LETTER TO THE EDITOR Hypersexual Disorder: A More Cautious Approach

Kafka (2009) has done an exemplary job of synthesizing disparate perspectives on dysregulated sexuality, and distilling the common elements into Hypersexual Disorder, a proposed new diagnosis for the fifth edition of the Diagnostic and Statistical ManualofMentalDisorders.Thereappears tobesubstantialclinical support for this disorder; however, strong empirical evidence demonstrating its validity is currently lacking. Further, previous criticisms of the theoretical assumptions underlying a dysregulated sexuality disorder, regardless of how it is conceptualized and labeled, have not yet been adequately addressed (e.g., Giles, 2006;Levine&Troiden,1988;Moser,1993;Rinehart&McCabe, 1997; Winters, Christoff, & Gorzalka, 2010). For these reasons, the addition of Hypersexual Disorder to the DSM may be premature. To meet the DSM definition for a mental disorder, it must be shown that Hypersexual Disorder represents a psychological or behavioral syndrome that is the manifestation of a dysfunction (American Psychiatric Association, 2000). In the case of Hypersexual Disorder, there is no clear explanation of the dysfunction. Kafka’s description indicates that the dysfunction is manifest as recurrent and excessive sexual thoughts, feelings, and behaviors. Basedonthisassertion,wearetoassumethat thereisnormalsexual expression and too much sexual expression (i.e., the dysfunction), and that there is a distinct and agreed upon boundary between the two. This is not the case. Kafka (1997)previouslyproposed that excessive sexuality (i.e., hypersexuality) was best operationalized as a weekly average of seven of more orgasms, the intention being that only a small proportion of the population would be identified as hypersexual (5–10%). This diagnostic marker has not been widely adopted by the academic and clinical communities, perhaps because there is a dearth of independent empirical support. Also, recent data suggest that a larger proportion of the population may meet this criterion, calling into question its specificity. For example, in our study utilizing an internet based convenience sample, 43.9% (2559/5824) of men and 21.5% (1538/7166) of women would have met this criterion for hypersexuality (Winters et al., 2010). These subjects reported a total weekly average sexual outlet of seven or more orgasms on Kafka’s (1997) Sexual Outlet Inventory. The other way in which increased or excessive sexual behavior has been operationalized is by its qualitative nature. Examples of sexual behaviors that are thought to be symptomatic of Hypersexual Disorder include: compulsive masturbation, protracted promiscuity, and pornography, sex chatroom, and phone sex addiction (e.g., Cooper, Scherer, Boies, & Gordon, 1999; Kafka & Hennen, 1999; Raymond, Coleman, & Miner, 2003). Yet, within the literature, there is no explanation provided as to how these are operationalized and measured. It is not clear when masturbation becomes compulsive, when promiscuity becomes protracted, and when the pursuit of sexual stimuli becomes a so-called addiction. Anonymous sex, onenight stands, and multiple partners are also considered hypersexual behaviors (e.g., Coleman, Raymond, & McBean, 2003; Kalichman & Rompa, 1995), but it seems that these behaviors are considered pathological only because of an ongoing, if not overtly stated, bias that sexual expression outside a traditional monogamous marital dyad is unhealthy. The criteria indicate that the sexual fantasies, urges or behaviors characteristic of Hypersexual Disorder may interfere with day-to-day responsibilities and activities. As has been noted previously, these types of experiences can be typical of healthy sexually active individuals, especially those in new sexual relationships (Gold & Heffner, 1998; Moser, 1993). Additionally, people often will repeatedly eschew activities and J. Winters (&) Forensic Psychiatric Services Commission, British Columbia Provincial Health Services Authority, #300–307 West Broadway, Vancouver, BC V5Y 1P9, Canada e-mail: [email protected]