VARIATIONS IN ORIENTATION, IDENTITY, ADDICTION, AND COMPULSION (E COLEMAN, SECTION EDITOR)
Controversies About Hypersexual Disorder and the DSM-5
Rory C. Reid &Martin P. Kafka
Published online: 16 September 2014
#Springer Science+Business Media, LLC 2014
Abstract Criteria for hypersexual disorder were proposed for
consideration for the Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5), but ultimately
rejected by the American Psychiatric Association despite a
field trial suggesting the criteria were valid and reliable. This
article highlights the vast array of controversial issues sur-
rounding the proposal for hypersexual disorder. While some
criticisms covered a broader scope of general concerns about
the field of psychiatric mental illness, many of these often
extended to the proposal for hypersexual disorder. It is impor-
tant to discuss both general concerns about psychiatric disor-
ders and those specifically focused on hypersexuality in order
to understand the challenges encountered in advancing the
criteria for hypersexual disorder. This article attempts to place
the controversies, criticisms, and issues about hypersexuality
in context from leading experts in the field.
Keywords Hypersexual disorder .Sex addiction .DSM-5 .
Hypersexual behavior .Sexualcompulsivity .Mentaldisorders
A constellation of debates have arisen over the proposed [1••]
diagnostic criteria for hypersexual disorder (HD) considered
for inclusion in the recently published Diagnostic and Statis-
tical Manual of Mental Disorders, Fifth Edition (DSM-5), by
the American Psychiatric Association (but ultimately it was
excluded). Moreover, researchers and clinicians seeking to
understand hypersexual behavior have also had controversies
arise among their groups about the legitimacy of this phenom-
enon and what labels might be most conceptually appropriate.
This article highlights some of the critical issues and offers
suggestions for future directions in the field of hypersexual
Politics, False Positives, and High Sexual Desire
The cultural climate in psychiatry in which HD was consid-
ered as a possible new diagnosis was particularly scrupulous
making its candidacy for the DSM an arduous endeavor from
its inception. Prior to publication, the DSM-5 Task Force and
Workgroups were already being heavily scrutinized by indi-
viduals such as previous DSM Editors Robert Spitzer (DSM-
III) and Allen Frances (DSM-IV) who used the Psychiatric
Times and other forums as a platform to openly publish their
criticisms. A number of criticisms were raised across all
psychiatric disorders, not just the HD proposal. Concerns
were raised about adding new diagnoses to the DSM-5 with-
out sufficient scientific research including anatomical and
functional imaging, molecular genetics, pathophysiology, ep-
idemiology, and neuropsychological testing. The adequacy of
literature reviews for changes to various diagnoses were crit-
icized. Ramifications for public policy and concerns about
potential misuse in the legal community were raised, particu-
larly for sexual disorders. The need to clarify definitional
issues across psychiatric mental disorders also surfaced with
concern about the trend in expanding the population of the
mentally ill, increasing the number of false-positive diagnoses
and potential for unnecessarily exposing individuals to potent
This article is part of the Topical Collection on Variations in Orientation,
Identity, Addiction, and Compulsion
R. C. Reid (*)
Department of Psychiatry and Biobehavioral Sciences, Semel
Institute for Neuroscience and Human Behavior, University of
California, Los Angeles, 760 Westwood Boulevard, Suite 38-153,
Los Angeles, CA 90024, USA
R. C. Reid :M. P. Kafka
Harvard Medical School, Harvard University, Boston, MA, USA
Curr Sex Health Rep (2014) 6:259–264
psychotropic medications [2•]. The potential for false posi-
tives (i.e., erroneously diagnosing an individual with a mental
disorder that is a normal variant of human behavior) were
specifically raised with respect to HD wherein the proposal
was purported to confuse “social disapproval and morality
with issues of health and disorder .”Moreover, it was stated
that the “…criteria do not adequately distinguish normal-
range high levels of sexual desire and activity from patholog-
ical levels of sexual desire and activity .”This latter con-
cern has also been raised by researchers who concur that high
sexual desire has not been differentiated from a dysfunction of
a biological mechanism with some supporting data suggesting
this maybe a legitimate criticism in need of further clarifica-
tion [4,5]. As part of the process of development of DSM-5,
proposed changes for psychiatric disorders and diagnostic
criteria were subject to commentary by both the general public
and various special interest groups. Direct attacks were even
launched in the media against specific members of the Sexual
and Gender Identity Disorders DSM-5 Task Force Committee
(Kenneth Zucker and Ray Blanchard) with efforts to petition
removing them for some alleged controversial viewpoints on
sex research. The panoply of issues on the table before the
field trials inferred that the best case scenario, if the criteria
were found to be valid and reliable, was that HD might be
considered for Section III: Emerging Measures and Models in
the DSM-5 (a section reserved for conditions which appear to
have some scientific merit but need further research before
they might be considered as formal disorders).
