Abstract
Background and aims
Scientific evidence for underpinning mechanisms of Compulsive Sexual Behavior Disorder (CSBD) is still scarce. This study explores impaired sexual delay discounting in compulsive sexual behavior (CSB) and its relationship with sexual sensation seeking (SSS) and borderline personality disorder (BPD) features in a general population sample.
Methods
Data were collected via an online survey in a German convenience sample. Participants (n = 311; 71.3% women, 27.3% men, 1.6% gender-diverse individuals) completed the Sexual Delay Discounting Task (SDT), Compulsive Sexual Behavior Disorder Scale-19 (CSBD-19), Sexual Sensation Seeking Scale (SSS scale), and Borderline Symptom List-23 (BSL-23).
Results
Higher CSB and SSS were linked to greater sexual delay discounting and a lower preference for condom or dental dam use, particularly in women. BPD features were associated with higher levels of CSB and SSS but did not moderate the relationship between these behaviors and sexual delay discounting. Men exhibited significantly more symptoms of CSB and SSS than women.
Discussion and Conclusions
The findings contribute to our understanding of CSB, especially in women, and suggest a relationship between sexual delay discounting, SSS and CSB. This finding suggests a need for gender-sensitive approaches and awareness of excitement seeking behavior in research and clinical interventions for CSB.
Introduction
Out-of-control sexual behavior is recognized as Compulsive Sexual Behavior Disorder (CSBD) in the International Statistical Classification of Diseases and Related Health Problems (11th edition; ICD-11; World Health Organization, 2022). It is conceptualized as an impulse control disorder and characterized by a persistent pattern of failure to control intense sexual impulses or urges, resulting in repetitive engagement in sexual activities, becoming a central focus of the person's life to the detriment of health, personal care, interests or daily responsibilities.
Research indicates that men generally score higher on CSBD indices and engage in sexual behavior more frequently than women (Böthe et al., 2020, 2023; Briken et al., 2022; Grubbs et al., 2023). While CSBD and compulsive sexual behavior (CSB) have been studied more extensively in men, the literature shows that women also commonly report CSBD symptoms. Prevalence rates vary widely from 2.42% to 13.1% across different studies (Böthe, 2020, 2023; Briken et al., 2022; Engel et al., 2019). These variations may stem from differences in assessment tools and conceptualizations of out-of-control sexual behavior, previously referred to as ‘hypersexual disorder’ or colloquially as ‘sex addiction’.
In the following sections, we refer to compulsive sexual behavior (CSB) to describe symptoms and self-reported lack of control over sexual behavior, when the clinical disorder (CSBD) has not been diagnosed according to ICD-11 criteria. CSB and CSBD are frequently linked to general impulsiveness (Antons & Brand, 2018; Böthe et al., 2019; Reid, Garos, & Carpenter, 2011, 2012; Walton, Cantor, & Lykins, 2017). Impulsivity and psychiatric comorbidity seem to play a role in CSB regardless of gender (Fuss, Briken, Stein, & Lochner, 2019; Kürbitz & Briken, 2021). Nevertheless, research on CSB and impulsivity has predominantly focused on men (Kowalewska, Gola, Kraus, & Lew-Starowicz, 2020; Kürbitz & Briken, 2021).
The conceptualization of CSBD as an Impulse Control Disorder suggests an overlap with sexual impulsivity. While there has been a paucity of experimental research into underlying mechanism of CSBD, the decision to conceptualize CSBD as an impulse control disorder was not based on data showing that underlying mechanisms are primarily problems of impulse control (Fuss, Lemay, et al., 2019). In the context of CSB, sexual impulsivity is understood as the inability to resist impulses, drives, or temptations for sexual behavior that could be personally damaging. It also involves acting prematurely on sexual urges, often with little premeditation. Like sexual impulsivity, CSB has also been linked to risky sexual behavior like unprotected sex in men who have sex with men (Benotsch, Kalichman, & Kelly, 1999; Coleman et al., 2010; Scanavino et al., 2018; Semple, Zians, Grant, & Patterson, 2006) and heterosexual samples (Luo et al., 2018; Ni et al., 2021). Briken et al. (2022) also report a higher occurrence of self-reported STIs in individuals with CSBD symptoms. Women exhibiting CSB also seem to have a higher risk for negative health consequences of sexual risk behavior like STIs and unintended pregnancy (Långström and Hanson, 2006; Roller, 2007; Ross, 1996). As there has been limited exploration of the connection between CSB and sexual impulsivity, our study aimed to contribute to the existing literature.
