Arch Sex Behav
DOI 10.1007/s10508-014-0356-5
ORIGINAL PAPER
Sexual Compulsivity Scale, Compulsive Sexual Behavior Inventory,
and Hypersexual Disorder Screening Inventory: Translation,
Adaptation, and Validation for Use in Brazil
Marco de T. Scanavino • Ana Ventuneac • H. Jonathon Rendina •
Carmita H. N. Abdo • Hermano Tavares • Maria L. S. do Amaral •
Bruna Messina • Sirlene C. dos Reis • João P. L. B. Martins • Marina C. Gordon
Julie C. Vieira • Jeffrey T. Parsons
Received: 1 October 2013 / Revised: 19 February 2014 / Accepted: 10 March 2014
 Springer Science+Business Media New York 2014
Abstract Epidemiological, behavioral, and clinical data on
sexual compulsivity in Brazil are very limited. This study sought
to adapt and validate the Sexual Compulsivity Scale (SCS), the
22-item version of the Compulsive Sexual Behavior Inventory
(CSBI-22), and the Hypersexual Disorder Screening Inventory
(HDSI) for use in Brazil. A total of 153 participants underwent
psychiatric assessment and completed self-reported measures.
The adaptation process of the instruments from English to
Portuguese followed the guidelines of the International Society
for Pharmacoeconomics and Outcomes Research. The reliabil-
ity and validity of the HDSI criteria were evaluated and the con-
struct validity of all measures was examined. For the SCS and
HDSI, factor analysis revealed one factor for each measure. For
the CSBI-22, four factors were retained although we only calcu-
lated the scores of two factors (control and violence). All scores
had good internal consistency (alpha[.75), presented high
M. T. Scanavino
M. L. S. Amaral
B. Messina

S. C. Reis
J. P. L. B. Martins
M. C. Gordon
J. C. Vieira
Department and Institute of Psychiatry (IPq), Clı́nicas’ Hospital (HC),
University of São Paulo Medical School (FMUSP),
Sao Paulo, Brazil
A. Ventuneac
H. J. Rendina
J. T. Parsons
Center for HIV/AIDS Educational Studies and Training (CHEST),
New York, NY, USA
H. J. Rendina
J. T. Parsons
Basic and Applied Social Psychology Doctoral Program, The
Graduate Center of the City University of New York (CUNY),
New York, NY, USA
J. T. Parsons
Department of Psychology, Hunter College and the Graduate
Center of the City University of New York (CUNY),
New York, NY, USA
•
temporal stability ([.76), discriminated between patients and
controls, and presented strong (q[.81) correlations with the Sex-
ual Addiction Screening Test (except for the violence domain =
.40) and moderate correlations with the Impulsive Sensation
Seeking domain of the Zuckerman Kuhlman Personality Ques-
tionnaire(q between .43and .55). The sensitivityof the HDSI was
71.93 % and the specificity was 100 %. All measures showed
very good psychometric properties. The SCS, the HDSI, and the
control domain of the CSBI-22 seemed to measure theoretically
similar constructs, as they were highly correlated (q[.85). The
findings support the conceptualization of hypersexuality as a
cluster of problematic symptoms that are highly consistent across
a variety of measures.
Keywords Sexual compulsivity
Hypersexual disorder

Compulsive sexual behavior
HIV
Psychometric properties
J. T. Parsons
HealthPsychologyDoctoralProgram,TheGraduateCenteroftheCity
University of New York (CUNY), New York, NY, USA
J. T. Parsons
The CUNY School of Public Health at Hunter College,
New York, NY, USA
M. T. Scanavino (&)
Rua Mato Grosso, 306, conj. 614, Sao Paulo, SP 01239-040, Brazil
e-mail: scanavino@gmail.com
C. H. N. Abdo
H. Tavares
Department of Psychiatry, University of São Paulo Medical School
(FMUSP), Sao Paulo, Brazil
123

Introduction
Sexual compulsivity (SC) is increasingly being recognized as an
important phenomenon among researchers and clinicians. Gener-
ally characterized as sexual fantasies, urges, and behaviors (e.g.,
excessive masturbation, excessive use of pornography, multiple
casual sex partners) that increase in intensity and frequency over
time and lead to negative outcomes, such as unemployment,
financial problems, divorce, social isolation, and sexually trans-
mitted infections (Black, 2000; Goodman, 2001; Kafka, 2010;
Kalichman & Rompa, 1995; Kuzma & Black, 2008; Morgen-
stern et al., 2011; Muench et al., 2007; Parsons, Grov, & Golub,
2012; Parsons, Kelly, Bimbi, Muench, & Morgenstern, 2007;
Raymond, Coleman, & Miner, 2003), researchers have drawn
on impulse control, emotion regulation, compulsivity, and addic-
tion models of behavior to obtain epidemiological evidence for
SC and its correlates (Kafka, 2010). The utility of standardized
instruments and rating scales has become paramount for
research conducted in the United States. In the context of public
health, it was critical to examine the association between SC and
an increased risk for HIV transmission in different sample pop-
ulations, such as HIV-positive men and women (Benotsch, Kalich-
man, & Pinkerton, 2001; Kalichman & Rompa, 2001), hetero-
sexual college students (Dodge, Reece, Cole, & Sandfort, 2004),
and male escorts (Parsons, Bimbi, & Halkitis, 2001). In the
clinical context, SC rating scales make it possible to differentiate
clinical and non-clinical samples, with regard to SC (Coleman,
Miner, Ohlerking, & Raymond, 2001; Delmonico, Bubenzer, &
West, 1998; Silveira, Vieira, Palomo, & Silveira, 2000), and to
evaluate the effect of an intervention in a clinical trial (Wainberg
et al., 2006).
