Assessment Methods and Management of Hypersexuality and Paraphilic Disorders

Daniel Turner; Daniel Schöttle; John Bradford; Peer Briken

Disclosures

Curr Opin Psychiatry. 2014;27(6):413-422. 

In This Article

Abstract and Introduction

Abstract

Purpose of review The recent implementation of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition introduced some important changes in the conceptualization of hypersexuality and paraphilic disorders. The destigmatization of nonnormative sexual behaviors could be viewed as positive, However, other changes are more controversial. In order to stimulate new research approaches and provide mental healthcare providers with appropriate treatment regimes, validated assessment and treatment methods are needed. The purpose of this article is to review the studies published between January 2013 and July 2014 that aimed at assessing the psychometric properties of the currently applied assessment instruments and treatment approaches for hypersexuality and hypersexual disorders or paraphilias and paraphilic disorder.

Recent findings Currently existing instruments can validly assess hypersexual behaviors in different populations (e.g. college students, gay and bisexual men, and patients with neurodegenerative disorders) and cultural backgrounds (e.g. Germany, Spain, and USA). Concerning the assessment of paraphilias, it was shown that combining different assessment methods show a better performance in distinguishing between patients with paraphilias and control groups. In addition to psychotherapeutic treatment, pharmacological agents aiming at a reduction of serum testosterone levels are used for hypersexual behaviors as well as paraphilic disorders.

Summary Although the currently applied assessment and treatment methods seem to perform quite well, more research about the assessment and evidence-based treatment is needed. This would help to overcome the existing unresolved issues concerning the conceptualization of hypersexual and paraphilic disorders.

Introduction

After nearly 20 years, the new Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) was published by the American Psychiatric Association in May 2013. With the debate about it and the actual construction process, some important changes and new developments to the conceptualization of hypersexuality and paraphilic disorders were introduced.[1]

Hypersexuality and Hypersexual Disorders

So far, different terms such as sexual addiction, sexual compulsivity, sexual preoccupation, and hypersexuality have been used to describe hypersexual behaviors in an individual, clarifying that the cause of hypersexual behaviors was and still is controversial. Within the present article, we will consistently refer to the terms 'hypersexual behavior' or 'hypersexuality' describing any above average sexual activity (fantasies, urges, and behaviors). In cases in which hypersexual behaviors became pathological, clinicians according to the previous DSM versions were supposed to diagnose a Sexual Disorder Not Otherwise Specified. However, because of the growing clinical experience and the state of scientific knowledge, it was suggested that hypersexual disorder should be included as a distinct entity within the Appendix of DSM-5 (Emerging Measures and Models). Kafka[2] in 2010 proposed the diagnostic criteria for a hypersexual disorder diagnosis. After revisions, hypersexual disorder was defined as recurrent and intense sexual fantasies, urges, or sexual behaviors over a period of at least 6 months, including four of five behavioral criteria (A criterion), causing clinically significant distress (B criterion), not being due to other substances or medical conditions (C criterion), and being at least 18 years of age (D criterion).[3] Especially, criterion A was criticized as not being able to distinguish between normal and pathological levels of sexual desire, thereby creating a high probability of false-positive diagnoses.[4] Others feared a pathologization of 'immoral' sexual behaviors, a misuse in forensic settings, or viewed hypersexual behaviors as a symptom of other psychiatric disorders.[5–7] Although some critics could be disproved, hypersexual disorder was not included in the DSM-5 because of the (in the Board of Trustees point of view) still insufficient state of research.[8,9] However, it should be noted that it was less questioned that there are individuals seeking help because of hypersexual behaviors and thus it becomes obvious that psychometrically sound assessment measures and treatment methods are needed not only to increase the current state of research, but also to provide clinicians with appropriate tools when seeing such patients. Within the current article, hypersexual disorder is defined based on the proposed DSM-5 criteria.[3]

Paraphilias and Paraphilic Disorders

The DSM-5 now distinguishes between paraphilias and paraphilic disorders, thereby aiming to destigmatize nonnormative sexual interests and behaviors, and demarcating them from pathological sexual interests and behaviors.[1] Whereas paraphilias are defined as 'any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners' (DSM-5, p. 685), paraphilic disorders are paraphilias that cause distress or impairment to the individual or harm to others.[1] Although these changes are viewed rather positive by most authors, some criticism also arose during the DSM-5 publication process.[10–12] For example, it was stated that the diagnostic criteria do not reliably differentiate between paraphilic and non-paraphilic sexual behaviors as the current definition is more influenced by political and sociocultural factors, and especially sexual minorities could be discriminated by the narrow wording.[11,13–15] In the same sense, the terms 'intense' and 'persistent' sexual interests shall still be used, although they lack a formal operationalization.[11] Furthermore, the DSM-5 pedophilic disorder diagnosis as the only paraphilic disorder (except for other specified paraphilic disorder and unspecified paraphilic disorder) does not specifically ask for the disorder occurring in a controlled environment or for the disorder being in full remission.[10,16] Thereby, the DSM-5 criteria imply that a pedophilic sexual interest cannot be changed, although the current state of research does not support this view.[10,16]

In order to stimulate new and more research as requested by the American Psychiatric Association and to increase comparability and generalizability between studies, well validated assessment methods are needed. Furthermore, mental healthcare providers need effective treatments that can be used in the clinical practice independently of the ongoing debate about the correct conceptualization of the diagnostic criteria.

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