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 , 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 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 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, , 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 Criteria

Several scales, including Sexual Excitation/Inhibition Scales (SES/SIS), Total Sexual

Outlets (TSO), Compulsive Sexual Behavior Inventory (CSBI), Kafka’s proposed Diagnosis for

DSM-5, Multidimensional Inventory of Development, Sex, and Aggression (MIDSA), and

Hypersexual Behavior Inventory (HBI), have been proposed to measure various aspects of hypersexuality (Janssen, Vorst, Finn & Bancroft, 2002; Kafka, 2003; Raymond, Coleman, &

Miner, 2003; Kafka, 2010; MIDSA, 2011; Reid, Garos, & Carpenter, 2011). Consistent with the 6 current controversies about the definition of hypersexuality, the scales proposed measure hypersexuality varying aspects of hypersexuality. For example, the HBI accentuates the coping mechanism to deal with negative emotions and consequences of hypersexuality (Reid, Garos, &

Carpenter, 2011). The Compulsive Sexual Behavior Inventory (CSBI) scale mainly focuses on compulsivity and sexual preoccupation (Raymond, Coleman, & Miner, 2003). These scales emphasize certain aspects of hypersexuality and consequently, if examined alone, would have limitations for exploring the complexity of hypersexuality.

The various conceptualizations of hypersexuality have yielded measurements that focus on different aspects of hypersexuality. In research, multiple models of hypersexuality have been used interchangeably. Either model, which addresses partial features of hypersexuality, attempted to fit all cases of hypersexuality. This situation has generated substantial confusion about the nature of hypersexuality. At the same time, some researchers tried to conceive hypersexuality as a complex structure and argued that the hypersexual symptoms might have multiple potential mechanisms (Bancroft & Vukadinovic, 2004; Bancroft, 2008). Moreover, based on the dual control model, sexuality is regulated by two different mechanisms, sexual excitation and sexual inhibition (Bancroft, Graham, Janseen & Sanders, 2009). Either heightened sexual excitation, which might cause strong sexual desire, or weakened sexual inhibition, which might cause inability to control one’s sexual behavior, could be associated with hypersexual symptoms. Other researchers have reported significant correlations between hypersexuality and negative emotions. Kafka and Hennen (2002) reported that the individuals from hypersexual subsample exhibited at least one other Axis I diagnosis. In a small sample of individuals who reported sexually compulsive behavior, most of their participants were found have comorbid

Axis I disorders, such as anxiety and mood disorders (Raymond, Coleman, & Miner, 2003). 7

Although the directionality of hypersexuality and negative emotions is still ambiguous, negative emotions and affective dysregulation could play an important role in the etiology of hypersexuality. In consideration of the various interpretations of hypersexuality, either existing conceptualization might only capture certain aspects of hypersexuality. Hypersexuality might consists of different subtypes.

With the increasing need to comprehensively understand the latent structure of hypersexuality, Winters, Christoff, and Gorzalka (2010) explored the factor structure of hypersexuality and wondered if it is possible to pull apart dysregulated sexuality from high sexual drive. Their CFA results supported that sexual compulsivity, sexual excitation and sexual desire loaded on one factor. Winters et al.’s (2010) concluded that dysregulated sexuality is indistinguishable from high sexual desire. Hypersexuality could mainly result from high sexual drive. The inability to control sexual behavior and the negative emotions associated with hypersexuality could be an indication of the high sexual drive.

Later, this single factor conceptualization was challenged because some clinical profiles of hypersexuality have been characterized by a relatively low sexual desire. Some clinical samples reported a feeling of anxiety and the need to soothe their anxiety with masturbation

(Cantor et al., 2013). Previous one-factor notion of hypersexuality argued that the high sexual drive seems to be the main cause of hypersexuality (Winters et al., 2010). Nonetheless, not all hypersexual symptoms are rooted in the high sexual drive. The dysregulated sexuality problem could be separated from the high sexual drive.

In addition to the sexual drive, the inclusion of dysregulated sexuality as a potential independent factor might contribute to the understanding of hypersexuality. Some recent data have challenged the single factor framework of hypersexuality and implied that hypersexuality 8 research should not rely on a single framework and ignore the diversity of hypersexual symptoms (Carvalho, Stulhofer, Vieira, & Jurin, 2015; Miner et al., 2016). Carvalho et al. (2015) questioned the single factor notion and used factor analyses to test whether hypersexuality can be characterized simply as a variant of the high sexual drive. Their results indicated that high sexual drive does not necessarily overlap with the dysregulated sexuality. The control problem and negative consequences loaded on a separate factor, rather than high levels of sexual desire and frequent sexual activity (Carvalho et al., 2015). More importantly, the control abnormalities of hypersexuality could be caused by the mechanism of sexual excitation and sexual inhibition

(Miner et al., 2016). The dysregulated sexuality may not be only controlled by the general high sexual drive.

Admittedly, the factor analyses from two studies yielded inconsistent results on the latent structure of hypersexuality (Winters et al., 2010; Carvalho et al., 2015). However, the selection of different scales could partly explain their results. In order to measure dysregulated sexuality,

Winters et al.’s study used the Sexual Compulsivity Scales (Kalichman & Rompa, 2001). The items in SCS addressed both the high sexual drive, negative consequences of hypersexual behavior, and inability to control one’s sexual behavior. For example, “My desires to have sex have disrupted my daily life.” “I think about sex more than I would like to.” Whereas, Carvalho et al. (2015) assessed dysregulated hypersexuality with a single item which emphasized one’s inability to reduce and control sexual fantasies, sexual urges, and sexual behavior. The

Hypersexual Behavioral Consequence Scale (Reid, Garos & Fong, 2012) items were used to assess negative outcomes of hypersexuality. The existing measurements of hypersexuality have their own presumptions of the etiology of hypersexuality. Despite the SCS scale was used to measure sexual compulsivity, the items of the scale covered multiple hypersexual-related 9 components. High scores on SCS scale could indicate both high sexual drive and dysregulated sexuality. Thus, the subsequent analysis in Winters’ study failed to tease apart the latent factors of hypersexuality.