Potential for Forensic Abuse of Hypersexual Disorder
The misapplication or abuse of HD as a diagnosis in forensic
settings was raised as a concern purporting the legal commu-
nity would advance HD as a mitigating factorin the defense of
hypersexual criminal defendants being prosecuted for felonies
such as child sex abuse [6,7]. Interestingly, these challenges
did not advance any data indicating that sex offenders suffer-
ing from a paraphilia such as pedophilia, for example, secured
for themselves reduced sentences. Conversely, criminals who
use a mental disorder as a defense sometimes receive longer
incarceration sentences. Moreover, the US Supreme Court has
even ruled it is constitutional to involuntarily commit an
individual with a mental disorder after they have served full
prison terms for their crimes as a form of preventative institu-
tionalization. Furthermore, a recent summary of the field trials
for HD among sex offenders found that a very small number
of these individuals would actually receive a current diagnosis
of HD . Even if an individual met criteria for HD, providers
failing to also diagnose a comorbid sexual disorder (such as a
paraphilia disorder) constitutes a problem with comprehensive
assessment by clinicians, not a problem with the HD criteria
Discounting by Dissecting the Diagnosis
Several individuals have attempted to criticize the HD pro-
posal by systematically discounting the high likelihood of
erroneous assessment of individual criterion for the condition.
One author, minimizing the A4 criterion “Repetitive but un-
successful efforts to control or significantly reduce these sex-
ual fantasies, urges, and behavior”stated that engaging in
highly desired and pleasurable activities despite potential risks
for harm is normal and by such reasoning “scuba diving,
mountain climbing, and freeway driving can be indications
of a psychiatric disorder [8•].”Such rationale is flawed and
could be similarly used to distort other well-established diag-
noses. For example, most parents of a newborn baby report
sleep disturbance nearly every day for a period of at least
2 weeks but they are not diagnosed with a major depressive
disorder because an alternative explanation for their lack of
sleep exists and they would likely deny experiencing the
required number of additional symptoms necessary for such
a diagnosis. However, in a few cases, it should be noted this
could be a possible sign of the onset of postpartum depression
but such is usually the exception, not the rule. As another
example, rarely do clinicians ask how much sadness is too
much sadness needed to assess for depressed mood states but
many have curiously (and in some cases cynically) asked how
much sex is too much sex indicative of hypersexuality. Thus,
systematically dissecting each criterion independent of the
broader scope of signs and symptoms ignores the high thresh-
old set for an HD diagnosis requiring four of the five behav-
ioral criteria to persist for a minimum of 6 months . Like
many other disorders, a minimum set number of signs and
symptoms must converge and persist over time in order for the
diagnosis to be considered. This approach is intended to
safeguard against potential false positives.
Mental Illness and Pathologizing Sexuality
Across the debate about conceptualizing HD as a mental
disorder is the larger controversy in the psychiatric communi-
ty about what actually constitutes a mental illness. Some
suggest abnormality should be both statistically deviant and
biologically disadvantageous . Others have sought a com-
promise by suggesting values can be considered in defining
“harm”associated with a disorder while maintaining “dys-
function”should be defined by evolutionary biology as a
failure of an “internal mechanism to perform its natural func-
tion .”In response to the various challenges of defining
mental disorders, some have suggested a psychopharmaco-
logical taxonomy of classifying disorders as any condition
that is alleviated by psychopharmacological products. How-
ever, this taxonomy only succeeds in categorizing a class of
disorders and fails to define the concept of a mental disorder.
