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Hypersexual Disorder was proposed by Martin Kafka in 2010 for inclusion in the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association (APA). The label "Hypersexual Disorder" was reportedly chosen because it did not imply any specific theory for what causes hypersexuality, which remains unknown. A proposal to add sexual addiction to the DSM system had been previously rejected by the APA, as not enough evidence suggested to them that the condition is analogous to substance addictions, as that name would imply

Although it was under consideration but has recently been rejected for inclusion in the Appendix of the DSM-V (December 2012), it is still of interest to note the proposed criteria, which is listed here. The label of Hypersexual Disorder would apply when an individual meets at least three of the five A criteria, as well as the B criterion. The C criterion serves to exclude individuals of this diagnosis, stating that the disorder should not be diagnosed if the A and B criterion only exist when the individual is under the influence of a psychoactive substance. It does not however exclude individuals who exhibit A and B criterion due to medical conditions or co-occurring psychiatric disorders. Also, it would apply only when the problem lasts six months or more and when the individual experiences significant distress or impairment in major life areas because of it. Under the proposal, an official diagnosis would also specify which behavior(s) are problematic such as: compulsive masturbation, pornography use, cybersex, sexual behaviour with consenting adults, telephone sex, strip clubs, or other.


 * A.2. Repetitively engaging in sexual fantasies, urges or behaviors in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability).
 * A.3. Repetitively engaging in sexual fantasies, urges or behaviors in response to stressful life events.
 * A.4. Repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges or behaviors.
 * A.5. Repetitively engaging in sexual behaviors while disregarding the risk for physical or emotional harm to self or others.
 * B. There is clinically significant personal distress or impairment in social, occupational or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges or behaviors.
 * C. These sexual fantasies, urges or behaviors are not due to the direct physiological effect of an exogenous substance (e.g., a drug of abuse or a medication).

The APA reports that the updated manual, called the DSM-5, will be released in 2013. The pre-2013 version of the manual, the DSM-IV-TR includes an entry called Sexual Disorder—Not Otherwise Specified (Sexual Disorder NOS), for disorders that are clinically significant, but do not have their own code. The DSM-IV-TR notes that Sexual Disorder NOS would 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".

Biocultural Causes & Manifestations
It has been proposed that Hypersexual Disorder and excessive sexual behavior stems from a history of childhood sexual abuse from an individual’s early sexual experiences. It is clear that early interactions have an effect on altering the mechanisms for the development of Hypersexual Disorder.

As with many psychological disorders presented in the DSM, Hypersexual Disorder does not exist exclusively. Etiology of hypersexual disorder related to early predispositions for early adolescent bipolar disorder, and other psychological disorders presented in the DSM, further discussed in comorbidity of Hypersexual Disorder.

Hypersexual symptoms and manifestations may be brought on by substance abuse. Typical substances that lead an individual to act out hypersexual behaviors are alcohol, cocaine, and methamphetamines. There is a clear relationship towards the use of these substances and an increase in thoughts, feelings, and fantasies that are associated with the urge to engage in hypersexual behaviors. The use and abuse of these substances can lead to an individual to continue to seek out sexual behaviors, in turn induced by substances, creating a cycle that may lead to the manifestation of Hypersexual Disorder. Gender similarities are present in regards to the effect of substances on hypersexual behaviors.

Another overlap between an etiology and a manifestation, the growth of the Internet and Internet culture has resulted in an increase in cybersex addiction. Romantic and sexual relationships are born online and maintained via electronic interaction, and these interactions are often accompanied with compulsive masturbation.

Sociocultural Perspectives & Stigma
One important reason that Hypersexual Disorder was declined from inclusion in the DSM-V is the topic of definitions. Among experts, there is no consensus as to the correct definitions or labels of hypersexuality, and many psychologists have argued against classifying this type of behaviour as a disorder due to cultural factors. Society has tried to control, monitor, and place stigma on sexual practices exhibited by members of certain societies for a long time, and many authors reject that hypersexuality and Hypersexual Disorder even exist In discussing how to classify and possibly treat persons with what is deemed to be hypersexuality, clinicians must take into account relationship variables, personal and cultural morals, the values of society, religious beliefs, as well as the subjective experience of the individual.

