Compulsive sexual behavior disorder in 42 countries: Insights from the International Sex Survey and introduction of standardized assessment tools

Behavioral Addiction Treatment Centers in the Hospitals of Türkiye: A Web-Based Research

This study investigates the current landscape of behavioral addiction treatment in Türkiye hospitals, considering both inpatient and outpatient approaches. The analysis involved examining the websites of 1393 hospitals across Türkiye based on various criteria. The review of the websites was conducted between June and September 2023. The findings reveal that out of these hospitals, comprising 822 public and 571 private institutions, only 51 provide treatment for behavioral addictions. Behavioral addiction treatments are available in 23 of the 81 provinces in Türkiye, and 24 out of the 51 hospitals offering treatment for behavioral addictions are located in İstanbul (47.1%), while three (5.9%) are located in Ankara. Among these 51 hospitals, 22 are public, and 29 are private. The primary focus of treatment revolves around internet and gambling addiction. Upon analyzing the patient groups served, it was observed that 49% (n = 25) of the hospitals specialize in treating adult patients, while 29.4% (n = 15) cater to pediatric patients. While the websites of 11 hospitals contain information about the behavioral addiction treatments offered, they lack any information on the patient groups to which they cater. The predominant treatment modalities include psychotherapy (25.49%), followed by psychopharmacotherapy (19.61%) and cognitive-behavioral therapy (17.65%). In conclusion, the treatment of behavioral addictions, such as those related to the internet, gaming, and shopping, are offered in hospitals across various regions and age groups. Considering that only 3.7% of hospitals in Türkiye treat behavioral addictions, this type of treatment is not widespread.

Chemsex and compulsive sexual behavior among sexual minority men

INTRODUCTION

Chemsex, or the use of specific psychoactive substances to enhance or prolong sexual encounters, is increasingly prevalent among sexual minority men and is linked to adverse health outcomes.

AIM

This study examines the co-occurrence of chemsex and compulsive sexual behavior disorder (CSBD) among sexual minority men and whether this co-occurrence is connected to mental and sexual health concerns.

METHODS

A sample of 289 sexual minority men (223 gay men and 66 bisexual men), recruited primarily through the dating/hookup application Grindr, completed measures of chemsex participation, CSBD, substance use disorder symptoms, and health outcomes. CSBD was measured with the Compulsive Sexual Behavior Disorder Scale-7 (CSBD-7), which uses a psychometrically validated cut-off for identifying individuals who are at high risk of experiencing CSBD.

RESULTS

Chemsex participation (15.2%) and falling above the CSBD-7 cut-off (34.3%) were prevalent, with 9.3% of participants endorsing both. Chemsex, compared to alcohol and marijuana use during sex, was more strongly associated with sexual and mental health outcomes. Individuals reporting chemsex and/or falling above the CSBD-7 cut-off, experienced greater depression and anxiety compared to those without these concerns. However, only individuals reporting the co-occurrence of chemsex and CSBD endorsed greater sexual health concerns, such as condomless anal sex and HIV infection. Participants only endorsing chemsex were not included in the analyses due to low frequency.

DISCUSSION

This study suggests that chemsex and CSBD co-occur and are connected to negative health outcomes, such as depression and condomless anal sex. Notably, differences in sexual health concerns (i.e., condomless anal sex, HIV infection, and the use of poppers and erectile dysfunction medications during sex) were only identified when participants endorsing chemsex were included in analyses, suggesting that CSBD's connection to sexual risk may arise from a subset of individuals struggling with chemsex. Lastly, chemsex, popper use, and erectile dysfunction medication use during sex appear more strongly connected to CSBD than marijuana or alcohol use during sex. Future research is needed using larger samples, longitudinal approaches, and more refined measures of chemsex.

Posttraumatic Stress Disorder Symptoms Moderate the Association between Childhood Sexual Abuse and Compulsive Sexual Behavior Among Adults in Residential Substance Use Treatment

Compulsive sexual behavior (CSB) is common among people with substance use disorders (SUDs) and these behaviors may mutually reinforce each other. Thus, research into risk factors for CSB in this population could inform interventions that reduce CSB and stifle this reinforcement pattern. People with SUDs report high rates of childhood abuse and posttraumatic stress disorder (PTSD) symptoms, which are also empirically supported risk factors for CSB. We examined the moderating effect of PTSD symptoms on the associations between forms of childhood abuse (i.e., physical, sexual, emotional) and CSB among 707 patients in residential treatment for SUDs (Mage = 40.8 years, SD = 12.1; 73.6% men). PTSD symptoms moderated the association between childhood sexual abuse, but not other forms of childhood abuse, and CSB. Childhood sexual abuse was positively related to CSB at high, but not low or mean levels of PTSD symptoms. Childhood emotional abuse was also related to CSB, whereas childhood physical abuse was not significantly related to CSB. Findings indicate that PTSD symptoms could exacerbate the association between childhood sexual abuse and CSB. Future applied studies might consider exploring whether trauma-focused interventions can reduce CSB in patients with SUDs who are survivors of childhood sexual abuse.

