Non-Paraphilic Hypersexuality –

Hypersexual Disorder, Compulsive Sexual Behavior Disorder or Sexual Addiction?

Rafaela Angelescu & Cristian Delcea*

University of Medicine and Pharmacy of Craiova, Romania
Department of Advanced Studies in Sexology, Sexology Institute of Romania
*Corresponding author: office@sexology.ro
International Journal of Advanced Studies in Sexology
Volume 2, 2020 | Issue 2, Pages 66-71 | ISSN 2668-7194 (print), ISSN 2668-9987 (online)
Citation: Angelescu R., & Delcea C., (2020). Non-Paraphilic Hypersexual Disorder –Compulsive
Sexual Behavior Disorder or Sexual Addiction. Int J Advanced Studies in Sexology. Vol. 2,
Issue 2, pp. 66-71. Sexology Institute of Romania.
DOI: 10.46388/ijass.2020.13.22
Full Article | Figures & data| References | Citations |Reprints & Permission

Abstract
The conceptualization of excessive sexual behavior has been intensely debated over the years,
and the concept of hypersexuality is still controversial.
The misunderstanding of hypersexuality and the debates regarding its correct definition have
limited the research and the effective treatment of this disorder (Franque, Klein & Briken, 2014).
After long debates, the indexation in ICD-11 (International Classification of Diseases, 11th
Revision, World Health Organization, 2018) of excessive and problematic sexual behavior as a
compulsive sexual behavior disorder (CSBD) is welcome. There are still debates about the category
of the disorder. In ICD-11, CSBD is classified as an impulse control disorder, but this classification
is controversial, as there is evidence that CSBD has many addictive features (Kraus et al., 2016).
Although the diagnosis of hypersexual disorder, proposed by Kafka, was not included in the
DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition, American Psychiatric
Association, 2013), this diagnosis was supported by both clinical contexts as well as by some research
that indicates that excessive sexual behavior can have serious consequences in an individual’s life
(Kafka, 2010; Kaplan & Krueger, 2010, Reid et al., 2012).
Keywords: hypersexuality, hypersexual disorder, compulsive sexual behavior disorder,
compulsive online sexual behavior, sexual addiction.
Introduction
Hypersexuality, or excessive sexual behavior, has been categorized as: sexual addiction
(Carnes, 1983; Goodman, 1983, 2001; Karila, et al., 2014), sexual compulsivity (Coleman, 1987,
2002), sexual impulsivity (Barth & Kinder, 1987; Reid, Berlin & Kingston, 2015), out of control
sexual behavior (Bancroft & Vukadinovic, 2004), hypersexual disorder (Kafka, 2010; Kaplan &
Krueger, 2010).
The prevalence of this disorder varies between 3% and 6%, with a higher rate in men
(male/female prevalence ratio varies between 2:1 and 5:1) (Tripodi, et al., 2013; Briken, et al., 2007).
 Theoretical approaches
There are various theoretical approaches and each term used to define problematic hypersexual
behavior corresponds to a specific approach. Overlaps or complementarities can also be observed,
the subject being still in a process of research and debate.
Problematic sexual behavior involves the presence of three general criteria: obsession
(thoughts, impulses, recurrent and persistent), compulsion (loss of the ability to choose to stop a
behavior) and the consequences of the behavior (Schneider, 1994).
Hypersexuality is a term that indicates excessive sexual behavior that can be considered normal,
when it is not accompanied by consequences, or abnormal when it significantly affects an individual’s
life or is associated with a mental disorder or medical condition (Kafka, 2010).
Barth and Kinder chose the term sexual impulsivity to refer to the inability to control strong
sexual desires or to reduce concern about sexual activity, practically the inability to stop initiating
action (Barth & Kinder, 1987).
Sexual compulsivity indicates the inability to stop or reduce ongoing sexual behavior.
Impulsivity and compulsivity are present in obsessive-compulsive disorders (OCSD), and are
two important factors for compulsive sexual behavior (Hollander, Poskar & Gerard, 2012).
Sexual addiction defines a recurring sexual behavior that cannot be controlled and is maintained
despite the negative consequences. Related to the addiction model, the compulsive model assumes
that sexual thoughts, images or impulses become obsessive and lead to repetitive, compulsive
engagement in sexual activities in order to reduce anxiety (IsHak, 2008).
The addiction model meets the criteria present in an addiction process defined by Goodman
(2001) as a recurrent and uncontrollable behavior despite the serious consequences, which becomes
progressive over time (Carnes, 1983, 2001; Goodman, 1993).
