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VSOTAConference

March20
th
,2014

HYPERSEXUALITYANDHYPERSEXUAL

DISORDER:

AGUIDEFORCLINICIANS
MartinKafkaMD
ClinicalAssociateProfessor
DepartmentofPsychiatry
HarvardMedicalSchool
mpkafka@rcn.com
Disclaimer
Thecontentofthispresentationwillpromote

qualityand/orimprovementsinhealthcare

andwillnotpromoteaproprietarybusinessor

commercialinterest.Thecontentofthis

presentationwillbewellbalanced,evidence

basedandunbiased.
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Cingulate cortex
Para-olfactory
area
Hypothalamus
Uncus
Amygdala
Para-hippocampal
gyrus
Hippocampus
Mamillary bodies of
hypothalamus
Fornix
Thalamus
Anterior nucleus of
thalamus
Orbitofrontal cortex
Corpus callosum
Medial
Prefrontal
cortex
HumanSexualDesire
The presence of sexual fantasies, urges or
behaviors accompanied by the subjective
conscious motivation to engage in sexual
behavior in response to relevant internal
or external social cues.
Lieblum, 1988; American Psychiatric Association, 1994; Everaerd, 2001; Levine 2002
GenderandtheBrain
Thesexhormones,especiallytestosterone

andestrogenareassociatedwithdistinct

patternsofbothbraindifferentiationand

sexualbehavioraldifferencesinmenand

women
Fetalbrainismasculinized bytestosterone
Testosteroneinmammalianbrainstructurallyaffects

limbicforebrainandprefrontalcortex
Postpubertalmalesareblessed/cursedwithtentimesas

muchtestosteroneasfemales
Testosterone
Adultfemaleshaveonetenththeamountofcirculating

testosterone(thesameamountasaprepubertalmale)
Decreasesinserumtestosteroneareassociatedwithfemalesexual

dysfunction,especiallydiminishedsexualdesireandarousal
Athresholdeffectfortestosteronetoestablishandmaintainsexual

motivation,arousalandperformanceispresentinbothmalesand

females
Inmales,exceptforextremevalues,moretestosteroneisnot

directlyassociatedwithgreatersexualarousalorbehavior

SexualoffenderstypicallydoNOThaveabnormaltestosterone

levels
Hypothalamus Pituitary
Hypothalamusandtestosterone
Whatisanormalsexualappetite

in

males
KinseyandTotalSexualOutletinmales
Genderdifferencesandsexual

behavior
Adultmalesreport:
moresexualfantasies
morediversesexualfantasies
initiatesexualbehaviormorefrequently
masturbatemorefrequently
reportmorelifetimepartnersthanadultfemales
morereadilysexuallyarousedbyvisualstimuli
moresexualdeviancy
Femalesexualarousalismorecontextually

dependent
Oliver,1993;Baumeister,2000
Sexualimpulsivityandgender
ParaphilicDisordersarealmostexclusively

malegenderdisorders
HypersexualDisordersaremarkedlyand

predominantlymalegenderdisorders
Exceptions(butstillpredominantlymale)
Sexualmasochism
Protractedpromiscuity,compulsivemasturbation
DSM5ParaphilicDisordertemplate
Duration:6monthsormore
Sexualdesire:
Recurrentandintensesexualarousal
Anomalousobjectofdesire
Manifestedasfantasies,urgesorbehaviors
Distress/impairmentmustbepresent
Paraphiliavs.ParaphilicDisorder
NewtoDSM5
CourseSpecifiers
Inacontrolledenvironment
i.e.institutionalsetting
Inremission
Nodistressorimpairmentinsocialfunctioningforat

least5yearswhileinanuncontrolledenvironment
DSM5ParaphilicDisorders
PedophilicDisorder
SexualSadismDisorder
SexualMasochismDisorder
TransvesticDisorder
VoyeuristicDisorder
FrotteuristicDisorder
ExhibitionisticDisorder
FetishisticDisorder
OtherSpecifiedParaphilicDisorder
OtherUnspecifiedParaphilicDisorder
HistoricalPrecursorsofHypersexualityand