The Multifaceted Impact of the SARS-CoV-2 Pandemic on Sexual Health, Function, and Behaviors: Implications for Public Health: A Scoping Review

BACKGROUND

The SARS-CoV-2 pandemic had a significant impact on sexual health and human behavior, revealing a widespread decline in sexual function and behaviors.

OBJECTIVE

To summarize these findings and highlight their importance for public health, this article discusses the changes observed in sexual function and behavior during the pandemic, as well as potential explanations for these trends.

METHODS

This study followed the PRISMA-ScR guidelines, using the keyword search commands: "sexual function" AND ("SARS-CoV-2" OR "COVID-19" OR coronavirus) and "sexual behavior*" AND ("SARS-CoV-2" OR "COVID-19" OR coronavirus) in the Scopus and PubMed databases. The search was conducted on 10 March 2024, including articles published from January 2019 to March 2024. Inclusion criteria required studies focusing on sexual health/function during the SARS-CoV-2 pandemic, excluding non-English articles and non-adult populations. Studies were screened based on relevance, methodological rigor, and sample size, with data extraction focusing on sexual behavior/function metrics. Results were synthesized to identify trends and propose explanatory models.

RESULTS

While some individuals experienced reductions in sexual desire and activities, others reported increases, indicating varied individual responses to stressors such as a pandemic. Two hypotheses are presented to explain these changes: terror management theory and the dual control model of sexual response. The critical role of public health in addressing sexual health and well-being needs during a health crisis is discussed, emphasizing the importance of providing clear information, ensuring access to remote sexual health services, and reducing stigma. The need to integrate sexual health into the global response to future health crises is highlighted to ensure a comprehensive approach to human well-being.

CONCLUSIONS

This review shows the multifaceted impact of the pandemic and social distancing in people's sexual function and behaviors, underscoring the importance of considering sexual health as an integral part of the emergency health planning and response, to promote the physical and mental well-being of the population during crises such as the SARS-CoV-2 pandemic.

Current Advances in Behavioral Addictions: From Fundamental Research to Clinical Practice

Gambling disorder is the only behavioral addiction recognized as a clinical disorder in DSM-5, and Internet gaming disorder is included as a condition requiring further research. ICD-11 categorizes gambling and gaming disorders as disorders due to addictive behaviors. Additional behavioral addictions may include compulsive sexual behavior disorder, compulsive buying-shopping disorder, and problematic use of social media. This narrative review summarizes the current state of knowledge regarding these five (potential) disorders due to addictive behaviors. All five (potential) disorders are clinically relevant and prevalent. Behavioral addictions frequently co-occur with other mental and behavioral problems, such as depression, anxiety, and attention deficit hyperactivity disorder. Validated diagnostic instruments exist, with empirical support varying across conditions. No medications have approved indications from regulatory bodies for behavioral addictions, and cognitive-behavioral therapy has the most empirical support for efficacious treatment. Given that behavioral addictions are prevalent, frequently co-occur with psychiatric disorders, may often go undiagnosed and untreated, and have been linked to poorer treatment outcomes, active screening and treatment are indicated. Public health considerations should be expanded, and impacts of modern technologies should be investigated more intensively. Treatment optimization involving pharmacotherapy, psychotherapy, neuromodulation, and their combination warrants additional investigation.