Research literature on SC conducted outside of the U.S. is
sparse. There are a few case reports (e.g., Gulzun, Gulcat, &
Aydin, 2007; Scanavino, Torres, Abdo, Rego, & Fernandez,
2009) and population-based studies (e.g., Langstrom & Hanson,
2006). Most of SC measures are not translated and adapted to
other languages, with just a couple of exceptions such as the
Sexual Compulsivity Scale (SCS) (Kalichman et al., 1994) and
the 22-item version of the Compulsive Sexual Behavior Inven-
tory (CSBI) (Miner, Coleman, Center, Ross, & Rosser, 2007).
The validated Spanish version of the SCS was investigated in a
sample of college students in Spain (Ballester Arnal, Gómez
Martı́nez, Gil Llario, & Salmerón Sánchez, 2012), while the
Spanish version of CSBI-22 was investigated in a sample of
Latino men in the U.S. (Miner et al., 2007). The SCS and CSBI-
22 are widely used, and their psychometric properties have been
evaluated in several different samples (Hook, Hook, Davis,
Worthington, & Penberthy, 2010). The main difference between
them is that the SCS is a unidimensional measure developed to
evaluate trends of repetitive sexual thoughts and behaviors,
while the CSBI-22 is a multidimensional measure that investi-
gates control over sexual behavior and sexual aggression and
violence.
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Arch Sex Behav
In the U.S., new efforts to establish an operational definition
of SC for researchersandclinicianswithcriteria forthe diagnosis
of hypersexual disorder were underway recently in order to
provide evidence for consideration for inclusion in the DSM-5
(Kafka, 2010, 2013; Womack, Hook, Ramos, Davis, & Pen-
berthy, 2013). The main criteria of hypersexual disorder were
supported by data that emerged from studies using standardized
instruments.Inparticular,thecriteriaregardingsignificantamounts
of time consumed by sexual behaviors, increases in sexual
behavior when experiencing stressful life events, difficulties in
controlling sexual behavior, risk taking behaviors associated
with sexual activity, and clinical distress or impairment in impor-
tant areas of functioning were supported by findings from previ-
ous studies using the SC rating scale (Kalichman & Rompa,
1995, 2001; Kalichman & Cain, 2004; McBride, Reece, &
Sanders, 2008; Miner et al., 2007). The proposal to include hyper-
sexual disorder in the DSM-5 was recently rejected because there
was not sufficient empirical evidence to support its inclusion as a
disorder (American Psychiatric Association, 2012). Neverthe-
less, the newly developed measure, the Hypersexual Diagnostic
Screening Inventory (HDSI), drafted based on the preliminary
recommendations for DSM-5 diagnostic criteria for hypersex-
ual disorder, was shown to be highly reliable in a sample of gay
and bisexual men in the U.S. (Parsons et al., 2013).
In Brazil, epidemiological, behavioral, and clinical data on
SC remain very limited. A search of PubMed and the‘‘Biblioteca
Virtual em Saúde’’ [Virtual Health Library] databases, which
include Medline, Lilacs, and the Cochrane Library, for studies
on SC conducted in Brazil did not identify any clinical or pop-
ulation-based studies that investigated SC and its connections
with HIV or sexually risky behavior. Recently, authors of this
paper worked together on the first empirical study to examine SC
in a treatment-seeking sample in São Paulo, Brazil. We set out to
investigate the psychometric properties of three measures, the
SCS, the CSBI-22, and the HDSI, in a sample composed of
sexually compulsive and non-sexually compulsive individuals
in São Paulo, Brazil. Adaptation and validation of SC rating
scales for use in Brazil will make it possible to investigate epi-
demiological data on SC in another culture, in particular the
connections between SC and sexual risk behavior for HIV
transmission, the prevalence of SC symptoms in the clinical con-
text, and the impact of interventions on SC symptoms. The data
may be compared with previous studies conducted in the United
States, and may increase our inter-cultural understanding of the
SC.
The goals of the current study were to (1) adapt the measures
(the SCS, the 22-item CSBI, and the HDSI) from English to
Portuguese (spoken in Brazil), and provide evidence for their
research utility in Brazil; (2) examine the correspondence
between previously well-utilized measures (SCS and CSBI) and
the newly proposed HDSI; and (3) examine the correspondence
between previously utilized SC diagnostic criteria and the
diagnostic criteria purported to be investigated by HDSI.
