Sexual Addiction & Compulsivity, 18:107–113, 2011

Copyright © Taylor & Francis Group, LLC

ISSN: 1072-0162 print / 1532-5318 online
DOI: 10.1080/10720162.2011.596762

EDITORIAL
What You Should Know about
Hypersexual Disorder

CHARLES P. SAMENOW
George Washington University, Washington, DC

INTRODUCTION

For many of us, the possible inclusion of Hypersexual Disorder (APA, 2010)
in the DSM-V comes with mixed emotions. Like you, I am thrilled to see years
of hard work, research, and advocacy finally being recognized. Furthermore,
I recognize the importance of providing our clients with a tangible diagnosis
that provides them with an understanding that they are not alone and hope
for treatment that we know can work. Yet, the term hypersexual disorder
seems very sterile. I know what it means when my clients say they are a
“sex addict.” I understand how the addiction model guides the formation of
this problem and how using an addiction sensitive approach we can treat it.
What will it mean for our clients and us when we start using the diagnosis
hypersexual disorder?
A few weeks ago, I was interviewed for Good Morning America about
the possible inclusion of hypersexual disorder in the DSM-V. Unfortunately,
the interview never made the air due to a string of current events that was
more pressing. During the interview, I kept slipping up. I continued to refer
to sexual addiction. At one point the interviewer asked me, “You keep using
the term sexual addiction instead of hypersexual disorder, is that OK?”
For this editorial, I thought I would describe how I would answer certain
questions about hypersexual disorder should I be interviewed again. It is still
uncertain whether hypersexual disorder will make the DSM. It is possible it
will be included in the appendix or eliminated all together. It will not make
the main pages in this first pass. Regardless, over the next several years we
are going to have to respond to this new diagnosis. We will have to include
it in our vocabulary and educate patients, families, and the public about it.
The following answers are more extensive than media sound bites. They
represent my thinking on this disorder. I encourage each of you to come
up with your own answers to these questions. Who knows, a producer may
knock on your door unexpectedly.

107
108 C. P. Samenow

What is Hypersexual Disorder?

Hypersexual disorder is a persistent and pervasive pattern of behavior in
which the individual loses control of their sexual fantasies, urges, or be-
haviors to a point that it causes that individual significant interpersonal
distress and/or impairment. The criteria for the disorder specifies that the
individual must spend excessive amounts of time seeking or engaging in
sexual activity, is unable to stop sexual behavior, continues sexual behav-
iors despite negative consequences to self or others, and/or uses sex as a
means to cope with anxiety, depression, or stressful life circumstances (APA,
2010).

How is Hypersexual Disorder Different from Sexual Addiction

or Compulsive Sexual Behavior?
Hypersexual disorder is consistent with the addiction model and the criteria
for substance dependence. The term hypersexual disorder is the preferred
term, however, because it is not associated with an etiologic model. It does
not confirm or reject the sexual addiction model or any other model for that
matter. Rather each selected criterion was derived from research literature
using multiple published rating scales that provide validity to the diagno-
sis. It objectively describes the phenomenon/symptoms without assuming
etiology.
Sexual Addiction was briefly in DSM-III-R (APA, 1987) but then removed
due to the lack of empirical research to support it (Kafka, 2010). Sexual ad-
diction is a specific term that implies a specific etiological model. The DSM
does not use the term addiction because that model has not been substanti-
ated or validated in the research literature. In other words, the term addiction
fails to describe a specific physiological interruption that has been described
universally and replicated. The DSM has preferred dependence and abuse
to describe disorders related to alcohol and drugs because these terms more
accurately describe the biological and psychological processes. However,
since tolerance and withdrawal have yet to be substantiated through the
research literature for sexual behaviors, the term sexual dependence would
be inaccurate.
The same is true for the term compulsive sexual behaviors or sexual
impulsivity. Both these terms assume a pathophysiological underpinning that
is currently not supported by the research literature. Although individuals
with hypersexual behaviors may have elements of obsessive compulsive
disorder or impulse control disorders, there are significant differences which
preclude including this disorder in those categories. I have described these
differences in a previous editorial (Samenow, 2010a).
 Editorial 109

