All right, everyone, welcome to our talk on compulsive sexual behavior disorders. That's 345. In the interest of being mindful of time, we'll go ahead and get started as folks trickle in. I'm Dr. Sarah West. I am a forensically trained psychiatrist who lives in Northeast Ohio and practices community mental health in addition to having a small forensic practice. I am pleased to be presenting today with a colleague of mine who I actually had the pleasure of meeting when she won the Rappaport Fellowship back in, well, three years ago. So we're going to say 2000. And she was my mentee at the time, and I have become her mentee. She's absolutely brilliant. She does a wonderful job with research. And this topic was her idea, and I was happy to ride her coattails. So today we're going to be talking about compulsive sexual behavior disorder. And we do have some surveys that we're going to ask you to participate in. She's much better with the technology than I am, but you can see the code on your screen there. And we will guide you through using it, I hope. All right. OK. There is our title slide. Oh, no, wrong direction. We have no disclosures to make. Our agenda is such that we'll tell you a little bit. We'll do some cases, tell you a little bit about how compulsive sexual behavior disorder has been presented in history, how we conceptualize it currently, how we treat it potentially. And then we'll talk about it in the context of culture, as well as forensic psychiatry, as we are both forensic psychiatrists. There have been multiple iterations of definitions in terms of criteria for this particular disorder. And it does go by a couple of different names. Compulsive sexual behavior disorder is as it is defined in the ICD-11 code. But the DSM, in reviewing the criteria, looked at it under the name of hypersexuality disorder. And they declined to put it in the DSM-5 back in 2013 when it was published. We're going to talk a little bit about why that's the case. We are going to talk about some sexual behaviors and how we would characterize them, because it's a complex picture. We're considering the ideas that they may be an addictive disorder or maybe something along the lines of obsessive compulsive disorder. And then maybe talk about the idea that it's somewhat linked to paraphilias, as well. And then we'll talk about, again, the CSBD in terms of a cultural context and a forensic context. All right, so here we have our first poll. And Kat, do I just have folks vote on this? Sure, so if you go to that link that I had in the beginning or that URL, or you can just raise your hand, too. So you can pick multiple options. The question is, what are your opinions about the diagnosis of hypersexual disorder and compulsive sexual behavior disorder, based on what you know coming into the presentation? And the options are, hypersexuality should have been included in DSM-5. Hypersexual disorder should not have been included in DSM-5. Compulsive sexual behavior disorder should have been included in ICD-11, which it currently was. Compulsive sexual behavior disorder should not have been included. And then hypersexual or compulsive sexual drives, urges, or behaviors should be recognized as a diagnostic entity or should not be recognized as a diagnostic entity. So we'll give a couple seconds to put in your responses. Sorry for people who came in late and didn't see the URL. I can probably back up to that, if that would be helpful. Oh, OK. Can you guys get that on the bottom there? Can you get it on the top? You can also type in poleev, E as in Edward, V as in Victor, .com slash Katherine, K-A-T-H-R-Y-N-B-233. It's full. Well, I guess I can't use the free verse. I can't use the free version anymore. There's too many people here. OK. So go to the next. All right. So Kat, do those then pop up? OK, well, we have, I'll read them out to you because they apparently didn't work. I think because we went backwards. So it says hypersexuality should have been included in DSM-5. 16% of the audience. Hypersexuality should not have been included in DSM-5. We got 8% of the audience. Compulsive sexual behavior disorder should have been included in ICD-11. We got 24% of the audience. Nobody seems to have thought it should not have been included in ICD-11. So OK, good. I guess that's why you came to this talk. And then 40% felt that it should be a diagnostic entity, and 12% think that it should not be a diagnostic entity. And I guess for the sake of time, let's do hand raises for the next one. All right, so we'll start off our talk with a case. And this should be kind of a run-of-the-mill case. We intended for this one to hopefully be a little diagnostically less complicated than the case we'll talk about after we give you all the information you need to know about CSBD. Here we have a 27-year-old man. He has a history of excessive alcohol use in college. He did stop drinking excessively after leaving school and hopefully maturing some. He was obviously a bright kid, graduated from Yale Law School and went on to practice as an attorney, but has had some issues at work. Some of the issues that have come up is that he was viewing pornography on his work computer and engaging in inappropriate sexual relationships with a number of female colleagues. He has no notable psychiatric history. He does state that he masturbates multiple times a day and has had consensual sex with approximately 300 female partners. He also noted that he recently had a breakup related to his infidelity. He is presenting not necessarily totally independently, but rather because he had learned of a recent complaint to the Bar Association related to his sexual behavior. In terms of diagnosis, we're going to present you with some options and we'll ask for hand raises. How many of you think that, even though we haven't discussed the criteria just yet, from what you know about CSBD, that this is compulsive sexual behavior disorder? Okay, so I would say that is a pretty solid amount of the audience. What about bipolar disorder? Anyone have concerns for that? And I appreciate we don't fully know his history. Okay, OCD. We have masturbating five times a day, 300 female partners. We'll talk about OCD as it relates to these criteria. Paraphilia, was there anything unusual or abnormal about this sexual behavior? Substance use disorder. He had a history of alcohol. That's a good thought. It's certainly something to explore further with him. Anybody think this is normal behavior, no disordered behavior? I would argue not, given that it seems like he's having some consequences related to it. And we know commonly in the DSM that's one of the criteria. And then how many people are just flat out unsure what this is? Yeah, okay, so that's why we're going to talk about it today. All right. I wanted to give you a little bit of historical context for hypersexuality. The term nymphomaniac was first proposed in Scottish medical literature in the 1700s as it relates to this disorder. Of course, its origin is Greek from nympho, which means woman or bride, and mania or excessive desire, love of. So treatment in the 1800s was not what it is today. There were caustic agents applied to one's genitals to quote unquote cool them off. Bleeding was used. I think that was a panacea back in those days. And then very specific to women, of course, because of their physiological design, was cold water douches, again, to cool off those hot genitals. Probably not particularly effective. Here's a word that you might have never heard before that you can impress your friends with at parties, satiriasis. Satiriasis is the male counterpart to nymphomania. It applies to men. And they refer to it as the Don Juan syndrome. In reading a little bit about the literature, Don Juan and Casanova are maybe in the same group, but there was a distinction made in that Casanova was a lover of women. He wanted as many relationships as possible. He adored women and would try to continue with many women at one time, whereas Don Juan was a little more malignant. He was considered to just have sexual conquest and leave the women when he was done with them. So that's why they named it Don Juanism as opposed to Casanovaism. There was some literature from the early days that associated it with priapism. And treatment was, I'd say, fairly similar to what women were treated, or how women were treated, in that men were encouraged to avoid erotic thought streams or conversations, bloodletting, again, was a panacea in those days. They were encouraged to have a diet that would precipitate a lack of sexual desire, and then alternating hot and cold baths. So, again, probably not particularly helpful. What I was surprised by is I thought that women would be vilified and men would be celebrated for having a great deal of sex. That really wasn't the case. There's not a lot of medical literature on this. Historically speaking, but it seems like it was recognized as a disorder in both men and women. So, now we have the 19th and 20th centuries coming along, and technology really has changed our access to sexual materials. Back in the day, brothels and sex shows were widely available without any use of technology, right? You could just show up at a physical location and engage in sexual activity or watch sex shows. Then magazines came along, Playboy being probably the prototype for this, and then getting maybe more and more explicit as the years have gone on. I don't know that magazines are quite as popular now that we have the internet. Next came videos, and those could be consumed at home if one had a VCR, and of course VHS was much more popular than the old Betamax for those of you who were around in the 80s. So, videos became available, and along with magazines, this is kind of the way that pornography could be consumed in the home in private without anyone knowing, per se, but of course you would have to purchase the magazine, order the magazine, or rent the videos or buy the videos. 