Is High Sexual Desire a Risk for Women's Relationship and Sexual Well-Being?

Assessment and treatment of compulsive sexual behavior disorder: a sexual medicine perspective

INTRODUCTION

The addition of compulsive sexual behavior disorder (CSBD) into the ICD-11 chapter on mental, behavioral, or neurodevelopmental disorders has greatly stimulated research and controversy around compulsive sexual behavior, or what has been termed "hypersexual disorder," "sexual addiction," "porn addiction," "sexual compulsivity," and "out-of-control sexual behavior."

OBJECTIVES

To identify where concerns exist from the perspective of sexual medicine and what can be done to resolve them.

METHODS

A scientific review committee convened by the International Society for Sexual Medicine reviewed pertinent literature and discussed clinical research and experience related to CSBD diagnoses and misdiagnoses, pathologizing nonheteronormative sexual behavior, basic research on potential underlying causes of CSBD, its relationship to paraphilic disorder, and its potential sexual health consequences. The panel used a modified Delphi method to reach consensus on these issues.

RESULTS

CSBD was differentiated from other sexual activity on the basis of the ICD-11 diagnostic criteria, and issues regarding sexual medicine and sexual health were identified. Concerns were raised about self-labeling processes, attitudes hostile to sexual pleasure, pathologizing of nonheteronormative sexual behavior and high sexual desire, mixing of normative attitudes with clinical distress, and the belief that masturbation and pornography use represent "unhealthy" sexual behavior. A guide to CSBD case formulation and care/treatment recommendations was proposed.

CONCLUSIONS

Clinical sexologic and sexual medicine expertise for the diagnosis and treatment of CSBD in the psychiatric-psychotherapeutic context is imperative to differentiate and understand the determinants and impact of CSBD and related "out-of-control sexual behaviors" on mental and sexual well-being, to detect forensically relevant and nonrelevant forms, and to refine best practices in care and treatment. Evidence-based, sexual medicine-informed therapies should be offered to achieve a positive and respectful approach to sexuality and the possibility of having pleasurable and safe sexual experiences.

Associations Between Pornography Use Frequency, Pornography Use Motivations, and Sexual Wellbeing in Couples

Pornography use is prevalent, even among partnered individuals. Although pornography use motivations represent key predictors of sexual behaviors, prior studies only assessed the associations between pornography use frequency and sexual wellbeing, with mixed results. This cross-sectional dyadic study examined the associations between partners' individual and partnered pornography use frequency, motivations, and sexual wellbeing. Self-report data from 265 couples (M_{age_men} = 31.49 years, SD = 8.26; M_{age_women} = 29.36 years, SD = 6.74) were analyzed using an actor-partner interdependence model. Men's greater emotional avoidance motivation was related to their own lower sexual function (β = -.24, p = .004) and greater sexual distress (β = .19, p = .012), while their higher sexual curiosity motivation was related to higher partnered sexual frequency (β = .15, p = .031), their own greater sexual satisfaction (β = .13, p = .022), sexual function (β = .16, p = .009), and lower sexual distress (β = -.13, p = .043). Women's higher partnered pornography use frequency was associated with their own greater sexual function (β = .15, p = .034) and lower sexual distress (β = -.14, p = .012). Additionally, women's higher individual pornography use frequency (β = .33, p < .001) and lower sexual pleasure motivation (β = -.35, p = .002) were associated with higher partnered sexual frequency. No partner effects were observed. Findings highlight that women's pornography use frequency and each partner's motivations might play crucial roles in couples' sexual wellbeing.

Sexual Motivations Underlying Compulsive Sexual Behavior in Women and Men From Germany and Hungary

BACKGROUND

There are ongoing debates about conflicting models on how to conceptualize compulsive sexual behavior. At the heart of these discussions is the question about the sexual motivations underlying compulsive sexual behavior, as different models assume different motivations.

AIM

The aim of the present study was to understand sexual motivations underlying compulsive sexual behavior and their relation to the most prominent conceptualizations of compulsive sexual behavior (eg, compulsive sexual behavior disorder [CSBD], sex addiction).

