[14] Hypersexual Disorder is proposed as a new sexual disorder diagnostic category. The rationale and empirical evidence in support of this proposal is elaborated in the review by Kafka (2009a). Empirical evidence in support of each A Criterion is contained in the section “Contemporary Pathophysiological Models for Hypersexual Disorder” of the aforementioned review. The three primary putative pathophysiological models are sexual desire/arousal dysregulation, sexual addiction, and sexual compulsivity. Each specific criterion is empirically supported by at least two of the three models. Kafka has listed some primary references for each criterion that follows, but this is not an extensive listing of all the available literature in support of these criteria. The scientific basis for each criterion is primarily extracted from rating scales whose factorial structure, validity, and reliability have been published.

Clinical Need. There is a significant clinical need, even a “demand” from mental health consumers, for mental health providers to recognize and diagnose a distinct group of men and women who have been seeking and are already receiving mental health care such as individual psychotherapy, 12-step group support, pharmacotherapy, and specialized residential treatments. These men and women are presenting to clinicians because of recurrent, “out of control” sexual behaviors that are not inherently socially deviant (i.e., normophilic, not paraphilic). Persons afflicted with these conditions are currently diagnosed as Sexual Disorder Not Otherwise Specified, a diagnostic wastebasket that the DSM-V editors would like to see diminished in scope. Clinical and research-based interest in this set of problematic nonparaphilic sexual behaviors is sufficiently established to have birthed a peer-reviewed journal published since 1990 dedicated exclusively to research and treatment of “sexual addiction/ compulsivity.”

Research Need. There is a significant research-associated need to consolidate an operational definition for such a condition so that research from varying theoretical perspectives can coalesce with a common set of criteria. Such a condition has been clinically described for over 200 years in Western cultures (by authors including Benjamin Rush, MD, one of the Founding Fathers of the USA), but a specific empirically supported and polythetic set of operationalized criteria, as proposed here for DSM-V, has not been validated. In the 10th edition of International Classification of Diseases, “excessive sexual desire” is noted but without any suggested operational criteria. A DSM-V sexual disorder associated with marked and persistent increased normophilic sexual behaviors with adverse consequences would be consistent with the aforementioned codified diagnosis. A DSM-V-based empirically derived definition should significantly enhance research efforts to explore some of the additional diagnostic validators for which there are no current data.

Adverse Consequences. The adverse personal, relational and public health consequences associated with this affliction rank it as one of the more serious but still neglected contemporary psychiatric disorders. In addition to significant pair-bond and marital dysfunction including divorce, persons afflicted with Hypersexual Disorder can be sexual risk-takers (Bancroft et al., 2003a) at substantially higher risk to acquire and disseminate sexually transmitted diseases, including HIV infection (Kalichman & Cain, 2004; Kalichman, Cherry, Cain, Pope, & Kalichman, 2005). Men and women with Hypersexual Disorder are more likely to incur or experience unintended pregnancies (Henshaw, 1998; McBride, Reece, & Sanders, 2008) as well. With the advent of the Internet, the viewing and downloading of pornographic images and videos has exploded. The use of pornography by employees in the workplace had become sufficiently problematic to engender industry-based responses and specialized filtering and monitoring systems (Cooper, Golden, & Kent-Ferraro, 2002). Sexual offenders who are “heavy” and persistent pornography users are more likely to recidivate (Kingston, Fedoroff, Firestone, Curry, & Bradford, 2008). Extensive users of Cybersex who persistently seek partners through that venue are more likely to acquire sexually transmitted diseases (McFarlane, Sheana, & Rietmeijer, 2000).

Hypersexual Disorder and its diagnostic neighbors. The paraphilic disorders are the nearest diagnostic neighbors of Hypersexual Disorder but these behavioral cousins differ at their core: Paraphilias are characterized by persistent, socially anomalous or deviant sexual arousal (e.g., Exhibitionistic Disorder, Fetishistic Disorder, Pedohebephilic Disorder), whereas Hypersexual Disorder is represented by normophilic sexual behaviors that are repetitive, excessive, or disinhibited (e.g., sexual behavior with consenting adults, pornography, and cybersex). Hypersexual Disorder is clinically apparent without paraphilias or independently co-associated with paraphilias (e.g., Voyeuristic Disorder and Hypersexual Disorder: telephone sex and masturbation) or expressed concomitantly with Hypersexual Disorder (e.g., Pedohebephilic Disorder and Hypersexual Disorder: [child] pornography and masturbation). In all of these examples, however, the Hypersexual Disorder, by definition includes a persistent and repetitive sexual behavior that is not inherently paraphilic.