Arch Sex Behav
Method
Translation and Cultural Adaptation
The International Society for Pharmacoeconomics and Out-
comes Research (ISPOR) guidelines for the translation and
cultural adaptation of self-report instruments were used (Wild
et al., 2005). We began by obtaining permission from the authors
of the original versions of the SCS, CSBI, and HDSI to adapt
their scales. Two Brazilian psychiatrists who were fluent in
English produced two independent versions of each measure in
Portuguese. We reconciled the two translated versions, resolv-
ing any discrepancies between the versions. A native English
speaker, who had lived in Brazil for the previous eleven years
and who had not worked with the original instrument or either of
the two translated versions, conducted the back translation of the
reconciled versions into English. A researcher in the U.S., who
was familiar with the measures, reviewed and compared the
back translation to the original instruments. To assess question
comprehension, a clinical sample of SC patients reviewed the
questions and indicated whether each question was difficult,
confusing, or caused embarrassment. To check each patient’s
level of understanding, we administered a sliding rating scale
(Clark, Lavielle, & Martı́nez, 2003), in which the patients were
asked to give a score from 1 (did not understand anything) to 5
(understood everything), including decimals (e.g., 1.1, 1.2), to
represent their level of understanding. The results of the
debriefing were analyzed in order to make final changes, and
then final proofreading was performed.
Regarding the SCS, there were no major discrepancies upon
reconciliation of the two translated versions. In the process of
reviewing the back translation by the American researcher, one
discrepancy of meaning was found between the back translation
and the original version. The American researcher noticed that
one of the alternatives to the answer‘‘slightly like me’’had been
translated to ‘‘not like me.’’ The mistake was corrected to
‘‘applies a little to me.’’The final version was administered to 17
sexually compulsive individuals for cognitive debriefing. The
majority (15 of to 17) did not consider any items confusing,
difficult,orembarrassing.A slidingscaleranging from 1 to 5was
used to evaluate the level of understanding of the whole test; the
mean was 4.82 (SD = .29), with a minimum of 4.0 and a max-
imum of 5.0.
No major discrepancies were found among the forward
translated versions of the CSBI-22. In the process of reviewing
the back translation, a discrepancy was noticed regarding the
meaning of the ninth statement‘‘How often have you developed
excuses and reasons to justify your sexual behavior,’’ where
‘‘developed excuses and reasons’’ had been translated to ‘‘gave
excuses.’’It was noted that‘‘to give excuses’’means to justify to
other people but to ‘‘develop excuses and reasons’’ means a
cognitive process of self-justification. We amended the Portu-
guese version based on this observation. The final version was
administered to 17 sexually compulsive individuals for cogni-
tive debriefing. The majority (15–17) did not consider any items
to be confusing, difficult, or embarrassing. A sliding scale
ranging from 1 to 5 was used to evaluate the level of under-
standing of the whole assessment; the mean score was 4.94
(SD = .03), with a minimum of 4.86 and a maximum of 5.0.
During reconciliation of the HDSI, the expression ‘‘risky
sexual behavior,’’which was used in the fifth A criteria (i.e., item
A.5), was changed to‘‘sexual risk behavior’’in the target trans-
lated version, as this is more commonly used by Brazilian health
professionals. No other major discrepancies were found among
the forward translated versions during the reconciliation process
or among the back translation and the original version during
review of the back translation. The final version was adminis-
tered to 14 sexually compulsive individuals for cognitive
debriefing. The majority (12 of 14) did not consider any item
confusing, difficult, or embarrassing. A sliding scale ranging
from 1 to 5 was used to evaluate the level of understanding of
whole assessment; the mean was 4.80 (SD = .29), with a mini-
mum of 4.0 and a maximum of 5.0.
Participants and Procedure
This article presents data from a study conducted at the Institute
of Psychiatry of the Clı́nicas’ Hospital (HC) of the University of
São Paulo Medical School (FMUSP), a public university-based
medical center in São Paulo. Participants were recruited through
advertisements for the research study via several media outlets,
including radio, magazines, and journals. The research study
was also advertised inside Clı́nicas’ Hospital by e-mail and on
wall posters.
Individuals who answered the advertisements were eligible
for the study if they were classified as having an excessive sexual
drive based on the tenth revision of the International Classifi-
cation of Diseases (ICD-10) criteria F52.7 (World Health Orga-
nization, 1992) and met the criteria for sex addiction based on
Goodman’s (2001) criteria. If the individuals did not meet these
criteria, they were eligible to serve as controls. In addition, the
participants had to be 18 years of age or older, and literate in
Portuguese. In order to reduce the effects of comorbid psycho-
pathology, the exclusion criteria for the study included a diag-
nosis of any of the following disorders: preference disorder
(ICD-10 F65), gender identity disorder (ICD-10 F64), schizo-
phrenia, schizotypal, and delusional disorders (ICD-10 F20-
F29), current manic episode (ICD-10 F30) or other mental dis-
orders related to brain dysfunction, injury, or physical disease
(ICD-10 F0.6).
In total, 326 individuals responded to the advertisements, of
whom 273scheduled an in-person screening interview. Ofthese,
207 (75.8 %) appeared for the in-person screening interviews,
and 196 individuals were considered eligible for this study.
Twenty-four individuals (11.6 %) did not return for assessment.
