Scientists Oppose Kafka's Kafkaesque Hypersexuality Disorder: Are 21.5 % of North American Women Mentally Ill?

SCIENTISTS OPPOSE KAFKA’S KAFKAESQUE HYPERSEXUALITY PROPOSAL:

A Canadian Survey Points out that 43.9 % of North American Men, and 21.5 % of North American women would be diagnosed as Hypersexual, if we enter into Kafka’s Hypersexuality Maze in 2013 through DSM-V. In our surveys on our  web sites, we have found that around 35 to 40 % of females would be misdiagnosed as hypersexual disorder according to the new HDSI of DSM-V.

Archives of  Sexual  Behavior (2010) 39:594–596

DOI 10.1007/s10508-010-9607-2

LETTE R    TO  T HE   EDITOR

Hypersexual Disorder: A More Cautious Approach

Jason Winters

Published online: 19 February 2010

Springer Science+Business Media, LLC 2010

J. Winters (&) Forensic Psychiatric Services Commission, British Columbia Provincial Health Services Authority, #300–307 West Broadway, Vancouver, BC V5Y 1P9, Canada

e-mail: jasonwinters@telus.net

Kafka (2009) has done an exemplary job of synthesizing dispa- rate 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 Manual of Mental Disorders. There appears to be substantial clin- ical support for this disorder; however, strong empirical evidence demonstrating its validity is currently lacking. Further, previous criticisms of the theoretical assumptions underlying a dysregu- lated 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 rea- sons, 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 Hyper- sexual 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. Based on this assertion, we are to assume that there is normal sexual 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) previously proposed 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 pro- portion of the population would be identified as hypersexual.

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 uti-lizing 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 symp- tomatic of Hypersexual Disorder include: compulsive mastur- bation, protracted promiscuity, and pornography, sex chat- room, 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 pro- miscuity becomes protracted, and when the pursuit of sexual stimuli becomes a so-called addiction. Anonymous sex, one- night stands, and multiple partners are also considered hyper- sexual 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 responsibilities for various non-psychopathological reasons. For example, some highly motivated tenure-track academics may sacrifice relationships with families and friends, and give up recreational activities to work long hours. While potentially problematic, this pattern of behavior is arguably not symptom- atic of a mental disorder.

Kafka has incorporated aspects of the addiction model of dysregulated sexuality into the proposed diagnostic criteria. Specifically, two of the criteria stipulate that repeatedly engaging in sexual fantasies, urges or behaviors in response to negative affect may be symptomatic of Hypersexual Disorder. Within the literature, there appears to be support for this link (e.g., Goodman,

1997). Comorbidity studies have also shown that dysregulated sexuality often co-occurs with mood and anxiety disorders (e.g., Black, Kehrberg, Flumerfelt, & Schlosser, 1997; Raymond et al.,

2003). However, there are two problems with these criteria.

First, the expressed sexuality may serve as a means to ameliorate the negative affect associated with some other underlying mental disorder (e.g., mood and anxiety disorders) that, when treated, also alleviates the problematic sexual fan- tasies, urges or behaviors. In other words, the repeated pattern of sexual urges, fantasies, and behaviors is not a symptom of its own distinct disorder. For individuals exhibiting increased sexual expression in response to sub-clinical levels of negative affect, it may simply be a matter of identifying better coping strategies rather than treating a distinct sexual disorder.

Second, if we are to accept that repeatedly engaging in sexual behaviors to enhance mood is symptomatic of a distinct sexual disorder, then we must also be willing to accept that repeatedly engaging in non-sexual rewarding behaviors for a similar effect is symptomatic of other corresponding mental disorders, espe- cially if accompanied by impairment in day to day functioning. Many people repeatedly engage in hobbies, activities, and work to ameliorate negative affect and, for some, those behaviors interfere with day-to-day life. Despite these similarities, the DSM does not include disorders of watching too much televi- sion, or shopping, exercising, or working too much. Perhaps the temptation to pathologize increased levels of sexuality is greater, as sex is highly proscribed within our culture and has a clear biological substrate.

The diagnosis indicates that there may be risk for harm to self or others as a result of the sexual urges, fantasies or behaviors. Much of the empirical work cited to validate a dysregulated sexuality disorder has linked it with risky sexual behaviors (RSB) (e.g., Kalichman & Rompa, 2001; Miner, Coleman, Center, Ross, & Rosser, 2007). While studies have shown that dysregulated sexuality correlates with RSB, it has also been demonstrated that dysregulated sexuality is associated with increases in all types of sexual behavior, not just those that are risky (e.g., Dodge, Reece, Cole, & Sandfort, 2004). Dysregu- lated sexuality may simply be a marker of high sexual desire (Winters et al., 2010), and therefore increases in all types of sexual behavior would be expected. Further, no direct causal

link between dysregulated sexuality and RSB has been estab- lished.

An essential component of the diagnosis is that the sexual

urges, fantasies or behaviors must cause distress or impair- ment. This is perhaps the most useful of the criteria, as it can best account for treatment seeking behavior. However, the effects of social constraints on sexual expression have to be taken  into  consideration  before  a  Hypersexual Disorder diagnosis can be given. An individual with conservative and restrictive views about sexuality and sexual expression may be distressed by any increase in sexual fantasies, urges, and behaviors, even those that are normophilic. Shame, anxiety, and guilt, especially if experienced in conjunction with high levels of sexual desire and unmet sexual needs, may be suf- ficient to cause such an individual to seek treatment.

Sexual desire incompatibility is also offered as an example of impairment that may be caused by Hypersexual Disorder (Kafka,

2009). However, sexual desire incompatibility does not neces-

sitate that one person within the dyad be hypersexual, only that there is a difference in the desired amount of sexual behavior and that no mutually satisfying compromise can be reached. Additionally, one could argue that sexual desire incompatibil- ity, compared to a Hypersexual Disorder, can better account for the use of pornography, phone sex, prostitutes, and strip clubs as a means of sexual outlet when sexual needs are not being met within a relationship.

Despite Kafka’s commendable effort to justify the inclu- sion of Hypersexual Disorder in the DSM, the requisite theo- retical and empirical foundations are lacking. Though increased or excessive sexuality can clearly be problematic and distressing for many people, and require clinical inter- vention, a distinct Hypersexual Disorder diagnosis may be of dubious value. Kafka (2009) acknowledged that there are still many issues that must be clarified, including: the disorder’s etiology; its position within the current Sexual Disorders; the heterogeneous clinical presentation and course; and a lack of neurophysiological and neurobiological data. Until these issues and the others outlined in this paper are addressed, adding Hypersexual Disorder to the DSM would be imprudent.

Arch Sex Behav (2010) 39:594–596                                                                                                                                                                       

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