260 Curr Sex Health Rep (2014) 6:259–264
Moreover, this approach is unreliable given the high number
of non-responders to medication across a broad range of
psychiatric disorders . Collectively, how a mental disorder
should be defined was a topic of passionate debate prior to
DSM-5 and continues to elicit ongoing controversial discus-
sion . By extension, this debate has been generalized to
whether HD should be classified as a mental disorder.
The concept of mental disorders has also been
condemned by some who suggest it is a value-laden
socially constructed phenomena used to impose confor-
mity to cultural norms. Not surprisingly, similar argu-
ments have been launched against the HD proposal with
allegations that HD pathologizes normal variants of
healthy sexual behavior, and hence, it does not meet
the requirements for “deviance [14,15].”Another fre-
quent criticism is that HD could be an extension or
manifestationofanexisting mental disorder [6,8•].
This latter critique should not be quickly dismissed
given high comorbidity rates of other mental illness
commonly reported among treatment-seeking samples
of hypersexual patients. Further, it is widely believed
among clinicians working with hypersexual patients that
sex is used to “cope”with challenging situations or as a
way of “coping”inthewakeofemotionaldistress.
Such assertions might imply that hypersexuality is an
attempt to compensate for maladaptive systems designed
to regulate emotion. Subsequently, wouldn’tthemore
parsimonious conceptualization of hypersexuality be
some type of an emotional dysfunction disorder or an
adjustment disorder rather than an independent patholo-
gy? If one argues for HD as an independent disorder,
they must also identify which internal functions are
failing to operate and advance some theory implicating
what mechanisms of action are purported to cause the
dysfunction. Sadly, sex researchers investigating hyper-
sexuality have often failed in this endeavor witha
few notable exceptions. For example, neurobiological
mechanisms linked to sexual excitation and sexual inhi-
bition has been advanced as a plausible explanation for
hypersexuality . A broader hypothesis about execu-
tive deficits in frontal lobe functioning reported mixed
findings where hypersexual patients self-reported execu-
tive deficits but did not exhibit executive dysfunctions
when tested [18,19]. Many have suggested addiction,
impulsivity, and compulsivity models , although it’s
questionable whether these conceptualizations really
constitute theoretical models given their lack of speci-
ficity, falsifiable testability, or explanatory power for the
construct of hypersexuality. Moreover, proponents of
these approaches have yet to clearly operationalize and
delineate the respective distinct contributions of addic-
tion, impulsivity, or compulsivity as they relate to hy-
persexual behavior. Instead, it is argued there is overlap
between these paradigms which further diminishes how
each is purported to exert its effect on hypersexuality.
As an illustration, advocates of “sex addiction”will
integrate components of impulsivity or compulsivity in
their rhetoric claiming that all addicts are impulsive
despite published research data that contradicts this as-
While significant consequences such as personal distress or
impairment are common denominators across many DSM
disorders, evidence linking excessive sexual thoughts, urges,
and behaviors to such consequences [22,23] is insufficient to
classify a phenomenon as a psychiatric disorder. There are
many issues in life resulting in significant negative outcomes
that do not rise to the level of pathology or constitute a mental
illness. For example, negative aspects of perfectionism can
interfere with relationships, contribute to job loss, predict
earlier mortality ,andhavebeenassociatedwithmental
illness such as eating disorders  and depression .
Perfectionism, however, has been characterized as a multidi-
mensional personality trait not a pathological condition. Nev-
ertheless, treatment approaches have been developed for at-
tenuating the distress associated with negative aspects of
perfectionism . Subsequently, perfectionism is taken seri-
ously by researchers and clinicians, can result in negative
consequences and personal distress, has been studied exten-
sively by the scientific community, and is the focus of treat-
ment by health care providers—all of this without having
perfectionism classified as a disease or mental illness. By
extension of this analogy, the pertinent question is whether
hypersexuality constitutes a problem in living, an internal
conflict around sexual values, a culturally bound construct,
or a personality trait or does this phenomenon adhere to the
more stringent standard required for a mental disorder?