A total of 172 (153 male and 19 female) individuals completed
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 Arch Sex Behav

all of the study assessments from October 2010 until December This study was reviewed and approved by the Ethics Com-
2011. Given that our competency to make any statistical analysis mittee at of the HC-FMUSP.
based on only 19 women enrolled in this study was limited, we
dropped data from women from our analyses. In this article, we Measures
report data from the 153 men enrolled in the study. The HDSI
became available for use a few months after the onset of the Participant Characteristics
study; thus, 32 individuals who were enrolled at the beginning of
the study were not assessed using the HDSI. As a result, we Participants were asked to report their age, gender, legal
evaluated data from the 121 men who completed the HDSI. marital status, race, years of education, and sexual orientation.
Participants provided informed consent and completed a 3-h
assessment that consisted of standardized self-report measures Sexual Compulsivity
and a psychiatric assessment. A nurse asked the participants to
report their sociodemographic characteristics and explained the The SCS (Kalichman et al., 1994; Kalichman & Rompa, 1995)
research process. The participants completed the measures on consists of 10 statements (e.g.,‘‘I have to struggle to control my
their own using a paper and pencil. Trained staff members over- sexual thoughts and behavior.’’) that are rated using a 4-point
saw the process of answering the self-report measures and pro- scale, ranging from 1 (not at all like me) to 4 (very much like me).
vided clarification to participants as requested. Two psychia- Total scores can range from 10 to 40, with higher scores indi-
trists who were familiar with screening people seeking SC treat- cating higher levels of SC symptomology. Some authors (Ben-
ment, and with conducting the treatment of those who met cri- otsch et al., 1999; Cooper, Delmonico, & Burg, 2000; Parsons
teria, were trained by the principal investigator to assess possible et al., 2001) have used a cutoff score of 24 or higher to indicate
cases of SC based on the HDSI algorithm score, namely, at least SC (Hook et al., 2010). A recent review of SC instruments found
four A criteria and one B criteria (see Method section). The high levels of internal consistency (Cronbach’s a) for the SCS
training happened with SC patients under treatment, who were across 30 samples, and that the SCS demonstrated good reli-
assessed and discussed by the psychiatrist team. Most of the ability and validity (Hook et al., 2010).
discrepancies were about participants presenting high severity
of symptoms but who did not get at least four A criteria. In these
Compulsive Sexual Behavior
occasions, we decided to keep the directions given by the DSM-
5 taskforce and these patients were not assigned as a possible
The CSBI (Coleman et al., 2001) originated from a 42-item scale
case of SC. The training stopped when we observed a minimum
that was based on the clinical experiences of individuals with
of discrepancies between the psychiatrist team. When we began
SC. In previous studies, factor analysis has been used and iden-
data collection, the psychiatrists conducted the clinical inter-
tified three factors, namely, control over sexual behavior, sexual
views in order to assess Goodman’s criteria for sexual addiction
violence, and sexual abuse. However, subsequent studies have
(Goodman, 2001) and the diagnostic criteria for excessive sex-
used different versions of this scale (Miner et al., 2007; Muench
ual drive, as well as the diagnostic criteria for the ICD-10 con-
et al., 2007). Given that many of the items that comprise the
ditions that were used as exclusion criteria (World Health
abuse domain are outdated and that studies have failed to iden-
Organization, 1992). They also reviewed the HDSI scores to
tify significant differences between SC subjects and controls
identify which participants met the screening criteria for hyper-
(Coleman et al., 2001), we utilized the more commonly used
sexual disorder. The psychiatrists also determined whether the
22-item version (CSBI-22) (Miner et al., 2007). Participants
questions seemed to be well understood by the participants, and
answer each item of the CSBI-22 using a 5-point Likert-type
if the questions were not understood, the psychiatrists provided
scale, ranging from 1 (very often) to 5 (never). In the CSBI-22,
clarification. Finally, following the algorithm recommended by
the scores can range from 22 to 110, with lower scores repre-
the DSM-5 taskforce, the psychiatrists determined who did and
senting more severe rates of SC (Miner et al., 2007). The CSBI-
did not meet criteria as a possible case of SC.
22 assesses two factors: control (13 items), which measures the
Individuals with SC were offered treatment, and individuals
ability to control sexual behavior, and violence (9 items), which
without SC were offered financial incentives to cover their
measures theexperience ofsexual violence. Investigationsofthe
transportation costs. The second wave of data collection began
psychometric properties of the CSBI show good reliability and
in the Spring of 2011. Of the 153 participants, 99 responded the
validity (Hook et al., 2010).
measures a second time with 2 weeks of interval. All 54 non-
responders were SC individuals (i.e., patients), and a greater
proportion of them identifiedas gay andbisexual,than those who Hypersexual Disorder
answered the retest. No differences on age, race, marital status,
income, and years of education were found among who answered The HDSI is a dimensional and diagnostic screening measure.
and did not answer the retest. Hypersexual disorder had been proposed for inclusion in the

123
Arch Sex Behav
DSM-5 as a diagnosis for patients who report a period of 6
months or more of recurrent and intense sexual fantasies, sexual
urges, and sexual behavior that cause significant distress or
impairment. There are seven core diagnostic criterion questions
included in the HDSI (five A and two B criteria). Each criterion
item is rated on a five-point severity index ranging from 0 (never
true) to 4 (almost always true) with a resulting total score ranging
from 0 to 28 points that can be used as a dimensional measure of
overall severity. To screen positive for a probable diagnosis of
hypersexual disorder, an individual must score three or four
points on at least four of the five A criteria and at least one of the
two B criteria. Part C contains a list of six domains of prob-
lematic sexual behaviors (e.g., masturbation, sexual behavior
with consenting adults, cybersex) and participants were asked to
report which types of behaviors had caused them problems in the
prior6 months(American PsychiatricAssociation, 2010; Kafka,
2010). This measure was recently found to be highly reliable in
discriminating differing levels of hypersexual disorder symp-
tomology in a non-clinical sample of highly sexually active gay
and bisexual men in the United States (Parsons et al., 2013).