Metacognitive beliefs and desire thinking as potential maintenance factors of compulsive sexual behavior

Using the Elaborated Intrusion Theory of Desire and the Self-Regulatory Executive Function model of psychopathology as bases, this study explored whether metacognitive beliefs and desire thinking (DT) are associated with higher levels of Compulsive Sexual Behavior (CSB). A total of 1185 participants from the general population were included in the study (mean ± SD age = 25.32 years ± 5.58; age range = 18-19 years; females = 76.7 %). Metacognitive beliefs, DT, CSB, anxiety and depressive symptoms were assessed. Correlation analyses and path analyses were run. Results of the path analysis showed that positive metacognitive beliefs about DT were associated with DT-Imaginal Prefiguration (DT-IP), which in turn was positively associated with DT-Verbal Perseveration (DT-VP). The latter was strongly and positively associated with negative metacognitive beliefs about DT, which in turn was linked to CSB. Moreover, DT-VP was also found to be directly linked to the outcome variable and positive metacognitive beliefs about DT were also directly linked to DT-VP and negative metacognitive beliefs about DT. The total Coefficient of Determination (0.45) indicated a good fit to the observed data. Metacognitive beliefs and DT may be potential maintenance factors in CSB. Metacognitive beliefs and DT could also be considered as potential therapeutic targets in clinical interventions aimed at reducing the severity of CSB.

Compulsive sexual behavior, sexual functioning problems, and their linkages to substance use among German medical students: exploring the role of sex and trauma exposure

Sexual problems relevant to psychotherapy, such as compulsive sexual behavior (CSB) and sexual functioning problems (SFP), have been related to harmful substance use in several studies. Substance use is prevalent among medical students (MS) and is often considered a maladaptive coping strategy for stress, as well as a risk factor for mental health issues. Sexual problems and substance use share trauma exposure and post-traumatic symptoms as risk factors for their development. This study aimed to explore the interaction effects between problematic sexual behaviors, substance use, and trauma among German MS. A cross-sectional study (n = 359; 69% women, 29% men) was conducted using an online questionnaire. MS at a German university were recruited via email. CSB (CSBD-19), SFP (SBQ), harmful alcohol (AUDIT) and drug use (DAST), childhood trauma exposure (CTQ), and current post-traumatic symptoms (IES-R) were assessed. Multivariate linear and ordinal regressions, as well as path analyses, were conducted to investigate associations between the study variables. CSB was identified in 3% of all MS. The most commonly reported SFPs were decreased sexual desire and difficulties achieving orgasms among women and premature ejaculation among men. Higher CSBD scores were predicted by male sex, elevated AUDIT scores, and increased frequencies of hyperarousal (IES-R). Path analyses revealed associations between the severity of emotional/sexual abuse, the intensity of post-traumatic symptoms, and both CSBD and AUDIT scores. Among female MS, less severe emotional abuse and more severe physical abuse in childhood predicted higher frequencies of orgasmic difficulties. The frequency of SFPs was correlated with the use of benzodiazepines among female MS, with cannabis and MDMA/ecstasy among male MS, and with cocaine/crack, speed, and AUDIT among both sexes. No interaction effects were found between SFPs, substance use, or trauma-related factors in the path analyses. To some extent, there appears to be a relationship between substance use, childhood trauma exposure, and currently persisting post-traumatic symptoms with problematic sexual behaviors among MS. However, further research is required to explore these relationships in greater depth and to identify the underlying pathways. Mental health support measures should incorporate the factors of sexuality, substance use, and trauma while also exploring their relationships with workload, career-related anxieties, and other curriculum-related factors.

The Bergen-Yale Sexual Addiction Scale (BYSAS): Longitudinal Measurement Invariance Across a Two-Year Interval

The Bergen-Yale Sexual Addiction Scale (BYSAS; [1]) is arguably the most popular questionnaire at present for assessing sex addiction. Employing Confirmatory Factor Analysis (CFA) and treating item scores as ordered categorical, we applied Weighted Least Square Mean and Variance Adjusted Chi-Square (WLSMV) extraction to investigate the longitudinal measurement and structural invariance of ratings on the BYSAS among 276 adults (mean = 31.86 years; SD = 9.94 years; 71% male) over a two-year period, with ratings at three yearly intervals. Overall, there was support for configural invariance, full loading, full threshold, the full unique factor invariance; and all structural (latent variances and covariances) components. Additionally, there was no difference in latent mean scores across the three-time points. The psychometric and practical implications of the findings are discussed.

The Role of Positive and Negative Metacognitions About Sex in the Relationship Between Psychological Distress and Problematic Consumption of Pornography. A Mediation Model

Objective

This study aims to examine how positive and negative metacognitions about sex (MSS) mediate the relationship between psychological distress and problematic consumption of pornography.

Method

821 individuals from Romania, aged 18-70 (M = 27.21; SD = 8.74), 64.4% of whom were women.

Results

Both positive and negative MSS mediated the link between psychological distress and problematic consumption of pornography.