HypersexualDisorder
Excessivesexualbehaviors

withadverse

consequences
BenjaminRush(17451813)
R.vonKrafftEbbing(19401902)
H.Ellis(18591939)
M.Hirshfeld(18681935)
DSMManuals:DonJuanism,satyriasis,

nymphomaniaandnonparaphilicsexual

addiction
Epidemiologyofhypersexuality
Hypersexualityandsexualoffending
RayKnight:Assessmentsoftheproclivityforsexualaggression
MultidimensionalAssessmentofSexandAggression(MASA;1994,1999)
Administeredtoover3000individuals
candiscriminatesexuallydeviantsamplefromcontrols(Zakireh,

RonisandKnight2008)
Demonstrateddimensionalhypersexualityassociatedwith
rape(Knight2003,2004)and
childmolestation(DaversaandKnight,2007)
Developedanempiricallyderivedscalesforsexualization,including

hypersexuality
Hypersexualityandsexualoffending
MultidimensionalInventoryofDevelopment,SexandAggression

(MIDSA;Knight,2008)
SexualizationandHypersexualityScales(derivedfromMASA)
Appliedin2largesamples(Walters,KnightandLangstom,2011)
Langstromsepidemiologialsample(5250menandwomen)
and716malesexoffenderstodemonstratethelatentdimensional

natureof

hypersexuality
Cautionedaboutneedformoreresearchtodelineateacategoricaldiagnosis

fromadimensionalcontinuousvariable
ManyDSMdiagnosesaredimensional,includingparaphilias,attention

deficithyperactivitydisorderandpersonalitydisorders
Fromdimensionalhypersexualityto

HypersexualDisorder
Constructinganewpsychiatricdisorder
Constructinganewdiagnosis:

HypersexualDisorder
Derivedfromextensiveliteraturereview(Kafka2010)
Findingcommonfactorsamongstratingscales

whosereliabilityandvalidityhavebeenpublished

andtestedinmultiplesamples
SexualCompulsivityScale(Kalichman1995,2001)
SexualAddictionScale(Carnes1989,Nelson2008)
CompulsiveSexualBehaviorInventory(Coleman2001,2007)
SexualInhibition/SexualExcitationScales(Bancroft1999,2003,2004)
HYPERSEXUALDISORDER(HD)
A.

Atleastsixmonths,recurrentandintensesexual

fantasies,sexualurges,andsexualbehaviorinassociation

withfourormore:
(1)excessivetimeconsumed
Repetitivelyengaginginsexualbehaviorinresponseto:
(2)dysphoricmoodstates(e.g.,anxiety,depression,boredom,irritability).
(3)

stressfullifeevents.
(4)

Repetitive,unsuccessfuleffortstocontrolor

significantlyreducesexualbehavior.
(5)

Disregardingtheriskforphysicaloremotionalharmto

selforothers.
ReprintedwithpermissionfromtheAmericanPsychiatricAssociation.All

RightsReserved.
HYPERSEXUALDISORDER
B.

Clinicallysignificantpersonaldistressor

impairmentinimportantareasoffunctioning
C.

notduetodirectphysiologicaleffectsof

exogenoussubstances(e.g.,drugsofabuseor

medications),acooccurringmedicalconditionor

toManicEpisodes.
D.

Thepersonisatleast18yearsofage.
ReprintedwithpermissionfromtheAmericanPsychiatricAssociation.AllRights

Reserved2013
HYPERSEXUALDISORDER:

behavioralspecifiers
Masturbation
Pornography
SexualBehaviorWithConsentingAdults
Cybersex
TelephoneSex
AdultEntertainmentVenues/Clubs
Other:
ReprintedwithpermissionfromtheAmericanPsychiatricAssociation.AllRightsReserved

2013
Whatabouthypersexualdisorderandsexual

offending?
Insampleof220consecutivelyassessedmales111(50.4%)were

paraphilicsexualoffenders.
Exhibitionism

(n=57)

51.8%
Voyeurism

(n=34)