Following the first directions given by the Task Force group for
the fifth edition of the Diagnostic and Statistical Manual of
Mental Disorders from the American Psychiatric Association,
in this article we investigated the both ways of applying HDSI, as
a dimensional measure (the sum of the scores) and as a diag-
nosticcriteriameasure(at least fourA criteria and oneB criteria).
Convergent Validity Measures
We used the Sexual Addiction Screening Test (SAST) (Carnes,
1989) and the Zuckerman Kuhlman Personality Question-
naire (ZKPQ) (Zuckerman, Kuhlman, Joireman, Teta, &
Kraft, 1993) to investigate convergent validity. The SAST
(Carnes, 1989) is used to screen for possible cases of sexual
addiction and was adapted and validated for use in Brazil by
Silveira et al. (2000). It consists of 25 questions, which are
answered either Yes or No. Research with a sample of men
with and without sexual addiction showed that the SAST had a
single factor and high internal consistency (Carnes, 1989).
The Brazilian version of the scale was tested in a sample of six
sexual addicts, 10 alcohol-dependent patients, 17 drug-
dependent outpatients, and 38 healthy controls. The internal
consistency was .89 (Cronbach’s a) (Silveira et al., 2000).
The ZKPQ (Zuckerman et al., 1993) consists of 99 pairs of
self-completion questions in which the subject has to choose the
statement from each pair that best describes him/herself. The
ZKPQ has been translated into several languages, including
Spanish (Aluja, Garcı́a, Cuevas, & Garcı́a, 2007; Gomà-i-Fre-
ixanet & Valero Ventura, 2008), Chinese (Wang et al., 2003),
and Portuguese (Souza, Omar, & Formiga, 2006). We admin-
istered only the 19 items of the Impulsive Sensation Seeking
(ImpSS) domain, which investigates the provision for novelty
seeking and non-planning impulsivity. This domain presents an
internal consistency of .77 (Cronbach’s a) (Zuckerman et al.,
1993).
Data Analysis
We performed separate factor analyses of the SCS, HDSI, and
CSBI using principal components extraction with orthogonal
rotation (Varimax method) for those scales in which more than
one factor was extracted. We relied on Catell’s scree test to
evaluate evidence of a meaningful factor in addition to Eigen-
values of at least 1 and meaningful item loadings. The items with
factor loadings of 0.50 or more were considered to meaningfully
load onto a factor. The internal consistency was evaluated using
Cronbach’s a coefficient. Reliability was assessed using the
Wilcoxon test, the intra-class correlation coefficient (rintra-class),
and Bland–Altman graphs. Convergent validity was evaluated
using Spearman correlations between the scores of each of the
questionnaires and the scores of the SAST and the ImpSS. To
verify the discriminant construct validity, we compared the
mean scores between the patients and the controls. In this ana-
lysis, we used the Mann–Whitney test, and we hypothesized that
the patients would have higher mean scores than the controls.
To evaluate the criterion validity (sensitivity, specificity,
positive, and negative predictive value) of the HDSI, we used the
provisional diagnostic criteria for Sexual Addiction from the
DSM IV (Goodman, 2001) as a diagnostic reference (gold
standard). This reference has been previously used by Silveira
et al. (2000) to validate the SAST for use in Brazil. We tested the
HDSI against the Goodman’s criteria using a two by two table
for calculating the prevalence of true positive (number of indi-
viduals meeting Goodman’s criteria and positive on HDSI),
false positive (number of individuals not meeting Goodman’s
criteria and positive on HDSI), false negative (number of indi-
viduals meeting Goodman’s criteria and negative on HDSI), and
true negative (number of individuals not meeting Goodman’s
criteria and negative on HDSI) cases. Then, we assessed the
sensitivity (number of true positives by the total with SC),
specificity (number of true negatives by the total without SC),
positive predictive value (number of true positives by the total of
positives on HDSI), and negative predictive value (number of
true negatives by the total of negatives on HDSI).
Statistical analyses were performed using STATA 10, and we
considered statistical significance when p\.05.