An increasingly utilized task to assess a tendency for sexual impulsivity and risk behavior is the Sexual Delay Discounting Task (SDT) by Johnson and Bruner (2012). Delay discounting implies that the value of a future reward decreases as the time to its receipt increases (Odum, 2011).
In a health context, the cost of a risky but in the short-term rewarding behavior is weighted against the later reward of protective or non-risky behavior. Choosing immediate rewards more frequently is linked to impulsive behavior (Levitt, Sanchez-Roige, Palmer, & MacKillop, 2020; Wainwright, Romanowich, & Bibriescas, 2020). Delay discounting of protected sex has been connected to sexual impulsivity and sexual risk behavior (Howe & Finn, 2020; Levitt et al., 2020; Ludwig et al., 2015). In the SDT, the short-term rewards of omitting safer sex measures and engaging in sex immediately (e.g., heightened pleasure) are contrasted with the long-term consequences of unprotected sex (e.g., contracting STIs). The SDT has shown potential in identifying impulsive or risky sexual behavior (Berry, Bruner, Herrmann, Johnson, & Johnson, 2022; Collado, Johnson, Loya, Johnson, & Yi, 2017; Gebru et al., 2022; Herrman et al., 2014; Leeman, Rowland, Gebru, & Potenza, 2019; Lemley, Jarmolowicz, Parkhurst, & Celio, 2018). Impulsivity-related conditions as well as self-reported measures of impulsivity and risky sexual behavior have been linked to a greater degree of sexual delay discounting (Collado et al., 2017; Finkenstaedt et al., 2024; Herrmann, Hand, Johnson, Badger, & Heil, 2014; Johnson & Bruner, 2012, 2016; Lemley et al., 2018; Negash, Sheppard, Lambert, & Fincham, 2016; Sweeney et al., 2020).
In contrast to impulsivity, which is comprised of the failure to resist impulses and consider negative outcomes, sexual sensation seeking (SSS) involves seeking pleasurable and novel experiences, often leading to risky sexual behavior like unprotected sex (Crawford et al., 2003; Kalichman et al., 1995; Voisin, Hotton, Tan, & Diclemente, 2013). We believed that the inclusion of an assessment of SSS in this investigation could provide insight into the role of thrill-seeking in CSB or delay discounting of protected sex.
In a recent study, we found more CSBD symptoms and greater delay discounting of protected sex in women with borderline personality disorder (BPD) compared to healthy controls (Finkenstaedt et al., 2024). In this study, sexual delay discounting was surprisingly not significantly correlated with CSBD symptoms, prompting the need for a more comprehensive exploration in a larger sample.
To explore the relationship between CSB and sexual delay discounting, we conducted an online survey with a general population sample. Our data collection approach prioritized a convenience sample to allow for broader generalizations regarding the occurrence and distribution of traits linked to sexual risk behavior. The aims of this study were to assess and compare levels of CSB, sexual delay discounting and SSS. Additionally, we sought to determine if relationships between these constructs exist. Based on our earlier findings, we postulated that a moderating influence of borderline symptoms on CSB and sexual delay discounting would be observed. Specifically, individuals with more pronounced borderline symptoms would exhibit higher levels of both CSB and sexual delay discounting.
Methods
Participants
The online survey was conducted in Germany from June 2020 through January 2022. Participants were recruited via word-of-mouth and social media platforms like Facebook. Eligible participants were at least 18 years old. An informed consent form was presented at the beginning of the survey. Two 50-euro cash prizes were raffled among those who completed the survey. Duplicate entries were prohibited, and incomplete survey responses were not included in the study, ensuring the data set to have no missing data. In total, 31.5% (n = 143) of participants did not complete the survey and were therefore excluded from analysis.