30.9%
Pedophilia

(n=32)

29.0%
Thelifetimeprevalenceofparaphiliarelateddisordersintheoffender

groupwas:
Compulsivemasturbation(n=75)

67.5%
Pornographydependence(n=47)

42.3%
Protractedpromiscuity(n=36)

32.4%
Phonesexdependence(n=7)

6.3%
LifetimePRDsareprevalentinmalesexualoffenders
(n=220:Kafka,1997,2003,2003)Briken2006
DSM5FieldTrialdata:

SexualoffendersandHD
Clinicalsamplesofhypersexual

disorder
Malesaremarkedlypredominant
45:1ratio??
Myclinicalpractice35/14002.5%arefemale
Femalesmorelikelytohavebeensexuallyabused
Ageofonset

adolescence
Ageofhelpseeking

mid30s

early40s


MultipleHDbehaviorsarecommon
simultaneous,serially
HDincidenceinmenwithPAand/or

HD
masturbation,promiscuity,pornography
(Kafka,1997)n=100
masturbation,pornography,promiscuity
(Kafka,2002)n=120
pornography(76%),masturbation(71%),

promiscuity(51%)
(Kafka,2014unpub)n=150,Reidetal2012
IsHypersexualDisorderabehavioral

addiction?
GamblingDisorder HypersexualDisorder
preoccupation preoccupation
tolerance inadequateempiricalbutpresent
withdrawal inadequateempirical,likelypresent
lossofcontrol lossofcontrol
responsetodysphoricaffect responsetodysphoricaffectandevents
1yearormore 6monthsormore
significantadverseconsequences
Maniaexcluded
significantadverseconsequences
Maniaexcluded
Lying Notincludedincriteriabutwho

wouldnt?
Masturbation
primarysexualoutletevenduringastableintimate

relationship
atleastonce/day
Maystartofforendnearlyeveryday
sometimesatwork
Maybeassociatedwithselfabrasionorinjury
Commonlycoassociatedwithothernonpartnered

HDbehaviors
Associatedwiththeleast distress

butcanbetime

consuming
AdultPornography
25%33%ofinternetsiteshavesexuallyrelated

content
4%classifiedaspornography
>2.5millionwebsites
Websites,filesharing,Usenetgroups
NewmaterialsEVERYDAY
malesprefervisualporn,thesexact
womenpreferromanceanderoticfiction

dominanceandsubmissionthemes
Pornographyspamadsmayfloodtheuserandalert

aspouseorpartner
OgasandGaddam,2011
(Child)pornography
BIGPROBLEM:
MENFINDPOSTPUBESCENTFEMALESHIGHLYSEXUALLY

AROUSING
Imagesofminors

belowage18
Possessionofand/ortransmissionofchildoradolescent

pornographyimages
Stateoffense

adjudicationmorevariable
Federaloffense
minimum5yearprisonsentence.
Childpornimagesmaybetagged

foreasier

recognitionbylawenforcement
(Child)pornography
USAisalargeconsumerofchildporn
Since2003,depictingmoreviolence/rape
adultpornography
escalationtoview/receivechildandadolescent

images
FTP:purposeful/inadvertentdissemination
(Child)pornography
Manymaleswhopossesschildpornarenotclassicalpedophiles
mosthavenopriorcriminalhistory
manymarried,middleclass,morehighlyeducated
1in8havehandsonvictims(Seto,Hansenetal.2011)
somemeetcriteriaforpedophiliabasedsolelyonviewinghistory
verylowrecidivismrateunless:
pedophilicfixation
priorhandsonvictims
antisocialpersonality
Sexualbehaviorwithconsenting

adults
A persistentpatternofsexualconquests
Caninclude onenightstands repetitiveuseof

prostitutes,escortservices, massageparlors ,

cruising ,repetitivebrieforlengthyaffairs,serial

polygamy,swinging,etc.
HookupsviatheInternetbecomingmorecommon
Grindr,Tinder,GetPure
findsexualpartnersquickly,safelyandwithout