Based on the current evidence that dysregulated sexuality could be separated from the sexual drive, we hypothesized that it might be possible to identify different forms of hypersexuality. One form of hypersexuality could be associated with high sexual drive, and the other form of hypersexuality could be associated with dysregulated sexuality. Furthermore, the high sexual drive factor might be linked with the excessive recruitment of dopamine in incentive neural circuitries. Enhanced activity of dopaminergic neurotransmission has been linked to mammalian sexual excitation (Ferguson et al., 1970; Everitt & Bancroft, 1991). Also,

Parkinson’s patients who received dopamine agonist therapy showed hypersexuality symptoms within eight months (Klos et al., 2005). The abnormality of reward system might influence the brain’s processing of rewarding sexual stimuli. The presentation of sexual stimuli appears to activate the reward system (Childress et al., 2008). Excessive dopamine could increase the activation of the reward system regions that control “wanting” in response to sexual stimuli (Oei,

Rombouts, Soeter, Van, & Both, 2012). The excessive recruitment of the reward system could induce a strong sexual drive towards potential sexual rewarding stimuli. The excessive sexual drive hypersexuality might be caused by the overactivation of the reward systems. In contrast, the other form of hypersexuality might be dysregulated sexuality. The over-reactivity of the amygdala can cause emotional dysregulation (Banks et al., 2007). The neuroimaging and lesion studies of hypersexuality have suggested that dysregulation of the amygdala and ventral striatum may be associated with hypersexuality (Robinson & Berridge, 2008). The dysregulated hypersexuality might be triggered by the over-reactivity of amygdala. 10

Considering that either current hypersexual-related scale only represents partial aspects of hypersexuality, the present study has incorporated various potential hypersexual-related components to explore the broader structure of hypersexuality. To avoid inaccurate presumptions on the construct of hypersexuality, the hypersexuality scale was divided into seven subscales:

Sexualized Coping, Sexual Preoccupation, Sexual Compulsivity, Consequences, Sexual

Excitation, Sexual Drive, and . Each subscale addressed a single hypersexual- related component.

Hypersexuality has been found to covary with various aspects of impulsivity, so we also incorporated scales measuring various aspects of impulsivity, derived from the Psychopathic

Personality Inventory (PPI-Revised), Multidimensional Personality Questionnaire (MPQ), and the MIDSA. Limited research has been done on the facets of personality that are related to hypersexuality (Reid, Dhuffar, Parhami, & Fong, 2012). Many studies have shown that the exploration of the personality aspects of psychiatric disorders can enrich the understanding of the underlying etiology and facilitate the design of treatment plans. For example, Franken, Muris, and Georgieva (2006) found a significant relation between the scores of Behavioral Approach

System (BAS) and substance abuse. Reid, Dhuffar, Parhami, and Fong’s (2012) study of covariations between the NEO-Personality Inventory-Revised and hypersexuality, affective dysregulation, difficulties coping with stress, and interpersonal sensitivity could be risk factors for hypersexuality. In addition, hypersexuality has been linked to emotional reactivity, risk- taking, a tendency not to adhere to traditional values, and to impulsivity (Miner et al., 2016).

From an online study, Rettenberger and Briken (2016) reported that hypersexuality is strongly correlated with SES/SIS scales and Fun Seeking-subscale of the BAS (BAS-FS). It is worthwhile 11 to investigate how different kinds of impulsivity might influence different forms of hypersexuality.

The measurement of impulsivity is conceived as a multifaceted construct (Buss &

Plomin, 1975; Whiteside, Lynam, Miller, & Reynolds, 2005). Multiple-scales, such as Barratt

Impulsiveness Scale (BIS), UPPS Impulsive Behavior Scale (Patton, Stanford & Barratt, 1995;

Whiteside & Lynam, 2001), have been created to measure various aspects of impulsivity., Little agreement has emerged, however, on the construct of impulsivity (Reid, Berlin, & Kingston,

2015). Although different scales emphasized various aspects of impulsivity, emerging research has been inconsistent on which forms of impulsivity relate to hypersexuality (Zapolski, Cyders &

Smith, 2009; Kastner & Sellbom, 2012; Miner et al., 2016). Moreover, patients diagnosed with hypersexuality have been found to manifest comorbid distress, negative emotionality, and Axis-1 disorders (Raymond, Coleman, & Miner, 2003; Skegg et al., 2010). The negative emotions could trigger the use of sexual behavior to achieve immediate relief and short-term affect regulation (Tice, Bratslavsky, & Baumeister, 2001). None of this previous research has, however, tried to link different kinds of impulsivity with various aspects of hypersexuality. To differentiate the role of different kinds of impulsivity with hypersexuality, we assessed the subtypes of impulsivity, risk-taking, and affective dysregulation in the present study. We hypothesized that the risk-taking impulsivity would be related to high sexual drive, whereas and negative emotion impulsivity would be related to problematic sexuality.

Most studies of hypersexuality are based on clinical samples who seek treatment for their hypersexuality (Kafka & Hennen,1999; Kafka & Hennen, 2003; Reid, Carpenter, Spackman, &

Willes, 2008; Kaplan & Krueger, 2010). Considering the possibility that hypersexuality might have subtypes, the over-emphasis on the clinical samples might create a biased understanding of 12 hypersexuality. Studies based on clinical sample and general samples yield inconsistent results.

Among samples of hypersexual men and women, Reid et al. (2012) reported parallel between neuroticism and hypersexuality. In a recent study of 2229 online recruited participants, the correlation was substantially lower than the previous finding (Rettenberger & Klein, 2015).

Winters et al., (2010) found men who seek help for their hypersexual behaviors were more likely to have religious beliefs, and increased religiosity has been found to link with negative sexual attitudes (Le Gall, Mullet & Shafighi, 2002). When religious people encounter hypersexuality, their religious constraints could increase their risk of negative emotions (Bancroft &

Vukadinovic, 2004). Due to the development of hypersexuality and possible comorbid mood disorders, samples who seek help for their high sexual drive could be characterized with increased distress and anxiety. To distinguish sexual drive component and problematic sex component, the sample of this study comprised college students and online participants.

