Three Diagnoses for Problematic Hypersexuality; Which Criteria Predict Help-Seeking Behavior?

Initial development and validation of item banks to measure problematic hypersexuality

Background

Problematic Hypersexuality (PH) is defined as a distress caused by hypersexuality, to the extent that seeking treatment is considered. PH was previously measured with instruments stemming from different perspectives on problems related to hypersexuality. These instruments might best be analyzed in unison to discover the most optimal set of characteristics to measure PH.

Methods

A total of 58 items were investigated with Item Response Theory (IRT). We included 1211 participants (592 women, 618 men, 1 other) from a representative Dutch general population sample of 18 years or older. In addition, 371 participants (116 women, 253 men, 2 other) in a web-based survey who sought information on their current level of PH were included. This latter group was divided into those that did or did not consider treatment and group differences in item averages were assessed.

Results

After item selection, 26 out of 58 items were retained and divided in two scales: Emotion Dysregulation-PH - 9 items representing the distressing emotional patterns coinciding with hypersexual preoccupation - and Negative Effects-PH - 17 items representing the negative consequences of patterns of hypersexual thoughts and behavior. Assumptions for IRT analyses were met (unidimensionality, local independence and monotonicity). After an IRT graded response model was fit, the scales showed sufficient reliability for the target population of hypersexual individuals. In the general population the scales showed large floor effects and were less reliable.

Conclusions

With this study a first step is taken in validating two complementary item banks to measure PH. Further development of the item banks should include the investigation of responsiveness. New items should be constructed to assess less-explored areas of PH and improve differentiating power of the scales. This study showed that diagnostic accuracy for PH is currently difficult to attain with a survey, even when using an extended item set representing the most unique characteristics of PH.

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 Structure of Compulsive Sexual Behavior: A Network Analysis Study

Compulsive sexual behavior is a phenomenon characterized by a persistent failure to control intense, repetitive sexual impulses or urges, resulting in repetitive sexual behavior that causes marked distress or impairment in personal, familial, social, educational, or occupational areas of functioning. Despite its major impact on mental health and quality of life, little is known about its internal structure and whether this phenomenon differs across genders, age groups, and risk status. By considering a large online sample (n = 3186; 68.3% males), ranging from 14 to 64 years old, compulsive sexual behavior was explored by means of network analysis. State-of-the-art analytical techniques were adopted to investigate the pattern of association among the different elements of compulsive sexual behavior, identify possible communities of nodes, pinpoint the most central nodes, and detect differences between males and females, among different age groups, as well as between individuals at low and high risk of developing a full-blown disorder. The analyses revealed that the network was characterized by three communities, namely Consequence, Preoccupation, and Perceived Dyscontrol, and that the most central node was related to (perceived) impulse dyscontrol. No substantial differences were found between males and females and across age. Failing to meet one's own commitments and responsibilities was more central in individuals at high risk of developing a full-blown disorder than in those at low risk.

Three Quarks for Hypersexuality Research

In some areas of sex research, we note room for methodological improvement of research practices. In particular, in the field of hypersexuality research, where societal norms have been influential, methodological improvement might advance goals of objectivity in research. We propose that hypersexuality research should: firstly, take into account relevant subpopulations; secondly, use Item Response Theory (IRT) to construct item banks for measurement instruments; and, thirdly, measure sexual desire and related important constructs where and how they play out—in daily life, changing from moment to moment. We show that comparing relevant subpopulations can lead to depathologizing normative, but highly frequent, sexual behavior. Using IRT can lead to more precise measurement instruments by assessment of characteristics of individual items. Measuring sexual desire as an inherently fluctuating process in everyday life, and as part of emotion regulation processes, can direct research towards relevant associations other research methods might miss. Bringing into practice our three proposals for improvement can procure a number of advantages. We illustrate these advantages mainly for the field of hypersexuality research, but our suggestions might also be beneficial for sex research in general.