commitment".
Sexualbehaviorwithconsenting

adults
Cybersex
Internetrelatedsexuallyoriented chatrooms ,messageboards,

webcams,instantmeetups,avatars
specificallyforsexualarousalandactivity,including

solicitation
Thisdoes

not

includevisualpornographyspecifier
Personsmayeithertalk,planormeetforsexor dosex
whileonline
Falseidentitiesarecommoninsexchatrooms
Stingoperations
Somecanbevictimizedandblackmailed
Malesmeetingmalesthroughcybersexmorelikelytohave

hadSTDsandprotractedpromiscuity(McFarlaneetal2000)
ClinicalAssessment
ClinicalAssessment
IFYouDONTASK

TheyDONTTELL!!
1.Haveyoueverhadpersistentorrepetitive

problemscontrollingyoursexualbehavior?
2.Hasyoursexualbehaviorevercausedyou

significantpersonaldistressorcausedsignificant

consequences
Medical
Interpersonal/pairbond
Legal
Workassociatedimpairment
ClinicalAssessment
3.Haveyoueverhadrepetitivesexual

activitiesthatyoufeltsoashamedofor

guiltyaboutthatyoukeptthemasecret?
4.Doyouthinkthatyouarespendingtoo

muchtimeengaginginsexualfantasy,

masturbationorothersexualbehaviors?
5.Haveyoueverfeltthatyoursexdrivewas

too strong ortoo high to control?
ClinicalAssessmentScales
Sexual Addiction Screening Test
(Carnes, 1989 n=191; 1991: Nelson, 2008 n=639 male veterans: Marshall, 2010 n=151; 74
male sex offenders and 77 community controls)
25 items, dichotomous, available for males and
females
www.sexhelp.com
Score > 13 indicative of sexual addiction
Sexual Compulsivity Scale (Kalichman,1995, 2004, Grov 2010)
Derived from characteristics of sexual addiction
Easy to administer, 10 items extensively tested,
established reliability and validity
www.personality-testing.info/tests/SCS.php
ClinicalAssessmentScales
HypersexualBehaviorInventory(HBI)
Reidet.al,2011;Reidetal2012;Kleinetal.2013
19item,3factor,selfreportmeasure
control,consequences,sexascoping
UsedinDSM5fieldtrial
Dimensional,notdiagnostic
HypersexualDisorderDiagnosticClinicalInterview
http://www.rory.net/tests.htm
PrevalenceofAxisIpsychiatric

comorbidity

inHDmales
MultipleAxisIcomorbidity

ispredominantinHD
Kafkaetal1994,1998,2002,
Dysthymia

6162%
Socialphobia

2225%
Alcoholabuse

2539%
ADHD1719%
ADHD

23,67%*
Bipolarspectrum0%
Blacketal,1997
Phobicdisorders 42%
MDD/Dysthymia

39%
Alcoholabuse

58%
*Reid,Carpenteretal2011,Blankenship&Laaser,2004
PrevalenceofAxisIpsychiatric

comorbidity

inHDmales
Kafka,2014unpublished

n=85

MINIPLUSv.6
AnyADHD

40%
Inattentivesubtype

27%
Combinedsubtype

13%
AdultADHD

30%
AnyBipolar

38%
BipolarII

19%
Cyclothymic/NOS

19%
Unipolar

MajorDepression

25%
Nonalcoholsubstanceabuse

22%
Alcohol,dysthymia,socialanxiety

20%each
AxisIcomorbidity:depression
MDDdiminishedsexualarousal,activityandpleasure,Hypoactive

SexualDesireDisorder
Subgroupsreportincreasedsexualbehavior

(Mathew,1979,1982;