Considering the complexity of hypersexuality, we considered in the present study different potential components of hypersexuality, and different facets of impulsivity related to hypersexuality should be investigated. The aim of this study was to explore the factor structure of hypersexuality and investigate whether different subtypes (Sexual Drive & Dysregulated

Sexuality) of hypersexuality exist. The in-depth understanding of the construct of hypersexuality generated by the present study could help clinicians to differentiate various forms of hypersexuality, assess the conditions of hypersexuality in different patients, and design multifaceted treatment approaches. Exploratory factor analyses were calculated to investigate the structure of hypersexuality and its connection with multiple forms of impulsivity. 13

Methods

Participants and Procedures

In the present study, 408 participants were recruited either through the Brandeis

Psychology Department Participants Pool or through Amazon Mechanical Turk (AMT). The

Brandeis sample included 69 undergraduate students and received credits for Introduction to

Psychology course after completion and were tested on computers in the laboratory. The AMT sample included 339 volunteers who received a $10 monetary award after completion.

Participants recruited via AMT will found access to the experiment through Human Intelligence

Tasks (HIT) on the AMT websites. Participants, who had completed at least 5,000 previous

HITs on AMT and had over 98% approval rating were invited to answer this survey. Prior to answering, participants were informed that the survey was consisted of a series of questions about personality, sexuality, and behavior. They told that their responses would be completely anonymous and confidential on the informed consent page. After participants agreed to the informed consent, they proceeded to several demographics questions and the rest of questionnaire. Participants recruited from AMT website were provided a code to receive compensation for their time after competition. All study procedures were approved by the

Institutional Review Board at Brandeis University.

Prior to data analyses, participants were removed if they met one or more of the following criteria: (a) scored two or higher on the Improbability Scale (see below); (b) scored above 3.22 on the Positive Image Scale (see below), or (c) completed the questionnaire in under

14.5 minutes. To ensure the reliability of participants’ responses, 16 subjects were removed from the whole sample. The following analyses were based on 392 participants, which represented 96.1% of the whole sample. 14

The sample ranged in age from 18-70 (mean = 34.26, SD = 12.24). The sample in this study consisted of men (n = 175, 44.6%) and women (n = 216, 55.1%). One participant did not report its gender. The ethnicity of the sample included African American (n = 29, 7.4%),

Caucasian (n = 284, 72.4%), Asian (n = 38, 9.7%), Hispanic (n = 29, 7.4 %), Native American (n

= 2, 0.5%) and other (n = 10, 2.6%). The majority of the sample was consisted of Caucasians.

The relationship status included never married (n = 158, 40.3%), in a relationship (n =88,

22.4%), married (n = 115, 29.3%), and Divorced (n = 21, 5.4%). Education among the sample included high school education (n = 90, 23%), some college (n = 133, 33.9%), bachelor’s degree

(n = 146, 37.2 %) and graduate degree (n = 22, 5.6%). (See Table 1)

Table 1 Demographic Variables For All Samples Brandeis & Turk n 392

Age 34.26 (SD = 12.24)

Gender Male 44.6% Female 55.1%

Sexual Orientation Heterosexual 88.5%

Homosexual 2.8% Bisexual 6.4% Not sure 1% Other

Ethnicity Asian 9.7% Black 7.4% Hispanic 7.4% Native 0.5% White 72.4% Other 2.6%

Education Less than High School 0.3% 15

High School 23% Less than College 33.9% Degree College Degree 37.2% Graduate Degree 5.6%

Income $0 - $17,000 13.5% $17,001 - $69,000 54.3% $69,001 - $139,350 19.1% $139,351 - $212,3000 5.4% 5 $212,301 - $379,150 0.8% 6 $379,151 or greater 1.3%

Relationship Status Single, never married 40.3% In a relationship 22.4% Married or domestic 29.3% partnership Divorced 5.4% Widowed 0.5% Separated 1.3%

Measures

Because of the lack of agreement on the measurement of hypersexuality, this study reviewed multiple scales which captures different aspects of hypersexuality and created seven potential traits of hypersexuality, including Sexualized Coping, Sexual Preoccupation, Sexual

Compulsivity, Consequences, Sexual Drive, Sexual excitability and Sociosexuality.

Behavioral Inhibition and Behavioral Activation Scales

The Behavioral Inhibition and the Activation Scales (BIS/BAS) contains 20 items and measures the sensitivity to behavioral inhibition system, which regulates avoidance behaviors and the activation system, which governs approach behaviors (Carver & White, 1994). Items are scored on 1 (Strongly Disagree) to 4 (Strongly Agree) Likert-like scale. The BIS scale includes 7 16 items about anticipation of punishment. The BAS scale includes three sub-scales: Reward

Responsiveness, Drive and Fun Seeking.

Sexual Inhibition and Sexual Excitation Scales

The SIS and SES scales contain 45 items. The SES was used to measure the propensity for sexual excitation (Janssen, Vorst, Finn & Bancroft, 2002). Five items were drawn from the

SES scale to cover the measurement of sexual excitation. All items are rated on a 0 (Definitively

False) to 4 (Definitively True) Likert-like scale. An example of an item from the original scale is

“When I think of a very attractive person, I easily become sexually aroused.”

Hypersexual Behavior Inventory

The HBI inventory includes measurements of sexual coping, consequences caused by hypersexuality and dysregulated control of hypersexuality (Reid, Garos& Carpenter, 2011).

Seven items were drawn from the HBI inventory to measure sexual coping. Items are rated on a

1 (Never) to 5 (Very Often) frequency scale. An example item from the original scale is “I use sex to forget about the worries of daily life.” Two items were taken from the HBI to measure the consequences caused by hypersexuality. An example from the original scale is “My sexual activities interfere with aspects of my life, such as work or school.”

Compulsive Sexual Behavior Inventory

The CSBI scale contains 22 items to measure the propensity for compulsive sexual behavior (Coleman, Miner, Ohlerking & Raymond, 2001). The CSBI scale includes a control subscale which measures the difficulty to regulate one’s sexual behavior. Items are rated on a 1

(Never) to 5 (Very Frequently) frequency scale. An example from the CSBI is “How often have you missed opportunities for productive and enhancing activities because of your sexual 17 activity?” Three items were chosen from the control subscale to measure the consequences caused by hypersexuality.