Sociodemographic characteristics and descriptives of the scores for the full study sample and by gender are displayed in Table 1. The mean age was 27.71 years (SD = 8.79) with a range from 18 to 67 years. Most participants were female (71.3%), followed by male (27.3%) and non-binary or gender-diverse individuals (1.6%). Comparisons between women and men can be found in Table 2.
Sociodemographic characteristics and descriptives of scores for the full study sample and by gender
| Full sample (n = 311) | Female (n = 221) | Male (n = 85) | Gender-diverse (n = 5) | |
| Age in years M (SD) | 27.71 ± 8.79 | 27.09 ± 8.6 | 29.62 ± 9.22 | 22.8 ± 1.64 |
| Gender n (%) | ||||
| Female | 221 (71.1) | |||
| Male | 85 (27.3) | |||
| Gender-diverse | 5 (1.6) | |||
| Nationality n (%) | ||||
| German | 282 (90.7) | 198 (89.6) | 79 (92.9) | 5 (100.0) |
| Other | 29 (9.3) | 23 (10.4) | 6 (7.1) | |
| Relationship status n (%) | ||||
| Single | 121 (38.9) | 77 (34.8) | 41 (48.2) | 3 (60.0) |
| Committed relationship | 149 (47.9) | 112 (50.7) | 36 (42.4) | 1 (20.0) |
| Married | 28 (9.0) | 21 (9.5) | 7 (8.2) | 0 (0.0) |
| Divorced | 5 (2.6) | 4 (1.8) | 1 (1.2) | 0 (0.0) |
| Other1 | 8 (2.6) | 7 (3.2) | 0 (0.0) | 1 (20.0) |
| Education n (%) | ||||
| No degree | 2 (0.6) | 1 (0.5) | 1 (1.2) | 0 (0.0) |
| Low | 6 (1.9) | 1 (0.5) | 5 (5.9) | 0 (0.0) |
| Intermediate | 21 (6.8) | 10 (4.5) | 11 (12.9) | 0 (0.0) |
| High | 282 (90.7) | 209 (94.6) | 68 (80.0) | 5 (100.0) |
| Employment status n (%) | ||||
| Full-time employed | 83 (26.7) | 46 (20.8) | 37 (43.5) | 0 (0.0) |
| Part-time employed | 30 (9.6) | 24 (10.9) | 5 (5.9) | 1 (20.0) |
| Marginally/Occasionally/Irregularly employed | 29 (9.3) | 25 (11.3) | 3 (3.5) | 1 (20.0) |
| Unemployed | 10 (3.2) | 5 (2.3) | 5 (5.9) | 0 (0.0) |
| Student/In training | 152 (48.9) | 117 (52.9) | 32 (37.6) | 3 (60.0) |
| Retired | 7 (2.3) | 4 (1.8) | 3 (3.5) | 0 (0.0) |
| Sexual orientation n (%) | ||||
| Heterosexual | 206 (66.2) | 138 (62.4) | 68 (80.0) | 0 (0.0) |
| Gay or lesbian | 16 (5.1) | 7 (3.17) | 9 (10.59) | 0 (0.0) |
| Bisexual | 77 (24.8) | 71 (32.13) | 6 (7.06) | 0 (0.0) |
| Pansexual | 7 (2.3) | 2 (1.0) | 2 (2.35) | 3 (60.0) |
| Asexual | 3 (1.0) | 3 (1.4) | 0 (0.0) | 0 (0.0) |
| Missing | 2 (0.6) | 0 (0.0) | 0 (0.0) | 2 (40.0) |
| Typical sexual desire per week M (SD)2 | 5.73 ± 2.12 | 5.39 ± 2.12 | 6.64 ± 1.9 | 5.8 ± 1.64 |
| CSBD-19 score M (SD) | 29.70 ± 9.45 | 28.09 ± 8.81 | 34.36 ± 9.66 | 22.0 ± 1.87 |
| CSBD-19 groups n (%) | ||||
| Low risk | 296 (95.2) | 212 (95.9) | 79 (92.9) | 5 (100.0) |
| High risk | 15 (4.8) | 9 (4.1) | 6 (7.1) | 0 (0.0) |
| SSS scale score M (SD) | 25.93 ± 6.7 | 25.2 ± 6.53 | 27.91 ± 6.9 | 24.6 ± 3.44 |
| BSL-23 score M (SD) | 15.45 ± 15.45 | 16.09 ± 15.62 | 13.68 ± 15.19 | 17.4 ± 11.8 |
| BSL-23 symptom severity n (%) | ||||
| None/low severity | 121 (38.9) | 79 (35.7) | 40 (47.1) | 2 (40.0) |
| Mild | 131 (42.1) | 97 (43.9) | 33 (38.8) | 1 (20.0) |
| Moderate | 37 (11.9) | 28 (12.7) | 7 (8.2) | 2 (40.0) |
| High | 17 (5.5) | 13 (5.9) | 4 (4.7) | 0 (0.0) |
| Very high | 3 (1.0) | 3 (1.4) | 0 (0.0) | 0 (0.0) |
| Extremely high | 2 (0.6) | 1 (0.5) | 1 (1.2) | 0 (0.0) |
Notes. M: mean. SD: standard deviation. Possible score ranges: Sexual desire per week: 0–10; CSBD-19: 19–76; SSS scale: 11–44; BSL-23: 0–92.