METHODS

We used self-reported data from 2 large samples of Hungarian and German populations (N = 9814). The Sexual Motivation Scale (SexMS), a 24-item self-report measure based on self-determination theory, was used to assess a diverse set of sexual motivations. Compulsive sexual behavior was assessed with the 19-item Compulsive Sexual Behavior Disorder Scale (CSBD-19), that is based on the ICD-11 diagnostic guidelines of CSBD. We used structural equation modeling to examine the hypothesized associations between sexual motivations and compulsive sexual behavior and examined potential gender differences in these associations.

OUTCOMES

Compulsive sexual behavior was assessed in relation to a set of sexual motivations.

RESULTS

Amotivation had the strongest positive association with compulsive sexual behavior, but integrated, introjected, and intrinsic motivations were also positively related to it. Importantly, these associations did not differ for women and men, and between the 2 samples.

CLINICAL IMPLICATIONS

Future research and treatment should also consider sexual motivations that are not listed among the ICD-11 guidelines for CSBD, including high levels of sexual interest, continuing the behavior despite having little satisfaction from it and coping with sex.

STRENGTHS & LIMITATIONS

Although we used large samples of general populations in 2 Western countries, this motivational background of compulsive sexual behavior awaits replication in a clinical sample of individuals experiencing CSBD.

CONCLUSION

The identified sexual motivations underlying compulsive sexual behavior are relevant for assessing and treating patients as motivations may be integrated into psychotherapeutic interventions. Koós M, Fuss J, Klein V, et al. Sexual Motivations Underlying Compulsive Sexual Behavior in Women and Men From Germany and Hungary. J Sex Med 2022;19:170-181.

Specific factors and methodological decisions influencing brain responses to sexual stimuli in women

Most of the neuroimaging studies on sexual behavior have been conducted with male participants, leading to men-based models of sexual arousal. Here, possible factors and methodological decisions that might influence brain responses to sexual stimuli, specifically for the inclusion of women, will be reviewed. Based on this review, we suggest that future studies consider the following factors: menstrual phase, hormonal contraception use, history of sexual or psychiatric disorders or diseases, and medication use. Moreover, when researching sexual arousal, we suggest future studies assess sexual orientation and preferences, that women should select visual sexual stimuli, and a longer duration than commonly used. This review is thought to represent a useful guideline for future research in sexual arousal, which hopefully will lead to a higher inclusion of women and therefore more accurate neurobiological models of sexual arousal.

Hypersexuality in Mixed-Sex Couples: A Dyadic Longitudinal Study

Emotion dysregulation and intimacy problems are theoretically underpinned correlates of hypersexuality (i.e., uncontrollable sexual urges, fantasies, and behaviors resulting in distress and impairment in different areas of functioning), but the directionality of these associations has not been established, as work in this area has relied on cross-sectional designs. Moreover, although hypersexuality may have significant adverse effects on romantic relationships and approximately half of treatment-seeking individuals are in a relationship, prior studies almost exclusively involved samples of men, regardless of their relationship status. The aim of the present study was to examine the directionality of associations between both partners' emotion dysregulation, physical (i.e., partnered sexual frequency) and relationship intimacy, and hypersexuality using a longitudinal, dyadic framework. Self-reported data of 267 mixed-sex couples (M_{age_men} = 29.9 years, SD = 8.2; M_{age_women} = 27.7 years, SD = 6.7) at baseline (T1) and six-month follow-up (T2) were analyzed using a crossed-lagged model within an actor-partner interdependence framework. Prior greater emotion dysregulation (T1) in both men and women was associated with their own later greater hypersexuality (T2). Women's prior greater hypersexuality (T1) was associated with their later lower relationship intimacy (T2). Lower levels of intimacy were not significantly associated with later hypersexuality. No partner effects were found in relation to hypersexuality. Findings suggest that men and women may use sexual behaviors to cope with negative emotions, which could, in turn, lead to hypersexuality. Intimacy problems did not precede hypersexuality, although women's hypersexuality may reduce their own relationship intimacy over time.