Multidimensional Inventory of Development, Sex, and Aggression

The MIDSA is a computerized, self-reported inventory which measures 14 domains of developmental history, sexual behaviors, sexual attitudes and aggressive behaviors (Prentky &

Knight, 1991; MIDSA, 2011). Besides, the MIDSA assesses the components of psychopathy and various aspects of sexuality. A number of studies have used the MIDSA inventory to explore psychopathy and sexuality (Knight, 2010; Graham, Walters, Harris & Knight, 2016). The hypersexuality scale from MIDSA provides a comprehensive coverage of the measurement of sexual drive. Twelve items were drawn from the MIDSA inventory to assess sexual drive and sexual preoccupation. Eight items were drawn from MIDSA to measure Sociosexuality.

Hypersexual Disorder Screening Inventory

HDSI, an inventory developed by the DSM-5 committee, consists of seven items for clinical screening of Kafka’s proposed diagnosis of Hypersexuality (DSM-5 Workgroup on

Sexual and Gender Identity Disorders, 2010; Kafka, 2010). Responses were based on the prior six months. Two items were drawn from the HDSI to measure the consequences of hypersexual behavior.

Hypersexuality Scale

The newly created scale for hypersexuality contains seven subscales: Sexual Excitation,

Sexual Preoccupation, Sexual Drive, Sociosexuality, Sexual Consequences, Sexual Coping and

Sexual Compulsivity. 18

The Sexual Excitation scale contains five items. The scale assesses the propensity of sexual excitation. All items of this scale are scored on a 0 (Definitely False) to 4 (Definitely

True) Likert-like scale. An example of the scale is “When I think of a very attractive person, I easily become sexually aroused.” Cronbach’s alpha was acceptable in this sample (α = 0.81).

The Sexual Preoccupation scale contains seven items. High scores on this scale indicate more sexual thinking and fantasies. All items of this scale are rated on a. An example of the scale is “Before going to sleep, I think about sex.” Cronbach’s alpha was acceptable in this sample (α

= 0.88).

The Sexual Drive scale includes five items. The scale measures the drive to seek and engage sexual activities. Four items of the scale are rated on a 0 (Definitely False) to 4

(Definitely True) Likert-like scale. The other item measures participant’s preferred frequency to have sex, ranging from 0 (Never) to 5 (Almost Every Day). An example of the scale is “There have been times when sex was on my mind so much that I had to make love or masturbate once a day or more.” Cronbach’s alpha was acceptable in this sample (α = 0.73).

The Sociosexuality scale, which includes eight items, assesses the willingness to engage in sexual activity outside of a . Eight items of the scale are rated on a 0

(Definitely False) to 4 (Definitely True) Likert-like scale. An example of the scale is “It is silly to be completely faithful to a throughout one's life.” Cronbach’s alpha was acceptable in this sample (α = 0.90).

The Sexual Consequences scale includes eight items. High scores on this scale indicate that hypersexuality brings negative consequences to one’s life. Four items of the scale are rated on a 0 (Definitely False) to 4 (Definitely True) Likert-like scale. Four items of the scale are rated 19

on a 0 (Never) to 4 (Over 50 Times) absolute frequency scale. An example of the scale is “I have

missed personal opportunities because of my sexual behavior.” Cronbach’s alpha was acceptable

in this sample (α = 0.83). To increase the internal consistency of the scale, one item was dropped

(α = 0.85).

The Sexual Coping scale, which includes ten items, measure the use of hypersexual

behavior as a coping mechanism. All items of this scale are scored on a (Never) to 5 (Almost

Every Day) temporal frequency scale. An example of the scale is “I avoid stress by sexual

activity.” Cronbach’s alpha was acceptable in this sample (α = 0.94).

The Sexual Compulsivity scale contains nine items. High scores on this scale indicate the

difficulty to control one’s sexual behavior. Four items are rated on a (Never) to 5 (Almost Every

Day) temporal frequency scale. Three items are scored on a 0 (Definitely False) to 4 (Definitely

True) Likert-like scale. Two items are rated on a 0 (Never) to 4 (Over 50 Times) absolute

frequency scale. An example of this scale is “I have felt an overpowering urge to do a sexual

behavior that I had thought about.” Cronbach’s alpha was acceptable in this sample (α = 0.87).

(See Table 2)

Table 2 Hypersexuality Scale Subscale Cronbach’s alpha Item Sexual Coping 0.94 I avoid stress by sexual activity. I use sex to avoid meeting my responsibilities. I use sex to procrastinate. I use sex to forget about the worries of daily life. Doing something sexual helps me feel less lonely. I turn to sexual activities when I experience unpleasant feelings. 20

When I feel restless, I turn to sex to soothe myself. Doing something sexual helps me cope with stress. Sex provides a way for me to deal with emotional pain I feel. I use sex as a way to try to help myself deal with my problems. Sexual Preoccupation 0.88 Before going to sleep, I think about sex. I have thought about sex. There have been times when I thought about sex all of the time. I have sex dreams when I sleep. I get sexually turned on easily. When I am bored, I daydream about sex. While working at a job, my mind will wander to thoughts about sex. Sexual Compulsivity 0.87 I sometimes think about sex so much that it gets on my nerves. I am always thinking about sex, no matter where I go or what I do. I am not able to control my sexual behavior. I have felt an overpowering urge to do a sexual behavior that I had thought about. I have not been able to stop myself from a sexual act, even when I wanted to stop. Sexual feelings overpower me. I have had a problem controlling my sexual feelings. I have to fight sexual urges. I can’t stop thinking about sex. Sexual Consequences 0.85 Aspects of my sexual behavior have made me feel guilty or shameful. My sexual thoughts or behavior have interfered with ability to make friends? 21

I have missed personal opportunities because of my sexual behavior. My sexual behavior makes me sacrifice important things I really want. My sexual behavior and fantasies have caused significant problems in important areas of my life. I engage in sexual activities that I know I will later regret. My sexual activities interfere with aspects of my life, such as work or school. I have tried to keep my sexual behavior a secret. Sexual Drive 0.73 There have been times when sex was on my mind so much that I had to make love or masturbate once a day or more. At times I have almost been driven insane by my thoughts about sex. I need to masturbate or have sex every day so that I feel less tense. I sometimes think about sex so much that it gets on my nerves. If I had my choice, I would prefer to have sex (choose the number that is most true for you): Sexual Excitation 0.81 When I think of a very attractive person, I easily become sexually aroused. When I see an attractive person, I start fantasizing about having sex with him/her. When I see others engaged in sexual activities, I feel like having sex myself. If I am watching a sexual scene in a film, I quickly become sexually aroused. 22

When I feel sexually aroused, I usually have an erection or get wet. Sociosexuality 0.90 It is silly to be completely faithful to a sexual partner throughout one's life. appeals to me. If I were invited to take part in an orgy with attractive people, I would probably not accept. I can imagine myself enjoying with different partners. I would have to be emotionally close to someone before I could feel okay about having sex with her or him It would be difficult for me to enjoy having sex with someone I did not know very well I could enjoy having sex with someone I was physically attracted to, even if I did not feel anything emotionally for them. It would be upsetting for me to have sex with someone I did not love.

