Evaluation and Treatment of Hypersexual and Other Sexual Dysfunctions

A. Over a period of at least 6 months, recurrent and intense sexual fantasies, sexual urges, and sexual behavior in association with four or more of the following five criteria:

1. Excessive time is consumed by sexual fantasies and urges and by planning for and engaging in sexual behavior

2. Repetitively engaging in these sexual fantasies, urges, and behavior in response to dysphoric mood states (e.g., anxiety, depression, boredom, and irritability)

3. Repetitively engaging in sexual fantasies, urges, and behavior in response to stressful life events

4. Repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, and behavior

5. Repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others

B. There is clinically significant personal distress or impairment in social, occupational, or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges, and behavior

C. These sexual fantasies, urges, and behavior are not due to direct physiological effects of exogenous substances (e.g., drugs of abuse or medications), a co-occurring general medical condition, or to manic episodes

D. The person is at least 18 years of age

Specify if masturbation, pornography, sexual behavior with consenting adults, cybersex, telephone sex, and strip clubs

[Reprinted from Reid RC, Carpenter BN, Hook JN, Garos S, Manning JC, Gilliland R, Cooper EB, McKittrick H, Davtian M, Fong T. Report of findings in a DSM-5 field trial for hypersexual disorder. J Sex Med. 2012;9(11):2868–77. with permission from Elsevier].

Subtypes of Hypersexual Disorder

Using the criteria proposed by Kafka for the DSM-5 [18], Kaplan and Krueger described in the details the subtypes of hypersexual disorders [19].

1.

Masturbation: The rates of excessive masturbation within hypersexual disorder range from 50 to 75% according to a number of studies [20–22].
2.

Pornography: Research studies show that 50–60% of patients with hypersexual disorder are dependent on pornography [20, 23].
3.

Sexual behavior with consenting adults: This behavior involved significant promiscuity, which ranges from 24 to 84% in men. Reid et al., in 2009, showed that 7% of a treatment-seeking male sample solicited sex workers regularly, 12% had unprotected multiple anonymous sex, and 21% had extramarital affairs [23].
4.

Cybersex: This behavior is defined as having online sexual conversations in chat rooms or text-messaging applications (“sexting”). Despite its provision of privacy and health protection sounding involvement, it is very clear that hypersexual behaviors encompassing excessive use, time spent, and associated dysfunctional behaviors are leading to significant impairments of social, occupational, and relationship functioning [24]. The exact prevalence of these behaviors is still understudy.
5.

Telephone sex: Studies from the late 1990s showed that about 37% of males struggling with hypersexual behaviors had excessive telephone sex [20]. However, in light of technological advancement of the Internet, telephone sex seems to be on the decline.
6.

Strip clubs: Many patients who are suffering from hypersexual behaviors report frequent dependence on strip clubs and their associated financial cost, excessive alcohol use, shame, and guilt. However, there is very little research in this area.

Best Practice and Evidence-Based Approach to Evaluation

The evaluation of hypersexual disorder includes three crucial components :

(a)

A thorough medical evaluation to rule out any potential medical, endocrinal/hormonal, and neurological causes of the behaviors.
(b)

A thorough evaluation of the effects of any substances (prescribed, over the counter, dietary supplements, herbs, or street drugs).
(c)

The impact on functioning. The negative impact of hypersexual disorder on functioning was described by Reid et al. [18] using data from the field trials of the DSM-5 proposed criteria, as depicted in Table 24-2.

Table 24-2.

Consequences associated among patients with hypersexual disorder

Has happened several times, %	Has happened once or twice, %	Hypersexual behavior consequences scale (sample items from the HBCS)
1.6	15.7	Caused job loss
16.5	22.8	Ended a romantic relationship
5.5	22.0	Contracted a sexually transmitted infection
0.8	16.5	Caused legal problems
29.1	23.6	Experienced unwanted financial losses
67.7	22.0	Emotionally hurt a loved one
66.9	11.0	Interfered with ability to experience healthy sex
73.2	20.5	Negatively affected mental health

Missing data reduced this sample from n = 138 to n = 127.

[Reprinted from Reid RC, Carpenter BN, Hook JN, Garos S, Manning JC, Gilliland R, Cooper EB, McKittrick H, Davtian M, Fong T. Report of findings in a DSM-5 field trial for hypersexual disorder, J Sex Med. 2012; 9(11):2868–77. with permission from Elsevier].

It is also important to utilize measurement instruments during the evaluation and treatment of hypersexual disorders. The literature reports at least 22 questionnaires to measure hypersexual behavior [25, 26]. Table 24-3 displays the three most utilized rating scales.

Table 24-3.

Rating scales for hypersexual disorder

Rating scale, author (Reference)	Description/items	Psychometric properties	Sample item
The sexual compulsivity scale [27]	Ten items rated on a four-point Likert scale from 1=“Not at all like me” to 4=“Very much like me”	Internal consistency Cronbach’s α = 0.84. Test-retest reliability = 0.73	“I feel that sexual thoughts and feelings are stronger than I am”
Hypersexual behavior inventory [28]	19 items using a five-point Likert scale to obtain a total score and measure three factors: control, coping, and consequences	Internal consistency Cronbach’s α: total score = 0.90, control = 0.78 coping = 0.86, and consequences = 0.78	“My sexual behavior controls my life”
The hypersexual disorder screening inventory [29]	7 items scored from 0 = “Never true” to 4 = “Almost always true”. The items are divided to 2 sections: Recurrent and intense sexual fantasies, urges and behaviors; Distress and impairment During the last 6 months	Internal consistency Cronbach’s α: = 0.88	“I have tried to reduce or control the frequency of sexual fantasies, urges, and behavior but I have not been very successful”

Best Practice and Evidence-Based Approaches to Treatment

The field still has yet to define and approve clinical and/or research diagnostic criteria that could pave the road for empirical research and establish solid evidence for specific interventions. For the time being, a biopsychosocial approach will need to be followed in order to help patients with hypersexual disorder reduce/eliminate the effects of biological and psychosocial factors that might have predisposed, precipitated, or perpetuated the symptoms. This approach should encompass biological interventions to address the effects of medical contributing factors and the effects of substances, as well as psychosocial interventions to address not only the effects of psychiatric disorders and traumas/losses but also the results of the behaviors which commonly worsen patients’ suffering. Guilt and shame about hypersexual behaviors coupled with loss of control/ability to stop, despite commitments to abstinence, not uncommonly lead to hopelessness and helplessness with or without full-blown depressive symptoms. The behaviors themselves end up by providing transient mood elevations and respite from self-deprecation and facing one’s reality of mounting social, occupational, and financial complications.

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