Hypersexuality: Equifinal, Cohesive, Clinical Presentation or Symptom Cluster with Multiple Underlying Mechanisms?

The Structure of Hypersexuality and Its Relation to Impulsivity

Among the multiple controversies surrounding hypersexuality is the important issue of whether it constitutes a univocal construct. Although an initial study supported its homogeneity, more resent research has identified two separate subcomponents-problematic sexuality and sexual drive. The present survey study addressed this issue in a sample that included both in-person tested college students (n = 69) and online respondents (n = 339). A factor analysis of scales attempting to capture the indicators of each subcomponent of hypersexuality yielded two correlated, but separate factors. Whereas Problematic Sexuality (PS) comprised scales measuring sexual compulsivity, using sex as a coping mechanism, and the negative consequences of sexual behavior, Sexual Drive (SD) was defined by frequent sexual activity, preoccupation with sexual fantasies, a predilection for impersonal sexual behavior, and facile sexual arousal. These two subcomponents of hypersexuality were found to covary with different types of impulsivity, further supporting their discrimination and providing external validation for their differentiation. Contrary to a priori hypotheses, however, PS correlated highly with Callous/Manipulative/Risk-Taking as well as with a predicted Affective Instability/Behavioral Disinhibition factor, suggesting that PS may constitute an equifinality of separate developmental trajectories for those high on both subtypes of hypersexuality.

The World Federation of Societies of Biological Psychiatry guidelines on the assessment and pharmacological treatment of compulsive sexual behaviour disorder

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.

Perspective: Can psychedelic-assisted therapy be a promising aid in compulsive sexual behavior disorder treatment?

Recently, there has been an increase in studies yielding evidence for psychedelics' anxiolytic and anti-depressive qualities. Preliminary evidence for treatment in substance addiction is also available. In our manuscript, we present a perspective on the possible effectiveness and mechanisms of action of psychedelics' introduction in the treatment of Compulsive Sexual Behavior Disorder (CSBD) and other p roblematic sexual behaviors, which are considered representative of the so-called "behavioral addiction" category. Evidence for the efficacy of Mindfulness Based Interventions in CSBD treatment is promising. Psychedelics- and mindfulness-induced states share common characteristics on both a subjective and objective level. One of the proposed mechanisms regards reduction of experiential avoidance through the promotion of exposure and acceptance. On the neurophysiological level, a shift from higher- to lower-level association regions and an impact on 5- HT2A receptors is observed. Elaborated mechanisms explain the possible enhancement of therapeutic processes by psychedelics. Psychedelics' relative safety and low addictive potential support their introduction into traditional forms of therapy for CSBD and other out of control behaviors.

The Covariation of Sexual Fantasies and Behaviors Among Self-Identified Sexually Aggressive Criminal and Noncriminal Samples

This study examined the association of sexually appetitive fantasies and sexually coercive behaviors among adult men convicted of nonsexual crimes (n = 159) and adult men with no criminal histories (n = 219). Individuals completed the Multidimensional Assessment of Sex and Aggression (MASA) and, on the basis of these reports, were classified whether or not they had ever attempted to assault or coerce someone sexually. Consistent with fewer opportunities to engage in sexual behavior, individuals with criminal histories reported generally less preoccupation, compulsivity, and frequency than did noncriminal individuals. Regardless of criminal history, self-identified sexually coercive men reported significantly more sexually appetitive fantasy and behavior in general and sexually deviant behavior in particular than did noncoercive males. Implications of these findings for research, theory, and dispositional decisions are discussed.

Psychometric Properties of Common Measures of Hypersexuality in an Online Canadian Sample

BACKGROUND

Hypersexuality has been posited as the central defining feature of Compulsive Sexual Behavior Disorder, and although the acceptance and inclusion of this construct in psychiatric nosologies provides some legitimacy, concerns surrounding terminology, assessment, and diagnosis remain.

AIM

The present study was an independent psychometric examination of 2 of the most commonly used measures of Compulsive Sexual Behavior Disorder; specifically, the gender invariance of the latent structure, reliability (test retest, internal consistency), and external correlates (concurrent validity) of these measures.

METHODS

The Sexual Compulsivity Scale and the Hypersexual Behavior Inventory were completed by 2 nonclinical online community samples of cisgender women (ns = 525 and 359), cisgender men (ns = 419 and 364), and transgender or non-binary individuals (ns = 38 and 11).

OUTCOMES

Criterion based measures of sexual history and total sexual outlet (number of orgasms per week) were gathered to validate Sexual Compulsivity Scale and Hypersexual Behavior Inventory total and factor scores.