1-900 numbers came into being probably in the 1980s and 1990s. They were popularized on late-night television for people to call up and have a live sexual interaction with someone they couldn't see but could hear on the other end. Then came the internet, and that really has revolutionized the availability of pornography in the home and the ability to have very little interaction with anyone else. So, Pornhub is probably one of the most popular sites, and OnlyFans is one of the newest. And I went on OnlyFans just to take a look at what it was. It very much advertises itself as being on the up and up, but from what I understand, it really does promote at least scantily clad people who can become quite popular by posting pics of themselves and ultimately get paid. Hypersexuality in the 1970s was recognized as something that was akin to addiction, and just like AA, which was founded many decades earlier, there is a Sex Addicts Anonymous group because of the similarities that people experienced when they felt they lost control over their ability to deal with sexual encounters in the same way that they did with alcohol. And so it is treated very much like a 12-step program in the way that AA functions. Some of their literature on their website includes this, which I thought was actually pretty useful for us to look at. So they define an inner circle of behaviors to avoid. These are things one must not do in the same way one must not drink alcohol. Then there's a middle circle where it really is considered a slippery slope of things that should be moderated. So maybe not absolute no's, but things like staying late on the computer with the possibility of then investigating pornography is something that they put a warning out about. And then finally, the outer circle is healthy activities that they would encourage folks to engage in to be mentally and physically well. So with that, I will turn it over to Kat to talk about what's normal. It's dangerous up here, guys. All right, so I'm going to start hitting you with some of the more recent literature and what our current understanding of compulsive sexual behavior disorder is. And one of the things that we need to start out with is one of the main reasons that it was hypersexual disorder, which was the one proposed for DSM-5, was rejected. One of the main issues that were brought up were because people were nervous that it was going to unfairly diagnose or malign individuals who just had a higher than normal sex drive. I think the thing that comes up often is this caricature of adolescents who are just super horny because they just discovered what sex was, and they must be having sex with everything and masturbating all the time. So is that true, first of all? What is the quote unquote normal average amount of sexual behavior somebody engages in? And I'm going to focus on from adolescence until about the fourth or fifth decade of life, when they did the field study for DSM-5 hypersexual disorder, it seemed like there was a lot of people presenting for treatment around the fourth decade of life, and they were reporting that their behavior started during their adolescence. So I'm focusing on that particular chunk for people today. This data was collected as part of CDC's survey. It included tens of thousands of individuals from 2006 to 2008. I'm focusing on heterosexual pairings, so keep that in mind just for the sake of time. But they do include data on same-sex relationships as well. And you'll notice that people who are identifying as having four or more partners, there's a chunk of people, but it's not a ton of people. And this is over the last 12 months. So four partners or more within the last 12 months, we're looking at 5% to 9% of heterosexual men. For women, we're seeing slightly lower numbers in terms of four or more among 20 to 44-year-olds, slightly higher numbers of individuals identifying one heterosexual partner from 20 to 44. But between men and women, the numbers were pretty comparable. This is a little bit of an aside, but I think this is really important for us to be paying attention to. Over the last five or so years, there's actually been a decline in sexual behavior in particular groups of people. In fact, in particular, unmarried men have seen a drop in sexual pairings over the previous year. And you'll see that in the none at all grouping on the left-hand side. And people identifying as having sex weekly or more has been declining over time. We don't really know why this trend started before COVID-19, but it'll be interesting to see how this kind of plays out over the years and try to figure out why. This was a study that looked at masturbation frequency among adolescents, so ages 14 to, I believe, 19. It was 820 participants, sorry, 14 to 17. And you'll see that among adolescent men, you're looking at about a quarter of the population identifying as having across the board masturbating a few times a year, masturbating a few times a month, masturbating a few times a week, and four or more times a week. Women, it was much less. Now, this is a really busy slide, and I'm not going to be expecting anybody to remember these numbers. The numbers I want you to focus on are the ones at the bottom in red. So this was a study out of Norway looking at 4,000 participants, ages 18 through 89. I focused on those first five decades of life. And you'll see that people identifying as masturbating one time or more a day or greater than once a day is actually relatively small and corresponds to the prevalence rates that I'm going to be talking about for CSBD. So when we're talking about people who are having a ton of sexual intercourse or a ton of masturbation, it doesn't seem like it's a whole lot of people. This was just a study looking at internet use for sexual purposes. And this ran the gamut from pornography all the way to using it for educational purposes. And you'll see that it actually increased over time. Adolescents younger than 18 were having less than individuals 26 through 40. And males were reporting about four to seven hours of online sexual activity a week, depending on their age ranges. Again, these are averages. This doesn't get down to the individual level, but just to give you a sense of what people are generally doing. However, after I explained all of that to you, I'm going to also say that we cannot rely solely on the amount of the sexual behavior, such as pornography consumption, to indicate a clinical problem. Both and colleagues, both done a lot of research in this area, and they surveyed a non-clinical sample of participants. And they found three distinct groups. Those who had non-problematic local sexual behavior, non-problematic low-frequency pornography, non-problematic high-frequency pornography, and problematic high-frequency pornography. And you'll see from that graph that there actually was a lot of overlap between the frequency and the pornography use between the problematic and non-problematic groups. There were also some meaningful differences between the problematic and non-problematic groups. Problematic high-frequency users had more discomfort answering pornography-related questions, had more depressive symptoms, had more relatedness difficulties with partners, with family members, had more proneness to boredom, had more self-reports of hypersexuality, and had lower self-esteem. What wasn't different between these groups were measures of sexual functioning, sociodemographic categories, and impulsivity and compulsivity scales. So kind of some interesting data. OK. So next, let's talk about what the definition of compulsive sexual behavior disorder is and disentangle it from hypersexual disorder. As we mentioned, hypersexual disorder was proposed by Kafka for the sexual and gender identity disorders workgroup for DSM-5. This was back in 2013 when DSM-5 was, I think he proposed it in 2010, and it was kicked around for a while. So they ultimately decided that despite there being a good field trial with some good reliable and valid data, that they weren't going to include it. What were the four main reasons? Pathologizing normal behavior, which is what I had just talked about. Insufficient scientific evidence. Not lack of scientific evidence, but they felt it was insufficient at the time. And this was on the heels of some articles that had come out that had really criticized DSM-5 for including too many diagnoses and too many disorders. So there was kind of a political climate that was going on, or a culture change that was going on in DSM at the time. There was also concern about medicalizing and moral behavior. Sarah's going to talk a little bit about people claiming sexual addiction for their bad behavior, but that was also a concern. And on the flip side, and very pertinent for Sarah and I, there was concern that it would be misused by the forensic system, and she'll talk a little bit about that. So ICD-11 chose to include a similar diagnosis, compulsive sexual behavior disorder, under their impulse control disorders category. And they define, the World Health Organization defines it as a persistent pattern of failure to control intense, repetitive sexual impulses or urges that results in bad behavior. Failure to control intense, repetitive sexual impulses or urges that results in behavior. That leads to one of the following. Engaging in repetitive sexual behavior is a central focus of the person's life. They neglect other aspects of their life. The person continues to engage despite little or no satisfaction from it. Multiple attempts to cut down has not resulted in reduction of the behavior. The individual continues to engage in repetitive sexual behavior despite the adverse consequences. It manifests over a period of six months or greater, not better accounted for by another condition, and cause marked distress or impairment, similar to most of our other disorders. Now there's some similarities between these two diagnoses, and I want everybody to pay attention to both the similarities and the differences, because you'll often see in the literature that they're being called the same thing, and these terms are used synonymously. They aren't, and if you aren't careful, in terms of which scale you're using, you might be misapplying one that actually overlaps better with one version of the criteria versus another. So their similarities is that there's an excessive focus and time on the behavior with