A leading-edge study to be published in the Journal of Sex & Marital Therapy later this winter presents evidence claiming confirmation of the existence of several clinically distinct subtypes of hypersexuality. This may finally lead to solving the current problem with treating all the varying cases of hypersexuality with one-size-fits-all approaches: it’s ineffective.

Moreover, this is in line with another new and impactful study comparing sex addiction and gambling disorder. As with many therapists treating clients experiencing the devastating results of out-of-control sexual behaviour, research is postulating that hypersexual behaviour disorder should be reinstated in the DSM as an addictive disorder, since its removal from the DSM-V.

Hypersexuality has gone by many guises over the years; sex addiction, sexual compulsivity, sexual impulsivity and hypersexual disorder to name a few. Despite being described as a behavioral or psychological complaint more than 200 years ago by psychiatrist Dr. Benjamin Rush in “Of the Morbid State of the Sexual Appetite”, it is still poorly understood.

The proposed diagnostic criteria for hypersexual disorder, although unaccepted by the DSM, are as follows:

1. Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors in association with three or more of the following five criteria:
   – Time consumed by sexual fantasies, urges or behaviors repetitively interferes with other important (non-sexual) goals, activities and obligations.
   – Repetitively engaging in sexual fantasies, urges or behaviors in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability).
   – Repetitively engaging in sexual fantasies, urges or behaviors in response to stressful life events.
   – Repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges or behaviors.
   – Repetitively engaging in sexual behaviors while disregarding the risk for physical or emotional harm to self or others.
2. 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 or behaviors.
3. These sexual fantasies, urges or behaviors are not due to the direct physiological effect of an exogenous substance (e.g., a drug of abuse or a medication)

Specify if: Masturbation, Pornography, Sexual Behavior with Consenting Adults
Cybersex,Telephone Sex, Strip Clubs or Other (examples: prostitutes, strip clubs/adult bookstores).

An article published in the Archives of Sexual Behavior previously suggested, based on patient’s reports of behaviors, that hypersexuality should be divided into two subgroups, paraphilic and nonparaphilic hypersexuality, with distinct subtypes within the nonparaphilic group (as explained below).

The main study in question, from researchers at the Centre for Addiction and Mental Health and Ryerson University, Toronto, Canada, aimed to test and explore this topology of hypersexuality and assess its clinical relevance. The research involved analysis of clinical chart data pertaining to 115 consecutive male cases of hypersexuality, that were often referred as cases of sexual addiction or sexual compulsivity. The researchers identified significant differences in both the sexual and mental health histories between the different hypersexual subtypes outlined below.

Paraphilic hypersexuals

Paraphilic hypersexuality , in addition to extreme frequencies of sexual behaviour, involves atypical sexual desires, often involving more sexually extreme activities such as urophilia (i.e. “golden showers”), masochism and cross-dressing.

In the study, individuals of the paraphilic hypersexual subtype (33 out of 115 participants) were more likely to report novelty seeking as a symptom of, or driving force behind, their sexual problems (79%) as compared with the rest of the sample (43%), a criminal history (46% vs. 21%), history of substance use problems (50% vs. 20%) a greater number of sexual partners, more preoperative transwomen partners (22% vs. 6%), a later onset of puberty, a later first age of pornography use or masturbation and a trend toward younger age at loss of virginity.

Nonparaphilic hypersexuals

The nonparaphilic subtypes include avoidant masturbation (typically with very frequent pornography use), chronic adultery, designated patient, and lastly, sexual guilt and better accounted for as a symptom of another condition.

Avoidant masturbator

The avoidant masturbator subtype (27 out of 115 participants) displayed a trend toward more frequently volunteering that they used sex as an avoidance strategy than the rest of the sample (100% vs. 41%) and toward being less likely to have ever been in a serious romantic relationship (70% vs. 86%).

With those who reported romantic relationships, there was a trend toward a higher chance of the relationship having ended (28% vs. 9%) or been strained as a result of their hypersexuality problems (56% vs. 50%). They were significantly more likely to report a history of anxiety problems (74% vs. 23%) and sexual functioning problems (71% vs. 31%), with delayed ejaculation being the most commonly reported sexual functioning problem (33% vs. 7%).

Chronic adulterer

The chronic adultery subtype (15 out of 115 participants), when compared with all other cases, were less likely to report a history of (or current) mood problems (15% vs. 55%) but an increased likelihood of complaints of premature ejaculation (13% vs. 2%), a delayed onset of puberty, a significantly lower level of education and a trend toward being less likely to have a criminal history (11% vs. 29%).

Designated patient

A designated patient is considered as when someone else, often a romantic partner, instigated the push for therapy. When those in the designated patient subtype ( 12 out of 115 participants) were compared with all other cases, they were less likely to report substance use problems (0% vs. 33%), more likely to have a stable work history (100% vs. 64%), and to be financially secure (100% vs. 49%), with a trend toward less likelihood of reporting engagement in novelty seeking in sexual encounters (29% vs. 64%).

Sex guilt

The sex guilt and symptoms of other condition subtypes could not be assessed due to insufficient numbers. The researchers suspected that that many men belong to both the sex guilt and designated patient subtypes due to a surprisingly low-level of relationship distress being reported in the designated patient subtype. The logic being that both the patient themselves feels guilt and distress for their behavior, as well as their partner distress, where seeing eye-to-eye resulted in less relationship distress. Whether these two subtypes are perhaps best classified as one requires further investigation.

The future of treatment and recovery from hypersexuality

The detection of nonintuitive but statistically significant differences between groups not only corroborates the existence of clinically meaningful subtypes among hypersexual referrals, it highlights a need to determine cost-effective treatment protocols with specific treatment targets.

Although one may argue that it’s hard to distinguish between personal sexual preferences and habits and hypersexuality disorder and its subtypes, current research and the accounts of therapists and hypersexuality sufferers, as well as their friends and family members suggests otherwise. Furthering this research, the pinnacle being developing treatments optimized to best treat different subtypes, may leave the DSM due for a thorough hypersexuality update.

References

Farré JM, Fernández-Aranda F, Granero R, Aragay N, Mallorquí-Bague N, Ferrer V, More A, Bouman WP, Arcelus J, Savvidou LG, Penelo E, Aymamí MN, Gómez-Peña M, Gunnard K, Romaguera A, Menchón JM, Vallès V, & Jiménez-Murcia S (2015). Sex addiction and gambling disorder: similarities and differences. Comprehensive psychiatry, 56, 59-68 PMID: 25459420

Kafka, M. (2009). Hypersexual Disorder: A Proposed Diagnosis for DSM-V Archives of Sexual Behavior, 39 (2), 377-400 DOI: 10.1007/s10508-009-9574-7

Sutton KS, Stratton N, Pytyck J, Kolla NJ, & Cantor JM (2015). Patient Characteristics by Type of Hypersexuality Referral: A Quantitative Chart Review of 115 Consecutive Male Cases. Journal of sex & marital therapy, 41 (6), 563-80 PMID: 25032736

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