Multiple addictions were also reported in people with sexual addiction (Carnes, 2001; Kaplan
& Krueger, 2010).
Other evidence suggests that CSBD shares many features with addictions. The data suggest
significant clinical, neurobiological, and phenomenological similarities between excessive
involvement in behaviors such as gambling, compulsive sex, compulsive shopping, and substance
addictions (Kraus et al., 2016).
Some neuroimaging studies have found, in the case of subjects with compulsive sexual
behavior, a higher reactivity in three brain regions related to rewards (ventral striatum, anterior
cingulate and amygdala), in response to explicit sexual images. The same areas are activated in the
case of substance addictions subjects (Voon et al., 2014).
Diagnosis and Assessment
Diagnostic criteria for hypersexual disorder proposed by Kafka for DSM-5 (Kafka, 2010):
A. The presence for a period of at least 6 months of recurrent and intense sexual fantasies,
sexual urges and sexual behavior in association with at least 3 of the following criteria:
 A.1. Sexual preoccupation or excessive time invested in sexual fantasies, impulses and
behaviors as well as in their planning, thus neglecting other areas of life.
A.2. Repetitive engagement in these fantasies, sexual urges and behaviors to cope with negative
moods (anxiety, depression, boredom and irritability).
A.3. Repetitive engagement in fantasies, starts and sexual behavior in response to stressful life
events.
A.4. Repetitive but unsuccessful efforts to control and significantly reduce these sexual
fantasies, impulses, and behaviors.
A.5. Repetitive engaging in sexual behavior without considering the risk of physical or
emotional harm to oneself or others.
B. The presence of personal distress, clinically significant, or significant impairment of
important areas of functioning of the individual (social, occupational, relational).
C. Sexual fantasies, impulses, and behaviors are not directly due to substance use (drugs or
medications), or a concomitant general medical condition or manic episodes.
D. The person is over 18 years old.
It will be specified if it regards: masturbation, pornography, consensual sexual behavior, sex
on the internet (cybersex), sex on the phone (hot line) or strip clubs, etc. (Kafka, 2010, 2013).
Assessing hypersexuality is an essential step in diagnosis. In addition to the empathy and
support given to the patient during the interview, it is necessary for therapists to control any possible
personal reactions of rejection towards certain sexual behaviors, so as not to accentuate patients’
feelings of guilt. It is also useful to know the different types of pornography and sexual services
accessed by users (Franque, Klein & Briken, 2016).
The objectives of the assessment during the interview are: the symptoms, the degree of
impairment of the individual’s functionality in different areas of life, family history, relationship and
sexual history (psychosexual development, history of sexual abuse, sexual behavior), medical and
psychiatric history, self-image perception, substance addiction problems, identification of risky
behaviors (self-destructive or sexual violence) (Kafka 2010; Tripodi et al., 2013; Franque, Klein &
Briken, 2016). The assessment of sexual dysfunctions is also necessary (Klein, 2015).
If the conceptualization of hypersexuality involves three important areas, practically, the
assessment and the treatment address behavior, cognitions and emotions, as well as the
social/relational area (Grubbs et al., 2017).
Hypersexuality is a behavioral disorder, but recurrent sexual behavior or excessive frequency
is not sufficient to diagnose the disorder. Therefore, the degree in which the functionality and quality
of life is affected, is a key indicator for diagnosis (Carnes, 2001; Kafka, 2010; Reid et al., 2012).
Sexual behavior has individual variations, and labeling as much, little or normal is subjective
and it depends to each individual. If it is seen as excessive or problematic only from the perspective
of conventional or religious norms, without causing dysfunctions in other areas of life, it cannot be
diagnosed as a disorder (Kafka, 2010).
 There may also be situations when persons who have addressed the specialist, claiming to be
sexually addicted, confuse the addiction with increased sexual desire.
The cognitive and emotional components are strong in hypersexuality. (Grubbs et al., 2017).
Cognitively, the sexual thoughts and fantasies of hypersexual people become obsessive and
difficult to control when hypersexual behavior becomes compulsive.
Emotionally, negative states such as: distress, anxiety and depression are co-morbid or
represent consequences of compulsive sexual behavior (Birchard, 2018b).
Excessive sexual behavior sometimes develops as an attempt to adapt to stress and other
negative emotional states, but this way of adapting will become a vicious circle as it generates even
more negative emotional consequences that will sustain the behavior (Kafka, 2010, 2013). This sets
up anxiety, shame and depression (Gilliland et al., 2011).
The negative consequences in social, professional and relational areas can be multiple, from
dysfunctions to conflicts, thus affecting the life of the individual (Reid et al., 2012).
