavior. The prevalence of being at risk for PPU (and to some degree HD) in the current representative sample was high. Such results raise questions about the appropriateness of the proposed cutoff criteria and the risk of overpathologizing normative sexual activity, if the cutoff thresholds are not tailored adequately. The results have implications for the assessment, diagnosis and theory of problematic sexual behavior.
... Recognizing compulsive sexual behavior disorder (CSBD) as a distinct disorder in the ICD-11 (WHO, 2018) is a great step forward after decades of debate on the clinical syndrome of out-ofcontrol sexual behavior and the more recent rejection of hypersexual disorder (HD), the proposed diagnosis in the DSM-5 (Kafka, 2010;2014). The inclusion of CSBD in the ICD-11 is expected to greatly improve treatment access and stimulate further research. ...
Article
Full-text available
After introduction of compulsive sexual behavior disorder (CSBD) in the ICD-11, many questions regarding etiology, classification and diagnostic criteria remain unanswered, providing rationale for further research. In this commentary, we critically review the ongoing discussion reflected in some relevant articles, and try to point out the risks of oversimplification of the broad clinical phenomenon, as well as attract attention to the neglected aspects, such as psychosexual development, intimacy disorder and the role of sexological expertise in the assessment and treatment of individuals presenting with out-of-control sexual behaviors. We also advocate for multimodal, transtheoretical approach and suggest that CSBD may be reconsidered as a condition related to sexual health.
... All are umbrella terms for various non-paraphilic problematic behaviors, which range from online and offline pornography use, cybersex, and telephone sex, and which result in excessive masturbation or other forms of sexual behavior with consenting adults. The concept of hypersexual disorder (8) received extensive attention and was proposed for inclusion in DSM-5, albeit unsuccessfully (9,10). Later on, the International Classification of Diseases underwent revision, resulting in acknowledgment within the Compulsive Sexual Behavior Disorder [CSBD; 11] as an official disorder that belongs under the umbrella of impulse control disorders (11). ...
Article
Full-text available
Background: Problematic sexual internet use has been attracting increasing research attention in recent years. However, there is a paucity of qualitative studies about how this problem manifests on a daily basis in the clinical population and whether the phenomenon should fall within the hypersexual, compulsive-impulsive, or addictive spectrums of disorders. Methods: Twenty-three semi-structured interviews, including AICA-C clinical interviews, were conducted with men who were in treatment for problematic internet sex use (aged 22–53; Mage = 35.82). The interview structure focused on the patterns of sexual behavior in question, their development, the manifestation of symptoms, and other associated psychosocial problems. A thematic analysis was applied as the main analytical strategy. Results: Typical problematic patterns included pornography use and cybersex, together with continuous masturbation for several hours several times a week. This pattern emerged relatively early in young adulthood and became persistent for years. The majority of participants fulfilled the criteria for behavioral addiction (as defined, e.g., by the components model of addiction), with loss of control and preoccupation being the most pronounced and withdrawal symptoms being the least. Together with the onset of erectile dysfunction, negative consequences were reported as being slowly built up over years and typically in the form of deep life dissatisfaction, regret, and feelings of unfulfilled potential. Discussion and Conclusion: The Addiction model is relevant for describing the difficulties in treatment-seeking men who suffer from problematic sexual internet use. However, the manifestations of the additional criteria are nuanced. In the case of negative consequences, their onset might be very slow and not easily reflected. While there was evidence of several forms of tolerance, potential withdrawal symptoms in online sex addiction need further attention to be verified.
Article
Full-text available
Hypersexuality is a dimensional indicator of sexual interest and behavior and typically includes the frequency, intensity, and time consumed by sexual activity. Hypersexuality has been identified as a psychologically meaningful risk factor for sexual offending. In fact, a relatively high proportion of sexual offenders report hypersexual behavior and this construct seems to be associated with re-offending in these men. The purpose of the present longitudinal investigation was to examine the rate of an objective, behavioral indicator of hypersexuality (Total Sexual Outlet) among 586 adult male sexual offenders and to determine the predictive utility of Total Sexual Outlet utilizing one of the longest follow-up periods used with sexual offenders (up to 20 years). Results indicated that approximately 12% of men met the clinical criterion for hypersexuality and that the presence of this construct was significantly associated with long-term sexual and violent recidivism. Results are discussed in terms of the importance of hypersexuality as an empirically supported risk factor and treatment target among sexual offenders.
Article
Full-text available
Mental health professionals may erroneously assume that clients seeking help for hypersexual behavior are ready to begin working on their issues at the outset of treatment. Prochaska and DiClemente (e.g., 1983, 1984) proposed the transtheoretical model (TTM) stages of change to advance their belief that clients move through several stages when attempting to alter specific target behaviors. If a clini-cian gets ahead of a client by administering interventions that are improperly matched with the client's readiness to change, treat-ment may be prematurely terminated or high levels of resistance may be encountered during therapy. In this study, clients (N = 67) who were referred for treatment in a specialty outpatient clinic for hypersexual behavior completed the Sexual Compulsivity Scale (Kalichman et al., 1994; Kalichman & Rompa, 1995, 2001) and the Stages of Change Scale (McConnaughy, DiClemente, Prochaska, & Velicer, 1989; McConnaughy, Prochaska, & Velicer, 1983). The data collected from these measures revealed that 70% (n = 47) of clients who expressed an interest in receiving help with issues re-lated to hypersexuality also had high levels of ambivalence about the changes they desired to make and that individuals with ADHD were significantly (chi-square, p ≤ .001) more likely to be in the contemplation stage than subjects presenting with alternative diag-noses. Implications for these finding are discussed and suggestions for future research are offered. Mental health professionals may erroneously assume that clients seeking help for hypersexual behavior are ready to begin working on their issues at the outset of treatment.