Lie Scales

To ensure participants were not responding at random, the Positive Image scale was drawn from the Multidimensional Inventory of Development, Sex, and Aggression (MIDSA,

2011). The Positive Image scale includes nine items to determine whether participants were responding to questions in an overly positive light. Items were rated on a 0 (Definitely False) to 4

(Definitely True) scale. An example item of this scale is “I am always polite, even to people who are rude.” A cutoff of 3.22 was used to exclude unreliable respondents. The scale has shown a 23 relatively low to moderate internal consistency in previous studies (α = .69; MIDSA, 2011).

Cronbach’s alpha in this sample was α = 0.59.

Besides, three items from the Improbability scale were drawn from MIDSA to determine how closely participants attended to the items (MIDSA, 2011). An example item from the scale is “I have not taken a shower or bath in the last year.” Items in this scale were rated on a 0

(Definitely False) to 4 (Definitely True) scale. Responses to this scale were recoded to identify unreliable participants. Responses other than 0 (Definitely False) were coded as 1. Participants with sum scores of two or above were removed from further data analyses.

Impulsivity Scales

Negative Emotion scale consists of 9 items which were used to assess the emotional dysregulation and tendency to deny negative emotions and the subsequent influence on behavior (MIDSA, 2011). All items on this scale are rated on a 0 (Definitely False) to 4

(Definitely True) Likert-like scale. An example of the scale is “My parents were not always fair when they punished me.” The internal consistency for adults α = .73. Cronbach’s alpha for this sample was acceptable (α = 0.88).

Lack of scale contains eight items (MIDSA, 2011). High scores on this scale indicate lack of concern for the misfortunes of others. Five items of this scale are rated on a 0

(Definitely False) to 4 (Definitely True) Likert-like scale. Three items are rated on a 0 (Never) to

4 (Over 50 Times) absolute frequency scale. An example of an item on the scale is “When I see someone being treated unfairly, I feel sorry for them.” The internal consistency for juveniles was

α = .75 and for adults α = .7 (MIDSA, 2011). Cronbach’s alpha for this sample was acceptable (α

= 0.68). 24

Lack of Perspective Taking scale consists of six items (MIDSA, 2011). High scores on this scale indicate one’s difficulty to see various perspectives and consider both sides of an issue.

Two items are rated on a 0 (Never) to 5 (Almost Every Day) temporal frequency scale. The rest items are rated on a 0 (Definitely False) to 4 (Definitely True) Likert-like scale. An example of this scale is “I find it difficult to see things from the "other guy’s" point of view.” The internal consistency for juveniles was α = .70 and for adults α = .78 (MIDSA, 2011). Cronbach’s alpha for this sample was acceptable (α = 0.69).

Conning and scale consists of six items (MIDSA, 2011). Participants who rated high on this scale admit to conning others, taking advantages of others, manipulating others by lying, and charming others into doing what one wants. All items are rated on a 0

(Definitely False) to 4 (Definitely True) Likert-like scale. An example item is “I have conned someone to get what I wanted.” Acceptable internal consistency was found in previous sample

(α = 0.74; MIDSA, 2011). Cronbach’s alpha for this sample was acceptable (α = 0.73).

Impulsivity scale contains eight items (MIDSA, 2011). High scores on this scale indicate acting on impulse, loss of control and moodiness. Five items of this scale are rated on a 0 (Never) to 5 (Almost Every Day) temporal frequency scale. Three items are rated on a 0 (Never) to 4

(Over 50 Times) absolute frequency scale. An example of this scale is “I have lost control of myself, even though I did not want to.” Previous sample reported acceptable Cronbach’s alpha (α

= 0.80; MIDSA, 2011). Cronbach’s alpha for this sample was acceptable (α = 0.81).

Pervasive Anger scale contains eight items (MIDSA, 2011). High scores on this scale represent instances of anger and failure to control one’s temper. Seven items are rated on a 0

(Never) to 5 (Almost Every Day) temporal frequency scale. One item is rated on a 0 (Never) to 4

(Over 50 Times) absolute frequency scale. An example of this scale is “I lose my temper easily.” 25

The internal consistency was acceptable in the previous sample (α = .86; MIDSA, 2011).

Cronbach’s alpha for this sample was acceptable (α = 0.86).

Psychopathic Personality Inventory & Psychopathic Personality Inventory – Revised

PPI contains one hundred and sixty items which measure various conceptual constructs related to psychopathy (PPI; Lilienfeld & Andrews, 1996; Lilienfeld, Widows & Staff, 2005).

The scale includes eight subscales: Machiavellian Egocentricity, Coldheartedness, Carefree

Nonplanfulness, Fearlessness, Social Potency, Blame Externalization, Impulsive Nonconformity, and Stress Immunity. Items were drawn from original PPI and PPI-revised to cover several traits related to impulsivity. All items are rated on a 0 (Definitely False) to 4 (Definitely True) Likert- like scale. For Machiavellian Egocentricity, Cronbach’s alpha was acceptable (α = 0.76). For

Social Potency, Cronbach’s alpha was α = 0.60. One item was removed from Social Potency subscale to increase the internal consistency (α = 0.65). For Fearlessness, Cronbach’s alpha was moderate (α = 0.40). For Blame Externalization, Cronbach’s alpha was acceptable (α = 0.88).