Amidst the landscape of the various controversies
noted above, it is important to put criticisms about the
HD proposal in context. There has been a long history of
resistance to pathologizing sexuality more broadly across
multiple domains , and so, resistance to classifying
HD as a psychiatric disorder was to be expected. Per-
haps, the greater obstacle given current advances in
science is that any new diagnostic proposal faces an
enormously strict standard requiring rigorous research
and empirical evidence. Indeed, given the heated debate
about HD, one wonders whether male hypoactive sexual
desire disorder could meet the strict standard of mental
illness required for the DSM-5 if the criteria for hypo
had to start from scratch. Yet, if individuals can have a
“hypo”sexual desire disorder it seems reasonable that a
“hyper”sexual disorder is also plausible. Nevertheless,
there is wisdom in exercising caution with respect to
pathologizing any phenomenon given the significant
ramifications for health care providers, the corporate
sector (e.g., insurance and pharmacological companies),
Curr Sex Health Rep (2014) 6:259–264 261
the scientific field, the legal community, the allocation of
public funding, the social policies, and the obvious im-
plications for patients having the stigma of a diagnosis.
Epidemiological Studies and Hypersexuality
Currently, there is a paucity of literature examining hypersex-
uality in non-clinical samples. A few studies have assessed
some limited facets of hypersexual behavior noting preva-
lence rates from 0.6 to 1.8 % in the general population [29,
30•]. However, epidemiological studies specifically applying
the diagnostic criteria for HD in representative community
samples is needed to clarify whether the proposed criteria
demonstrate validity and reliability in distinguishing a patho-
logical condition associated with hypersexual behavior. The
lack of such epidemiological research was a major concern of
the DSM-5 committees and the APA in considering the HD
proposal. One challenge associated with these types of studies
and the psychiatric conceptualization of a mental disorder is
that a standard of normality is established through a reference
group and the bandwidth of sexual behaviors among humans
appears to be quite broad. Therefore, care will need to be taken
to determine what reference group should be used as a com-
parison to evaluate deviance and, by extension, abnormality
indicative of a mental disorder among hypersexual subjects.
Some dialogue is also needed to help clarify how “severity”
should be defined.
Collectively, the scientific evidence for HD to be consi-
dered a mental illness is incomplete at the present time based
on the current psychiatric definitions for a mental disorder.
Primarily, objective data identifying internal biological dys-
function (e.g., genetic abnormality, deficits in brain function,
etc.) are lacking. This, of course, assumes that natural func-
tions are objectively discoverable, and therefore, dysfunctions
are subsequently measurable.
Neuroimaging and Hypersexual Behavior
While there are some neuroimaging studies [31•,32,33]
beginning toemerge investigating brain function and response
to sexual stimuli among hypersexual subjects, these pilot
studies are in their infancy use correlational cross-sectional
designs, and fall short of controlling for a host of potential
confounds that might offer alternative explanations for the
findings. Moreover, visual sexual stimuli used in neuroimag-
ing studies are emotionally salient and increase blood flow to
multiple brain regions also implicated in reward processing,
motivation, vigilance, and attention [34••]. Subsequently, al-
ternative hypothesis neglected in these studies might offer
more parsimonious explanations for the findings. Despite
these shortcomings, neuroimaging can play an important role
in helping illuminate possible underlying neurobiological
mechanisms that might be implicated in hypersexuality and
have the potential to provide evidence of dysfunction.
The issues that led to the exclusion of HD from the DSM-5 are
complex. This article has attempted to identify some of the
more prominent issues raised in response to the HD proposal.
As outlined above, many of these issues extend beyond the
scope of the HD proposal and constitute more general chal-
lenges to the broader field of psychiatric diagnosis and partic-
ularly focus on how mental illness is conceptualized. Whether
or not the HD proposal will end up in subsequent updates to
the DSM has yet to be determined.
The DSM-5 field trial conducted through UCLA found
evidence in support of the validity and reliability of the HD
criteria [35••]. Yet, this article highlights the need for more
research if HD is to be classified as a mental disorder. Scien-
tists should also explore alternative non-pathological models
to help clarify the phenomenon of hypersexuality. For exam-
ple, models examining reward processing and reward sensi-
tivity might offer new insights and directions for the field.
Care must be taken by clinicians to avoid misdiagnosing
individuals. In the case of HD, cultural values, sexual orien-
tation, and religiosity  should be considered in working
with those seeking help for hypersexual behavior as these
factors may play an important role in case conceptualization
(e.g., hypersexuality reframed as internal conflict with reli-
gious values as opposed to a disordered pattern of behavior).