1 Other most often meaning open relationship.
2 On a scale from 0–10.
Symptom scores: Group difference between dichotomized genders (Gender-diverse excluded)
| Females (n = 221) | Males (n = 85) | p | Effect size | |
| CSBD-19 score M (SD) | 28.09 ± 8.81 | 34.36 ± 9.66 | <0.001 | r = 0.65** |
| CSBD-19 groups n (%) | 0.279 | r = 0.12 | ||
| Low risk | 212 (95.9) | 79 (92.9) | ||
| High risk | 9 (4.07) | 6 (7.1) | ||
| SSS scale score M (SD) | 25.2 ± 6.53 | 27.91 ± 6.9 | 0.001 | r = 0.38** |
| BSL-23 score M (SD) | 16.09 ± 15.62 | 13.68 ± 15.19 | 0.093 | r = 0.19 |
| BSL-23 symptom severity n (%) | 0.06 | r = 0.22 | ||
| None/low severity | 79 (25.8) | 40 (47.1) | ||
| Mild | 97 (31.7) | 33 (38.8) | ||
| Moderate | 28 (9.2) | 7 (8.2) | ||
| High | 13 (4.2) | 4 (4.7) | ||
| Very high | 3 (1.0) | 0 (0.0) | ||
| Extremely high | 1 (0.3) | 1 (1.2) |
Notes. M: mean. SD: standard deviation. Possible score ranges: CSBD-19: 19–76; SSS scale: 11–44; BSL-23: 0–92.
*. Correlation is significant at the 0.05 level (2-tailed).
**. Correlation is significant at the 0.01 level (2-tailed).
Measures
The study was conducted via the survey tool Qualtrics. Participants started with a short demographic questionnaire. To assess sexual delay discounting, participants completed the Sexual Delay Discounting Task, which was modified into an online version and included lesbian women by offering dental dams as protection. It presented participants with thirty photographs of individuals of diverse appearances. Aligning with the original model, the task offered to choose between women and men, excluding other gender identities. Participants selected photographs of people with whom they would like to have sex, assuming they were not currently in a monogamous relationship and that sex carried no risk of pregnancy.
Subsequently, the selected portraits were to be assigned to four different scenarios: Select the person 1) you would most want to have sex with, 2) you would least want to have sex with, 3) that would most likely have an STI, 4) that would least likely have an STI. For each of the selected partners, participants rated their likelihood of having unprotected sex immediately vs. using an immediately available condom or dental dam on a visual analog scale (VAS) from 0 to 100%. Secondly, they rated their likelihood of having unprotected sex immediately vs. waiting different delays (1 h, 3 h, 6 h, 1 day, 1 week, 1 month, 3 months) for protection. Figure 1 illustrates an example of both VAS trials.
Example of VAS for the different delay trials
Citation: Journal of Behavioral Addictions 2025; 10.1556/2006.2025.00028
Following the SDT, participants completed the Compulsive Sexual Behavior Disorder Scale-19 (CSBD-19; Böthe et al., 2020), the Borderline Symptom List-23 (BSL-23; Bohus et al., 2009), and the Sexual Sensation Seeking Scale (SSS scale; Kalichman et al., 1994).