RESULTS

Results supported the factorial validity of both assessment measures: correlated 3 factor solutions were established through exploratory factor analysis of 1 sample, and confirmatory factor analysis in the second sample. Multiple group confirmatory factor analysis, conducted on the 2 combined samples, also supported the gender invariance of the 3-factor solutions. Additional basic psychometric indices of test-retest and internal consistency reliability and criterion-related (concurrent) validity conducted across the 2 online samples were supported.

CLINICAL IMPLICATIONS

Common measures of hypersexuality have potential for use in its assessment, treatment, and management.

STRENGTHS & LIMITATIONS

Study strengths include: the inclusion of 2 fairly large and diverse online samples, thorough checks for insufficient effort/validity of responding, validity and reliability methodology (ie, measurement at multiple time points, obtaining behavioral indicators of sexual health), and a comprehensive set of psychometric analyses to inform conclusions regarding the external validity, reliability, and latent structure of hypersexuality measures across gender groups. Study limitations include: potential concerns related to validity and accuracy of responding owing to a reliance on self-report, the potential for selection bias, and limiting the examination of the latent structure of hypersexuality to cisgender men and women such that the results may not generalize to gender diverse populations.

CONCLUSION

Hypersexuality is a multidimensional construct, with a common latent structure among cisgender men and women, consistency in measurement over time, and meaningful concurrent associations with behavioral criteria that have relevance for sexual health. Olver ME, Kingston DA, Laverty EK, et al. Psychometric Properties of Common Measures of Hypersexuality in an Online Canadian Sample. J Sex Med 2022;19:331-346.

The Structure, Covariates, and Etiology of Hypersexuality: Implications for Sexual Offending

PURPOSE OF REVIEW

A substantial increase in research on the structure, covariates, and etiology of hypersexuality has emerged during the last decade. It is the goal of this review to summarize and integrate this research and to indicate some practical implications for clinical and forensic practice, especially as applied to those who have sexually offended.

RECENT FINDINGS

Studies from the last half-decade converge on the conclusion that hypersexuality has both problematic and high sexual drive components. Both aspects have consistently been found to be distributed dimensionally and not categorically. Each subdimension covaries differentially with specific types of impulsivity. In addition to sexual abuse, psychological or emotional abuse has emerged to be a potent developmental antecedent of hypersexuality. Current research has focused on the problematic dimension of hypersexuality and has neglected to specify the criteria for high sexual drive. Lacking are large-scale representative and clinical samples that provide determination of optimal cutoffs for treatment and dispositional decisions for both dimensions of hypersexuality. Research on the etiology of both aspects of hypersexuality is in its infancy, and more differentiated assessments of developmental abuse histories are required.

Offence-Supportive Cognitions, Atypical Sexuality, Problematic Self-Regulation, and Perceived Anonymity Among Online and Contact Sexual Offenders Against Children

Cognitions that support sexual offending, atypical sexuality, and problems with self-regulation are important indicators of offending among men who engage in contact sexual offences against children (e.g., Hanson & Morton-Bourgon, 2005). While sexual interest in children-a major indicator of atypical sexuality-has been identified as a risk factor for online sexual offending against children (Seto & Eke, 2015), several other indicators, such as offence-supportive cognitions, sexual preoccupation, sexual coping, and perceived anonymity-a presumed risk factor for online sexual offending-have not yet been investigated among men who use the internet to solicit children or to consume child sexual exploitation material. This study investigated the associations between offence-supportive cognitions, atypical sexuality, self-regulation using sex, and perceived anonymity with sexual offending behaviors against children in a sample of 241 men convicted of various sexual and non-sexual offences. Results from logistic regressions show that offence-supportive cognitions, sexual interests in children, and sexual coping, but not sexual preoccupation and perceived anonymity, are associated with either or both online and contact sexual offending behaviors against children. Our results support the prior finding showing that men with online sexual offences are more paraphilic or sexually preoccupied then men with only contact offences against children. They also suggest that offence-supportive cognitions, atypical sexual interests, and sexual coping may be motivating factors, and therefore relevant risk factors, for online sexual offending against children.

What should be included in the criteria for compulsive sexual behavior disorder?