Conclusion

MSS plays a crucial role in understanding the dynamics between psychological distress and problematic consumption of pornography. The study contributes to filling a gap in the literature by exploring MSS in this context. Theoretical and practical implications are discussed.

The Associations Between Attachment Insecurity and Compulsive Sexual Behavior Disorder or Problematic Pornography Use: The Mediating Role of Emotion Regulation Difficulties

Compulsive sexual behavior disorder (CSBD) was previously considered an attachment disorder, while emotion dysregulation was thought to potentially be a key characteristic of it. However, this theoretical model was not tested in previous empirical research. In our cross-sectional study, we tested whether emotional regulation (ER) difficulties can be adopted as an explanatory mechanism for the relationships between attachment avoidance and anxiety, as well as CSBD and its most prevalent behavioral presentation-problematic pornography use (PPU). Participants (n = 1002; Mage = 50.49 years, SD = 13.32; men: 50.2%) completed an online survey regarding the investigated variables. In mediation analyses, attachment avoidance and anxiety were treated as simultaneous predictors, ER difficulties as a mediating variable, with CSBD/PPU severity as dependent variables. Emotion regulation difficulties and attachment anxiety had a direct positive effect on both CSBD and PPU. The direct effect of attachment avoidance on PPU was non-significant, and significant for CSBD depending on the measure used. Moreover, all the relationships between both insecure attachment dimensions and CSBD/PPU symptom severity were at least partially mediated by ER difficulties. Our results corroborate the theoretical claim that ER difficulties may be a useful framework for explaining the impact of attachment insecurity on CSBD/PPU. Theoretical and practical implications of the findings are discussed.

Compulsive sexual behaviour in Iranian married women: Prevalence, sociodemographic, sexual, and psychological predictors across-country

Background and Aims

This study addresses the scarcity of research on Compulsive Sexual Behavior Disorder (CSBD) in non-Western cultures and women, exploring its prevalence, sociodemographic, sexual history characteristics, and sexual and psychological health factors in Iranian married women.

Methods

A cross-sectional study involving 772 heterosexual married women was conducted between 2022 and 2023, covering all 31 provinces of Iran. Participants were categorized as CSBD+ (at-risk individuals) and CSBD- (low-risk individuals) based on a pre-established cut-off point of ≥18 by the Compulsive Sexual Behavior Disorder Scale -7. Depression, anxiety, obsessive-compulsive disorder, self-esteem, sexual distress, sexual satisfaction, relationship satisfaction, and sexual dysfunction were assessed as psychological and sexual health variables by standardized scales.

Results

The prevalence of CSBD was 3.8% in women. Linear regression analysis showed that lower education, being jobless, substance use, pornography use, paraphilic behaviors, conflict on sex frequency, relationship, orgasm and sexual dissatisfaction, higher sexual arousal, depression, and obsessive-compulsive symptoms were positively associated with CSBD. The univariate analysis, at a stringent significance level of 0.005, mirrored the regression findings. Additionally, women with CSBD+ exhibited lower religiousness and higher anxiety compared to those without CSBD-.

Discussion and Conclusions

Raising awareness of CSBD is crucial for health systems and individuals for better policy-making and help-seeking behavior. Identifying risk factors like substance use presents opportunities for prevention, and the association of CSBD with sexual and mental health variables suggests addressing co-occurring issues for improved treatment outcomes. Recognizing culture and gender-specific sexual and psychological correlates enables targeted and effective treatment approaches.

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.

LGBQ-affirming clinical recommendations for compulsive sexual behavior disorder

Background and aims

Since the inclusion of Compulsive Sexual Behavior Disorder (CSBD) in the International Classification of Diseases (11th ed.), there has been little effort placed into developing clinical recommendations for lesbian, gay, bisexual, and queer (LGBQ) clients with this condition. Thus, we develop preliminary clinical recommendations for mental health professionals working with LGBQ clients who may be struggling with CSBD.

Methods

The present paper synthesizes the CSBD literature with advances in LGBQ-affirming care to develop assessment and treatment recommendations. These recommendations are discussed within the context of minority stress theory, which provides an empirically supported explanation for how anti-LGBQ stigma may contribute to the development of mental health conditions in LGBQ populations.

Results

Assessment recommendations are designed to assist mental health professionals in distinguishing aspects of an LGBQ client's sociocultural context from CSBD symptomology, given recent concerns that these constructs may be wrongly conflated and result in misdiagnosis. The treatment recommendations consist of broadly applicable, evidence-based principles that can be leveraged by mental health professionals of various theoretical orientations to provide LGBQ-affirming treatment for CSBD.