neglect of the self and decline in functioning. It becomes a more centralized aspect of the person's life. There's a feeling of impaired control over the behavior, there's significant distress or impairment, and there's continued behavior despite the adverse consequences. But there's some important differences too. I want to point out that hypersexual disorder was modeled after hypoactive sexual disorders criteria, and after paraphilic disorders criteria. You'll notice that compulsive sexual behavior disorders criteria very much overlaps with kind of an addiction model, or the addictive kind of behavior that we, categories that we think about. Hypersexual disorder included this idea of emotional dysregulation. So using sex as a means of coping with negative emotions or negative emotional states, anxiety, depression, and as a form of maladaptive coping. So trying to use sex to avoid things like avoid stress, not stress, sorry, avoid responsibilities and kind of ignore personal responsibilities, that kind of stuff. Compulsive sexual behavior disorder didn't include those. You'll notice in the criteria. But they did include this idea of diminished pleasure from activities. This idea that somebody could masturbate past the point of orgasming to the point where they're not even enjoying it anymore, but they still feel compelled to do the behavior. ICD-11 is a little bit more loose in terms of their diagnostic criteria. So whereas DSM is very specific, you need to hit four out of five criteria, ICD-11 is a little bit more loose in terms of trying to get the gestalt of the disorder. Something that ICD-11 also included that I think is incredibly important is comments about moral incongruence. So the diagnosis can't be made just because somebody's sexual behavior or masturbation practices conflict with kind of the culture they were raised in or the religion they were raised in as just the reason for the distress, right? That could certainly happen, but that means that if the distress is just because, oh, I was raised in a religious home and I'm masturbating every day and I think that's wrong, that's not quite fitting with the spirit of the disorder. And that becomes up to us as the psychiatrists, psychologists, social workers, to kind of disentangle where this is coming from because the treatment will be very different. The other thing that is different between hypersexual disorder and compulsive sexual behavior disorder is that hypersexual disorder defined the initial criteria as recurrent and intense sexual fantasies, urges, or sexual behaviors. Compulsive sexual behavior disorder, like the name suggests, you have to have the behavior. It's not just the fantasies and urges. Does this matter? Does it matter that we're keeping, that we removed that sexual fantasy as well? Well, according to Skagg, this was kind of an old study. This was a study out of New Zealand. They looked at 1,000 young adults in their 30s, and they asked, do you have any out-of-control sexual experiences in the last 12 months? And they specifically asked, any out-of-control fantasies, out-of-control urges, or out-of-control behaviors? And did any of these experiences interfere with your life? Did you perceive that you needed help for these, and did you receive help from these? It's kind of a busy slide, but you'll see that there were a fair amount of people that identified as having sexual fantasies that they felt were outside of their control, and felt that they were impacting their life. And I think this is, it's important to recognize, because when we look back at prevalence studies, and I'll get to that in a second, it's going to change how many people are identifying as having the disorder, but it's also, when they removed it, it made the diagnosis much cleaner, potentially left out some people, but also the fantasy part could be overlapping with OCD criteria. When we think about distress over thoughts that feel like they're outside of the control, that starts to get into some of those intrusive thoughts we think about with OCD. So while the diagnosis gets cleaner, we may be left leaving some people out that may need some clinical attention, but it does make things a little bit more clear. Okay, what about prevalence? Dickinson et al. from 2018 is often cited as kind of the high range of the prevalence rate. They found 10% of men and 7% of women were meeting criteria, or they identified as being compulsive sexual behavior disordered individuals. However, they used this criteria, they used a scale called the compulsive sexual behavior inventory, and if you go into the actual inventory, the criteria overlap much better with hypersexual disorder criteria. They include those, the emotional dysregulation, the avoidance, and they also include a couple different questions that don't have anything to do with either of the criteria. So again, really important to be asking why some of these are higher. They found more disordered sexual behavior in extremes of income, less education, ethnic and sexual minorities. The other thing that they did that I think was what drove some of these numbers to be higher is their definition included sexual fantasies, behaviors, and urges, not just the behaviors, and they also focused on individuals who are less than age 50. Now, we don't know, I think, enough about the course of compulsive sexual behavior disorder to know if you had extended your age ranges, if they would still be meeting criteria in their later years of life, and how that would have diluted the prevalence. So just some things to think about. Both et al. did a sample across multiple different languages and multiple different internet sampling populations, and they found a fair, much lower, not much lower, but a fairly lower prevalence rate from Dickinson, with men about four to seven percent, and women anywhere from zero to five percent. And Brickin et al., oh, and I should say, too, the compulsive sexual behavior disorder scale 19 actually fits much better and overlaps much better with compulsive sexual behavior disorder criteria, so keep that in mind. Brickin et al., Brickin's done a lot of great work in this area, and they had the simplest model of all. They asked the individual, did you experience intense and recurring sexual impulses that resulted in behavior? If yes, how much distress or impairment did it cause? And if it was no or slight distress, it would be compulsive sexual behavior. Moderate to severe would be compulsive sexual behavior disorder. They found numbers slightly lower than both et al., and what they did that I thought was really important and interesting is, in order to kind of remove some people that might have that moral incongruence, they did it in kind of a crude way. They basically just asked, were you raised in a religious household or in a conservative household, and do you hold conservative or religious views? And they removed those people from the prevalence. And you'll see that the numbers went down. So I think there's much more nuance to that. I think this kind of shows that, you know, there are a subgroup of people that we're gonna have to be thinking more thoughtfully about whether they apply to this disorder, but it is a good way to remember that we need to be thinking about that moral incongruence piece. They also found some meaningful differences between these groups. Those with compulsive sexual behavior only, not the disorder, reported more orgasms, more liberal sexual attitudes. Those with compulsive sexual behavior disorder had more treatment for mental health diagnoses within the last 12 months outside of their sexual proclivities. Lower life satisfaction, more conservative sexual attitudes as well. And both, compared to the non-compulsive sample, had more history of sexual abuse, more sex knowledge that they gained from pornography, and increased masturbation and pornography use. Okay, moving on to etiology. We're still in very early stages of understanding compulsive sexual behavior disorder. I think early models really overlap with an addiction framework, even though we still need far more data in order to know if that really holds true. The early studies are also relatively small, about 20 to 30 individuals per study. Mostly male patients, mostly heterosexual patients. They use different scales across studies, so it's kind of hard to compare individuals across studies. And the cues are often different. So sometimes they'll use erotic cues versus explicit cues, so people kissing and hugging and touching versus people engaging in sexual acts. And then videos versus pictures, so actual videos of individuals versus pictures. So different across studies. Oh, I'm sorry. There we go. This was a recent study that came out. They were looking at micro-RNAs. And I will not do this paper justice by trying to explain their exact procedure, but I will say that they did find this particular micro-RNA, 4456, that was hypo-expressed in individuals with compulsive sexual behavior disorder. They used heterosexual disorder criteria, truthfully, but seemed to be overexpressed in that population with associated hypermethylation, an important epigenetic consequence, and those with hypersexual disorder versus healthy controls. And this micro-RNA was associated with genes that were then associated with overexpression in the amygdala and hippocampus, and associated with the oxytocin pathway. Oxytocin is an important molecule that's released during sexual engagement and orgasm, and the amygdala, as I'll mention in a second, is important in CSBD. Okay, there's been a couple neuroimaging studies looking at functional MRIs. If you're gonna combine all the data, there seems to be an increase in activation in the dorsal anterior cingulate cortex, in the ventral striatum, in the amygdala, in patients with compulsive sexual behavior, as opposed to those without. There's also increased functional connectivity between those areas that's associated with an increase in desire of sexual behavior, but not, or viewing of a sexual stimulus without the associated reporting increase in liking the sexual stimulus, and this is important. There is an increase in ventral striatal activity in anticipation