Women in Relationships and Their Pornography Use: A Systematic Review and Thematic Synthesis

A systematic review and thematic synthesis were conducted on the motivations, purposes, and influence of pornography use among women who are in committed relationships. Pornography use was identified as having both positive and negative outcomes for women's sexual and relationship lives. Women watched pornography for diverse reasons: to feel sexually empowered, to enhance sexual arousal, and for masturbation purposes. Shared use of pornography with partners provided variety in sexual activities, could aid communication about sexual issues and helped improve intimacy. Pornography use can help some women feel sexually empowered, relaxed and better able to enjoy their sexual lives.

The negative consequences of hypersexuality: Revisiting the factor structure of the Hypersexual Behavior Consequences Scale and its correlates in a large, non-clinical sample

Introduction

Despite the growing literature about hypersexuality and its negative consequences, most studies have focused on the risk of sexually transmitted infections (STI’s), resulting in relatively few studies about the nature and the measurement of a broader spectrum of adverse consequences.

Methods

The aim of the present study was to examine the validity and reliability of the Hypersexual Behavior Consequence Scale (HBCS) in a large, non-clinical population (N = 16,935 participants; females = 5854, 34.6%; M_age = 33.6, SD_age = 11.1) and identify its factor structure across genders. The dataset was divided into three independent samples, taking into consideration gender ratio. The validity of the HBCS was investigated in relation to sexuality-related questions (e.g., frequency of pornography use) and the Hypersexual Behavior Inventory (Sample 3).

Results

Both the exploratory (Sample 1) and confirmatory (Sample 2) factor analyses (CFI = 0.954, TLI = 0.948, RMSEA = 0.061 [90% CI = 0.059–0.062]) suggested a first-order, four-factor structure that included work-related problems, personal problems, relationship problems, and risky behavior as a result of hypersexuality. The HBCS showed adequate reliability and demonstrated reasonable associations with the examined theoretically relevant correlates, corroborating the validity of the HBCS.

Conclusion

Findings suggest that the HBCS may be used to assess consequences of hypersexuality. It may also be used in clinical settings to assess the severity of hypersexuality and to map potential areas of impairment, and such information may help guide therapeutic interventions.

Spotlight on Compulsive Sexual Behavior Disorder: A Systematic Review of Research on Women

PURPOSE OF REVIEW

World Health Organization recently included compulsive sexual behavior disorder (CSBD) to the upcoming 11th edition of International Classification of Diseases (6C72). Despite the potential benefits of this decision (eg, the acceleration of research in the field will allow the development of effective treatments), previous research focused mainly on men, and as a result, we do not have an accurate clinical picture of compulsive sexual behavior (CSB) among women. Therefore, in this systematic review, we aim to present available knowledge on this topical subject. Literature search was conducted in the guideline of PRISMA methodology. Studies were identified from multiple databases including Academic Search Ultimate, SocINDEX, PsycARTICLES, PsycINFO, PubMed, and MEDLINE. Out of a total of 10,531 articles identified and screened, 58 were included in this review. Included studies covered the following topics: prevalence and etiology of CSB, behavioral and cognitive processes involved, comorbidities, personality traits, psychosocial and interpersonal difficulties, traumatic experiences, and treatments.

RECENT FINDINGS

Available studies indicate that CSB symptom severity is lower in women than in men. Overall, women reported consuming pornography less often than men and exhibit lower rates of feeling urges to these materials. CSB symptoms (including problematic pornography use) have been found to be positively related to trait psychopathy, impulsivity, sensation seeking, attention-deficit/hyperactivity disorder symptoms, obsessive-compulsive disorder, pathological buying, sexual dysfunctions, general psychopathology, child sexual abuse, while negatively related to dispositional mindfulness.

SUMMARY

Conclusions that can be drawn from prior studies are considerably limited. There are no accurate estimates of the CSB prevalence or severity among women, and studies have been mostly conducted on non-clinical populations, which has limited application for women diagnosed with CSBD.

