Abstract
The current understanding of compulsive sexual behavior disorder (CSBD) is primarily based on studies involving non-clinical samples of heterosexual men, resulting in significant gaps in knowledge regarding women with CSBD. The commentary highlights the domains where further research is necessary, including incidence and prevalence, etiology, diagnostic criteria, comorbidities, sexual patterns, personality profiles, and barriers to help-seeking among women with CSBD. Bridging this research gap is essential for improving clinical care, developing tailored interventions, and increasing awareness about CSBD in women among healthcare providers, policymakers, and the general public.
Compulsive Sexual Behavior Disorder (CSBD) in the 11th edition of the International Classification of Diseases (ICD-11) (6C72; WHO, 2022) is characterized as a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behavior, which persist for over six months and cause marked distress or significant impairment in important areas of psychosocial functioning. For over four decades, vigorous scholarly debate has existed surrounding its etiology and biological underpinnings, which continues to date (Grubbs et al., 2020).
Although the new standardized definition of CSBD in ICD-11 is crucial for expanding access to healthcare for millions worldwide, its codification as a mental health disorder remains controversial. On the one hand, CSBD's inclusion in the ICD-11 provides an opportunity for researchers and clinicians to collect accurate data, which may result in developing relevant therapeutic interventions tailored to this population. On the other hand, it reveals the shortcomings of previous studies on this topic, particularly with regards to gender, sexual, and ethnic/racially diverse populations. As noted by several researchers in the field, nearly all the current knowledge on CSBD is based on data from primarily non-clinical samples of heterosexual men (Grubbs et al., 2020; Kowalewska, Gola, Kraus, & Lew-Starowicz, 2020). Simply put, it means that potential gender differences in risk and protective factors, CSBD symptoms severity, diagnosis, and possible treatments have rarely been fully considered, resulting in severe methodological shortcomings (e.g., lack of clinical interventions tailored to specific groups, lack of psychometrical evaluation of available instruments on women). It is important for clinicians and researchers to gain a more accurate understanding of how gender gaps in previous CSBD studies may impact the health and wellbeing of women living with CSBD. Through this letter, we would like to draw attention to this issue by highlighting the domains where further research on CSBD among women is necessary to improve both individual care and public health globally.
First, there is insufficient knowledge on the incidence and prevalence as well as the etiology of CSBD among women. In the case of incidence and prevalence, most studies have focused on male samples and used unstandardized assessment methods and a variety of indices of CSBD (Bőthe, Potenza, et al., 2020). Thus, available estimates of CSBD differ enormously between populations and the true proportion of women who experience CSBD may be substantially over- or underestimated (Kürbitz & Briken, 2021). After the release of the recommendations for future studies on CSBD among women put forth by Kowalewska et al. (2020), researchers have begun to tackle certain points raised by the authors. For example, some data on the frequency of clinically significant indications of CSBD has begun to emerge. Specifically, data on the occurrence of CSBD have been collected among community samples across 42 countries, genders, and sexual orientations as a part of the International Sex Survey (Bőthe et al., 2023). Studies on such numerous and culturally diverse populations will undoubtedly contribute to a deeper understanding of this condition. However, concerning the prevalence of CSBD, more research is needed involving large nationally representative samples, such as a study conducted on a probability-based German nationality sample (Briken et al., 2022). Regarding etiology, existing evidence suggests that men and women differ in many aspects of their sexuality (including reactivity, preferences, attitudes). Yet, the degree to which men, women, and gender-diverse individuals (identifying themselves with a gender outside of the man or woman dichotomy) experience similar or different CSBD symptomatology remains unclear.
Despite recent initiatives in the field (Bőthe et al., 2023), one of the most crucial issue remains around the need for in-depth psychometric evaluations of available instruments in terms of their validity and reliability in diagnosing CSBD symptoms in women, with a strong emphasis on establishing norms from clinical samples, which include adequate representation of women in clinical studies. Visible concentration on male participants in previous studies might have resulted in several unintended consequences. CSBD might exhibit distinct presentations in women as opposed to men, potentially resulting in the misinterpretation or oversight of symptoms specifically in women. Additionally, due to the unconventional manifestation of symptoms or inadequate understanding, CSBD in women might not be promptly diagnosed, leading to delayed treatment or misdiagnosis. Research on women with CSBD can help refine diagnostic criteria (which may not fully capture the symptoms and experiences unique to women), improve the clinical accuracy of assessment tools, and further prevent the underrecognition and underdiagnosis of this condition in women.