of erotic versus non-monetary stimuli as well. There also seems to be an attentional bias between those healthy volunteers versus those with compulsive sexual behavior. This was a dot probe analysis, and basically showed that there was a greater attentional bias in those with compulsive sexual behavior to areas that had erotic cues versus neutral cues. And one of the things that, one of the proposals that people think might be happening is something called incentive salience, or changes in incentive salience. And this is a model that has been discussed in addiction as being kind of different than the traditional idea of this reinforcement of behavior because we just like the behavior, because of that dopamine rush. And those who propose this say that the pleasure centers of the brain mediate desire, not pleasure. So with addiction, there is a separation between liking of a stimulus and wanting a stimulus at first. Over time, that wanting of the stimulus gets hyper driven to the point where people are kind of just pushing for, pushing for more and more and more. But if you ask an addict, do you like the cocaine or do you like this particular thing, they may say not as much as I used to, or may not have any associated liking of the stimulus. This is over time, that wanting becomes more intense and reinforced with learning, resulting in more intense urges, more intense seeking out of that stimulus, and more focus on and interaction with cues that are linked to the reward. And these states are, or this liking, or sorry, this wanting is heightened by stress states. So it's primed by dopamine. So that kind of makes sense when we think about people kind of engaging in this behavior in kind of increased stress states. But it also makes sense because when we think about compulsive sexual behavior disorders criteria in ICD-11, one of those criteria is continuing to engage in the behavior despite not liking it or not finding any enjoyment from it. So why would that be the case? And I have seen individuals who have had kind of this compulsive sexual behavior masturbate to the point of chafing, masturbate past the point of orgasm for minutes to hours. So why would that be the case if there's no hope for having another orgasm and there's just pain associated? There's something wrong with the wanting, that seeking out. And finally for etiology, there is some data, it's not great data, for testosterone, dopamine, and the hypopituitary adrenal axis. The testosterone, I will say, depending on the study, some are showing increased testosterone, some are not. So I don't think we have enough data to say testosterone's involved. The reason that dopamine gets brought in is that we know with patients with Parkinson's disease who are on L-DOPA, Carbidopa, you can have an increase in compulsive sexual behavior. So that's kind of something that is making people think there's probably something wrong with dopamine. And then when you think back to that pleasure centers of the brain that are often mediated by dopamine, that's also kind of something that's getting people kind of curious, but we don't know enough yet. And so stay tuned, because now that ICD-11 has criteria, I think we're gonna see more research articles come out. And my final part of the presentation is on treatment. So I know we're all probably mental health clinicians in here, so I think we all know how to do a thorough diagnostic assessment. But what are some additional things you wanna think about? You wanna do a detailed social, psychiatric, medical, and sexual history. And your sexual history is going to be more robust than you probably would have otherwise done. You're gonna wanna include cognitive distortions around sex, particularly if the individual was raised in a really strict household, if they have any kind of religious views that impact how they feel they should behave around sex. You're gonna wanna ask about interpersonal relationships and how that influences their sex life. Ask about chem sex practices. How many people here know what chem sex is? Okay, so some of you. So chem sex, I remember seeing this a lot in New York City in the emergency room. It's the use of illicit substances in order to enhance the sexual experience. So these can be anything from using ecstasy to enhance that kind of sexual desire, all the way to amyl nitrates to open up the anal sphincter to facilitate anal sex. So a lot of different chemicals can go into it, and some of them can increase sexual drive and desire, so you're gonna wanna ask about that as well. Also ask about risky sexual behavior. There has been an association with compulsive sexual behavior and condomless sex, increased risk of HIV, so make sure you're asking about that and doing a thorough education for your patient. You can use scales to facilitate your interview, but keep in mind, make sure you read the scales, understand the criteria, and know what overlap there is. Be mindful of which scale you're using and why you're using it. Evaluate for trauma. As I mentioned, people with compulsive sexual behavior disorder have an increased risk of trauma history, so make sure that you're asking about that because they might need some trauma-informed care, and be mindful around that. Evaluate morality and religion. Ensure a thorough physical exam. If you're not the one doing the physical exam, because most psychiatrists don't do their own physical exams, make sure they're seeing a primary care doctor. Consider doing a urinalysis and STD testing. I have had compulsive sexual masturbators that have had repeat UTIs just because they're masturbating with unclean hands, so just make sure that you're assessing for that, even if they don't have any symptoms. And then also consider endocrine if they have other physical symptoms, but I wouldn't do that routinely. You wanna also rule out other etiologies. If they have Parkinson's disease, you're obviously gonna be thinking about dopamine agonists, but think about other types of things that might be interfering. If there are other neurological signs, you wanna rule out things like Kluber-Busey syndrome, frontal temporal lobe dementia, both of which can be associated with increased hypersexuality. And also look at other etiologies, such as bipolar disorder for increased hypersexual behavior. Be mindful that there's a lot of co-occurring disorders for compulsive sexual behavior disorder, including depression, anxiety, eating disorder, including bulimia, substance use disorders, especially a big comorbid co-occurring disorder. And paraphilic disorders can be co-occurring as well. They are not necessarily co-occurring, though. Paraphilic disorders are an important comorbidity, but you have to make sure that you're distinguishing them. There has been a school of thought that compulsive sexual behavior disorder or hypersexual disorder previously should actually be included among the paraphilic disorders, but that has fallen, as far as I can tell, in the literature, out of favor. Paraphilic disorders are mostly problems around the overlap seems to be that there is persistence and recurrence in the fantasies, urges, or behaviors, but the focus is on atypical objects, activities, or situations. So the person with hypersexual or compulsive sexual behavior disorder, it's not that their focus is on something that's abnormal, it's that there's too much of it. There's too much focus on it. But you can have both at the same time. Both cause distress or impairment. And you'll see these are, there's a relatively high comorbidity between the two, and those are the comorbid rates that were found. Moving on to treatment. I'm just gonna focus on naltrexone and SSRIs because this is a psychiatric conference, and for the sake of time, there has been some early data on cognitive behavioral theory, Hallberg did a couple studies, then he looked at group model for CBT, across seven sessions, comparing it to weightless group, and found some positive results, although the follow-up, there was only about a fifth of the original group that was followed up with, most of them fell off the radar. But some early signs, and we know cognitive behavioral therapy is good across diagnoses. Acceptance and commitment therapy similarly has a lot of really good data around it, and is also meant to be a transdiagnostic approach. There has been a couple studies looking at acceptance and commitment therapy, specifically in compulsive sexual behavior disorder, but again, it's a handful of studies right now. 12-step has also been proposed, but not every sex addicts group is the same. Different groups have different definitions of abstinence, for instance, and there's been some concern around, what does it mean to tell somebody you have to be abstinent for the rest of their life, or what does it mean that they can only have sex with their partner, but can't engage in other behaviors, and how is that going to affect recovery? So I think there's still a lot that needs to be ironed out before we can really say sex addicts anonymous is really a good treatment modality for our patients. Anti-libidinal agents, before I move on, they've shown some promise in paraphilic disorders, but there hasn't been a ton of data on it, looking at it in compulsive sexual behavior disorders. Turner and colleagues from the World Federation of Society of Biological Psychiatry come out with, that federation comes out with really good data guidelines when there really isn't any other guidelines for us to follow. They do a really good, thorough review of the literature, and they really recommend saving anti-libidinal agents, so those are things like Lupron, medroxyprogesterone, things that we would normally think about in really serious cases of paraphilic disorder, save those for cases where you might have a problem with sexual offending and nothing else is working, so don't reach for those first. Naltrexone has shown some promise, and I think this makes sense, right, when we're thinking about that liking versus wanting model, that desire, that dopamine reward pathway disrupting that. Naltrexone is a preferential mu opioid receptor antagonist. There have been case studies that have shown benefit in