Hypersexuality: Univocal or Equivocal Nature? Rui Du Supervised by Professor Raymond Knight Senior Honors Thesis Presented to Department of Psychology Brandeis University 2017 Copyright by Rui Du 1 Abstract Many theories have been generated to explain hypersexuality, which has been defined as “recurrent and intense sexual fantasies, sexual urges or sexual behaviors” (Kafka, 2010). Measures of the construct vary widely in the behaviors and fantasies they assess, but little research has examined the core nature of the construct or the relation among the various impulsivity scales purported to measure it. In the present study, a Qualtrics administered survey examined the relation among the various aspects of hypersexuality. The survey explored the structure of hypersexuality and help to determine whether it constitutes a univocal construct or comprises multiple related components. Principle axis factor analysis yielded a two factors structure for hypersexuality. Dysregulated sexuality was found to be related to negative emotions and affective dysregulation. These findings suggest that hypersexuality could comprise various subtypes. The differentiation of different possible subtypes and exploration of the underlying mechanisms would enrich the research in this field. Introduction Sex, which is a basic need for the survival of species, requires an instinctual drive and reward-based reinforcement to achieve continuation of the species (Frascella, Potenza, Brown, & Childress, 2010). When sexual behavior lowers life and psychological satisfaction and deters other non-sex related works, the sexual drive can, however, become problematic. Since the 19th century, clinicians and researchers have observed the occurrence of excessive sexual behaviors despite the potential risks and negative consequences. Excessive and persistent normophilic sexual behaviors have been documented in early clinical samples. Terms such as Don Juanism (Stoller, 1975) in males and nymphomania (Ellis & Sagarin, 1964) in females were used to depict this excessive sexual desire and behaviors. 2 Recently, with the ongoing and cumulative research, the potential underlying pathology of the excessive and maladaptive sexual behavior has been controversial and has generated intensive debate. In 2010 Kafka proposed the inclusion of hypersexuality in the DSM-5. He characterized it as a normophilic sexual desire disorder with an impulsivity component. In his proposal, Kafka addressed that the diagnosis of hypersexuality should be based on the recurrent or intense sexual fantasies and behaviors that might lead to distress and impairment (Kafka, 2010). Although researchers have studies hypersexual behavior and its potential related traits over the last few decades, the concept and definition of hypersexuality remain controversial. Moreover, since Kafka’s proposed diagnosis for hypersexuality was dismissed from the DSM-5, the debates on the definition of hypersexuality has intensified, and more and more researchers and clinicians have turned their attention and interests directly to this area. Models proposed to explain hypersexuality Previous research has proposed various theories of the nature of hypersexuality. Kinsey et al. started to assess the frequency of sex based on TSO (total sexual outlet/week). The number of orgasms achieved by any sexual behavior was counted, and the total score measured the construct (Kinsey et al., 1948). Langstorm and Hanson (2006) assessed a large representative community sample and found that the most sexually active 5%-10% people were affected by excessive sexual fantasies and compulsive and disinhibited sexual behavior. Considering the distribution of TSO in various samples, Kafka (1997) proposed that hypersexuality could be characterized as the persistence of seven or more orgasms/week over a minimum duration of 6 months. Recent studies have suggested, however, that this relatively high TSO may only capture a small proportion of the population that is vulnerable to hypersexuality (Kingston & Firestone, 2008). Also, it has been hypothesized that the increased access and usage of pornography and 3 dating apps might raise the total TSO. Consequently, the frequency of orgasms itself may not capture the constructs of hypersexuality. Carnes (1983) used the concept of sexual addiction to describe excessive and maladaptive sexual behavior. Carnes (1983) argued that people who have hypersexual behavior tend to lose control as the frequency of sexual activities increases, and as they continue to pursue orgasms they encounter potential risky consequences, such as STDs, marital or relationship issues, and negative effects on work and study. In light of the seemingly similar symptoms between hypersexuality and substance dependence, the sexual