When it comes to cultural and societal considerations, although there are no formal classifications of hypersexuality, there are many aspects that must be taken into consideration. Author Robert Weiss strongly suggests that normative sexuality cannot be determined using a fixed moral or religious agenda. Definitions that try to conceptualize normative sexual behaviour and attitudes must adapt not only to social norms and culture, but are also unique to the time in history they are formed. It should also be noted that hypersexuality, including behaviours and tendencies, should not be diagnosed simply based on an individual’s concept of their own sexuality being outside the acceptable norms of their culture. In addition, it has been advised that this type of behaviour should not be diagnosed on the basis on an individual’s fetishistic or paraphilic preferences or by their sexual orientation or sexual arousal patterns.

Levine and Troiden (1988) have made a considerable effort to highlight various sociocultural variables and the significant role they play. This emphasis is placed not only on the development of hypersexuality within members of a society, but also how definitions of hypersexuality and normative sexuality vary largely in different societies. In comparing dissimilar societies around the world, they focus on the fact that, in pathologizing and labeling variations of sexual behaviour, individuals who exhibit these behaviours face severe social consequences, such as stigma.

Further, what behaviours and tendencies might be considered hypersexual in one culture may not be in another. The following examples are two societies that show great variability in their labels of normative sexuality and are provided in order to illustrate the importance of sociocultural factors: Mangaia and Inis Beag. While Mangaia holds very sexually liberated standards that encourage all people to engage in frequent casual sex with multiple partners, the society of Inis Beag is strongly sexually repressive, with people being raised to regard sexual activity as a disgusting, but necessary, evil. Therefore, what is considered sexually normal in one society may be considered outside the boundaries of normal sexuality for another, leading members of different societies to use separate definitions to conceptualize Hypersexual Disorder.

Internet Culture
In North America, research shows that the population of individuals who identify as ‘sex addicts’, or what they believe to be Hypersexual Disorder, is slowly moving away from the middle-aged male population and is now spreading into both younger age groups and becoming more evenly distributed among women as well. Literature points towards ever increasing technology as a strong potential factor in the rise of individuals who display hypersexual tendencies. Although updated research is required in order to make specific assumptions, clinical research indicates that the increase in what our society deems hypersexuality is correlated with the escalation of technology (e.g. smartphones, laptops, etc.) since the late 1990’s. This technology boom has given society the ability to access and afford such possibly addicting behaviours as pornography and casual sexual encounters at any time.

This generation has brought with it a reliance on technology, most notably parallels in the amount of time that individuals spend on the Internet. Excessive Internet use has often been compared to symptoms that individuals experience during pathological addictions such as gambling. There is a link between Hypersexual Disorder and a preoccupation with Internet pornography (pornography addiction). This results in tendencies that manifest Hypersexual Disorder, such as the tendency to engage in cybersex and cyber-relationships, leading to a strict dependency on the Internet for sexual occurrences. With cybersex, there is a perception of trust and intimacy, which may be due to the anonymous nature of the act. These feelings of intimacy can lead to addictive tendencies in engaging in excessive Internet usage, accompanied with powerful masturbation tendencies.

Further, initial propositions for Hypersexual Disorder were due to the fact that it caused distress within the individual. Similarly, correlations have been found between time spent on the Internet and negative consequences for the individual.

Substance Abuse
Substances that bring about feelings that characterize Hypersexual Disorder are alcohol, cocaine, ecstasy, and methamphetamines. The use of these substances bring about an increase in sex drive, and increase in performance, and an increase in pleasure during sexual performance that have led to an obsession with sex, most notably in methamphetamine abusers. Strikingly, individuals who abuse cocaine and methamphetamines have indicated that the association between their substance of choice and sex has resulted in the belief that it will be difficult to ever separate the use of the substance and sexual behavior. This cycle of abuse results in a manifestation of Hypersexual Disorder symptoms, with a reliance on abusive substances.

Comorbidity
Comorbidity can be explained as the lifetime or current occurrence of two or more psychiatric disorders within the same individual. One of the major criticisms of the proposed diagnosis of Hypersexual Disorder is that people who present with hypersexual behaviour and tendencies also present with other diagnoses. For this reason it has been speculated that hypersexuality may be explained as a symptom of other disorders, but may not be its own disorder.