it with or without the use of concurrent SSRIs with doses of naltrexone greater than 100 milligrams. There have been several case series with doses between 100 and 200 milligrams, both in paraphilic and non-paraphilic individuals with compulsive sexual behavior disorder, but these studies are small, there is about 20. There are about 20 individuals per study, but these medications are relatively safe just as long as you're not using it in hepatic disease, kidney disease, severe suicidality, pregnancy, or opioid use. This was a study by Savard et al in 2020. They looked at individuals using hypersexual disorder criteria. Their naltrexone dosages were about 50 milligrams. And you'll see that there was a significant decline in the hypersexual disorder score on the scale that they used. They stopped the medication at week four, and you'll see an increase in the score by week eight. They didn't look past that. So it's unclear if there would be a natural increase back to baseline, but it was still a significant increase, or a decrease in the symptom severity between baseline and week eight. So some promise, but you may not be able to discontinue the medication. SSRIs have also shown promise. There was a small double-blind study on citalopam versus placebo. There was only 28 individuals in that study, but it did show a decrease in sexual desire and drive, decrease in masturbation, and decrease in pornography. Golub and Potenza looked at a case series of three individuals, and they used peroxetine plus CBT. But what was interesting about their study was that while the masturbation went down, the compulsive masturbation went down, or all three of their participants had increase in other sexual behaviors like extramarital affairs during their time when they were on peroxetine, and they didn't meet criteria for mania or any other disorder. So kind of unclear if maybe the peroxetine was decreasing anxiety that was inhibiting them from doing these behaviors anyway. That may be a reason for it, but the target behaviors, the compulsive masturbation and pornography decreased. Recommendations from Turner et al, after their review of the literature, suggested fairly high doses of sertraline, fluoxetine, and peroxetine as kind of the place to start. Obviously, you're gonna wanna monitor for the emergence of mania or suicidality. This is the treatment guidelines that Turner et al, the World Federation of Society of Biological Psychiatry recommended. It's a really busy slide, but just kind of reiterated what I just told you. And finally, I found this book to be really, really helpful. I did a review of it for the Journal of the American Academy of Psychiatry and the Law. It's actually available downstairs. I went to go look to see if they actually had a copy. But it's a really good introduction. It also has a chapter on women specifically, on forensics, which Sarah's gonna talk about a little bit. But if you wanted to learn a little bit more and more about the history of the diagnosis, I think this is a really good place to start. And with that, I'm gonna turn it over to Sarah. Thank you. Thanks so much, you guys. As you can tell, Kat did all the heavy lifting with the research. She did such a good job with that. I got the fun job of turning to the internet, which, as we talked about earlier, is a very powerful tool. The first thing I wanted to bring to your attention is the wide availability and discussion of what we may or may not consider a disorder on the internet. So Dr. Drew Pinsky, who became popular many decades, not many, multiple decades ago, on MTV, did take to a show called Sex Rehab where he brought some B.C. D-list celebrities out to talk about their sexual behavior disorders and, I guess, open up at least a forum for discussion. In reviewing YouTube clips, looking at this particular show, he did get some flack for this. There were a number of people like Bill Maher who questioned him, is this really a disorder that you're touting or is this just an excuse for people to engage in bad behavior? If you have money, you're in luck because there are a number of very bougie places that you can go to treat your sexual behavior disorder. I mean, I've never stayed in a place that nice in all my life, and you can stay in multiple countries even. So the prices are astronomical. This particular website that I featured here will tell you if they take insurance or not, but some of them are up to $60,000 per month. So just to give you a sense of how much you can spend to treat your sexual behavior disorder. I also had the opportunity to look at some celebrities. As we know, especially over the last couple of decades, we've seen people come forward from Hollywood and profess that they have a sex addiction. So I wanted to be, at first I thought this seemed really easy. I remembered multiple cases when Kat and I were formulating how we were gonna present this, and I found maybe it's not quite as easy as I thought. I tried to be very thoughtful about looking up quotes. I wanted to make sure that the people were comfortable coming forward and being quoted in the media, saying what they said. I certainly don't wanna engage in gossip mongering or outing people who do not have a sexual addiction and it's just a rumor. So I was thoughtful about who I chose in this selection and to ensure that the quotes are legitimate and that they have come forward officially to say this. The first is David Dukovny, and I think he is a fascinating example because this highlights one of the things that we come to know about people who have addictions, paraphilias, a variety of issues that they don't want to necessarily own. So in 1997, when he actually married his wife, another celebrity by the name of Taya Leone, he came forward to say if you're single and in the public eye and you have a few dates, you're a sex addict, right? So we really see that minimization, if not flat out denial of any disordered sexual behavior. However, he came forward to make a statement in 2008 to the press that he has voluntarily entered one of those fancy facilities for the treatment of sex addiction and that he asks for respect and privacy to protect his wife and children. So he was still married at this time. He remained married to Taya Leone from 1997 to 2014. They split up at the time that he entered the rehab, got back together, and then split up again to ultimately divorce in 2014. Now, while this is going on, he engaged in a show called Californication, which is, I saw on a YouTube clip, him kind of portraying what he was going through in real life and how this wasn't amenable to treatment if he's acting out as this character, Hank Moody. So I wanted to show you a brief clip here about, this is the season, and for your benefit, I have engaged in watching the show myself. I'm about through season one. It ran for seven seasons from 2007 to 2014. Mind you, this is right around the time he was not only in rehab, but supposedly in recovery and still married to his wife. So with that, I will play you a clip here. You're out there touching anything that moves, you're not writing. You have this incredible talent and you're just flushing it down the toilet. What's going on with you, man? I'm disgusted with my life. As your friend and agent, may I suggest that you start looking for a nice girl? I wouldn't even know what to say to a nice girl. Mia. Nice to meet you, Mia. So, you're a famous writer, huh? More like a one-hit wonder. Well, now I'm definitely not going to sleep with you. Why is there a naked lady in your bedroom? You wait right there, okay? There's no hair on her vagina. Do you think she's okay? I'll check. Hey, what'd we wrap? That would be my husband. Who is it? I'll kill him. Defile me. I'll be right there. Are you kidding me? Consider yourself defiled. I need you. I'm getting married. He asked and I said yes. Now, don't I get some saying this? No. Are you sure? Because it seems like I should. Daddy's trying out a new look. Are you mentally insane? Yes, and I'm extremely high-functioning. You're a really classy guy. Think I made her laugh? Sure. A little. On the inside. Okay, big guy, you and me. We've never done this before, but desperate times call for desperate measures. Well, normally I would suggest that a bunch of Our Fathers or a couple of Hail Marys. What about a ... ? Hmm? Bad dream? Hank is going to hell. Hmm. All right. So, I have to tell you, the jury was out when I first started watching this show, but I see why it's popular. There's witty banter, and I've actually kind of become attached to the main character. I did not expect to. I wanted to show you that clip just to highlight some of the things that sexual behaviors and compulsive sexual behavior disorder, should we think that this main character had it, can do to be disruptive to one's life. He was involved in a wonderful relationship, had a daughter. He lost that because of his behaviors. His agent thinks he's not performing to the level that he could because of his behaviors as a writer. And so, I think it is interesting to me that his life has kind of mirrored this, and he's acting these things out on the big screen for us all to see. It is on Showtime, and with streaming available now, it is accessible if you are interested in this show. The next celebrity we'll talk about is none other than the infamous Kanye West. He, of course, was married to Kim Kardashian for a number of years, and we have all witnessed the ups and downs of his mental health in the media. Of course, being respectful of the Goldwater Rule and not diagnosing people without having seen them, I will refrain from sharing with you what I feel like his diagnosis is, but he does talk a little bit about some of his sexual behaviors. He was quoted as saying, like for me, Playboy was my gateway into full-on pornography addiction. My dad had left a Playboy out at age five, and it's affected almost every choice I have made for the rest of my life. So, we see pornography being brought up as a source of compulsive sexual behavior, and then we also wonder again some of his actions that have been publicized in the media, what this diagnosis might actually be, if there are comorbidities, and