However, the correct diagnosis of this disorder is a challenge because hypersexual behavior can
have several etiologies.
Causes of hypersexuality
Because multiple comorbidities are reported, it is necessary to consider diseases or other
problems that may coexist with excessive sexual behavior: mental illness, organic disease, problems
regarding substance abuse (Kafka, 2010).
It is important to investigate whether hypersexuality is not directly due to other mental
disorders, medical causes, or is not the direct effect of substance use (drugs or medications) (Kafka,
2010).
Mental health problems that may coexist with hypersexuality: anxiety, mood disorders,
posttraumatic stress disorder, autism, bipolar disorder (in the manic episode), paraphilias,
schizophrenia, oligophrenia (cortical inhibitory processes are diminished), dementia, personality
disorders (especially borderline personality disorder and obsessive-compulsive disorder), alcohol or
drug addiction (can facilitate the development of hypersexuality, as it affects sexual and social
inhibitions).
Medical conditions, endocrine or neurochemical imbalances that may be associated with
hypersexual behavior:

• Neurological or neurodegenerative diseases such as: epilepsy (cortical inhibitory processes

are diminished), Alzheimer’s disease, Kleine-Levin syndrome (sleep disorder - hypersomnia),
Kluver-Bucy syndrome (bilateral affection of the two temporal lobes in their medial portion; it may
be the result of herpes encephalitis, trauma or oxygen deprivation), Huntington’s disease or chronic
Huntington’s chorea (neurological, degenerative, hereditary disease);
• Brain injuries or surgeries in the frontal or temporal lobes (in the medial area);
• Encephalitis, tuberculosis (tuberculosis toxins can have a stimulating action on the
hypothalamic centers of sexual behavior);
 • Endocrine disorders such as hyperestrogenism, hyperandrogenism, hyperthyroidism, may
also be accompanied by hypersexuality (but there is insufficient evidence regarding the mechanisms);
• Imbalance in the levels of serotonin, dopamine and norepinephrine in the brain.
Hypersexuality may be linked to high levels of these neurotransmitters (Kafka, 2010);
• Some medications, such as dopaminergic agonists, used to treat Parkinson’s disease
(levodopa, ropinirole, pramipexole), or cabergoline, also a dopaminergic agonist, indicated for the
inhibition of lactation and the treatment of hyperprolactinemia, may cause disorders related to the
control of hypersexual impulses, gambling addiction, compulsive appetite, compulsive spending or
shopping.
Introduction of Compulsive Sexual Behavior Disorder (CSDB) in ICD-11
In ICD-10 the diagnosis of Excessive Sexual Activity can be found in which the chapter refers
to “Sexual dysfunction not caused by an organic disorder or disease”.
In 2018, the WHO (World Health Organization) announced the inclusion in ICD-11 of this
disorder as Compulsive Sexual Behavior Disorder (CSBD), thus recognizing it as a mental disorder.
Compulsive involvement and decreased control are the basic features of impulse control disorders.
The diagnosis for this disorder results from the persistent pattern of difficulty or failure in
efforts to control sexual impulses, which leads to repetitive sexual behaviors over a long period of
time (minimum 6 months), associated with negative consequences that can endanger the individual’s
or others’ life, or causes a significant impact on the areas of life of the individual (family, relationship,
professional, social, etc.) (WHO, 2018).
There are still debates about the category of the disorder. In ICD-11, CSBD is classified as an
impulse control disorder, but this classification is controversial, as there is evidence that CSBD has
many addictive features (Kraus et al., 2016).
In the DSM-5, pathological gambling was reclassified as a “Substance-Related and Addictive
Disorders”. A similar approach should be applied to CBS, which is currently considered to be an
impulse control disorder in ICD-11 (Kraus et al., 2018).
This diagnosis, CSBD, also includes compulsive sexual behavior on the internet that affects the
life of the individual. Over 80% of people with compulsive sexual behavior report excessive or
problematic pornography use (Kafka, 2010; Reid et al., 2012).
The development of technology and almost unlimited access to sexual material on the internet
has led to an increase in the consumption of pornography and other sexual services on the internet
in recent years.
Internet sex or cybersex includes: watching erotic or pornographic content, explicit sexual
discussions, sexual interactions on forums, video chat, searching for potential sexual partners for
offline relationships, involvement in explicit sexual acts on social networks or other means of
communication on the internet (Southern, 2008).
The number of people engaging in sexual activities on the internet is high, but many do not
complain of difficulties related to these activities (Cooper, 2000). However, users can develop
problematic sexual behaviors on the internet if they are obsessively preoccupied with accessing these
services and persist in this sexual behavior, although they face negative consequences in their lives
(Carnes, 2001).