What are the Arguments Against Including Hypersexual Disorder

in the DSM-V?
There are several arguments against hypersexual disorder. Many of them
are misguided and show a poor understanding of the proposed diagnosis.
The main objection is that the diagnosis is over inclusive. This means that
individuals with normal variations of sexual behavior may be inadvertently
classified as having a mental disorder. The proposed diagnostic criteria, how-
ever, were specifically modified with a strict standard of an individual having
to meet 4 of the 5 criteria for the diagnosis to prevent this from happening
(Kafka & Krueger, 2011a). The diagnosis does not capture those who enjoy
lots of sex or multiple variations. It’s about quality, not quantity.
Another argument is that the disorder provides an excuse for misconduct
or improper behavior. This argument, however, could be used for almost any
diagnosis in the DSM. We hold depressed mothers who neglect their children
accountable for the actions just as we hold schizophrenics who commit acts
of violence when they are still of sound mind. Explanations of behavior
are different from excuses. Ultimately, it is more important how one uses a
diagnosis as opposed to the diagnosis itself. The most egregious concern is
that hypersexual disorder will be used as a defense against sexual violence.
Again, clients and lawyers may choose to use (or abuse) a diagnosis as they
please. This doesn’t mean the diagnosis has no merit. In fact, the diagnoses
may actually help improve clinical accuracy by identifying true motivations
in sexual crimes (e.g., deviant sexual arousal vs. novelty-seeking, risk-taking,
or self-regulation of stress or dysphoria [Kafka & Krueger, 2011a]).
Finally, some argue that hypersexual disorder is merely a symptom of
another disorder. In other words it is non-specific. They point to how the
criteria link sexual behavior as a response to dysphoric mood, anxiety and
stressful life circumstances. Perhaps this is just a maladaptive coping mech-
anism or manifestation of another illness? Until the exact underpinnings of
this disorder (and many of the DSM disorders) are understood, it will be
hard to answer this question. However, the DSM-IV-TR (APA, 2000) includes
alcohol and drug dependence, Gambling Disorder, and Binge Eating Disor-
der. And while the criteria for these disorders do not include the connection
depression and anxiety, it is well known that they go hand-in-hand with
depression, anxiety, and stressful life circumstances. Comorbid conditions
can be diagnosed concurrently or sequentially with other Axis I disorders.
Hypersexual Disorder is no exception (Kafka & Krueger, 2011b)

Why Should Hypersexual Disorder be Included in the DSM?

As a clinician who sees many individuals whose sexual behaviors have gotten
them into trouble and harmed themselves and those around them, offering a
110 C. P. Samenow

diagnosis provides my clients with understanding and hope. It allows them

to understand they are not alone and that there is treatment out there to
help them. Furthermore, formal recognition of this disorder will allow for
increased education and advocacy. It will be included in health professions
curricula that will improve screening and treatment. Formal recognition will
open doors for research dollars that will allow further understanding of
the biological, psychological, and social etiologies and contributors of this
disorders as well as pave the way for research on “best practices.” Although
there are other practical issues such as insurance reimbursement that also
merit inclusion, ultimately it is what the diagnosis can do for the patient that
makes its inclusion vital.

Is Hypersexual Disorder Even Real?

Hypersexual disorder is real. It affects men and women of all ages, races,
genders, and ethnicities. Its original terms, Don Juanism and satyriasis, point
to its existence over time. Although we don’t yet know its full origins, the
complex biological, psychological, and social influences that impact the neu-
ral pathways of the mind are no less real than the HIV virus, a cancer cell, or
the inflammatory response. And the damage it causes individuals and their
relationships is no less real than the damage to the liver, kidneys, heart, etc.
that more classic “diseases” cause. Kafka’s review article provides the most
up-to-date review of the scientific literature supporting this disorder (Kafka,
2010).

What Causes Hypersexual Disorder?

The cause of hypersexual disorder is not yet fully known. It is most likely
a complex relationship between abnormal brain chemistry and abnormal
brain development. These changes may be genetically determined and/or
influenced by important environmental factors. It is important to not apply
what is known about the brain or other disorders to this disorder when
empirical proof does not exist. Again, Dr. Kafka’s review article (Kafka,
2010) along with my editorial (Samenow, 2010b) review the current scientific
knowledge about this disorder. Like many disorders in the DSM, the exact
underpinnings of this disorder are still under discovery.

If Hypersexual Disorder is not Included in the DSM-V,

Does it not Exist?
The DSM is a living document. It has evolved over time and continues
to evolve as science progresses. Disorders are continuing to be discovered,
modified, and removed. The sexual disorders are an area where this evolving
 Editorial 111

process has been quite noticeable. If hypersexual disorder does not make this
version of the DSM, there will still be people who continue to have problems
with their sexual behaviors. It will be incumbent upon us to continue to
refine how we think about this disorder and engage in high quality rigorous
research to validate its inclusion.

How Can I Help Improve the Chances That This Disorder

be Recognized?
The most important thing we can do at this time is to contribute to the
research literature. There are several ways to contribute:

(a) Consider enrolling as a site for a field trial of the proposed criteria. Infor-
mation for the field trial can be found by contacting: roryreid@ucla.edu
(b) If you a clinician, consider collaborating with an academic partnership.
You may have a wealth of data at your fingertips and a seasoned re-
searcher can help work with you to find ethical, sensitive, and scientifi-
cally rigorous ways of participating.