Discussion and Conclusions

The present article provides theoretically and empirically supported recommendations for mental health professionals who want to provide LGBQ-affirming care for CSBD. Given the preliminary nature of these recommendations, future research is needed to investigate their clinical applicability and efficacy.

Compulsive sexual behavior disorder: The importance of research on women

The current understanding of compulsive sexual behavior disorder (CSBD) is primarily based on studies involving non-clinical samples of heterosexual men, resulting in significant gaps in knowledge regarding women with CSBD. The commentary highlights the domains where further research is necessary, including incidence and prevalence, etiology, diagnostic criteria, comorbidities, sexual patterns, personality profiles, and barriers to help-seeking among women with CSBD. Bridging this research gap is essential for improving clinical care, developing tailored interventions, and increasing awareness about CSBD in women among healthcare providers, policymakers, and the general public.

Examination of Gender Differences in Depression, Relationship Satisfaction, and Problematic Pornography Use Among Romanian Gay Men and Lesbian Women

This study investigates factors influencing the psychological well-being of gay and lesbian individuals in Romania. Participants (N = 172) included 61.6% gay and 38.4% lesbians, currently in relationships, aged between 18 and 62 years (M = 28.28; SD = 9.53). Surveys assessed relationship satisfaction, depression, and problematic pornography use. Significant associations were found among these variables, with gender differences observed. We tested a regression model for problematic pornography use, where depression provided additional explanatory power to the initial model. Age, gender, and depression accounted for 18% of the variance in problematic pornography use. The theoretical and practical implications are discussed.

Psychometric properties of the Alcohol Use Disorders Identification Test (AUDIT) across cross-cultural subgroups, genders, and sexual orientations: Findings from the International Sex Survey (ISS)

INTRODUCTION

Despite being a widely used screening questionnaire, there is no consensus on the most appropriate measurement model for the Alcohol Use Disorders Identification Test (AUDIT). Furthermore, there have been limited studies on its measurement invariance across cross-cultural subgroups, genders, and sexual orientations.

AIMS

The present study aimed to examine the fit of different measurement models for the AUDIT and its measurement invariance across a wide range of subgroups by country, language, gender, and sexual orientation.

METHODS

Responses concerning past-year alcohol use from the participants of the cross-sectional International Sex Survey were considered (N = 62,943; Mage: 32.73; SD = 12.59). Confirmatory factor analysis, as well as measurement invariance tests were performed for 21 countries, 14 languages, three genders, and four sexual-orientation subgroups that met the minimum sample size requirement for inclusion in these analyses.

RESULTS

A two-factor model with factors describing 'alcohol use' (items 1-3) and 'alcohol problems' (items 4-10) showed the best model fit across countries, languages, genders, and sexual orientations. For the former two, scalar and latent mean levels of invariance were reached considering different criteria. For gender and sexual orientation, a latent mean level of invariance was reached.

CONCLUSIONS

In line with the two-factor model, the calculation of separate alcohol-use and alcohol-problem scores is recommended when using the AUDIT. The high levels of measurement invariance achieved for the AUDIT support its use in cross-cultural research, capable also of meaningful comparisons among genders and sexual orientations.

Development and Validation of the Metacognitions about Sex Scale: Exploring its Role as a Mediator between Negative Affect, Emotion Dysregulation Strategies, and Compulsive Sexual Behavior Disorder

Metacognitions about sex are theorized to shape cognitive appraisal, coping mechanisms, and regulation or dysregulation before, during, and/or after exposure to sexual stimuli. In our study, we examined the construct structure and validity of the Metacognitions about Sex Scale (MSS) among a sample of adolescents. We estimated the convergent validity of the MSS by factors: negative affect, dysregulated thoughts, and impulsivity, and compulsive sexual behavior (CSB). We also ran a structural equation model in which we examined the possibility that metacognitions about sex would mediate the association between negative affect, dysregulated thoughts, and impulsivity on the one hand, and CSB on the other. The study population included 662 adolescents (252 boys and 410 girls, M = 16.70, SD = 1.32) between 13-18 years of age. The analyses indicated that the factorial structure of the MSS comprised the two expected factors. We also found that positive and negative metacognitions about sex significantly mediated the effect of negative affect, dysregulated thoughts, and impulsivity on CSB. The findings provide evidence that MSS among Israeli adolescents are psychometrically appropriate for use by researchers and practitioners in the prevention and treatment of CSB.