One study estimated the percentage of users with problematic behavior at 17% (Cooper, 2000),
but another Swedish study found that their percentage is lower, at 10% (Månsson, 2003).
However, there are descriptions that show that this behavior develops as: a consequence of the
inability to adapt to certain negative states (the individual tries to use his behavior to cope with stress,
anxiety or depression - Schwartz MF, 2000), a conditioned behavior, a dissociative relapse of lifelong
trauma or a courtship disorder (Southern, 2008).
The description of compulsive sexual behavior as an adaptive attempt of the individual to cope
with stress, anxiety or depression, also emerges from the frequent association of anxiety and mood
disorders with this type of behavior.
Given these comorbidities, it would be useful, as specialists, to assess how the reduction of
social and personal interactions, imposed in the context of the Covid-19 pandemic, influences and
affects the sexual life of individuals during this period.
Clinicians reported an increase in anxiety, mood disorders and alcohol consumption in
conditions of social isolation. Pornographic sites such as PornHub and online sex-chat or video-chat
sites have reported a significant increase in user access.
We may wonder whether the current social context could represent, amid increasing stress,
anxiety and depression, a predisposing factor for the development of compulsive sexual behavior on
the internet, as an adaptive reaction to negative emotional states.
Conclusions
For the correct diagnosis of this disorder, a complex clinical interview is necessary, that allows
the assessment of the mental and physical health state of the individual, of the functionality in various
areas of life, as well as a thorough differential diagnosis considering the multiple causes that can
promote the development of a hypersexual behavior.
Understanding, defining and correctly diagnosing this disorder are important prerequisites for
proper treatment, and allow also warning of certain risk factors for the development of this disorder.
Although many people who engage in sexual activities on the internet do not report problems
in their personal lives or other areas of activity, sex on the internet can become problematic when the
concern becomes obsessive and the behavior becomes compulsive and persistent, despite the negative
consequences.
The efforts of sex therapists to make prevention programs through psychoeducation and sex
education can contribute enormously to improving people’s sexual health.
Such a program could aim to inform the population about predisposing or risk factors that may
promote the development of compulsive sexual behavior on the internet, as well as the negative
consequences resulting from this behavior.
Bibliography
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders.
5th edition. Washington, DC.
Bancroft, J., Vukadinovic, Z. (2004). Sexual addiction, sexual compulsivity, sexual impulsivity, or
what? Toward a theoretical model. Journal of Sex Research, 41(3), 225–234.
Barth, R.J., Kinder, B.N. (1987). The mislabeling of sexual impulsivity. Journal of Sex and Marital
Therapy, 13(1), 15–23.
Briken, P., Habermann, N., Berner, W., Hill, A.(2007). Diagnosis and treatment of sexual addiction:
a survey among German sex therapists. Sexual Addiction and Compulsivity,14 (2),131–43.
Birchard, T. (2018b). Group cognitive behavioural therapy for compulsive sexual behavior. In: T.
Birchard & J. Benfield, editors. The Routledge international handbook of sexual addiction. London,
England: Routledge, 190-202.
Carnes, P. (1983). Out of the shadows: Understanding sexual addiction. Minneapolis: CompCare.
Carnes, P., Delmonico, D.L., Griffin, E. (2001). In the shadows of the net: breaking free of
compulsive online sexual behavior. Center City (MN): Hazelden Publishing.
Coleman, E. (1987). Sexual compulsivity: definition, etiology, and treatment considerations.
Journal of Chemical Dependency Treatment, 1, 189–204.
Coleman, E. (2002). Is your patient suffering from compulsive sexual behavior? Psychiatric Annals,
22, 320–5.
Cooper, A., Delmonico, D.L., Burg, R. (2000). Cybersex users, abusers, and compulsives: new
findings and implications. Sexual Addiction and Compulsivity, 7, 5–29.
Franque, F., Klein, V., Briken, P. (2014). Which techniques are used in psychotherapeutic
interventions for nonparaphilic hypersexual behavior? Sexual Medicine Reviews, 3, 3–10.
Franque, F., Klein, V., Briken, P. (2016). Non-paraphilic Hypersexual Disorder. In: R. Balon,
editor. Practical Guide to Paraphilia and Paraphilic Disorders. Switzerland: Springer International
Publishing, 197–209.
Gilliland, R., South, M., Carpenter, B N., Hardy, S.A. (2011). The roles of guilt and shame in
hypersexual behavior. Sexual Addiction and Compulsivity, 18, 12–29.