Associations between Fluctuating Shame, Self-Esteem, and Sexual Desire: Comparing Frequent Porn Users and a General Population Sample

In the present study, we explore the proposed cyclic models for problematic hypersexuality (PH) that involve shame, self-esteem, and sexual desire. These cyclic models are characterized by temporal associations but have not been investigated previously with intensive longitudinal designs. In this study, we collected up to 70 measurements per participant within a period of seven consecutive days, which allowed us to investigate associations between fluctuations of shame, self-esteem, and sexual desire. Participants were divided in four subgroups: (1) women (n = 87); (2) men (n = 46) from a general population convenience sample; (3) men watching porn >2 times per week, showing non-problematic hypersexuality (NH; n = 10); and (4) men watching porn >2 times per week, experiencing PH (n = 11). Multilevel analyses, including cross-level interactions, were used to investigate between-group differences in intraindividual processes. Results showed that prior increases in shame forecasted higher current sexual desire for men with PH, but not for the other groups, suggesting that men with PH use sexual desire to downregulate dysphoric feelings of shame. Differences between groups in associations between self-esteem and sexual desire were also found. Based on our results, we propose the Split Pleasure/Shame model, which represents emotion dysregulation in PH, and juxtapose this with the pleasurable experience of sex by non-PH groups. Further intensive longitudinal research is necessary to test this model and, more generally, to investigate the fluctuating nature of sexual desire.

Exploring Hypersexuality Pathways From Eye Movements: The Role of (Sexual) Impulsivity

BACKGROUND

Impulsivity is regarded as a key factor underpinning hypersexuality like-conditions. However, impulsivity is a multifaceted construct, and existing research has not been capturing such complexity, which includes the effects of domain-general and domain-specific impulsivity in hypersexuality.

AIM

The aim of this study was to test the predictive role of specific impulsivity domains, ie, domain-general and domain-specific, in hypersexuality and its associated consequences.

METHODS

Fifty-five men and 58 women went through an emotional Go/-no-Go task (including sexual, high-valence positive, and neutral pictures), aimed at capturing domain-general and domain-specific impulsivity. Ocular metrics were further considered in order to increase the validity of the experimental task, and provide a metric of attention capturing. The study was carried out in a community sample.

OUTCOMES

Self-reported (general)impulsivity and commission errors toward high-valence positive and sexual pictures (signaling domain-general and domain-specific impulsivity, respectively) were settled as independent variables, along with Time to First Fixation to stimuli, capturing early/uncontrolled attention. Scores on hypersexuality and negative consequences emerging from hypersexual behavior were settled as outcome variables.

RESULTS

Self-reported (general)impulsivity was the only predictor of hypersexuality scores, while negative consequences were best accounted by higher fixation time to sexual pictures. In all, findings did not support the role of domain-specific impulsivity (ie, sexual impulsivity) in hypersexuality.

CLINICAL TRANSLATION

Findings tentatively suggest that hypersexuality, as captured at the community level, may be best positioned within the general spectrum of psychopathology, thus influencing educational and clinical intervention protocols aimed at addressing hypersexuality related complaints. Protocols would be expected to primarily target general psychopathology phenomena, rather than specific sexual aspects.

STRENGTHS & LIMITATIONS

This study implemented an innovative approach to capture different impulsivity domains, thus adding to previous literature in the field. However, the current study precludes the generalization of findings to clinical samples, where psychological comorbidities are expected to impact results. Further, findings must be read with caution given to limited effect sizes.

CONCLUSION

While hypersexuality was related to self-reported (general) impulsivity, findings on the negative consequences associated with hypersexual behavior mirrored response patterns found in depression. Such evidence aligns with the assumption that hypersexuality related phenomena might be better positioned in the psychopathology domain, rather than simply framed as a specific sexual problem. Carvalho J, Rosa PJ, Štulhofer A. Exploring Hypersexuality Pathways From Eye Movements: The Role of (Sexual) Impulsivity. J Sex Med 2021;18:1607-1614.