Furthermore, previous research on men revealed that CSBD often co-occurs with other psychiatric comorbidities such as depression, anxiety, and substance use disorders (Kaplan & Krueger, 2010; Kraus, Potenza, Martino, & Grant, 2015). Problematic pornography use coupled with compulsive masturbation have been shown to be the dominant clinical presentation of CSBD among men (Gola et al., 2018; Kafka, 2010; Reid, Carpenter, et al., 2012). Little is known about sexual patterns, co-occurrence with other mental disorders, personality profiles, as well as sexual function problems among women experiencing CSBD. Available data suggests that women view pornography less often than men and report lower rates of feeling urges to use pornographic materials (Kowalewska et al., 2020). However, it is important to note that certain reports indicate that a small subset of women also engages in frequent or risky use of pornography (e.g., Ballester-Arnal, Castro-Calvo, Gil-Llario, & Gil-Julia, 2017; Bőthe, Tóth-Király, et al., 2020). One of the few studies on women seeking treatment due to CSBD points to the need for further exploration of problematic pornography use as well as the number of past year sexual partners and frequency of past week masturbation, as potential risk factors or behavioral manifestations of CSBD (Kowalewska, Gola, Lew-Starowicz, & Kraus, 2022). Another comparison of treatment-seeking women with and without CSBD symptoms (assessed by self-report questionnaires) revealed significant inter-group differences in the frequency of the aforementioned behaviors, as well as the severity of depression and anxiety symptoms, and some aspects of impulsivity (Kowalewska, 2023). Previous studies have also shown that women with CSBD (as compared to men with CSBD) exhibited elevated levels of distrust toward others, decreased self-confidence and ambition, and a stronger preference for excitement and stimulation (Reid, Dhuffar, Parhami, & Fong, 2012). Moreover, empirical evidence and clinical observations indicate that women tend to report a higher frequency of childhood traumas and are more affected by attachment ruptures (McKeague, 2014). In future studies, it would be beneficial to focus on the potential psychological role of certain behaviors, its impact on relationships, and sexual and psychosocial functioning.
Apart from the better understanding of the clinical picture of women with CSBD, it is recommended that future research examine gender differences and/or similarities in neuronal mechanisms of CSBD, as well as genetic vulnerability factors for the development and maintenance of this disorder among women. Specifically, neuroimaging (Gola et al., 2017; Klucken et al., 2016; Voon et al., 2014) and genetic (e.g., Jokinen et al., 2017; Chatzittofis et al., 2016; Bostrom et al., 2019) research focusing on men with CSBD have unveiled partial similarities or shared characteristics akin to addiction disorders. Recognizing commonalities with extensively researched provides a framework for potentially more effective treatments and a deeper comprehension of CSBD, ultimately benefiting individuals affected by this condition.
Due to cultural norms and the social expectations around gender roles, women's sexual function problems have been underreported in clinical and research settings likely due to perceived shame and stigma. According to McKeague (2014), shame may serve as the primary emotional element of CSBD (referred to as sexual addiction in the past), and its impact is heightened for women due to negative cultural messages. The lack of adequate knowledge about the mechanisms of CSBD in women and the commonly prevailing stereotypes may diminish help seeking among women. For example, Kowalewska et al. (2022) reported that 68.2% of women had not sought treatment for CSBD in the past but reported significant levels of symptoms. These findings highlight the need to identify barriers for help seeking among women, particularly as it relates to the role of (lack of) social support in this group. Apart from the four possible barrier categories for women not seeking such treatment (i.e., individual, social, research, and treatment) that have been identified so far (Dhuffar & Griffiths, 2016), the emphasis should also be placed on factors such as age, marital status, race/ethnicity, religiosity, access to healthcare, and other comorbid mental health problems.
In conclusion, for many years, research on CSBD has predominantly focused on male participants, creating a substantial knowledge gap regarding its incidence, prevalence, clinical profile, as well as psychosocial, neuronal, and cultural factors contributing to the development and maintenance of CSBD among women. This lack of representation has resulted in several consequences. Initially, CSBD might exhibit distinct presentations in women as opposed to men, potentially resulting in the misinterpretation or oversight of symptoms specifically in women (e.g., women may engage more in interpersonal sexual activity, while men tend more toward solitary behaviors). Secondly, due to the unconventional manifestation of symptoms or inadequate understanding, CSBD in women might not be promptly diagnosed, leading to delayed treatment or misdiagnosis. Thirdly, the lack of adequate data on how women respond to therapies can create treatment disparities. Lastly, because of the reduced focus on gender-specific aspects of diseases in medical education, healthcare professionals may have limited awareness regarding certain conditions as they manifest in women. Addressing current research gaps will lead to significant improvements in understanding CSBD in women, facilitate clinical care by formulating practical implications (e.g., diagnosis, therapy, prevention) for clinical work in a more inclusive manner, and guide efforts to improve access and engagement in treatment. It can also help raise awareness among healthcare providers, policymakers, and the general public about the prevalence and impact of CSBD in women.
Funding sources
Shane W. Kraus received support from the Kindbridge Research Institute.
Authors' contribution
EK and SWK were responsible for the concept and writing the initial draft of this manuscript. EK, BB, and SWK were responsible for the editing, critical revisions, and approving the final version of the manuscript.
Conflict of interest
The authors report no conflicts of interest with respect to the content of this manuscript.
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