Goodman, A. (1993). Diagnosis and treatment of sexual addiction. Journal of Sex and Marital
Therapy,19(3), 225–251.
Goodman, A. (2001). What’s in a name? Terminology for designating a syndrome of driven sexual
behavior. Sexual Addiction and Compulsivity, 8, 191–213.
Grubbs, J. B., Hook, J.P., Griffin, B. J., Cushman, M.S., Hook, J, N., Penberthy, J. (2017). Treating
Hypersexuality. In: Z.D. Peterson, editor. The Wiley Handbook of Sex Therapy. John Wiley &
Sons Ltd., 115–128.
Hollander, E., Poskar, S., Gerard, A. (2012). Subtypes and spectrum issues. In: J. Zohar, editor.
Obsessive-Compulsive Disorder: Current Science and clinical practice. John Wiley &Sons Ltd.,
135–157.
IsHak WW., Boyle, A. Sexual desire disorders. In: IsHak W.W., editor. The guidebook of sexual
medicine. Beverly Hills: A&W Publishing; 2008, 97–8.
Kafka, M.P. (2010). Hypersexual disorder: a proposed diagnosis for DSM-5. Archives of Sexual
Behavior. 39, 377–400.
Kafka, M.P. (2013). The development and evolution of the criteria for a newly proposed diagnosis
for DSM-5: Hypersexual disorder. Sexual Addiction and Compulsivity, 20, 19–26.
Kaplan, M.S., Krueger, R. B. (2010). Diagnosis, assessment, and treatment of hypersexuality.
Journal of Sex Research, 47, 181–198.
Karila, L., Wéry, A., Weinstein, A., Cottencin, O., Petit, A., Reynaud, M., Billieux, J. (2014).
Sexual addiction or hypersexual disorder: different terms for the same problem? A review of the
literature. Current Pharmaceutical Design, 20, 4012–4020.
Klein, V., Jurin, T., Briken, P., Stuhlhofer, S. (2015). Erectile dysfunction, boredom and
hypersexuality among coupled men from two European countries. Journal of Sexual Medicine,
12(11), 2160–7.
Kraus, S.W., Voon, V., Potenza, M.N. (2016). Should compulsive sexual behavior be considered an
addiction? Addiction, 111(12), 2097–2106.
Kraus, S.W., Krueger, R.B., Briken, P., First, M.B., Stein, D.J., Kaplan, M.S., Voon, V., Abdo,
C.H.N., Grant, J. E., Atalla, E., Reed, G.M. (2018). Compulsive sexual behavior disorder in the
ICD-11. World Psychiatry, 17(1), 109–110.
Månsson, S-A., Daneback, K., Tikkanen, R., Löfgren-Mårtenson, L. (2003). Love and sex on the
internet. Göteborg: University of Gothenburg; [in Swedish].
Reid, R.C., Carpenter, B.N., Hook, J.N., Garos, S., Manning, J.C., Gilliland, R., Cooper, E.B.,
McKittrick, H., Devtian, M., Fong, T. (2012). Report of findings in a DSM-V field trial for
hypersexual disorder. Journal of Sexual Medicine, 9(11), 2868–77.
Reid, R C., Garos, S., Fong, T. (2012). Psychometric development of the Hypersexual Behavior
Consequences Scale. Journal of Behavioral Addictions, 1(3), 115–122.
Reid, R.C., Berlin, H.A., Kingston, D.A. (2015). Sexual impulsivity in hypersexual Men. Current
Behavior Neuroscience Reports, 2(1), 1–8.
Schneider, J.P. (1994). Sex addiction: controversy within mainstream addiction medicine, diagnosis
based on the DSM-III-R and physician case histories. Sexual Addiction and Compulsivity, 1,19–44.
Schwartz, M.F., Southern, S. (2000). Compulsive cybersex: the new tea room. In: A. Cooper,
editor. Cybersex: the dark side of the force: a special issue of the Journal Sexual Addiction and
Compulsivity. New York: Routledge, 127–44.
Southern, S. (2008). Treatment of compulsive cybersex behavior. Psychiatric Clinics of North
America, 31(4), 697–712.
Tripodi, F., Giuliani, M., Petruccelli, I., Simonelli, C. (2013). Hypersexual behavior. In: Kirana,
P.S., Tripodi, F., Reisman, Y., Porst, H., editors. The EFS and ESSM syllabus of clinical sexology.
Amsterdam: Medix Publisher, 1144–82.
World Health Organization. Internațional Classification of Diseases and Related Health Problems,
10th Revision.
World Health Organization (2018). Internațional Classification of Diseases, 11th Revision.