The CSBD-19 is an ICD-11 based instrument consisting of 19 items, each rated on a Likert scale ranging from 1 (“totally disagree”) to 4 (“totally agree”). The items cover various domains related to compulsive sexual behavior, including loss of control, preoccupation with sexual thoughts and behaviors, negative consequences, and distress. Sample items include “I could not control my sexual cravings and desires” and “My sexual behaviors had negative impact on my relationships with others”. The scale has been cross-culturally validated in 26 languages and 42 countries (Cronbach's α = 0.68–0.90; Böthe et al., 2023). The cut-off score was determined at 50 out of 76 points, with an equal or higher result indicating a high likelihood of suffering from CSBD, although the scale is not clinically validated yet (Böthe et al., 2020).
The Sexual Sensation Seeking Scale provides 11 items describing sexual sensation seeking behavior like sexual adventurism or unprotected sex. A sample item would be “I like wild, uninhibited sexual encounters.” Respondents can answer on a four-point Likert scale ranging from 1 (“not at all like me”) to 4 (“very much like me”). Kalichman et al. (1994) reported acceptable internal consistency for the SSS scale (Cronbach's α = 0.75).
The BSL-23 measures symptoms of borderline personality disorder with 23 items rated on a five-point Likert scale from 0 (“not at all”) to 4 (“very strong”). It includes statements about the ability to feel present, rapid mood changes, feeling vulnerable or lonely, and desire to self-harm in the past week, e.g. “I was lonely” or “Criticism had a devastating effect on me”. The mean score can further be categorized into six groups ranging from no/low symptoms to an extremely high symptom load (Kleindienst, Jungkunz, & Bohus, 2020). The scale possesses high internal consistency, with Cronbach's α values ranging from 0.94 to 0.97 across various samples (Bohus et al., 2009).
Statistical analysis
Statistical analysis of demographics, discounting data and questionnaires were computed with SPSS 29. Graphpad Prism 10 was utilized to visualize the best fit hyperbolic curve of discounting data.
For a detailed account of the statistical analysis of the delay discounting data, please refer to Finkenstaedt et al. (2024). Given the skewed distributions of discounting data, CSBD-19, and BSL-23 values, non-parametric rank tests were employed for statistical comparison. The sample of participants who identified as ‚gender-diverse‘ consisted of only five people and was therefore deemed too small for meaningful comparative analyses between different gender identities. These participants were therefore excluded in the subanalyses comparing groups. The level of significance was set at 0.05. Pearson's correlation coefficient r was used to calculate the effect size for nonparametric tests (Fritz, Morris, & Richler, 2012). Cut-offs are set at 0.1 for a small, 0.3 for a medium, and 0.5 for a large effect (Cohen, 1988).
Mann-Whitney U tests were conducted to compare differences between dichotomized genders, and sign tests to compare the different conditions of the SDT. Spearman's rank correlations were used to detect relationships between the variables. Moderation analyses were conducted using regression models in which the interaction terms between BPD features and CSB, SSS and discounting data were included.
Ethics
The study was approved by the psychological ethics committee of the University Medical Center Hamburg-Eppendorf (LPEK-0089b). All participants provided informed consent, and procedures followed the Declaration of Helsinki.
Results
Figure 2 displays the best fit hyperboloid curves of delay discounting data for each partner condition by gender. Across the whole sample, participants were more likely to use immediately available protection (r = 0.39, p < 0.001; r = 0.48, p < 0.001) or delayed protection (r = 0.77, p < 0.001; r = 0.65, p < 0.001) in the partner conditions “most want sex” and “least likely STI” than in the corresponding others. The effect remained in the analyses separated by gender. Women scored higher than men in near to almost all partner conditions. However, the general likelihood of using a condom or dental dam when one is immediately available (zero-delay) was only significantly lower for men in the 'least likely STI' condition (r = 0.4, p < 0.001). The greater degree of delay discounting of protected sex (AUC) in men was significant in the 'most want sex' and 'least likely STI' categories (r = 0.35, p < 0.01; r = 0.33, p < 0.01).