Hypersexual Disorder and polythetic criteria. The polythetic operational criteria “A” proposed for Hypersexual Disorder are derived from items or domains specifically included in published validated instruments noted in support of each criterion. None of these aforementioned scales, however, contains all of the specific diagnostic A criteria proposed for Hypersexual Disorder. Dimensionalized diagnostic and treatment tracking/outcome assessment instruments including these proposed diagnostic criteria for Hypersexual Disorder have been prepared by the Paraphilias Subworkgroup and these assessment instruments could be compared with the aforementioned scales as independent validators in field trials.

At present, the decision to formulate Hypersexual Disorder as requiring 4 out of 5 “A criteria” is based on clinical consensus amongst the members of the Paraphilias Subworkgroup and two advisors (David Delmonico, Ph.D., and Michael Miner, Ph.D.) who were selected specifically to help to formulate this proposed diagnosis. Hypersexual Disorder is a heterogeneous disorder with multiple behavioral specifiers. The choice to require 4 out of 5 A-criterion items as a threshold for the disorder was based on clinical grounds and is intended to minimize the rate of false-positive diagnoses of Hypersexual Disorder. The ideal number of A criteria required to ascertain a hypersexual behavior and the threshold for Hypersexual Disorder needs to be subjected to rigorous field testing.

Significant gaps in basic knowledge remain. There are significant gaps in the current scientific knowledge base regarding additional antecedent, concurrent, and predictive validators for Hypersexual Disorder. For example, developmental risk factors, family history and aggregation studies, cognitive markers, and a distinct neurobiological substrate for Hypersexual Disorder are not currently known. More empirically-based knowledge of Hypersexual Disorder in females is needed, in particular. As is true of so many psychiatric disorders, the comment that “more research is needed” is certainly applicable to these conditions, but Dr. Kafka would proffer that there is sufficient evidence to move the currently proposed Hypersexual Disorder to field trials and possible inclusion in DSM-V.

[15] Criterion A1: Time-consuming sexual behaviors (Kafka, 2003; Kafka & Hennen, 2003; Kalichman & Cain, 2004; Kalichman et al., 2005; Kalichman & Rompa, 1995, 2001).

[16] Criterion A2: Sexual behavior in response to dysphoric affects (Bancroft et al., 2004; Bancroft et al. 2003b; Bancroft, Janssen, Strong, & Vukadinovic, 2003; Reid, Harper, & Anderson, 2009).

[17] Criterion A3: Sexual behavior in response to stressful life events. “Stress” and “stressful life events” are not “affects” as in Criterion A2. This criterion was added to include those men who could identify “events” and “stress” as recurrent precipitants associated with their sexual behavior and has been noted in the referenced scales as well (Miner, Coleman, Center, Ross, & Rosser, 2007; Nelson & Oehlert, 2008).

[18] Criterion A4: Volitional impairment associated with sexual behaviors (Kalichman & Cain, 2004; Kalichman et al., 2005; Kalichman & Rompa, 1995, 2001; Miner et al., 2007; Nelson & Oehlert, 2008).

[19] Criterion A5: Risk-taking associated with sexual behaviors (Bancroft et al., 2004; Janssen, Goodrich, Petrocelli, & Bancroft, 2009; Kalichman & Cain, 2004; Kalichman et al., 2005; Kalichman & Rompa, 1995, 2001; Miner et al., 2007).

[20] Empirical evidence in support of Criterion B is contained in the review section, “Hypersexual Disorders: clinically significant distress or impairment in social, occupational or other important areas of functioning (Kafka, 2009a). The personal distress and psychosocial role impairment associated with Hypersexual Disorders is well documented by various rating instruments including those that assess the dimensional severity of hypersexual behaviors as well as specific scales assessing “outcomes” (Kalichman & Rompa, 1995, 2001; McBride et al., 2008; Miner et al., 2007; Nelson & Oehlert, 2008). Role impairment “consequences” can include marital/pair-bond dysfunction and divorce/separation, increased STDS, excessive spending on sexual services and school/employment role dysfunction.

[21] The empirical support for the C Criterion is included in the three sections of the Kafka’s (2009a) review: “Hypersexual Disorders and associated features,” “Hypersexual Disorders and Paraphilias,” and “Hypersexual Disorders associated with neuropsychiatric illness, neurodegenerative conditions and drug-induced conditions.” 