how that is a very complex interplay of potential diagnoses. Next, we have Jada Pinkett Smith. I wanted to include her because she has been on a talk show that she herself popularized and has had a public forum to say things about herself and sexual behavior, and she's a woman, so this was one of the few women I found who came forward to talk about her maybe disordered sexual behavior. She says, My addictions jump around. When I was younger, I definitely think I had a sex addiction. Everything could be fixed by sex. She said that she used sex toys multiple times a day to give herself five orgasms a day at the age of 21, and she said, If you want to have a lot of sex, that's great, but why are you having all that sex? That's what you've got to look at. So, again, we get snippets of celebrities' lives through the popular media. Of course, everybody, you never know what's going on in people's homes, but this is her talking a little bit about some behavior that may have caused trouble that we know about, again, through the media in her relationships. Russell Brand is an actor who was very vocal about and has written a book about his battle with addiction to substances and also includes sex in that. He said, When I became sexually aware as a teenager, I got very obsessive about sex. So there we see obsessive in terms of potentially linked to an OCD sort of diagnosis. I was very uncomfortable with my body, so my problems were around porn and food. And Kat mentioned the fact that there may be some eating disorder comorbidities associated with this. I lost lots of weight and moved from the suburbs into the city. Women were now attracted to me. I went crazy with that. Sexual addiction for me was worse when I was clean. So there, again, we see the complex interplay of addictive behavior to substances and how that may overlap with sexual behaviors that have become addictive as well. Finally, for celebrities, we have Charlie Sheen. Charlie Sheen has said a lot of things in the media and was looking, to use the lay terminology, a little crazy when he came forth to tell everyone how he was winning. Some history on Charlie Sheen, and I felt that this was an important thing because he did testify to this under oath. In 1995, when he testified in the trial of Madam Heidi Fleiss, he admitted that he spent $53,000 on sexual services related to prostitution in a 15-month period between 91 and 93. So we have a documented history of potentially excessive sexual intercourse in risky situations, and in 2015, he came forward to say that he had HIV related to his sexual encounters. So we see some medical complications and things flowing from his behaviors that we would attribute to maybe some excessive or careless sexual behaviors, which, of course, when we look at addiction, that is one of the criteria if one continues to use when one is experiencing psychological or physical ramifications from that. And then the last guy I wanted to talk about, maybe not a celebrity, but certainly has made the news from being behind the scenes, Harvey Weinstein was convicted and is currently serving time for a number of completely sexually inappropriate behaviors. He volunteers, guys, I'm not doing okay, but I'm trying. I've got to get help. You know what? We all make mistakes. So he did himself go to rehab prior to his incarceration. So this does lead us to talk about forensic implications of this disorder. I want to talk about the Supremes. Not those Supremes, though. We're talking about these Supremes. I have very intentionally left the Supreme Court as I would like it to be back when Ruth Bader Ginsburg was still sitting as a justice. She actually had weighed in on becoming a justice in 1993, weighed in on three of these four cases. I will talk more specifically about Kansas v. Hendricks and Kansas v. Crane, but these are Supreme, U.S. Supreme Court decisions that impact sexually violent predator laws. And sexually violent predator laws exist in a number of states, and they allow for the civil commitment of sexually violent predators following the completion of their criminal sentence for their sexual convictions. Allen v. Illinois is a case in 1986 that establishes these proceedings as civil. Despite the fact that they flow from criminal activity and no one would be placed as a sexually violent predator under civil commitment but for their criminal charge and conviction, they define them as civil because it is an attempt to get someone treatment, so to speak, as opposed to simply being punitive. Kansas v. Hendricks and Crane are probably the most popular cases. I do teach these to the fellows. These are identified by Apple, our forensic organization, as landmark cases. That's to say they're ones we want to pay attention to, and for the last 15 years I have taught them to the fellows, and Kansas v. Hendricks in particular sticks out. So we'll talk about that momentarily. And then our most recent decision regarding SVP laws comes in U.S. v. Comstock from 2010, which suggests that in federal sexually violent predator laws, Congress does have the authority to commit. So very rarely does the U.S. Supreme Court ever decide for the sex offender. They really do see them as a different class of people when compared to other offenders. There's no murder registry, there's no child murder registry, but there does exist, of course, sex offender registries. So Kansas v. Hendricks is a case that was heard in the U.S. Supreme Court in 1997. Mr. Hendricks, not a great guy, convicted of repeated sexual abuse. When he came up for release from his prison sentence, he told them, go ahead and release me, I'm absolutely going to do this again, and the only way you will be able to stop me is by killing me. So the Supreme Court, as you may know, grants cert in cases. That means that any Supreme Court, whether it's state or U.S., has the option of what cases they want to hear. They were tired of people talking about them treating sex offenders unfairly, and I believe selected this case in particular to hear because Mr. Hendricks seemed like such a bad actor. So looking at the law that would have placed Mr. Hendricks in a facility, civilly committed him following the completion of his criminal sentence, Kansas' SVP Act allowed for the commitment of individuals with a very broadly stated mental abnormality. So rather than civilly committing folks, as we do in most of our states, for a mental illness, this broadened the term to mental abnormality, who are likely to engage in predatory acts of sexual violence. They said that this mental abnormality, unlike in most court systems, does include personality disorders. So if you can be proven to be antisocial, that satisfies the requirement of a mental abnormality that would go on to allow for civil commitment. The U.S. Supreme Court said this term of mental abnormality does satisfy substantive due process, and they also said, you know what, since this act is not punitive, it's civil in nature, double jeopardy and ex post facto don't apply. So this was them just saying, you know what, sex offenders don't have a whole lot of rights in terms of the post-prison sentence timing. They are treated differently. Kansas v. Crane, I believe, was granted again because the Supreme Court relies on precedent. They do not want to reverse their decisions, and they were tired of people questioning them. Mr. Crane, the same SVP law applies obviously here. It's out of the same state, and Mr. Crane was convicted of aggravated sexual battery. The question before them was one of due process related to the 14th Amendment which asks, does the sexually violent predator have to have complete lack of control of his behavior or is only some lack of control necessary when we're looking at the SVP law? And they determined that some lack of self-control is just fine. They do not have to completely lack self-control. Now the interesting point about this, to tie this back into what Pat was talking about, is this happens to be one of the criteria of compulsive sexual behavior disorder. That's namely that they cannot control the behavior or they are compelled to do so. This does get a little tricky in terms of forensics because not only in this case, but if we look at some states with an arm, a volitional arm as part of their insanity defense, that talks a lot about control and whether one's able to control their behavior. So this is a medical construct of control versus a legal construct and sometimes the lines get a little blurry. To give you a sense of how many states are willing to civilly commit people convicted of a sexually violent crime following the completion of their prison sentence, here we are. So we have a number of states here and the federal government as well. We wanted to give you an example of how an SVP law may be written. This is where CAT practices in Virginia and Virginia suggests that anyone who has been convicted of a sexually violent offense or anyone who has been found incompetent to stand trial when charged with a sexually violent offense, here we see that term mental abnormality again and then not a lack of control, but rather difficult to control. So very much echoes Kansas's SVP law, most are written in the same way. And then Virginia also talks about how one may be released from the facility where they have been civilly committed if they believe that the condition has changed so that one is no longer a sexually violent predator. A little bit of research for you here. We have 2013, our oldest study, 586 adult males were looked at. These are convicted sexual offenders and approximately 12% met the clinical criteria for hypersexuality. I will point out that this was prior to, at least the research was done prior to, the publication of the DSM-5. So these criteria might not be the same as what we would be thinking about today. They also noted that increased risk of long-term sexual and violent recidivism did occur with the criterion for hypersexuality. In 2015 a study comes out to suggest that a paraphilia, which is pedophilia more specifically, that pedophilic interest is more commonly associated with antisocial traits than it is with the criteria for compulsive sexual behavior