Left column: Best-fit hyperboloid curves of mean likelihood of condom use plotted against delay in hours for each of the partner conditions, separated by gender. Right column: Mean likelihood of condom use plotted in equally spaced delay intervals
Notes. SEM: standard mean error. STI: sexually transmitted infection.
Citation: Journal of Behavioral Addictions 2025; 10.1556/2006.2025.00028
The mean of CSBD-19 scores was 29.70 (SD = 9.45), within a minimum of 19 and a maximum of 76 possible points. The CSBD-19 demonstrated excellent internal consistency (Cronbach's α = 0.92). Overall, 4.8% of the full study sample could be categorized having a high-risk of compulsive sexual behavior disorder according to the CSBD-19. Men scored significantly higher (M = 34.36, SD = 9.66) than women (M = 28.09, SD = 8.81, r = 0.65, p < 0.001) and presented a higher percentage of individuals in the high-risk group (7.1% vs. 4.1%).
The mean sum of the Sexual Sensation Seeking Scale results across all participants was 25.93 (SD = 6.7), with men (M = 27.91, SD = 6.9) rating higher than women (M = 25.2, SD = 6.53, r = 0.38, p = 0.001). On a scale from 11 to 44, the scores on average ranged on the middle to lower side of distribution. The SSS scale also showed strong internal consistency in the present study (Cronbach's α = 0.86).
The distribution of BSL-23 results for the full sample was strongly right-skewed with a mean score of 15.45 (SD = 15.45) on a scale ranging from 0 to 92. The BSL-23 exhibited high internal consistency (Cronbach's α = 0.95). The whole sample displayed 22 individuals (7.1%) which could be categorized into the high, very high, or extremely high symptom severity groups. Women did not exhibit significantly more borderline symptoms (M = 16.09, SD = 15.62) than men (M = 13.68, SD = 15.19, p = 0.09). The distribution of the BSL-23 groups did not differ significantly between men and women (p = 0.06).
Greater sexual delay discounting and a lower preference for condom-use were associated with higher CSBD scores as well as greater sexual sensation seeking in the full sample and in women (Table 3). Effect sizes for discounting data correlations ranged generally in the small effect dimension.
Spearman's rank correlations (rs) of full sample and dichotomized genders
| Full sample (n = 311) | Female (n = 221) | Male (n = 85) | |||||||
| 1 | 2 | 3 | 1 | 2 | 3 | 1 | 2 | 3 | |
| 1. CSBD-19 score | – | – | – | ||||||
| 2. SSS scale score | 0.53** | – | 0.58** | – | 0.31** | – | |||
| 3. BSL-23 score | 0.32** | 0.13* | – | 0.34** | 0.22** | – | 0.46** | −0.02 | – |
| Zero-delayMost want sex | −0.18** | −0.23** | −0.09 | −0.19** | −0.18** | −0.13 | −0.02 | −0.3* | −0.03 |
| Zero-delayLeast want sex | −0.17** | −0.14* | −0.13* | −0.14* | −0.15* | −0.1 | −0.19 | −0.11 | −0.23* |
| Zero-delayMost likely STI | −0.16** | −0.15** | −0.13* | −0.16* | −0.16* | −0.1 | −0.14 | −0.15 | −0.21 |
| Zero-delayLeast likely STI | −0.23** | −0.23** | −0.03 | −0.17* | −0.18** | −0.04 | −0.1 | −0.23* | −0.07 |
| AUCMost want sex | −0.28** | −0.26** | −0.04 | −0.31** | −0.25** | −0.11 | 0.01 | −0.16 | 0.04 |
| AUCLeast want sex | −0.19** | −0.17** | −0.08 | −0.18** | −0.15* | −0.09 | −0.09 | −0.11 | −0.11 |
| AUCMost likely STI | −0.18** | −0.16** | −0.06 | −0.17* | −0.15* | −0.08 | −0.08 | −0.13 | −0.07 |
| AUCLeast likely STI | −0.28** | −0.24** | −0.08 | −0.29** | −0.21** | −0.13* | −0.04 | −0.23* | −0.01 |
*. Correlation is significant at the 0.05 level (2-tailed).
**. Correlation is significant at the 0.01 level (2-tailed).
No patterns of significant associations between borderline symptoms and sexual delay discounting data could be observed in this non-clinical population.