Paraphilias may be comorbidly expressed with Hypersexual Disorders (Briken, Habermann, Kafka, Berner, & Hill, 2006; Kafka, 2003; Kafka & Hennen, 2003; Kingston et al., 2008) and certain Axis I psychiatric (Black, Kehrberg, Flumerfelt, & Schlosser, 1997; Kafka & Hennen, 2002; Kafka & Prentky, 1998; Raymond, Coleman, & Miner, 2003), or concurrent neuropsychiatric conditions (Krueger & Kaplan, 2000) can be associated with hypersexual behaviors or Hypersexual Disorders. A diagnosis of Hypersexual Disorder would be made only under those circumstances as long as the full criteria (4/5 A criteria + B criteria) were established and the behavior(s) persisted six or more months.

[22] Empirical evidence in support of Hypersexual Disorder Specifiers is contained in the review by Kafka (2009a), section “What behaviors are affected in Hypersexual Disorders?” The following are some primary references: Bancroft and Vukadinovic (2004), Briken, Habermann, Berner, and Hill (2007), Cooper, Delmonico, and Burg (2000), Kafka and Hennen (1999), Raymond et al. (2003), and Reid, Carpenter, and Lloyd (2009).

References

Bancroft, J., Jannsen, E., Carnes, L., Strong, D. A., Goodrich, D., & Long, J. S. (2004). Sexual activity and risk taking in young heterosexual men: The relevance of sexual arousal, mood and sensation seeking. Journal of Sex Research, 41, 181-192.

Bancroft, J., Janssen, E., Strong, D., Carnes, L., Vukadinovic, Z., & Long, J. S. (2003a). Sexual risk-taking in gay men: The relevance of sexual arousability, mood and sensation seeking. Archives of Sexual Behavior, 32, 555-572.

Bancroft, J., Janssen, E., Strong, D., Carnes, L., Vukadinovic, Z., & Long, S. L. (2003b). The relation between mood and sexuality in heterosexual men. Archives of Sexual Behavior, 32, 217-230.

Bancroft, J., Janssen, E., Strong, D., & Vukadinovic, Z. (2003). The relation between mood and sexuality in gay men.Archives of Sexual Behavior, 32, 231-242.

Bancroft, J., & Vukadinovic, Z. (2004). Sexual addiction, sexual compulsivity, sexual impulsivity or what? Toward a theoretical model. Journal of Sex Research, 41, 225-234.

Black, D. W., Kehrberg, L. L. D., Flumerfelt, D. L., & Schlosser, S. S. (1997). Characteristics of 36 subjects reporting compulsive sexual behavior. American Journal of Psychiatry, 154, 243-249.

Blanchard, R. (2009b). The DSM diagnostic criteria for Pedophilia. Archives of Sexual Behavior. Sept 16 [Epub ahead of print]. DOI 10.1007/s10508-009-9536-0

Blanchard, R. (2009c). The DSM diagnostic criteria for Transvestic Fetishism. Archives of Sexual Behavior.Sept 16 [Epub ahead of print]. DOI 10.1007/s10508-009-9541-3

Briken, P., Habermann, N., Berner, W., & Hill, A. (2007). Diagnosis and treatment of sexual addiction: A survey among German sex therapists. Sexual Addiction & Compulsivity, 14, 131-143.

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 Sciences, 51, 683-688.

Cooper, A., Delmonico, D. D., & Burg, R. (2000). Cybersex users, abusers, and compulsives: New findings and implications. Sexual Addiction & Compulsivity, 7, 5-29.

Cooper, A., Golden, G. H., & Kent-Ferraro, J. (2002). Online sexual behaviors in the workplace: How can human resource departments and employee assistance programs respond effectively? Sexual Addiction & Compulsivity, 9, 149-165.

Henshaw, S. K. (1998). Unintended pregnancy in the United States. Family Planning Perspectives, 30, 24-29.

Janssen, E., Goodrich, D., Petrocelli, J. V., & Bancroft, J. (2009). Psychophysiological response patterns and risky sexual behavior in heterosexual and homosexual men. Archives of Sexual Behavior, 38, 538-550.

Kafka, M. P. (2003). Sex offending and sexual appetite: The clinical and theoretical relevance of hypersexual desire.International Journal of Offender Therapy and Comparative Criminology, 47, 439-451.