Kafka (1997) also proposed an operational definition of what hypersexual behaviour entails, which is called the Total Sexual Outlet (TSO). An individual’s TSO is defined as the cumulative total number of orgasms that is achieved by any single or combination of sexual behaviours, such as masturbation, sexual intercourse, non-penetrative sex, etc. He stated that a persistent TSO of seven or more orgasms per week for a duration of at least 6 months from the age of 15 onward is the minimum threshold to be considered for Hypersexual Disorder. In examining men with paraphilias and paraphilic-related disorders (PDRs), Kafka and Hennen (2003) hypothesized that, although the proposed Hypersexual Disorder is not classified as a pathological disorder, these men would also have increased sexual behaviour equal to or higher than the minimum TSO outlined above. The results demonstrated that 57% of males in their sample had a TSO of seven or greater, confirming the above hypothesis. In both men with paraphilias and PDRs, the predominant sexual outlet over their lifespan was compulsive masturbation (90.6%), followed by sexual intercourse (8.4%). Another study that exclusively included male participants presenting with hypersexual behaviour found substantial comorbidity of at least one paraphilia. Together, these results suggest that behaviour consistent with the proposed criterion for Hypersexual Disorder tends to occur in individuals who also present with paraphilias, although there is no literature which significantly shows that having one diagnosis increases the risk of having the other.

It has also been shown that many other psychiatric disorders may be associated with or lead to hypersexual behaviour. Several authors have noted that individuals with hypersexual behaviour and tendencies also present with an Axis I or II disorder at some point in the lives, such as a mood disorder (e.g. depression), anxiety disorder, psychoactive substance use disorders, and/or obsessive-compulsive disorder (OCD). As well, hypersexual behaviour in the case of excessive pornography and cybersex has been linked to OCD, because individuals may engage in anxiety producing behaviour (such as finding their idealized pornographic medium) and only become attracted to specific depictions of sexual behaviour.

In regards to medical disorders, numerous neurological conditions such as brain injuries, Kleine-Levin syndrome, and Kluver-Bucy syndrome have the possibility of causing the symptoms that characterize Hypersexual Disorder. Individuals who have been diagnosed with bipolar disorder may exhibit swings in sexual behaviour depending on their current mood state. Hypersexual behaviours have been found in early adolescents who have presented with symptoms of bipolar disorder, such as mood elation, racing thoughts, and a decreased need for sleep. It has been hypothesized that Hypersexual Disorder and the mania resulting from bipolar disorder may co-occur, but the DSM-IV-TR instead defines hypersexual behaviour as a symptom of mania and/or schizoaffective disorder. Along the same lines, symptoms of Hypersexual Disorder may co-exist with Attention Deficit Hyperactivity Disorder (ADHD). This disorder causes many individuals to experience mania, which not only can induce but may also maintain hypersexual behaviour and tendencies.

Gender Similarities & Differences
When it comes to discussing Hypersexual Disorder and hypersexual behaviour, literature tends to exclude women from current research, most likely due to the misunderstandings that women do not experience such behaviour or what is known as sexual addiction. Ferree (2001) links this exclusion of women from hypersexuality literature to both societal stigma and stereotypes, and indicates that whether Hypersexual Disorder is a compulsion, addiction, or otherwise, it is largely considered a male phenomenon. Historically, women with excessive sexual desire (nymphomania), were seen as rare; it has become societal custom to expect that women more commonly suffer from Hypoactive sexual desire disorder (HSDD) or a new disorder proposed for the DSM called Sexual Interest/Arousal Disorder (SIAD). However, a main reason for this belief is that women themselves rarely talk about it, most likely due to stigma.

Popular belief assumes men have stronger sex drives, think about sex more frequently and have more sexual partners than women do, but some current literature is working to dissolve these assumptions. For example, it has been suggested that although men may actually think about sex more often on a day-to-day basis, this is because men are more attentive to their own needs while women tend to be more attentive to the needs of others. Because women have typically been socialized to inhibit the expression of their own needs and desires, women with hypersexual behaviours and tendencies usually do not come forward, prolonging the silence of this proposed disorder.