disorder. In 2019 it is assumed that what drives people who are considered sex addicts, those who attend sexual addicts anonymous and sex offenders, is the same. That they're both preoccupied with sex and sexual fantasies and sexual behaviors. However, the rates of compulsive sexual behavior disorder are going to be far higher in the attendance of sex addicts anonymous than it is in actual sex offenders who have been convicted for their crimes. And finally in 2022 we have a study that mirrors that of the one in 2013. They looked at 18 men, sorry 418 men incarcerated for sex offenses and suggested about half of the earlier number, 6%, met the criteria proposed for hypersexuality disorder. And again I'll highlight that those are different sets of criteria. Two of those diagnostic criteria did turn out to exhibit slightly more correlation with sexual recidivism. And now that you guys are so educated about compulsive sexual behavior disorder, I turn to our more complicated case that may be some of your patients. These are not unheard of. As psychiatrists we tend to see the more complex folks. And I'm going to tell you a little bit about Sheila F., who I believe meets this description. She's a 36 year old woman and she has a history of childhood sexual trauma. She was raised Catholic. She has had one psychiatric admission at the age of 24, at which time she was diagnosed with bipolar disorder. She was actually during that admission moved to an all-female unit after having sex separately with two male peers on her previous unit. She has had some diagnostic workup done. Labs and head imaging all look normal. So we're ruling out medical causes of potential hypersexuality or any kind of brain issue that may lead to behaviors consistent with hypersexuality. She reports that she's had over 200 sexual partners and has a history of engaging in risky sexual behavior. That's to say she's had sex without protection in risky situations where she doesn't know the history of her partners or in unsafe environments such as in back rooms or on the side of the road. She's had a total of six miscarriages and four elective pregnancy terminations, which to her has led to extreme guilt. She thinks about this a lot. She perseverates on it. And again, with women who experience criteria for this disorder, it's important to note this is complicated, of course, by the fact that hypersexuality can lead to pregnancy, which obviously wouldn't happen in men. We don't see that in other addictive disorders in that alcohol affects men and women pretty much the same and we don't have extra complications like we would with sex. She tells us she's divorced with times two and has three children and she comes to medical attention at the present because she has recently made a suicide attempt via overdose. So we have what looks like a pretty complicated presentation. All right. So with a show of hands, we will ask at this point, what do you think this is? How many people think this is compulsive sexual behavior disorder? Okay. I see a handful of people who are brave enough to throw that out there. And what about bipolar disorder? Okay. We have some evidence for that. We have a previous admission at a young age where we would expect that she may have a first episode. We have a recent suicide attempt that's potentially suggestive of depression. We certainly know that manic folks can engage in hypersexual behavior. So I can see that. How about obsessive compulsive disorder? I agree. I don't think we see a whole lot of evidence of that. Again, we would be thinking about obsessions. I would say that her guilt is probably maybe more associated with the ruminations of depression and excessive guilt as opposed to obsessions that come along with OCD. Paraphilic disorders. Okay. I agree. I don't think we see too many unusual sexual practices here. Substance use disorder. Certainly a consideration worth thinking about. We didn't ask or we didn't talk about that specifically, but certainly worth investigating. Do you think this woman has a disorder? Again, we look at the idea that in the DSM oftentimes we see that if there are dysfunctions related to behaviors or feelings that it is often disordered. And then how many people are unsure about this woman's diagnosis? Yeah. Me too. Okay. That's complicated. But these are the kind of folks we're going to see and it is worth keeping compulsive sexual behavior disorder in our differential. Okay. So some take-home points from our talk today. CSBD or compulsive sexual behavior disorder is a new diagnosis. It exists in the ICD-11. It can be coded and it does overlap with hypersexuality disorder as proposed for inclusion, but was not included in the DSM-5. There is a good deal of data and research that is emerging, especially now that we have established it as a diagnosis according to the ICD-11. And it will likely increase with the idea that again it is a diagnosis. Studies often vary in their definition. As Cat mentioned, it's very much worth looking at the criteria because they do differ and some people may choose to use their own criteria. It looks like in terms of treatment options that we care about as psychiatrists, naltrexone and SSRIs are our best options and that's not surprising given the nature and potential origin of this disorder. And then finally, we don't know how the legal system will respond to this as a disorder. We know how Hollywood has kind of taken it and run with it as a potential excuse for behaviors. We certainly don't expect the legal system to do the same, but I'm curious to see what happens. And with that, we'd like to thank you for joining us today. We welcome any questions. Please use the microphone. I'm Steven Bluestone from New York, I'm full-time private practice. First off, thanks for the talk, it was wonderful. I have a weird story with all this. Several therapists who refer patients to me specialize in sexual compulsion and addiction, so I became a de facto, you know, filled up my practice without my wanting to. And one of them had clear obsessive compulsive disorder. Almost all of the others had clear ADHD, which was not something I was looking for or expected, but it's become something that I now sort of am hardened to, that when someone's referred to me as, from one of these people, it's like, uh-oh, another ADD-er. But I have yet to see a single one of them have their behavior change with stimulant treatment. Other behaviors change, but not the sexual behavior. So I now actively warn them. I say, you know, I'm diagnosing ADD, it will not change your, I see this all the time, it won't change your sexual behavior, forget that idea. So I'm wondering, is that, because that wasn't on the list of comorbidities, I'm wondering, is that something you've seen, or not particularly? I haven't seen it. I'm trying to remember if it came up in other studies. I want to say that it did, and there is some overlap between increasing, people with compulsive sexual behavior disorder have increased risk in boredom and things like that. But then it becomes tricky, because is it just because of the boredom, and they're filling their time, and then trying to disentangle that? But I haven't seen that listed as something that's frequently comorbidly diagnosed. Again, I was not looking for it, and it's now I'm, now I do. You should, you should publish your results. We need more data. And also, just a fun thing to mention, you were talking about the 12-step groups. I'm aware of four different 12-step groups, S-A, S-C-A, S-A-A, and S-L-A-A. Wow. Yes. Sex and Love Addicts Anonymous, Sexaholics Anonymous, Sex Addicts Anonymous, and Sexual Compulsives Anonymous. It sounds like you've heard of all of these. Yes. I have no idea what the differences are, but apparently, as in all such things, they have various disagreements and disputes and debates. But I'm fascinated. I'm not aware of any other addiction where there's four competing 12-step groups like that. That's a very good point. So that was kind of the distinction between Don Juan and Casanova, the idea that sex and love are separate or together or, and as Kat mentioned, before recommending something where, like S-A-A or any of these other 12-step groups, we have to have a better understanding of what's happening. I think when we recommend A-A or N-A, we more solidly understand how those 12-step meetings are run. But even there, there's some variation between what sobriety is and whether Matt's acceptable. So it's good to maybe get a feel if you're recommending these groups as to what happens there. So thank you so much for your comments. Appreciate it. Yes, sir. Yeah. Thank you for the presentation. Especially when you had like these celebrities going up there, it made me think about how much comorbidity there is with this and how, at least in my own clinical experience, I wouldn't really expect to just see what you presented today as far as like a compulsive sexual behavior disorder. I see things like with addiction, with PTSD, with bipolar. And then I guess sort of on a, I don't know, since you're both forensically trained, where I'm also seeing this just one day a week, I'm working at a jail and I see patients with very severe mental illnesses, schizophrenia, schizoaffective bipolar, engaging in compulsive masturbation. And there is clearly something related but different going on in the brain there. I just think of like the dopamine, but also like the obsessiveness and stuff like that. So I know this is not necessarily a specific question, but I guess just it strikes me that maybe this occurs all on its own, but I wonder if this is not just more something that occurs with other things going on the vast majority of the time. Yeah. And there's a school of thought that thinks that might be an outcropping of disorders that we already know, but it does seem to be individuals who do experience it on their own and seek treatment for it on their own and it can be disentangled. But because of all the comorbidities, especially with anxiety and depression, I think that's definitely a good thought and something we have to be really thoughtful of. The other comorbidity that I've noticed, at least in my clinical