Kafka, M. P. (2009a). Hypersexual disorder: A proposed diagnosis for DSM-V. Archives of Sexual Behavior.Nov 24 [Epub ahead of print]. DOI: 10.1007/s10508-009-9574-7 

Kafka, M. P. (2009b). The DSM diagnostic criteria for Fetishism. Archives of Sexual Behavior. Oct 1 [Epub ahead of print]. DOI: 10.1007/s10508-009-9558-7

Kafka, M. P. (2009c). The DSM diagnostic criteria for Paraphilia Not Otherwise Specified. Archives of Sexual Behavior. Sept 25 [Epub ahead of print]. DOI: 10.1007/s10508-009-9552-0

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., & Hennen, J. (2002). A DSM-IV Axis I comorbidity study of males (n = 120) with paraphilias and paraphilia-related disorders. Sexual Abuse: A Journal of Research and Treatment, 14, 349-366.

Kafka, M. P., & Hennen, J. (2003). Hypersexual desire in males: Are males with paraphilias different from males with paraphilia-related disorders? Sexual Abuse: A Journal of Research and Treatment, 15, 307-321.

Kafka, M. P., & Prentky, R. A. (1998). Attention Deficit Hyperactivity Disorder in males with paraphilias and paraphilia-related disorders: A comorbidity study. Journal of Clinical Psychiatry, 59, 388-396.

Kalichman, S. C., & Cain, D. (2004). The relationship between indicators of sexual compulsivity and high risk sexual practices among men and women receiving services from a sexually transmitted infection clinic. Journal of Sex Research, 41, 235-241.

Kalichman, S. C., Cherry, C., Cain, D., Pope, H., & Kalichman, M. (2005). Psychosocial and behavioral correlates of seeking sex partners on the internet among HIV-positive men. Annals of Behavioral Medicine, 30, 243-250.

Kalichman, S. C., & Rompa, D. (1995). Sexual sensation seeking and sexual compulsivity scales: Reliability, validity and HIV risk behavior. Journal of Personality Assessment, 65, 586-601.

Kalichman, S. C., & Rompa, D. (2001). The Sexual Compulsivity Scale: Further development and use with HIV positive persons. Journal of Personality Assessment, 76 379-395.

Kingston, D. A., Fedoroff, P., Firestone, P., Curry, S., & Bradford, J. M. (2008). Pornography use and sexual aggression: The impact of frequency and type of pornography use on recidivism among sexual offenders. Aggressive Behavior, 34, 341-351.

Krueger, R. B., & Kaplan, M. S. (2000). Disorders of sexual impulse control in neuropsychiatric conditions. Seminars in Clinical Neuropsychiatry, 5, 266-274.

McBride, K. R., Reece, M., & Sanders, S. (2008). Using the Sexual Compulsivity Scale to predict outcomes of sexual behavior in young adults. Sexual Addiction & Compulsivity, 15, 97-115.

McFarlane, M., Sheana, S., & Rietmeijer, C. (2000). The internet as a newly emerging risk environment for sexually transmitted diseases. Journal of the American Medical Association, 284, 443-446.

Miner, M. H., Coleman, E., Center, B. A., Ross, M., & Rosser, B. R. S. (2007). The Compulsive Sexual Behavior Inventory: Psychometric properties. Archives of Sexual Behavior, 36, 579-587.

Nelson, K. G., & Oehlert, M. E. (2008). Psychometric exploration of the Sexual Addiction Screening Test in veterans.Sexual Addiction & Compulsivity, 15, 39-58.

Raymond, N. C., Coleman, E., & Miner, M. H. (2003). Psychiatric comorbidity and compulsive/ impulsive traits in compulsive sexual behavior. Comprehensive Psychiatry, 44, 370-380.

Reid, R. C., Carpenter, B. N., & Lloyd, T. Q. (2009). Assessing psychological symptoms patterns of patients seeking help for hypersexual behavior. Sexual and Relationship Therapy, 24, 47-63.

Reid, R. C., Harper, J. M., & Anderson, E. H. (2009). Coping strategies used by hypersexual patients to defend against the painful effects of shame. Clinical Psychology and Psychotherapy, 16, 125-138.

____  Pornography (some examples include: Internet video, images and webcasts, magazines, DVDs/ videos, X-rated TV and films)

____  Sexual Behavior with Consenting Adults (direct contact)

         (some examples include: use of escort services, prostitutes,   repeated “one–night stands”, anonymous brief sexual encounters, repeated affairs, massage parlor visits that include sex.)

____  Cybersex activities (some examples include: Internet-related sexual talk, sexual behavior associated with web-cams, other ‘virtual’ sexual behaviors)

A.1 is a list of the seven typical Hypersexual Disorder behavioral specifiers.