addiction term has become widely popularized (Kafka, 2010). Although the sexual addiction model captures the “loss of control” and adverse consequences of hypersexuality, current research has not yielded sufficient data to support the addiction model. Moreover, the clusters of symptoms that may constitute hypersexuality have remained controversial. The neurological similarities found between hypersexuality and substance dependence were limited to a small sample of solely heterosexual males. Also, researchers have studied the addiction model mainly on the abuse of substances (American Psychiatric Association, 2010). The limited empirical data have failed to show that hypersexuality has specific withdrawal and tolerance symptoms characteristic of addictive disorder (Kraus, Voon, & Potenza, 2016). Coleman (1990) has argued that hypersexuality is best conceptualized as a variant of a compulsivity problem. From this perspective, hypersexuality is characterized as intrusive and irresistible sexual fantasies and urges. Excessive and irresistible sexual thoughts increase anxiety, and compulsive behavior may reduce anxiety. People with hypersexuality could practice repetitive sexual behavior to reduce anxiety and negative emotions (Coleman, 1990). Kalichman and Rompa (1995) introduced the Sexual Compulsivity Scale (SCS) to evaluate repetitive and 4 risky sexual behavior. Some studies have demonstrated the validity and reliability of SCS across different samples. Higher SCS scores have been found to correlate with an increased frequency of masturbation, of sexual partners, and of risky sexual behaviors (Dodge et al., 2004; McBride et al., 2008). Although the compulsivity model seems to be a possible construct for hypersexuality, the compulsivity model fails to account for half of the sample’s condition (Levine, 2010). Researchers attempted to explore parallels between hypersexuality and obsessive-compulsive disorder (Garcia & Thibaut, 2010). This conceptualization argues that hypersexual behavior may be used as coping mechanism to reduce anxiety and avoid negative emotions. A study using Compulsive Sexual Behavior Inventory and Barratt Impulsiveness Scale found that people with hypersexuality were more impulsive and compulsive than the control group (Miner, Raymond, Mueller, Lloyd, & Lim, 2009). Bancroft and Janssen (2000) proposed a “dual control model” to explain excessive and uncontrollable sexual behaviors. The model proposed that sexual behavior is mediated by sexual excitation and inhibition systems. Bancroft linked sexual excitation and inhibition to neurobiological mechanisms rather than specific sexual behavior. He hypothesized that both central arousal system and downstream inhibitory pathways contribute the complex interaction between sexual excitation and inhibition (Bancroft & Janssen, 2000). To measure the propensity of sexual excitation and inhibition, Janssen, Vorst, Finn, and Bancroft (2002) developed the Sexual Excitation Scale and the Sexual Inhibition Scales (SES/SIS). Based on the dual control model, people with either high sexual excitation or low sexual inhibition might be vulnerable to hypersexuality. The dual control model and the psychometrically validated SES/SIS have become popular among researchers in the study of sexual variability in humans (Bancroft, 2009). 5 Although many concepts and models have been proposed to depict hypersexuality, researchers have not yet reached agreement on the definition of hypersexuality. Moser (2010) questioned the existing frameworks of hypersexuality. The DSM-5 Substance-Related Disorders category also refused to include hypersexuality for the same reason (APA, 2010a). With the increasing interest in hypersexuality, research has gradually begun to identify and measure different aspects of hypersexuality. For example, problematic sexual behavior has been found to be related to both impulsivity and compulsivity (Coleman, Raymond, & McBean, 2003). Hypersexuality has been found to serve as a coping mechanism to deal with negative emotions, shame, and guilt (Reid, Harper & Anderson, 2009; Gilliland, South, Carpenter, & Hardy, 2011). Considering the potential aspects of hypersexuality, a single framework may not effectively explain the complexity of hypersexuality. Because of the existing contradictions among various frameworks and results from different clinical samples, it is crucial to examine whether a multitude of frameworks better account for its manifestations. Currently, there is an insufficient amount of research to determine the univocal or equivocal nature of hypersexuality. The present study reviewed the potential components of hypersexuality and created measures of each component to better explore the structure of hypersexuality. Various Hypersexuality