Bancroft2003;Schultz,2013)
Malesresistanttocognitivetherapyfordepressionhaddysthymia

withincreasedTSO(Nofzinger,1993)
MaleswithPAs

andPRDs

haveincreasedTSOandmood

disorders(Kafka,1997,2002,2007,Schultz2013)
Malesrespondtodysphoric

affectthroughactionand

impulsivity
A selfmedication oraddictiondynamic(Carnes1983,Martinetal,2013)
AxisIcomorbidity:hypomania
Increased/riskysexualbehaviorisassociatedwith

hypomaniasdiagnosticcriteria
Thebipolarspectrummayinclude6%oftheadult

population
Themeandurationofhypomanic

episodesis12days
Myclinicalexperiencepromiscuityisapredictorof

increasedlikelihoodofmooddisorders
esp.bipolarspectrum
Bipolars

typicallyhavesexualimpulsivityduringboth

phasesoftheirmooddysregulation
Cyclothymia

andOtherSpecifiedBipolarDisorderare

underdiagnosed
AxisIcomorbidity:ADHD
SexualproblemsandADHD
prevalenceinadultsinUSA4.4%(Kessleretal2006)
Sexualadjustmentproblems(20%)greaterthancontrols

(2.4%)
Sexatanearlierage
Moresexpartners
MoreS.T.D.s

(17%vs.4%)
highrisksexuallifestyle (Barkley,1998)
Moreunplannedpregnancy(Hosain

etal,2012)
ADHDCassociatedwithparaphilias,pornographydependence

andsexoffending
Kafka,2003,2007
TreatmentInterventions
Gooddataislacking
Hereandnowbeforethereandthen
externalinterventionstolimitaccess
Phoneblock,internetfilterswithkept

passwords,movethecomputertoamore

publiclocation,changeISPs,removecredit

cards

(Behun

etal

,2012)
Includespousetofacilitatedisclosure??

be

CAREFUL
Assessrelationshipstability,valuesand

religion,psychiatricstabilityandco

dependence
TreatmentInterventions
Frequent12stepmeetingswithadaily

contactwithsponsor
SLAA,SAA,SA
Differing bottomlines
612monthsof celibacy
Buildarecoverynetwork
Individualpsychotherapy,group+

meds
Manyuseaddictionmodel
SomeCBT
Nopublishedoutcomestudieswithcontrols
PharmacotherapyforHypersexual

Disorder
DiagnoseandthentreatAxisIcomorbidity

associatedwithimpulsivity
Oneplacebocontrolleddoubleblindstudy(n=21)
Citalopramforhomosexualpromiscuity(Wainbergetal

,2006)
Noeffectonhomosexualpromiscuity,highplacebo

responserate,decreasedTSO.12weektrial,

masturbationdecreased,pornographyusedecreased
PharmacotherapyforHD
Uncontrolledstudies(Kafka,1992,1994,2000)
Clinicalexperiencewith>250malestreatingAxisI

comorbidityassociatedwithHD
SSRIs,psychostimulantsormoodstabilizer

combinationseffectivelyamelioratesormarkedlyreduce

bothparaphilicandnonparaphilicsexualimpulsivity
Casesreportsbyotherinvestigators
PharmacotherapyforHypersexual

Disorder
Useincombinationwithindividualand/orpsychotherapyor

grouptherapy(including12stepprograms)
moodstabilizers.SSRIsorpsychostimulants
standarddoses
SSRIsexual dysfunction

maydissipate
lowerTSO/weekto13ifpossible
minimizemasturbationifanintactrelationshippersists

ordevelops
Lamotrigine,valproateandoxycarbamazepine
Naltrexoneandtopiramate
casereports
targetsxareurges

andcraving
DiagnosingHypersexualDisorderin

DSM5
HDcanbediagnosedas:
OtherSpecifiedDisruptive,ImpulseControl,

andConductDisorder:hypersexualdisorder
(orotherdescriptors,eg.recurrenthypersexualbehaviors,

sexualaddiction)312.89:F91.8
Additionaltreatmentconsiderations
Amedical/psychiatricmodel
basedonacomorbidityoranaddictionmodel
destigmatizebehaviorsfrom moral to medical
thespouseorpartnerisleftwiththemostdifficultdecisions
Outcomemaydependonrelationshipstatus
residualpornographyorotherformsofimpersonalsex
SocietyfortheAdvancementofSexualHealth
Resources/reading/workbooksathttp://www.sash.net/

and

SASHbookstore

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