The Hypersexuality

Hypersexuality is extremely frequent or suddenly increased sexual urges or sexual activity. Although hypersexuality can be caused by some medical conditions or medications, in most cases the cause is unknown.
Mental health problems such as bipolar disorders can give rise to hypersexuality, and alcohol and some drugs can affect social and sexual inhibitions in some people. A number of theoretical models have been used to explain or treat hypersexuality. The most common one, especially in the popular media, is the sexual addiction approach, but sexologists have not reached any consensus. Alternative explanations for the condition include compulsive and impulsive behavioral models.

The International Classification of Diseases (ICD-10) of the World Health Organization includes “Excessive Sexual Drive” (coded F52.7), which is divided into satyriasis for males and nymphomania for females, and “Excessive Masturbation” (coded F98.8). A proposal to include a diagnosis called hypersexual disorder, simply describing the symptom without implying any specific theory, is under consideration for inclusion in the appendix of the DSM, but not in the main list of official diagnoses.

The American Psychiatric Association (APA) rejected a proposal to add sexual addiction to its list of psychiatric disorders, the Diagnostic and Statistical Manual of Mental Disorders (DSM). Some authors have questioned whether it makes sense to discuss hypersexuality at all, arguing that labeling sexual urges "extreme" merely stigmatizes people who do not conform to the norms of their culture or peer group.

Epidemiology

The number of people who are hypersexual, or believe that they are hypersexual, is unknown. Although several estimates have been published, it is not clear on what basis they were made. The estimates asserted are usually 3–6% of the United States population.

Many proposed definitions of hypersexuality are relative to cultural or peer group norms. Surveys of convenience samples suggest that 3–5% of high school or college age males masturbate on a daily basis. In the Kinsey studies, 7.6% of males engaged in some sexual behavior leading to orgasm (masturbation, sexual intercourse, oral sex, etc.) on a daily basis or more. In the Laumann study (a large-scale representative survey of sexual behavior), 1.9% of men ages 18–59 masturbated daily, and 1.2% masturbated more than once per day.

Etiology

There is no consensus among experts as to the causes of hypersexuality, and many etiological factors have been proposed. Some research suggests that some cases can be linked to biochemical or physiological changes that accompany dementia. Psychological needs also complicate the biological explanation, which identifies the temporal/frontal lobe of the brain as the area for regulating libido. Persons suffering from injuries to this part of the brain are at increased risk for aggressive behavior and other behavioral problems including personality changes and socially inappropriate sexual behavior such as hypersexuality. The same symptom can occur after unilateral temporal lobectomy. There are other biological factors that are associated with hypersexuality such as premenstrual changes, and the exposure to virilising hormones in childhood or in utero. It should be noted that there can be psychological causes for this condition. Hypersexuality, in these cases, may be related to the longing for intimacy with another individual. Often, this desire is inappropriately expressed. This can be, once again, related to the condition of dementia. As this illness progresses, loss of self-esteem is often inevitable. A loss of cognitive function as a result of this disease may be compensated for through hypersexuality. In research involving use of anti-androgens to reduce undesirable sexual behaviour such as hypersexuality, testosterone is deemed necessary, but not sufficient, for sexual drive. Other proposed factors include a lack of physical closeness, and forgetfulness of the recent past.

Pathogenic overactivity of the dopaminergic mesolimbic pathway in the brain—forming either psychiatrically, during mania, or pharmacologically, as a side effect of dopamine agonists, specifically D3-preferring agonists—is associated with various addictions and has been shown to result among some in overindulgent, sometimes hypersexual, behavior.

Models and labels

Sexologists have been describing cases of hypersexuality since the late 1800s. In some cases, the hypersexuality was a symptom of another medical disease, such as Klüver-Bucy syndrome or bipolar disorder, or the side effect of a medication, such as the drugs used to treat Parkinson's disease. In other cases, the hypersexuality was reported to be the primary problem.

Sexologists have not reached a consensus over how best to describe when hypersexuality is the primary problem. Some researchers assert that such situations represent a literal addiction; other researchers assert that such situations represent a type of obsessive-compulsive disorder (OCD) or “OCD-spectrum disorder”; and other researchers assert that it is a disorder of impulsivity. Moreover, some authors assert that there is no such thing as hypersexuality at all and that the condition merely reflects a cultural dislike of exceptional sexual behavior.

Consistent with there not being any consensus over what causes hypersexuality, authors have used many different labels to refer to it, sometimes interchangeably, but often depending on which theory they favor or which specific behavior they were studying. Contemporary names include compulsive masturbation, compulsive sexual behavior, cybersex addiction, erotomania, “excessive sexual drive”, hyperphilia, hypersexuality, hypersexual disorder, problematic hypersexuality, sexual addiction, sexual compulsivity, sexual dependency, sexual impulsivity, “out of control sexual behavior”, and paraphilia-related disorder. Other, mostly historical, names include Don Juanism, the Messalina complex, nymphomania, and MEN.

Addiction model of hypersexuality

The most commonly discussed way of understanding hypersexuality is with an addiction model. The concept of hypersexuality as an addiction was started in the 1970s by former members of Alcoholics Anonymous who realized they experienced a similar lack of control and compulsivity with disruptive sexual behaviors as with alcoholism. Multiple 12-step style self-help groups now exist for people who identify as sex addicts, including Sex Addicts Anonymous, Sexaholics Anonymous, Sex and Love Addicts Anonymous, and Sexual Compulsives Anonymous.

It is predicted that repetitive, high-emotion, high-frequency sexual behavior may cause changes in neural circuitry that, in turn, may cause perpetuated hypersexuality.