Results
Participant Characteristics
The sociodemographic characteristics of the participants are
shown in Table 1. The majority of the participants were White
(71 %) and heterosexual (69 %). Approximately half of the
participants were sexually compulsive and single. The mean age
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 Arch Sex Behav

Table 1 Sociodemographic characteristics of male participants who pro- Table 2 Exploratory factor analysis of the SCS, HDSI, and CSBI Scales
vided full data and those who completed the Hypersexual Disorder
Screening Inventory (HDSI) Factor loadings
SCS HDSI CSBI
Full sample Sample with HDSI
(n = 153) (n = 121) Scale item Factor 1 Factor 1 Factor 1 Factor 2 Factor 3 Factor 4
number
n % n %
b b b
1 0.7695 0.9191 0.9067
Sexually compulsive b b b
2 0.9063 0.9376 0.9162
Yes 89 58.2 41 33.9 b b b
3 0.8936 0.8643 0.7449
No 64 41.8 80 66.1 b b b
4 0.8508 0.9138 0.9019
Race b b b
5 0.8234 0.8679 0.8872
White 110 70.9 86 71.1 b b b
6 0.7951 0.9329 0.9161
African descent 40 27.3 32 26.4 b b b
7 0.9133 0.9137 0.8938
Other 3 1.8 3 2.5 a b b b
8 0.9034 0.6501
Sexual orientation a b b b
9 0.8695 0.7766
Straight 105 68.6 85 70.2 a b b b
10 0.5886 0.7424
Gay/bisexual 48 31.4 36 29.8 a a b b b
11 0.6534
Marital status a a b b b
12 0.7184
Married 57 37.3 43 35.6 a a b b b
13 0.8624
Divorced 15 9.8 13 10.7 a a b b b b
14
Single 81 52.9 65 53.7 a a b b b
15 0.7302
M SD M SD 16 a a b b b b

a a b b b
Age 36.4 10.2 36.3 10.5 17 0.6628
a a b b b
Years of education 13.9 4.1 13.8 4.0 18 0.7868
a a b b b
19 0.7264
a a b b b
20 0.7904
a a b b b
and years of education of the participants were 36 and 14 years, 21 0.6398
a a b b b
respectively. 22 0.6369
% variance 0.6923 0.82 0.41 0.11 0.08 0.08
Psychometric Properties explained
SCS sexual compulsivity scale, HDSI hypersexual disorder screening
We conducted an independent factor analysis for each scale inventory, CSBI compulsive sexual behavior inventory
a
(SCS, HDSI, and CSBI-22). The factor analyses of the SCS and Not applicable—no relevant scale item
b
the HDSI each extracted a single factor that met our criteria. The Item loading was less than 0.50. Factors 3 and 4 from the CSBI scale were
extracted factor explained 69.23 % of the variance for the SCS excluded from further analyses
and 81.77 % for the HDSI. Therefore, in keeping with prior
research, we calculated the scores of the SCS and HDSI as the These two factors accounted for a cumulative variance of
total sum of the item responses. The scores of the SCS ranged 51.71 % of all 22 items, and 68.30 % considering just the 17
from 10 to 40, and the scores of the HDSI ranged from 0 to 28. items retained (1–13; 17–19; 21). We calculated mean scores for
The factor analysis of CSBI-22 revealed four factors that had each factor to allow for comparison between them despite dif-
an eigenvalue greater than 1 that explained a cumulative vari- ferent numbers of items. Based on their respective items, we
ance of 67.35 %. However, after examining the Catell’s scree determined that the first factor related to control (control
test and the factor loading patterns, we determined that only the domain) and second factor related to violence (violence domain)
first two factors met the criteria for being substantially mean- (see Table 2).
ingful factors—the third and fourth factors contained only one or The results of the reliability and validity analyses are pre-
two items with strong loadings and did not deviate from the scree sented in Table 3. As can be seen, the SCS, HDSI, and two CSBI
line. The first factor consisted of questions 1–13 and the second subscales all demonstrated strong internal consistency, with all
factor consisted of questions 17, 18, 19, and 21. With regards to alpha coefficients exceeding 0.75 and most exceeding 0.90.
the two factors that were ultimately dropped, the third factor With regards to discriminant validity, patients had significantly
consisted of question 20; and the fourth factor consisted of higher scores on all four variables when compared to controls.
questions 15 and 22. Questions 14 and 16 did not load on to any Additionally, statistically significant correlations were found
factor. between all the scores and the SAST. The correlations were high

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Arch Sex Behav

Table 3 Summary of the reliability and validity statistics for the SCS, HDSI, and CSBI scales
Scale Internal Discriminant validity Convergent validity Test–retest reliability
consistency
Control Patient Sig. SAST ImpSS Time 1 Time 2 z Sig. ICC
A M SD M SD q q M SD M SD

SCS 0.95 15.3 5.4 32 4.9 *** 0.81*** 0.53*** 19.5 8.1 19.3 7.6 0.7 ns 0.77***
HDSI 0.96 2.6 3.3 21.2 5.6 *** 0.81*** 0.50*** 7.2 7.7 7.3 8.0 -0.8 ns 0.80***
CSBI-control 0.97 57.3 7.1 26.2 8.2 *** -0.87*** -0.48*** 48.6 14.3 48.8 13.8 -0.5 ns 0.81***
CSBI-violence 0.75 19.6 1.0 18.6 2.1 *** -0.36*** -0.41*** 19.4 1.3 19.4 1.3 -0.7 ns 0.92***
* p\.05. ** p\.01. *** p\.001

Table 4 Correlation matrix from the SCS, HDSI, and CSBI Scales
Scale 1. 2.
q q
1. SCS – construct. As factor analysis was not performed in the original
2. HDSI 0.87*** – studies (Kalichman et al., 1994; Kalichman & Rompa, 1995),
3. CSBI-control -0.86*** -0.86***
4. CSBI-violence -0.33*** -0.43***
* p\.05. ** p\.01. *** p\.001
(q[.81) for all domains except the violence domain (q = .36),
where the correlation was moderate. The correlations between
the scores and the ImpSS were statistically significant for all
domains. The correlations between the scores and the ImpSS
were moderate, ranging from .50 to .55. However, for the vio-
lence domain, the correlations were moderate but smaller
(q = .42).