For Impulsive Nonconformity, Cronbach’s alpha was acceptable (α = 0.79). For Carefree

Nonplanfulness, Cronbach’s alpha was α = 0.62. One item was removed from the scale to increase internal consistency (α = .70).

Inventory of Callous-Unemotional Traits

ICU scale contains twenty-four items which assess callousness and unemotional traits

(ICU; Frick 2004). Six items were drawn from the ICU scale. All items were rated on a 0

(Definitely False) to 4 (Definitely True) Likert-like scale. An example of this scale is “When I do something wrong, I do not feel bad about it.” Previous study indicated an acceptable Cronbach’s 26 alpha (α = 0.77; Essau, Sasagawa & Frick, 2006). Cronbach’s alpha for this sample was acceptable (α = 0.73).

Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988). Anxiety will be measured using the twenty-one item BAI. The BAI is a short self-report survey of common symptoms of anxiety. Responses indicate the degree to which they agree with suffering from each symptom, ranging from 0 (Not at All) to 3 (Severely) point scale. Ten items were drawn from the scale to assess the level of anxiety or anxiety-related symptoms. Internal consistency has been found to be acceptable (α = .92) in previous samples (Beck, Brown, Epstein, & Steer,

1988). Cronbach’s alpha for this sample was acceptable (α = 0.89).

Demographics

Prior to the rest of the questionnaire, five questions which include sex, race, education, , household income, and age were asked.

Results

Factor Analysis of Hypersexuality Scales

A principle axis analysis (PFA) was conducted on the seven subscales of hypersexuality

(Sexual Excitation, Sexual Preoccupation, Sexual Drive, Sociosexuality, Sexual Consequences,

Sexual Coping and Sexual Compulsivity) with oblique rotation. The Kaiser-Meyer-Olkin measure indicated the adequacy of the sampling for the analysis, KMO = 0.88 (‘great,' according to Field, 2009). Bartlett’s test of sphericity x2 (21) = 1584.14, p < 0.001, which verified that correlations between scales were sufficiently large for PFA. Two components had eigenvalues over Jolliffe’s criteria of 0.7 and in total explained 74.03% of the variance. The screen plot indicated an inflexion that would justify retaining two components. Given the adequate sample 27 size, the convergence of the screen plot and Jolliffe’s criteria of 0.7, two components were retained in the final analysis. Table 3.1 shows the factor loadings after oblique rotation. Table 3.2 contains the correlations between seven hypersexuality scales. The different aspects of hypersexuality that cluster on the same components suggest that the first component represents a

Sexual Drive factor and the second component represents a Dysregulated Sexuality factor.

According to the pattern matrix, Sexual Excitation, Sexual Drive, Sexual Preoccupation, and

Sociosexuality loaded on the Sexual Drive factor. Besides, Sexual Consequences, Sexual Coping and Sexual Compulsivity loaded on the Dysregulated Sexuality factor.

In addition, the factor structure of hypersexuality in male samples and female samples were checked. Both male samples and female samples indicated a similar two-factors structure.

Table 3.1 Hypersexuality Pattern Matrix Factor 1 2 Sexual Excitation 0.823 Sexual Drive 0.712 Sexual Preoccupation 0.687 Sociosexuality 0.657 Sexual Compulsivity -0.949 Sexual Consequences -0.746 Sexual Coping -0.546 Extraction Method: Principal Axis Factoring. Rotation Method: Oblimin with Kaiser Normalization.

Table 3.2 Hypersexuality Correlation Matrix

Sexual Sexual Sexu Sexual Sexual Sexua Sociosexual Compulsivi Preoccupati al Excitati Consequenc l ity ty on Drive on es Copin g 28

Correlati Sexual 1 0.684 0.655 0.52 0.702 0.694 0.368 on Compulsivit y Sexual 0.684 1 0.748 0.642 0.431 0.653 0.475 Preoccupati on Sexual 0.655 0.748 1 0.649 0.495 0.637 0.505 Drive Sexual 0.52 0.642 0.649 1 0.41 0.514 0.527 Excitation Sexual 0.702 0.431 0.495 0.41 1 0.567 0.341 Consequenc e Sexual 0.694 0.653 0.637 0.514 0.567 1 0.389 Coping Sociosexual 0.368 0.475 0.505 0.527 0.341 0.389 1 ity Sig. (1- Sexual 0 0 0 0 0 0 tailed) Compulsivit y Sexual 0 0 0 0 0 0 Preoccupati on Sexual 0 0 0 0 0 0 Drive Sexual 0 0 0 0 0 0 Excitation Sexual 0 0 0 0 0 0 Consequenc es Sexual 0 0 0 0 0 0 Coping Sociosexual 0 0 0 0 0 0 ity

Factor Analysis of Different Impulsivity

A principle axis analysis (PFA) was conducted on the different impulsivity scales with oblique rotation. The Kaiser-Meyer-Olkin measure indicated the adequacy of the sampling for the analysis, KMO = 0.79 (‘good,' according to Field, 2009). Bartlett’s test of sphericity x2 (36) =

1614.24, p < 0.001, which indicated that correlations between scales were sufficiently large for

PFA. Two components had eigenvalues over Kaiser’s criteria of 1 and in combination explained

63.52% of the variance. The screen plot showed inflexion that would justify retaining two 29 components. Given the sufficient sample size, the convergence of the screen plot and Kaiser’s criteria of 1, two components were retained in the final analysis. Table 4.1 shows the factor loadings after oblique rotation. Table 4.2 contains the correlations between different impulsivity scales. The different impulsivity that cluster on the same components suggest that the first component represents a Risk-taking/Callousness factor and the second component represents a

Negative Emotions/Emotional Dysregulation factor. If cutoff was set as 0.50, blame externalization would be excluded from the Negative Emotions/Emotional Dysregulation factor.

According to the pattern matrix, emotional dysregulation, anxiety, impulsivity, and pervasive anger loaded on the Negative Emotions/Emotional Dysregulation factor. Risk-Fearlessness,

Noncomformity, Callousness and Machiavellian Egocentricity loaded on the Risk- taking/Callousness factor.

In addition, the factor structure of different impulsivity in male samples and female samples were checked. Both male samples and female samples indicated a similar two-factors structure.