Compulsivity model of hypersexuality

Compulsions are behaviors a person performs in order to reduce feelings of anxiety or tension. According to this explanation of hypersexuality, persons engage in whatever sexual behavior in order to reduce feelings of tension, instead of to express sexual desire. Because engaging in the behavior can worsen the situation causing the tension, the person experiences a longer-term increase in tension, despite the shorter-term relief, resulting in a self-perpetuating cycle.

Impulsivity model of hypersexuality

Barth and Kinder (1987) argued against classifying hypersexuality as an addiction or as a compulsion, arguing instead for classifying it as an impulsivity problem. They argued that an addiction entails a substance and withdrawal states, whereas sexual behavior has neither, and that compulsive behaviors exclude intrinsically enjoyable activities, whereas sexual behavior is intrinsically enjoyable. Hypersexuality does, however, contain the essential elements of an impulsivity problem: (1) It pertains to the failure to resist an impulse, drive, or temptation. (2) There is an increasing sense of tension before the behavior. (3) There is an experience of either pleasure, gratification, or release at the time of committing the behavior.

Medical disorders and drugs causing hypersexuality

People who suffer from bipolar disorder may often display tremendous swings in sex drive depending on their mood. As defined in the DSM-IV-TR, hypersexuality can be a symptom of hypomania or mania in bipolar disorder or schizoaffective disorder. Pick’s disease causes damage to the temporal/frontal lobe of the brain; people suffering with Pick’s disease show a range of socially inappropriate behaviors.

Several neurological conditions such as Alzheimer's disease, various types of brain injury, Klüver-Bucy syndrome, Kleine-Levin syndrome, and many more neuro-degenerative diseases can cause hypersexual behavior. Sexually inappropriate behavior has been shown to occur in 7-8% of Alzheimer's patients living at home, at a care facility or in a hospital setting. A positive link between the severity of dementia and occurrence of inappropriate behavior has also been found. Hypersexuality has also been reported to result as a side-effect of some medications used to treat Parkinson's disease. Some street drugs, such as methamphetamine, may also contribute to hypersexual behavior.

Hypersexuality can be caused by dementia in a number of ways, including disinhibition due to organic disease, misreading of social cues, understimulation, the persistence of learned sexual behaviour after other behaviours have been lost, and the side-effects of the drugs used to treat dementia.

Other possible causes of dementia-related hypersexuality include an inappropriately expressed psychological need for intimacy and forgetfulness of the recent past.

Some patients with autism also exhibit hypersexuality. A variety of treatments have been tried for hypersexuality in autistic patients, with no clear consensus as to their applicability.

Official diagnostic status

The Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association (APA) includes an entry called Sexual Disorder Not Otherwise Specified (Sexual Disorder NOS) to apply to, among other conditions, “distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used.” A proposal to add Hypersexual Disorder to the appendix (but not the main list of official diagnoses) of the DSM is currently under consideration by the APA.

The International Statistical Classification of Diseases and Related Health Problems (ICD-10) of the World Health Organization (WHO), includes two relevant entries: One is “Excessive Sexual Drive” (coded F52.7), which is divided into satyriasis for males and nymphomania for females. The other is “Excessive Masturbation” or “Onanism (excessive)” (coded F98.8).

The DSM-V work group has considered hypersexuality as a sexual disorder and has proposed the following diagnostic criteria for use in DSM-V which has been rejected but is still worth consideration. The diagnosis is as follows. You must have recurrent and intense sexual desires, sexual urges or sexual behaviours over the period of 6 months or more with 3 of the 5 following criteria; time consumed with sexual fantasies conflicts with other important goals, repetitively engaging in sexual fantasies in response to dysphoric mood states, repetitively engaging in sexual fantasies in response to stress, repetitive but unsuccessful attempts to control such behavior, and repetitively engaging in sexual behaviours with disregard for physical or emotional harm to self or others. There must also be clinically significant personal distress or negative effect on social or occupational aspects of life and the sexual behavior must not be because of an exogenous susbstance. Some behaviors that are specific to this disorder are masturbation, pornography, sex, cybersex, telephone sex, and going to strip clubs.

A proposal to add Sexual Addiction to the DSM system has been rejected by the APA, as not enough evidence suggested to them that the condition is analogous to substance addictions, as that name would imply.

Treatment

There does not yet exist any treatment approach uniformly endorsed by experts and/or community groups. Most clinical authors recommend a multifaceted or multimodal approach that includes a variety of treatments, including certain classes of anti-depressants (selective serotonin reuptake inhibitors, or SSRIs) that reduce sex drive in some people, motivational interviewing, and individual, group, or couples' therapy (including cognitive-behavioral, psychodynamic, and relapse-prevention).

The cognitive-behavioral treatment was first introduced to drug and alcohol addiction, one technique involved using relapse prevention; to train a set of skills, cognitive interventions and life style changes to identify and cope with stressors of relapse.

Historical uses

Richard von Krafft-Ebing

Krafft-Ebing described several cases of extreme sexual behaviours in his seminal 1886 book, Psychopathia Sexualis. Although he also used the term "hypersexuality" in that book, he was describing conditions that would now be called premature ejaculation.

Nymphomania in the Victorian age

Many Victorian era mental institutions treated nymphomania as an exclusively female mental illness. Women were classified as mentally ill for nymphomania if they were a victim of sexual assault, bore illegitimate children, "abused themselves" (i.e. masturbated), or were deemed promiscuous. Upon arrival at the asylum, doctors would give the woman a pelvic exam. If doctors felt that the woman had an enlarged clitoris, she would undergo treatments. These treatments included induced vomiting, bloodletting, leeches, restricted diet, douches (cold showers, sprays, or jets of water) to the head or breasts, and, at times, clitoridectomies.