The correlations among the scores are also presented in
Table 4. The SCS, the HDSI, and the control domain of the
CSBI-22 are highly correlated (q[.85). The violence domain
showed moderate correlations with the other scores (q[.32).
Ninety-nine individuals completed the questionnaire a sec-
ond time, which corresponded to 64.70 % of the individuals who
answered the SCS and the CSBI and 81.81 % of the individuals
who answered the HDSI. There were no differences between the
means of the scores obtained at the two time points. Moreover,
there was a high correlation between the scores obtained at test
and at retest (ricc[.76 for all). The Bland–Altman plots of all the
scores are presented in Fig. 1, showing a random distribution of
points around the means, which suggested that there were no
specific differences between the scores of the test–retest when
compared tothemean differences. Only a limited numberof data
points fell outside of the limits of the standard deviation.
The sensitivity and specificity of the HDSI, when tested
against the Goodman’s criteria (gold standard), were 71.93 and
100 %, respectively. Therefore, the probability that a participant
who screened positive for hypersexual disorder using the HDSI
had a hypersexual disorder (positive predictive value) was
100 %. In contrast, the probability that a participant who did not
screen positive for hypersexual disorder in the HDSI did not
have the disorder (negative predictive value) was 80 %.
Discussion
3.
q Our factor analysis of the SCS retained all 10 statements in one
single factor, indicating that a single factor represented the SC
– there were no previous suggestions as to how many factors
0.33*** should comprise the factor analysis. The study by Kalichman
and Cain (2004), which used a sexually transmitted infection
treatment-seeking sample population, identified two factors,
social disruptiveness (Items 1–4) and personal discomfort
(Items 5–10), for use in the factor analysis (Kalichman & Cain,
2004). A Spanish study of college students also identified two
factors, interference of sexual behavior (Items 1–4, 10) and
failure to control sexual impulses (Items 5–9) (Ballester Arnal
et al., 2012). The two factor models in these studies accounted
for of 60 and 50 % of the variance, respectively. Our model with
one factor accounted for greater proportion of the variance when
all 10 statements were included in the analysis. Furthermore, the
internal consistency of our study was high, in accordance with
previous studies using samples of gay men, inner city men and
women, persons seeking treatment for sexually transmitted
infections, and HIV-positive men and women, which found,
respectively, alphas values of .86, .87, .88, .89, and .92 (Kalich-
man & Cain, 2004; Kalichman & Rompa, 1995, 2001). Our test–
retest coefficient was also high, and in accordance with a study of
106 gay men which reported a two week temporal stability coef-
ficient of .95, while the 3 month temporal stability coefficients
ranged from .64 (community sample of same-gender sexually
active men) to .80 (sample of inner city men and women) (Ka-
lichman & Rompa, 1995). The SCS showed significant evidence
of convergent validity with the SAST, which also measures SC,
and the construct convergent validity also tested searching
correlation with sensation seeking. We tested the ImpSS domain
of the ZKPQ and found a significant correlation with sensation
seeking, which is consistent with several previous studies. Some
of these studies used a specific measure of sexual sensation seek-
ing and found correlation coefficients ranging from .50 (sample
of undergraduate students) (Gullette & Lyons, 2005) to .70 (com-
munity sample of same-gender sexually active men) (Kalichman
& Rompa, 1995). Similar to our results, other studies have

123

Fig. 1 Bland-Altman graphs for SCS, HDSI, CSBI-control, and violence domain
investigated correlations with general sensation seeking and
have found correlations coefficients ranging from .43 (sample of
inner city men and women) to .57 (community sample of same-
gender sexually active men) (Kalichman & Rompa, 1995). In
previous studies, the SCS was used to distinguish between
several characteristics, such as age orincome (Hook et al., 2010),
whereas in our study, the SCS enabled discrimination between
SC patients and the controls. We did not find any previous
studies that examined this type of discriminant validity of the
SCS.
Our factor analysis of the CSBI-22 replicated the control
domain of the original factor analysis (Coleman et al., 2001;
Miner et al., 2007), retaining all 13 statements regarding
control in one single factor. However, we only partly replicated
the results for the violence domain, retaining four of the nine
statements regarding violence. Despite this result, we decided
to test two of the four retained factors because the total
cumulative variance was close to the 58 % cumulative variance
reported in the original study (Coleman et al., 2001). We
examined the psychometric properties of the CSBI-control and
123
Arch Sex Behav
violence domains and found that the internal consistency was
high. Previous studies have reported that the internal consis-
tency of the total scores ranges from .67 to .87 (Hook et al.,
2010) and that the internal consistency was .96 for the control
domain and was .88 for the violence domain (Coleman et al.,
2001), which are similar to our results. Furthermore, our test–
retest coefficient was high for the CSBI domains, in accor-
dance with an online study of 1,026 Latino men who have sex
with men, which reported a seven- to ten-day stability coeffi-
cient of .86 (Miner et al., 2007). The CSBI-control domain
showed high evidence of convergent validity with the SAST,
and the convergent validity with the ImpSS was moderate,
which is similar to the results reported above for the SCS. The
violence domain showed significant convergent validity with
the SAST and the ImpSS, although the degree was moderate.