Given that relationship discord is often a catalyst for
treatment-seeking individuals, distress related to hypersexual
behavior might be more parsimoniously explained by rela-
tionship incompatibility. As one critic has accurately noted,
“If sexual desires or activities cause distress, this may be
because of the attitude of the individual towards the sexual
desires or activities, not because the desires or activities are
inherently pathological .”Patients receiving treatment for
hypersexuality should be given adequate informed consent
regarding their treatment. For example, clinicians should dis-
close to patients the status of mental health illness if a diag-
nosis is warranted and converselyindicate when a patient does
not meet the criteria for a mental disorder. While “sex addic-
tion”is not a sanctioned disorder by the American Psychiatric
Association, patients should be told that hypersexual behavior
often cooccurs with other mental disorders. Regardless of the
presence or absence of a mental disorder, patients should be
reassured that their issues can be the focus of treatment, with
the caveat that treatment specifically focused on hypersexual-
ity may not be covered by insurance providers.
Clinicians should understand there is no current gold stan-
dard of care for treating hypersexuality and empirical outcome
262 Curr Sex Health Rep (2014) 6:259–264
studies in the field have been found to have significant meth-
odological limitations . Some providers have reported the
quandary of how to classify patients who might have previ-
ously been categorized under DSM-IV by the designation
Sexual Disorder Not Otherwise Specified. In the new DSM-
5 classification system, hypersexuality is not considered a
variant of paraphilia, a sexual dysfunction, or an unspecified
sexual disorder. However, since there is evidence that many
patients seeking help for hypersexual behavior exhibit prob-
lems with impulse control,  it may be appropriate in those
cases to use a designation of “Unspecified disruptive, im-
pulse-control, and conduct disorder”(ICD 312.9) [William
Narrow, M.D., Research Director for DSM-5 Task Force,
personal communication 9/5/13]. As research continues to
elucidate the phenomenon of hypersexual behavior, providers
should be encouraged to continue to develop empirically
supported treatments and best practice guidelines, as has been
applied to other constructs like perfectionism.
Finally, even among opponents of the HD proposal, there is
an acknowledgment that some patients genuinely struggle to
regulate their sexual behavior in a way that causes significant
problems and negative consequences. Thus, it is imperative
that mental health professionals, researchers, and scientists
collaborate when possible to find ways to help alleviate the
suffering and distress encountered by those experiencing hy-
Compliance with Ethics Guidelines
Conflict of Interest Dr. Reid has no formal declarations of conflicts.
He was the principal investigator for the DSM-5 field trial on hypersexual
disorder conducted by UCLA. Dr. Kafka was a member of the DSM-5
Workgroup on Sexual and Gender Identity Disorders.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
Papers of particular interest, published recently, have been
•• Of major importance
1.•• Kafka MP. Hypersexual disorder: a proposed diagnosis for DSM-V.
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questions in psychiatric diagnosis: a pluralogue part 1: conceptual
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written articles that discusses some of the major concerns around
defining mental illness in the psychiatric community.
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nent of the HD proposal. While some of his viewpoints have been
somewhat strident, he does raise important questions to be ad-
dressed for HD researchers.
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reactivity in individuals with and without compulsive sexual behav-
iours. PLoS ONE. 2014;9(7):e102419. This is one of the more tightly
controlled neuroimaging studies that also used the HD criteria in the
assessment of subjects. This study showed significant differences in
various brain regions among sexually compulsive subjects paralleling
those also found in subjects with substance abuse.
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the ‘pornography addiction’model. Curr Sex Health Rep. 2014;6:
94–105. While this paper has been very controversial, it highlights
the need for theory in guiding the scientific study of HD and offers
plausible alternative viewpoints in conceptualizing hypersexual
35.•• Reid RC, Carpenter BN, Hook JN, Garos S, Manning JC, Gilliland
R, et al. Report of findings in a DSM-5 field trial for hypersexual
disorder. J Sex Med. 2012;9(11):2868–77. This was the UCLA field
trial for the DSM-5 proposed criteria for HD wherein the re-
searchers found evidence for the validity and reliability of the HD
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264 Curr Sex Health Rep (2014) 6:259–264