Article
Full-text available
Adjudication of sexually violent predator commitment laws places demands on science. In the current article, the authors discuss the determination of mental abnormality and its reliance on medical nosological systems. Second, the authors examine the determination of current risk by reviewing three common concerns: (a) mechanistic estimations of risk, (b) mitigation of risk as a function of age, and (c) estimation of contemporaneous (dynamic) risk. The authors focus specifically on determinations of risk posed by the nexus of mental abnormality with prior history of sexually violent acts. Third, the article examines relevant, though sometimes nonstatutory, considerations, namely, the standards and the expectation for the treatment provided in high-security civil commitment programs. Potentially important dynamic or time-varying factors that may mitigate risk, such as offender age and treatment, are considered. Recommendations to promote good science and to avoid bad science are included with respect to determinations of mental abnormality, risk of reoffending, and treatment.
Article
Full-text available
An understanding of the latent structure of attention-deficit/hyperactivity disorder (ADHD) is essential for developing causal models of this disorder. Although some researchers have presumed that ADHD is dimensional and others have assumed that it is taxonic, there has been relatively little research directly examining the latent structure of ADHD. The authors conducted a set of taxometric analyses using data from the NICHD Study of Early Child Care and Youth Development (ns between 667 and 1,078). The results revealed a dimensional latent structure across a variety of different analyses and sets of indicators for inattention, hyperactivity/impulsivity, and ADHD. Furthermore, analyses of correlations with associated features indicated that dimensional models demonstrated stronger validity coefficients with these criterion measures than dichotomous models. These findings jibe with recent research on the genetic basis of ADHD and with contemporary models of ADHD.
Article
Introduction. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for hypersexual disorder (HD) have been proposed to capture symptoms reported by patients seeking help for out-of-control sexual behavior. The proposed criteria created by the DSM-5 Work Group on Sexual and Gender Identity Disorders require evaluation in a formal field trial. Aim. This DSM-5 Field Trial was designed to assess the reliability and validity of the criteria for HD in a sample of patients seeking treatment for hypersexual behavior, a general psychiatric condition, or a substance-related disorder. Method. Patients (N = 207) were assessed for psychopathology and HD by blinded raters to determine inter-rater reliability of the HD criteria and following a 2-week interval by a third rater to evaluate the stability of the HD criteria over time. Patients also completed a number of self-report measures to assess the validity of the HD criteria. Main Outcome Measures. HD and psychopathology were measured by structured diagnostic interviews, the Hypersexual Behavior Inventory, Sexual Compulsivity Scale, and Hypersexual Behavior Consequences Scale. Emotional dysregulation and stress proneness were measured by facets on the NEO Personality Inventory—Revised. Results. Inter-rater reliability was high and the HD criteria showed good stability over time. Sensitivity and specificity indices showed that the criteria for HD accurately reflected the presenting problem among patients. The diagnostic criteria for HD showed good validity with theoretically related measures of hypersexuality, impulsivity, emotional dysregulation, and stress proneness, as well as good internal consistency. Patients assessed for HD also reported a vast array of consequences for hypersexual behavior that were significantly greater than those diagnosed with a general psychiatric condition or substance-related disorder. Conclusions. The HD criteria proposed by the DSM-5 Work Group on Sexual and Gender Identity Disorders appear to demonstrate high reliability and validity when applied to patients in a clinical setting among a group of raters with modest training on assessing HD. Reid RC, Carpenter BN, Hook JN, Garos S, Manning JC, Gilliland R, Cooper EB, McKittrick H, Davtian M, and Fong T. Report of findings in a DSM-5 Field Trial for hypersexual disorder. J Sex Med 2012;9:2868–2877.
Article
The proposals that have emerged from the DSM-5 revision process have triggered considerable controversy, especially regarding potential invalid inflation of diagnostic categories. To illustrate the kinds of issues that have emerged, I closely examine the proposed new categories of sexual disorder. The DSM-5 Sexual and Gender Identity Disorders Work Group is proposing the addition of three categories of disorder to the DSM-5—hypersexuality, hebephilia (as part of a revised pedophilia category that would become pedohebephilia), and coercive paraphilic disorder (basically a “nonconsent” or rape paraphilia). These proposals are driven by perceived clinical or forensic needs. I argue, however, that their conceptual soundness remains problematic; each could lead to large numbers of false positive diagnoses (i.e., diagnoses that mistakenly label a normal variant of behavior as a mental disorder), with potential for serious forensic abuse in “sexually violent predator” civil commitment proceedings. KeywordsDSM-5–Diagnosis–Validity–Sexual disorder–Hebephilia–Hypersexual disorder–Paraphilic coercive disorder–Harmful dysfunction–False positive