Similar to the study by Coleman et al. (2001), where partici-
pants who self-identified with pedophilia and sexual addiction
scored lower on the CSBI than the control group, the CSBI-
control and violence domains could be used to differentiate
between patients and controls in the current study.
Arch Sex Behav
Reid et al. (2012) investigated the reliability and validity of
the criteria for hypersexual disorder in a sample of 207 patients
seeking treatment for SC (152), general psychiatric conditions
(35), and substance-related disorders (20) using a structured
diagnostic interview. They found high inter-rater reliability
(among the team of interviewers), good stability over time, and
good sensitivity and specificity (Reid et al., 2012). In contrast to
Reid et al., we assessed the symptoms of hypersexual disorder
using the HDSI as a self-report measure, and we assessed the
diagnostic criteria for hypersexual disorder using a psychiatric
assessment based on the HDSI diagnostic criteria. As we
employed a different study design and methodology, our
dimensional and diagnostic criteria results positively validate
the criteria for hypersexual disorder, as previously proposed by
the DSM-5 and by the study by Reid et al. (2012). In our study,
the HDSI showed very good psychometric characteristics. The
factor analysis enrolled all seven statements in one single factor,
accounting for a high proportion of variance. The internal con-
sistency, reproducibility, and convergent and discriminant con-
struct validity were good and were similar to those reported for
the SCS and the CSBI-control domain. The HDSI psychometric
properties found in the current study are in accordance with the
study of Parsons et al. (2013) which confirmed that a uni-dimen-
sional structure was an adequate fit to the measure, and also dem-
onstrated the validity of the measure and its associations with
other scales of similar constructs.
Regarding the limitations of the current work, our findings
showedthat theHDSIproduceda 28 % rateof falsenegatives but
hadno false positiveswhen usedto predict thegold standard(i.e.,
Goodman’s criteria). As such, using the HDSI in clinical settings
to screen for possible cases of SC may lead to under-diagnosis of
cases who would meet Goodman’s diagnostic criteria. Typi-
cally, screening measures are designed to maximize sensitivity
(i.e., minimize the rate of false negatives) at the expense of
specificity (i.e., inflating the rate of false positives) in order to
refer all potential cases for further diagnostic screening. That is
not the case of HDSI in our study. However, it is worth noting
that to reach the Goodman’s criteria one needs to endorse 3 out of
7 of the criteria, while to reach the Hypersexual Disorder criteria,
one needs to endorse 4 out of 5 of the A criteria and 1 out of 2 of
the B criteria (i.e., 5 total criteria). These findings suggest that the
HDSI may utilize more rigorous screening criteria than the
Goodman’s and may identify those at an even higher level of risk
than Goodman’s criteria.
Goodman proposed the provisional criteria for SC in 2001,
adapting from the criteria of substance dependence from the
DSM-IV. On the other hand, the HDSI was created in 2010 to
assess the criteria of Hypersexual Disorder, which was devel-
oped without regard for a specific underlying etiology or treat-
ment approach (i.e., without regard forwhether it was an impulse
disorder, compulsive disorder, addiction, etc.). Despite the fact
that currently there is no SC diagnosis within the DSM, patients
still regularly seek treatment for sexual behavior which they feel
is beyond their control and causing them distress (i.e., the
characteristic features of SC). In this context, an updated and
scientific-based measure, such as HDSI, can help the clinician to
make decisions regarding the treatment. The HDSI also can be
very useful in the research field currently, because of the need of
searching for more evidences to SC.
Another limitation is that our study enrolled 153 male par-
ticipants who answered research advertisements in São Paulo,
Brazil. Therefore, caution should be exercised in attempting to
generalize our findings to other populations. São Paulo is a
large city with ten million inhabitants, including many immi-
grants who are responsible for the important socio-cultural
diversity.
We also analyzed correlations between the scales and found
high correlations, except for the violence domain. Therefore, we
can conclude that the SCS, the HDSI, and the CSBI-control
domain seem to measure theoretically similar constructs of SC.
Furthermore, all three assessments will be useful for prospective
or intervention studies, as they demonstrated high test–retest
coefficients. Because all three assessments had good convergent
validity with sensation seeking and because SC and both con-
structs are associated with sexual risk behavior related to HIV
transmission, we also consider that all three assessments will be
important measures for studies of the impact of SC on HIV risk
behavior in Brazil. The CSBI includes a violence domain, which
the SCS and the HDSI do not include; therefore, when measures
of sexual violence are one of the goals of a study (for example,
involving sexual offenders), the CSBI is the most appropriate
tool. In contrast, for studies in clinical settings, the HDSI can be
used as a diagnostic screening instrument, as this tool simplifies
the recognition of SC in clinical environments and therefore
enables proper treatment.
Acknowledgments This study was supported by Grants from the São
Paulo Research Foundation (FAPESP), Grant 2010/15921-6.
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