population, is intellectual disability. I don't know if anybody here works with folks with intellectual disability, but I think that also they have an increased risk of impulse control problems and difficulty with communication and they might be using sexual behavior as a form of self-soothing, a form of self-control. So we want to disentangle that as well. And I really like the comments about the correctional environment. I think it gets complicated by a number of factors that are not present as a correctional psychiatrist. I consider those things. Boredom's huge, so some people are maybe excessively masturbating due to boredom. And then there's maybe an antisocial component that they're on display, they're displaying their genitalia to correctional officers and others in the pod. So that could have an ulterior motive as well. So thank you for that. Yes, sir? You didn't mention anything about the etiology and whether you think a lot of these behaviors are from incidents that happen in their life, experiences they had that may have really turned them on to being hypersexual, or whether you think people are just wired this way, whether it's from these celebrities, some of the women, the men that they said from a very early age felt very sexually charged and it's not surprising how their adult behaviors are, or do you see this as from different experiences in life and is something that psychotherapy really helped understand more? It might not change it, but there really are good explanations of why people are this way. Yeah, absolutely. I think I hadn't seen anything with more like psychodynamic psychotherapy or other kinds of insight-oriented therapies looking at this. It was more of those kind of manualized therapies, I think, because they're easier to study because they're manualized, but it's a good thought. I think the other thing is that trauma history is a really key piece. It's not quite clear exactly if there's something meaningfully different about those who have behavior that might meet criteria and have had a trauma past versus those who hadn't had any trauma past or any experiences we can kind of equate to the behavior as kind of driving the behavior. I think we just need more data, but it's interesting. Or how much do you think it's hormonally mediated? I mean, certainly in adolescence, for men, the testosterone is there for the women that are very hypersexual. Any thoughts on what that might be about? I think we're not quite sure about testosterone's role in this particular disorder quite yet, just because, for instance, the micro RNA study, there was one study that I looked at that was like testosterone, increased testosterone levels are absolutely associated with it, and then the micro RNA study, which had more participants and looked at testosterone as well, just as another measure, found no significant increase in testosterone among those with compulsive sexual behavior disorder. They weren't adolescents. I'd be curious about that as well. I think when Reid did his field study, he was asking participants, too, who were seeking treatment, when did you start experiencing compulsive sexual behavior? And a lot of them said, during my adolescence. So I think we do need to maybe look at that more in terms of, is that where the testosterone increase is being seen? And that's what's developing the disorder, but more data. Thank you. Yes. I have a couple questions. One, hopefully, will be brief, and that is, since that isn't in the DSM-5 yet, what is the appropriate diagnostic code to use? I have two patients with excessive sexual behaviors who are tangentially responding well to naltrexone, but I'm not sure what code to use in my documentation right now. I couldn't find an addictive behavior or compulsive behavior NOS, and there isn't anything about hypersexual desire right now. No. Would it be under other sexual... It wouldn't quite fit under paraphilic disorder. It wouldn't fit under impulse control disorder per se, but maybe under... Is there an NOS category under where hypoactive sexual behavior... Not that captures excessive that I could find. No. I mean, there's definitely not going to be anything that captures this. I think, at least in my clinic there, we use ICD criteria, so that kind of helps with that, but I don't really have a great answer for that. I would check out that book that I recommended, The Compulsive Sexual Behavior Disorder. I believe Kruger goes through what it would be in the current iteration of DSM, but hopefully in the next iteration we'll have some better answers for that. Thanks. And then the second question is about the idea of the sequelae of the person's behavior as the sort of defining aspect of the condition. Given the complexity and breadth of human sexuality and human sexual behaviors, there's a lot of elements that it seems like you'd have to nail down with these kinds of behaviors, and I'm thinking about people who identify as functional alcoholics who drink large volumes of alcohol but don't seem to have any obvious sequelae. There could be people who may meet certain types of the criteria but don't seem to otherwise be having adverse effects of this in their life, and some of that's going to be contextual. I was curious about the first two slides about sexual behaviors, whether all those individuals were characterized in terms of their relationship status, whether they were in monogamous or non-monogamous relationships, whether they were partnered at all. It seems like there's a lot of information missing because some of the ways that these things may be defined as having an adverse consequence are going to be contextual. One of the things that some people with self-proclaimed sex addictions talk about is the clandestine nature of their connections, and when it's above board they're no longer interested. So it may not be the sex itself, it may be some other charge in the behavior that they're seeking, and it really has nothing to do with the sex other than that's a vehicle for a clandestine behavior that's less destructive than cocaine. That's interesting because that makes it seem almost more like a paraphilic disorder, right? Like it's something about kind of hiding that is the sexual arousal, not the sex itself. So I'd be curious to kind of disentangle that. The other thing I was thinking about when you were talking about this, wait, and I lost it. I lost it. It almost sounds like we need cage questions for, yeah, I mean the cage questions kind of hit the... I remember it. I was watching somebody else present on this particular disorder that worked with people with compulsive sexual behavior, and what he said too was that oftentimes these people are presenting not on their own but brought in by a spouse, and then what do you do with those patients, right? They're not going to be interested in treatment. Do they really meet criteria? Well, maybe because it seems to be impacting their relationship, but what's their spouse bringing into it as well? And is it really messing with the relationship because it's so over the top or because it's how the spouse is seeing it and making them feel about something? So then you would probably need some family therapy to try to disentangle that dynamic. And could there be some analogous comparison with these behaviors and say something like the difference between OCD and OCPD, where the dysfunction is either internal or essentially external, or external relationships and contextual relationships rather than it being an internal experience of distress? Yeah, and I think while there's some overlap with OCD and CSBD, I think there's also a lot of meaningful differences, right? Like the content of the thoughts, whether they're perceived as intrusive or fantasies. In CSBD, they seem to be more egocentronic. In OCD, they seem to be more egodistonic. And then the compulsive behavior, one is to kind of—I'm not an OCD expert, so if there is an OCD expert in this audience, please forgive me—but the behavior in OCD seems to be more about relieving anxiety and avoiding some dreaded outcome, whereas CSBD is for the sex itself. So different targets, different fantasy, or different thought elements. Thank you for your question. We'll take one last question. Thanks. To say thank you for an excellent talk, by the way. Can I ask, with CSBD, are the symptoms stable over time? And the reason I ask is I've had patients that are sort of in their mid-20s. I think of one specific example of somebody that basically would have fit nicely into the CSBD box in kind of over a period of a few years and noticed that he was starting to watch different types of pornography, engage with sex workers, and then things started to get even more sinister after that. But that might be a very specific example, but I'm curious if kind of the difference between the more serious sex offenders and CSBD is just that anti-social element. I wonder if there's any evidence that one can progress into the other. That's a good question. I don't know. I think it's really interesting that sex offenders have such a small rate of CSBD compared to what you would think. In terms of the progression, I know that the behaviors can certainly change over time, but I don't know whether or not they kind of mellow out over time or worsen over time. In Reid's field study that went along with the DSM-5 criteria, what people were reporting was that I started in adolescence and it progressively worsened through my 20s and into my 30s and that's when I felt like I needed treatment. But then what happens after their 30s and 40s? I don't know. Yeah, with certain paraphernalia, there seems to be some evidence that people almost grow out of them as they get into their older age. I'm just wondering if this stays stable. Is this going to be a constant problem as people? I guess time will tell, right? I mean, we've just identified this disorder. Now, I guess we'll have to watch for the lifetime, Stequelle. Thank you guys again so much.

Compulsive Sexual Behavior Disorder

ICD-11

DSM-5

CSBD

Hypersexuality Disorder

Diagnostic Challenges

Neuroimaging Studies

Addiction Framework

Naltrexone

SSRIs

Forensic Implications

Trauma

Mental Health Disorders