Statistically significant positive links as calculated by Spearman's rank correlations between CSB and SSS as well as CSB and borderline symptoms could be detected in the full sample and split by gender with medium effects sizes (Table 3). However, it has to be noted that the number of male participants was insufficient to achieve a power level of 0.9.
More borderline symptoms were correlated with higher levels of SSS in the full sample (rs = 0.13, p = 0.019), and in women (rs = 0.22, p < 0.001), but not in men (rs = −0.02, p = 0.85). No effect of age could be detected on any of the constructs in the whole sample and split by gender.
Multiple regressions showed no moderating effect of borderline symptoms on CSB and SSS in sexual delay discounting or general preference for protection use. However, the regression models lacked significance and statistical power in the sub analysis of men and had a generally weak goodness-of-fit (Supplemental Tables).
Discussion
In this study utilizing a behavioral task, we found associations between higher CSB and sexual sensation seeking with greater sexual delay discounting and a lower preference for condom or dental-dam use, particularly in women.
Although BPD features did not significantly moderate the interaction of CSB and SSS with sexual delay discounting, there were significant positive correlations between CSB and BPD features across genders.
Sexual delay discounting
In the Sexual Delay Discounting Task, participants were highly likely to use an immediately available condom or dental dam, but discounted protection use as delays increased. The whole sample, as well as men and women individually, discounted safer sex more when the partner was deemed most attractive or least likely to have an STI. These results align with previous studies using the SDT observing similar trends regarding partner sensitivity (Johnson & Bruner, 2013; Quisenberry, Eddy, Patterson, Franck, & Bickel 2015; Collado et al., 2017).
Furthermore, our results indicate a small but significant relationship between greater sexual delay discounting and higher levels of both CSB and SSS, especially in women. It is important to note that, due to the limited number of male participants, valid conclusions about the effects in men cannot be drawn. The effect in the full sample likely stems from the female subsample. This may reflect the unique importance of condom use for women, given its dual role in preventing unintended pregnancies and mitigating biological vulnerability to sexually transmitted infections (STIs). In general, women have a higher biological risk of contracting STIs from men without a condom than vice versa, due to several biological factors (World Health Organization, 2013). However, it is important to recognize that individuals may vary in their understanding of and responses to these risks. The finding also suggests that the delay discounting of protected sex is partly driven by sensation seeking, an active behavior, rather than, for example, a reactive behavior due to negative coping mechanisms.
This highlights the complexity of sexual decision-making, and our findings contribute to the understanding of the mechanisms behind CSB and its relationship to sexual choices.
It should be pointed out, that impulsivity was not directly measured in this study. The SDT captures decision-making processes related to immediate versus delayed gratification, rather than impulsivity per se which is a multifaceted construct. Thus, while our results suggest an interplay between sexual delay discounting and CSB, further research should investigate other aspects of sexual or general impulsivity in relation to CSB. Numerous studies report a relationship between general impulsivity and CSB in both men and women (Antons & Brand, 2018; Kowalewska et al., 2020; Reid et al., 2011; Walton et al., 2017). A study of individuals seeking treatment for hypersexual disorder found relevant scores of trait impulsivity in men and women (Reid, Dhuffar, Parhami, & Fong, 2012). In a large Hungarian online sample using the Hypersexual Behavior Inventory (HBI), self-reported impulsivity contributed even more to hypersexuality than compulsivity in both men and women (Böthe et al., 2019).
Given the potential connection among sexual impulsivity and CSB, it would be valuable to explore whether a symptomatic or mechanistic relationship exists between these behaviors.
Sexual sensation seeking and CSB
The overall occurrence of CSBD according to the CSBD-19 was 4.8%, with 4.1% in women and 7.1% in men. These results align with larger-scale estimates ranging from 0 to 5.5% in women and 4.2–8.17% in men (Böthe et al., 2020, 2023; Briken et al., 2022). Men exhibited significantly more CSBD symptoms and SSS than women, reflecting findings from prior research on CSB and CSBD (Brenk-Franz, Weiser, Hammelstein, Brähler, & Strauß, 2021; Briken et al., 2022; Burri, 2017; Kürbitz & Briken, 2021). Men demonstrating CSB tend to be younger and report higher levels of SSS (Castro-Calvo, Gil-Llario, Giménez-García, Gil-Juliá, & Ballester-Arnal, 2020).