Compulsive sexual behavior disorder (CSBD) is currently defined in the eleventh revision of the International Classification of Diseases (ICD-11) as an impulse control disorder. Criteria for hypersexual disorder (HD) had been proposed in 2010 for the fifth revision of Diagnostic and Statistical Manual (DSM-5). In this article, we compare differences between HD and CSBD and discuss their relevance.Significant differences between HD and CSBD criteria include: (1) the role of sexual behavior as a maladaptive coping and emotion regulation strategy listed in criteria for HD but not in those for CSBD; (2) different exclusionary criteria including bipolar and substance use disorders in HD but not in CSBD, and (3) inclusion of new considerations in CSBD, such as moral incongruence (as an exclusion criterion), and diminished pleasure from sexual activity. Each of these aspects has clinical and research-related implications. The inclusion of CSBD in the ICD-11 will have a significant impact on clinical practice and research. Researchers should continue to investigate core and related features of CSBD, inlcuding those not included in the current criteria, in order to provide additional insight into the disorder and to help promote clinical advances.

The Relation of Childhood Abuse Experiences to Problematic Sexual Behaviors in Male Youths Who Have Sexually Offended

Psychological abuse and sexual abuse, either alone or in combination, have been implicated as developmental antecedents of problematic sexual thoughts and behaviors in studies of sexually aggressive males (Jesperson, Lalumière, & Seto, 2009; Knight & Sims-Knight, 2011; Levenson & Grady, 2016; Seto & Lalumière, 2010). Recently, psychological abuse perpetrated by a male caregiver has emerged as strongly associated with subsequent hypersexuality in adult males who had sexually offended. In a study of 529 adult male sexual offenders, Kingston, Graham, and Knight (2017) found that male caregiver psychological abuse was the most prominent correlate of hypersexual thoughts and behaviors in adulthood, above and beyond the effects of other abuse types, such as physical abuse and sexual abuse. Consequently, we hypothesized that, among juveniles who had sexually offended, higher self-reported levels of childhood psychological and sexual abuse, in contrast to other types of childhood maltreatment experiences, would covary with higher subsequent levels of normophilic sexualized thoughts and behaviors. Consistent with Kingston et al., Male Caregiver Psychological Abuse accounted for a significant amount of the variance in subsequent reported hypersexuality in this juvenile sample. Furthermore, this factor also emerged as a significant correlate of deviant sexual behaviors and fantasies, such as paraphilic interests and pedophilic preference. Sexual Abuse was also found to be significantly associated with hypersexuality. These findings provide additional support for the demonstrated relation between psychological abuse by a male caregiver and subsequent problematic sexual thoughts and behaviors. These data are also consistent with other research that suggests a gender symmetry effect in the impact of parental discipline and the differential effect of male caregiver abuse on male children.

Hypersexual Behavior as a Symptom of PTSD: Using Cognitive Processing Therapy in a Veteran with Military Sexual Trauma-Related PTSD

Hypersexual behavior is a construct that is well recognized yet vaguely conceptualized, leading to some arguments that it may be comprised of multiple etiologies. Childhood sexual abuse is often acknowledged as a common experience among those with sexually addictive behaviors, yet the intersection between PTSD and sexual addiction has not been fully explored. This case illustrates the use of Cognitive Processing Therapy, an empirically supported treatment for PTSD, as a means to treat both PTSD symptoms and hypersexual behaviors in a veteran who had experienced military sexual trauma. Treatment led to a meaningful decrease in both types of symptoms, even in the absence of a structured treatment approach for sexual addiction. It is argued that differential diagnosis, including functional analysis of hypersexual behaviors, is crucial in treatment planning. Further, attention to trauma and PTSD is important in veterans and others for whom PTSD is part of the etiology of hypersexual behavior; trauma-focused CBT therapies can provide a useful treatment approach in these cases.

Taxometric Analysis of the Latent Structure of Pedophilic Interest

The present study examined the latent structure of pedophilic interest. Using data from phallometric tests for pedophilic interest across four samples of offenders (ns = 805, 632, 531, 261), taxometric analyses were conducted to identify whether pedophilic interest is best characterized as taxonic or dimensional. Across the samples, the majority of analyses supported taxonic latent structure in pedophilic interest. Visual inspection of taxometric curves indicated trichotomous latent structure (i.e., three-ordered classes) may characterize pedophilic interest in these samples. In a second step of taxometric analysis, the results supported trichotomous latent structure, indicating the presence of a complement taxon and two pedophilic taxa. In comparison with the complement taxon, the men in the first pedophilic taxon were non-exclusively pedophilic and had similar rates of sexual recidivism and sexual compulsivity. The men in the second pedophilic taxon were exclusively pedophilic, had more child victims and total victims, sexually re-offended at a higher rate, and were more sexually compulsive. The finding of trichotomous latent structure in pedophilic interest is both consistent and inconsistent with previous taxometric studies and has implications for research, assessment, and treatment of pedophilic interest.