Table 4.1 Impulsivity Pattern Matrix Factor 1 2 Emotional Dysregulation .853 Anxiety .833 Impulsivity .751 Pervasive Anger .678 Blame Externalization .450 Risk and Fear .753 NonComformity .681 Callousness .673 Machiavellian .583 Extraction Method: Principal Axis Factoring. Rotation Method: Oblimin with Kaiser Normalization.

30

Table 4.2 Impulsivity Correlation Matrix

Anxi Perva Ris Callous Non- Impulsi Machiav Emotion Blame ety sive k- ness Comfor vity ellian al Externali Anger fea mity Dysregul zation r ation Correla Anxiety 1 0.403 0.0 0.119 0.235 0.549 0.199 0.75 0.468 tion 02 Pervasive 0.40 1 0.1 0.113 0.237 0.706 0.336 0.564 0.385 Anger 3 4 Risk-fear 0.00 0.14 1 0.43 0.545 0.243 0.439 0.223 0.222 2 Callousnes 0.11 0.113 0.4 1 0.492 0.243 0.466 0.312 0.346 s 9 3 NonComf 0.23 0.237 0.5 0.492 1 0.387 0.436 0.395 0.362 ormity 5 45 Impulsivit 0.54 0.706 0.2 0.243 0.387 1 0.447 0.667 0.382 y 9 43 Machiavel 0.19 0.336 0.4 0.466 0.436 0.447 1 0.333 0.41 lian 9 39 Emotional 0.75 0.564 0.2 0.312 0.395 0.667 0.333 1 0.488 Dysregulat 23 ion Blame 0.46 0.385 0.2 0.346 0.362 0.382 0.41 0.488 1 Externaliz 8 22 ation Sig. (1- Anxiety 0 0.4 0.009 0 0 0 0 0 tailed) 87 Pervasive 0 0.0 0.013 0 0 0 0 0 Anger 03 Risk-fear 0.48 0.003 0 0 0 0 0 0 7 Callousnes 0.00 0.013 0 0 0 0 0 0 s 9 Non- 0 0 0 0 0 0 0 0 Comformi ty Impulsivit 0 0 0 0 0 0 0 0 y Machiavel 0 0 0 0 0 0 0 0 lian Emotional 0 0 0 0 0 0 0 0 Dysregulat ion Blame 0 0 0 0 0 0 0 0 Externaliz ation Correlation between Hypersexuality and Impulsivity Factors 31

Risk-taking/Callousness factor was significantly correlated with Sexual Drive factor, r =

0.45, p (two-tailed) < 0.001. Moreover, Risk-taking/Callousness factor was significantly

correlated with Dysregulated Sexuality factor, r = 0.55, p (two-tailed) <0.001. The correlation

between Risk-taking/Callousness factor and Dysregulated Sexuality factor was not significantly

higher than the correlation between Risk-taking/Callousness factor and Sexual Drive factor (z =

0.096, p = 0.003)

Negative Emotions/Emotional Dysregulation factor was significantly correlated with

Sexual Drive factor, r = 0.27, p (two-tailed) < 0.001. Besides, Negative Emotions/Emotional

Dysregulation factor was significantly correlated with Dysregulated Sexuality factor, r = 0.47, p

(two-tailed) < 0.001. The correlation between Negative Emotions/Emotional Dysregulation

factor and Dysregulated Sexuality factor was significantly higher the correlation between

Negative Emotions/Emotional Dysregulation factor and Sexual Drive factor (z = 0.196, p <

0.001). (See Table 5)

Table 5 Correlation between Sexuality and Impulsivity Factors Sexual Frequency Problematic Sexuality Risktaking/Callousne Pearson Correlation .452*** .548*** .096** p = .00306 ss Sig. (2-tailed) .000 .000 N 392 392 NegativeEmotions/E Pearson Correlation .268*** .474*** .206**** p <.0001 motional Dysregulation Sig. (2-tailed) .000 .000 N 392 392 .184*** -.079 p = .00019 ns ** Correlation is significant at the 0.01 level (2-tailed). Blame Externalization excluded from the Negative Emotions/Emotional Dysregulation factor.

Discussion 32

Because of the ongoing debates about the conceptualizations of hypersexuality, an agreement on either the definition or the measurement of hypersexuality has been elusive.

Different studies exploring hypersexuality have focused on varying theoretical models, including sexual behavior frequency, compulsive sexual behavior, high sexual drive, impulse-control dysfunction, and sexual addiction. Unfortunately, there has been a paucity of research attempting to compare and contrast various models of hypersexuality, which could be a complex construct that consists of various subtypes. The present study predicted that hypersexuality would consist of two subtypes. One subtype would be characterized by the sexual drive. The other subtype would be characterized by dysregulated sexuality. Principle axis analysis (PFA) yielded results that indicated that the seven hypersexual-related components loaded on two different factors. Components related to excessive sexual thoughts and drive loaded on the

Sexual Drive factor. Components related to compulsive sexual behavior, sexual coping, and potential negative consequences of hypersexual behavior loaded on the Dysregulated Sexuality factor. Male samples and female samples exhibited similar results in their PFA. More importantly, our pilot Brandeis sample revealed a similar two-factors structure to the factor structure found in the pilot Amazon Turk sample. Despite the gender differences, the similar factor structure of males and females reinforced the prediction that there are two potential subtypes of hypersexuality. For Sexual Drive subtype, heightened sexual fantasies, desire, and behavior characterize this hypersexual dimension. For Dysregulated Sexuality subtype, the need to use sex as a coping mechanism to deal with negative emotions might play a greater role on this dimension. The temporal relief from sexual coping might promote the future use of sex as a coping mechanism. Individuals might increase the use of sexual coping and eventually become unable to control their sexual behavior. 33

We also examined how various impulsivity might be related to different subtypes of hypersexuality. Impulsivity is an equivocal construct comprising multiple subcomponents

(Whiteside, Lynam, Miller, & Reynolds, 2005). We predicted that the different types of impulsivity may be related to different kinds of hypersexuality. Whereas Risk-taking might be related to the high sexual drive, emotional dysregulation impulsivity might be related to the dysregulated sexuality. We selected measures of impulsivity that were hypothesized to capture these two types of impulsivity. The PFA of our impulsivity scales yielded a two-factor structure.