TABLE 1 Validated Rating Scales For Use in Clinical Practice

Condition Scales

Hypersexual behavior Hypersexual Disorder Screening Inventory (HDSI)

Hypersexual Disorder: Current Assessment Scale
(HD:CAS)
Hypersexual Behavior Inventory (HBI)
Sexual Addiction Screening Test (SAST)
Women’s Sexual Addiction Screening Test
(W-SAST)
Compulsive Sexual Behavior Inventory (CSBI)
Sexual Compulsivity Scale (SCS)
Depression Beck Depression Inventory (BDI)
Hamilton Rating Scale (HAM-D)
Patient Health Questionnaire – 9 (PHQ-9)
Quick Inventory of Depressive
Symptomatology-Clinician Rating (QIDS-C), and
the QIDS-Self-Report (QIDS-SR)
Bipolar Disorder Mood Disorders Questionnaire (MDQ)
The Composite International Diagnostic Interview
(CIDI) Bipolar Disorder Screening Scale
ADHD Conners Adult ADHD Rating Scale (CAARS)
Substance Related Disorders Alcohol Use Disorder Identification Test –
Consumption (AUDIT-C)
CAGE-AID
Suicide Suicide Behaviors Questionnaire-Revised (SBQ-R)
The Suicidal Ideation and Risk Level Assessment
112 C. P. Samenow

(c) Apply scientific rigor to your clinical practice. This means using validated
rating tools on patients as well as validated rating scales for co-morbid
conditions such as depression, bipolar, and substance related disorders.
If you work in the areas of trauma, attachment, or other schools of
thought, consider identifying and utilizing tools that measure key con-
structs. For example, I have experience using the Family Adaptability
and Cohesion Evaluation Scale (FACES) to measure family functioning
(Olsen, 1992). These tools should not only be used for initial screening,
but monitoring progress. By using these tools, you may be able to con-
tribute to the research literature. I have included a list of accepted tools
in Table 1.
(d) Don’t propagate pseudoscience. Always be careful that when you are
writing, speaking on, teaching, appearing in the media, or even edu-
cating patients that you are only speaking based on information that is
substantiated in the research literature. Be careful not to make jumps
about the causes of sexual problems based on literature from other dis-
ciplines. This may seem minor, but to gain credibility, we as a profession
must stick to the science.
(e) Read, read, read. This is an ever changing field. We have learned a lot
since this field came “out of the shadows.” It is critical that we stay up
to date on current evidence-based literature on where we are heading.

CONCLUSION

In conclusion, “I suffer from hypersexual disorder” may not quite have the
same ring as “I am a sex addict.” But the ability to say this opens the door
to hope for many individuals who are suffering and, signifies the formal
recognition of the hard work so many of our readership has placed into
describing, understanding, and treating this disorder. Furthermore, it sends
a message to the world that this is not some “fad” diagnoses, but instead
is a real entity that has been arrived at through the most rigorous scientific
research.

REFERENCES

American Psychiatric Association. (2010). Hypersexual disorder. http://www.dsm5.

org/ProposedRevisions/Pages/proposedrevision.aspx?rid=415
American Psychiatric Association. (2000). Diagnostic and statistical manual of men-
tal disorders (4th ed., text revision). Washington, DC: Author.
American Psychiatric Association. (1987). Diagnostic and statistical manual of men-
tal disorders (3rd ed., rev.). Washington, DC: Author.
Kafka, M. P. (2010). Hypersexual disorder: A proposed diagnosis for DSM-V. Archives
of Sexual Behavior, 39, 377–400.
 Editorial 113

Kafka, M. P. & Krueger, R. B. (2011a). Response to Halpern (2011). Archives of

Sexual Behavior 40, 489–490.
Kafka, M. P. & Kruger, R.B. (2011b). Response to Moser’s (2010) critique of hyper-
sexual disorder for DSM-V. Archives of Sexual Behavior. 40, 231–232.
Olson D, Bell R, & Portner J. (1992). FACES II. Minneapolis: Life Innovations, P.O.
Box 190, Minneapolis, MN.
Samenow, C. (2010a). Classifying problematic sexual behavior—it’s all in the name.
Sexual Addiction & Compulsivity, 17, 3–6.
Samenow, C. (2010b). A biopsychosocial model of hypersexual disorder/sexual ad-
diction. Sexual Addiction & Compulsivity, 17, 69–81.
Copyright of Sexual Addiction & Compulsivity is the property of Routledge and its content may not be copied
or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission.
However, users may print, download, or email articles for individual use.