Validation of a Brief Pornography Screen across multiple samples

BACKGROUND AND AIMS

To address current gaps around screening for problematic pornography use (PPU), we initially developed and tested a six-item Brief Pornography Screen (BPS) that asked about PPU in the past six months.

METHODS AND PARTICIPANTS

We recruited five independent samples from the U.S. and Poland to evaluate the psychometric properties of the BPS. In Study 1, we evaluated the factor structure, reliability, and elements of validity using a sample of 224 U.S. veterans. One item from the BPS was dropped in Study 1 due to low item endorsement. In Studies 2 and 3, we further investigated the five-item the factor structure of the BPS and evaluated its reliability and validity in two national U.S. representative samples (N = 1,466, N = 1,063, respectively). In Study 4, we confirmed the factor structure and evaluated its validity and reliability using a sample of 703 Polish adults. In Study 5, we calculated the suggested cut-off score for the screen using a sample of 105 male patients seeking treatment for compulsive sexual behavior disorder (CSBD).

RESULTS

Findings from a principal components analysis and confirmatory factor analysis supported a one-factor solution which yielded high internal consistency (α = 0.89-0.90), and analyses further supported elements of construct, convergent, criterion, and discriminant validity of the newly developed screen. Results from a Receiver Operating Characteristic (ROC) curve suggested a cut-off score of four or higher for detecting possible PPU.

CONCLUSIONS

The BPS appears to be psychometrically sound, short, and easy to use in various settings with high potential for use in populations across international jurisdictions.

The Relational and Bodily Experiences Theory of Sexual Desire in Women

We review the theory and research on women's sexual desire and present a theory that incorporates internalized representations of relational and bodily experiences into our understanding of the full range of desire in women. To this end, we move away from the current tendency to focus on low sexual desire in women and instead consider desire on a spectrum or continuum from absent or diminished to high desire across multiple sexual orientations, including heterosexual, bisexual, and lesbian. We review definitions of sexual desire, as well as the epidemiology and etiology of hypoactive sexual desire, the most prevalent sexual complaint in women, including the biological, psychological, and relationship correlates of inhibited sexual desire. Subsequently, we examine the research on highly sexual women, who tend to experience high levels of sexual desire, sexual agency, and sexual esteem, and distinguish between high sexual desire and hypersexuality. We introduce two important constructs that are integrated into the Relational and Bodily Experiences Theory (RBET) of sexual desire in women: attachment and sexual body self-representations, suggesting that women's internalized representations of self and other that stem from childhood and their capacity to embody their sexual bodies are integral to our understanding of the phenomenology of sexual desire in women. RBET calls for further research into the links between attachment, sexual body self-representations, and desire, and suggests that clinical interventions for sexual desire difficulties in women should emphasize internalized working models of relationships (i.e., attachment) and integrate bodily based approaches.

A Model of Female Sexual Desire: Internalized Working Models of Parent-Child Relationships and Sexual Body Self-Representations

The etiology of low female sexual desire, the most prevalent sexual complaint in women, is multi-determined, implicating biological and psychological factors, including women's early parent-child relationships and bodily self-representations. The current study evaluated a model that hypothesized that sexual body self-representations (sexual subjectivity, self-objectification, genital self-image) explain (i.e., mediate) the relation between internalized working models of parent-child relationships (attachment, separation-individuation, parental identification) and sexual desire in heterosexual women. We recruited 614 young, heterosexual women (M = 25.5 years, SD = 4.63) through social media. The women completed an online survey. Structural equation modeling was used. The hypotheses were supported in that the relation between internalized working models of parent-child relationships (attachment and separation-individuation) and sexual desire was mediated by sexual body self-representations (sexual body esteem, self-objectification, genital self-image). However, parental identification was not related significantly to sexual body self-representations or sexual desire in the model. Current findings demonstrated that understanding female sexual desire necessitates considering women's internalized working models of early parent-child relationships and their experiences of their bodies in a sexual context. Treatment of low or absent desire in women would benefit from modalities that emphasize early parent-child relationships as well as interventions that foster mind-body integration.