One type of impulsivity is characterized by risk-taking and callousness. The other type of impulsivity was characterized by negative emotions and emotional dysregulation. Negative

Emotion/Emotional Dysregulation impulsivity significantly was found to correlate significantly more with Dysregulated Sexuality than with Sexual Drive, and Sexual Drive correlated significantly more with Risk Taking than with Emotional Dysregulation. More importantly, male samples and female samples of this study exhibited similar factor structures of hypersexuality and impulsivity. Inconsistent with our a priori hypotheses Risk-taking/Callousness was significantly correlated with both Dysregulated Sexuality and Sexual Drive. Risk- taking/Callousness seems to be involved critically in both Sexual Desire and Dysregulated

Sexuality subtypes. Individuals characterized by negative emotion and emotional dysregulation may be more likely to experience moodiness, and the inability to regulate one’s emotions may further increase levels of anxiety and stress. The reinforced negative emotion may also expose the individual to the danger of increased sexual problems. Risk-taking/Callousness did not significantly correlate more with Sexual Desire than Dysregulated Sexuality. Individuals with high sexual drive might be more likely to perform reward-seeking and risk-taking behaviors. At the same time, the risk-taking and callousness traits could induce many conflicts in social 34 interactions. The conflicts and poor interpersonal relationships may lead to increasing negative emotions and promote increased sexual coping.

Emerging evidence has already indicated the distinctiveness between problematic sexuality and high sexual drive (Carvalho et al., 2015). Although dysregulated sexuality and sexual drive may have different underlying mechanisms, the present results suggest that either one could ultimately contribute to hypersexual symptoms. Moreover, the dual control model of sexuality has already indicated that subtypes of hypersexuality may potentially be characterized by different mechanisms. Individuals with either heightened sexual excitation or weakened sexual inhibition have been hypothesized to be more vulnerable to hypersexuality (Bancroft &

Janssen, 2000; Moser, 2011). It is reasonable to propose that different subtypes of hypersexuality exist. Previous studies relied on a single theoretical model to define hypersexuality, and inconsistent results have emerged from various studies. Individuals in clinical samples who have sought help for their hypersexuality might be more likely to be characterized by the Dysregulated Sexuality. Several studies have revealed that clinical samples with hypersexuality were more likely to be influenced by religious beliefs and moralistic attitudes (Winter et al., 2010; Grubbs, Exline, Pargament, Hook & Carlisle, 2015). The negative attitudes toward sexuality might bring more stress and anxiety when individuals encounter higher levels of and motivation. Besides, clinical samples which were assessed by existing hypersexuality scales and clinical sample who sought help for their hypersexual symptoms could display inconsistent features. Some clinical samples might not exhibit distress and emotional dysregulation in the early stage of hypersexuality. The current hypersexuality assessments may not capture the complexity of hypersexuality. Thus, a scale which incorporates different aspects of hypersexuality should be considered to understand the structure of 35 hypersexuality. Without further empirical data to support the specific conceptualization of hypersexuality, studies that employ conflicting definitions and models of hypersexuality will continue to yield inconsistent results.

The study has several limitations. In sexuality research, assessing sexual behavior and related traits relies heavily on self-report. The accuracy of retrospective self-reports remained controversial (Schroder, Carey & Vanable, 2003). Due to the concern of privacy or anonymity, participants might not provide accurate responses to the survey. The diversity of our sample was also limited. Participants were mainly college students and Turk volunteers. College students, who are very young in age, have relatively less experience in sex. The Turk sample, however, has a significant border age range. Consider the various developmental profiles, samples from different age groups may exhibit certain aspects of hypersexuality. Turk samples, who tended to make responses very quickly, might respond without a full understanding of items. However, the result from our study is consistent with Carvalho et al.’s (2015) two-factors structure of hypersexuality. The similar factor structure found in both males and females also reinforced the two-factors structure of hypersexuality.

The scales used to assess various aspects of hypersexuality, certainly have room for improvement. Because of the limited sample size, the items-level factor analyses could not be performed to generate a more accurate scale. In Sexual Consequence and Sexual Coping, certain items could imply multiple aspects of hypersexuality. Participants might assume that the inability to control strong sexual desire indicates high sexual drive rather than control abnormalities. The negative consequences of hypersexuality could be conceived as the inability to control sexual behavior. The participants’ presumptions on certain items could increase the ambiguity of the scales. Future research should generate a less ambiguous and accurate hypersexuality scale to 36 explore the different components of hypersexuality. The gender differences of hypersexuality still require more investigations Although male and female samples displayed a similar factor structure of hypersexuality, the male-female difference in sexuality could still contribute to different mechanisms of hypersexuality. Anne Peplau (2003) reported that men show a greater sexual desire on many measures of sexual desire than women do. Aggression is strongly linked to sexuality for men. The current scale might have a bias on certain items and overlook the gender differences in sexuality.

In addition to the sexual drive, this study also suggests that hypersexuality should also be seen through the lens of emotion dysregulation. Recent studies (Reid & Carpenter & Reid,

Garos, Carpenter, & Coleman, 2011) addressed the link between hypersexuality and emotion dysregulation. The negative emotions or inability to control these emotions could trigger a serial of impulsive behaviors. However, it should be noted that the directionality between hypersexuality and emotion dysregulation remains elusive. The hypersexuality, on the other hand, might be a symptom of other psychological disorders. The role of emotion regulation in hypersexuality should be addressed in the future studies.

The present research supported both the hypothesis that two subtypes of hypersexuality exist and that these two types were differentially related to different kinds of impulsivity. The study indicated the importance of differentiating subtypes of hypersexuality and incorporating such differentiations into future research. In the present study, it is essential next to explore items-based factor analyses to develop better subscales of both hypersexuality and impulsivity and to do exploratory analyses to maximize the covariations among subcomponents. Also essential is the replication of the results on broader more representative samples to enhance the generalizability of the existence of subtypes of hypersexuality. The growing hypersexuality 37 research using neurological indicators would also enrich the understanding of the neural mechanisms of that might covary with different hypersexuality subcomponents. The differentiation hypersexuality into more homogeneous subcomponents would benefit both the assessment and treatment of hypersexuality.

38

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