Although the research regarding women who present with hypersexual behaviour or “sex addicts” is lacking in comparison to men, the idea has been brought forward that this type of “excessive” sexual behaviour may stem from different causes in men and women. While a higher percentage of both men and women who meet the proposed criteria for Hypersexual Disorder report previous abuse, women are more likely to have been sexually or physically abused, suffer from posttraumatic stress disorder (PTSD), or suffer from an eating disorder. Men, on the other hand, more frequently report histories of childhood emotional abuse. However, experiencing childhood sexual abuse predicts a greater chance of developing symptoms of Hypersexual Disorder later in life in both men and women.

There are also different life consequences for women who exhibit hypersexual behaviour than for men who do the same. Women who act on their hypersexual desires, which may include engaging in sexual activity with multiple partners, face riskier health consequences than men, such as a greater susceptibility for sexually transmitted infections (STI’s), and potential pregnancy. Historically, such as in the Victoria era, hypersexual women were judged harshly and many were classified as mentally ill. In North American society today, it has also been suggested that hypersexual women, as well as their partners and children, may face more shame and stigma than men do because of double standards. However, more research in this area is needed.

Women who report hypersexual behaviour engage in many of the same types of behaviour as men, although it is very rare for women to exhibit voyeurism. This behaviour may include:
 * Compulsive masturbation
 * Frequent pornography use
 * Internet sexual activity (e.g. cybersex)
 * Multiple partners
 * Anonymous sexual encounters
 * Telephone sex
 * Voyeurism

There is also a link that exists between hypersexual behaviour and tendencies and a preoccupation with Internet pornography, and this appears to manifest independently of gender. It is a common myth that women are more likely than men to become attached to the love and intimacy aspects of sexual behaviour, and therefore would not meet Kafka’s criteria for this proposed disorder. This assumption may be true to a certain extent, because women’s sexual behaviour has been shown to typically be more relationship-oriented, and more likely than men’s to involve another person. However, this does not prove true for all women (or all men) who display hypersexual tendencies, and research is lacking in this specific area.

Finally, women and men are equally likely to experience symptoms of hypersexual disorder or sex addiction comorbidity with other mental illnesses.

Criticism
The proposal to include Hypersexual Disorder into the DSM-5 has come under criticism in regards to the function of the diagnostic criteria. The major criticism is that currently there is no consensus on how to define, assess, or diagnose men and women with problematic patterns of adult sexual behaviour.

Other criticisms focus on the lack of scientific and clinical evidence for this disorder.
 * The DSM requires that a mental disorder represent a behavioural or psychological syndrome that is the manifestation of a dysfunction. It has been argued that there is no defined explanation of the dysfunction in Hypersexual Disorder because it has not (and quite possibly cannot) been defined exactly where the boundary between normal and excessive sexual expression lies.
 * Kafka’s conceptualization of a Total Sexual Outlet (TSO) of seven or more orgasms a week to define excessive desire has been shown to capture the sexual behaviour of a large proportion of the population, which suggests that this concept is not specific enough to explain hypersexuality as a disorder.
 * Those who support that Hypersexual Disorder is a real disorder state that there is much literature on excessive sexual behaviour that includes detailed case studies. Authors who dispute this disorder assert that the literature that captures this disorder are only able to do so because the varying definitions that make up Hypersexual Disorder have not been defined uniformly and are therefore being defined subjectively.
 * The distress criteria has also been criticized because the term “distress” lacks a clear operational definition, and it is unclear if it indicates the distress of the individual or secondary distress experienced from desiring and/or engaging in practices outside of societal expectations.
 * It is argued that, by creating labels such as Hypersexual Disorder that attempt to define normative sexuality, professionals are pathologizing sexual practices simply because they do not follow the social script for sexual norms.
 * Comorbidity studies have demonstrated that behaviour proposed in the criteria for Hypersexual Disorder often co-occurs with anxiety, mood, and personality disorders. Therefore, it cannot be concluded that the repeated pattern of sexual behaviour, fantasies, and/or urges are symptoms of its own disorder.
 * There is a lack of focus on discrepancy of desire between two partners, which may result in the partner with the higher level of desire being given the label “hypersexual”.
 * Kafka acknowledges that there is a lack of neurophysiological and neurobiological data in regards to Hypersexual Disorder.