According to Böthe et al. (2020), gender differences may be explained by social norms especially influencing women in regard to CSBD symptoms. They often stem from traditional gender roles, which tend to stigmatize female sexual expression and promote restraint or modesty in sexual behavior (Bay-Cheng, Bruns, & Maguin, 2018; Lefkowitz, Shearer, Gillen, & Espinosa-Hernandez, 2014). The same might be the case for sexual sensation seeking within men, as they are often socialized to have a more active and adventurous sex life (Baumeister, Catanese, & Vohs, 2001; Baranowski & Hecht, 2015). Such gendered expectations can shape attitudes toward CSB and sexual sensation seeking, reinforcing disparities.
Medium to large positive effects were found for the relationship between CSBD symptoms and SSS across genders. This resonates with previous research identifying a connection between CSB and SSS: Individuals with CSB in a study of two independent community samples were more likely to express SSS and a positive attitude towards sexuality (Castro-Calvo et al., 2020). In an online study in men and women, SSS was correlated with greater sexual compulsivity, and with higher levels of sexual functioning in women (Burri, 2017). Klein, Rettenberger, and Briken (2014) found a link between SSS and hypersexual behavior in a female online-sample. A survey of 1,749 participants identified fun-seeking traits and extraversion, alongside sexual excitation, as significant predictors of CSB (Rettenberger, Klein, & Briken, 2016).
Collectively, these studies suggest that an aspect of excitement-seeking, as indicated by sexual sensation seeking, may play a role in CSB.
Sensation seeking and impulsive sexual behavior are associated with engaging in risky sexual behaviors such as unprotected sex and promiscuity, which are also features of certain presentations of CSB (Crawford et al., 2003; Lemley et al., 2018; Sweeney et al., 2020; Voisin et al., 2013; Walton et al., 2017). It is important to consider these tendencies in individuals seeking treatment for CSBD. For example, therapists could work with their patients to find ways of satisfying their sexual sensation seeking without exposing themselves to sexual risks. This may include the development of non-penetrative sensual and physical techniques. However, for some individuals, the appeal of risky sexual behavior may stem precisely from the fact that it is perceived as “forbidden” or “dangerous.” Reflecting on these motivations could be beneficial, as it may help individuals make more conscious and informed decisions about their sexual behaviors.
CSB and borderline personality disorder
Lastly, this study did not find a significant moderating effect of BPD features on the relationship between sexual delay discounting, the general likelihood to use protection, and CSB and sexual sensation seeking. Additionally, no correlation was found between BPD symptoms and the discounting of protected sex.
Apart from sexual delay discounting, BPD features were independently associated with higher levels of CSBD symptoms in both men and women. They were also positively correlated with increased levels of SSS in women. This suggests that while BPD features in healthy individuals may not change the relationship between the delay discounting of protected sex and CSB and SSS, they are linked to more pronounced expressions of these behaviors.
This finding resonates with previous research linking BPD features and CSB in women (Elmquist, Shorey, Anderson, & Stuart, 2016; Finkenstaedt et al., 2024; Jardin et al., 2017). Both CSB and BPD are characterized by difficulties with impulse control and emotion regulation. They are associated with sexual risk behaviors like changing sexual partners or unprotected sex and distress related to sexual behavior (Harned, Pantalone, Ward-Ciesielski, Lynch, & Linehan, 2011; Lloyd, Raymond, Miner, & Coleman, 2007; Miner & Coleman, 2013; Sansone & Sansone, 2011; Sansone & Wiederman, 2009). These behaviors may originate as maladaptive coping mechanisms in response to negative emotions or stress, common aspects in CSB/CSBD and BPD (Briken, 2020; Qian, Townsend, Tan, & Grenyer, 2022; Reid, Carpenter, Spackman, & Willes, 2008; Schultz, Hook, Davis, Penberthy, & Reid, 2014).
Strengths and limitations
Strengths of this study include its contribution to the research on mechanisms of CSBD symptoms aligned with ICD-11 criteria and its focus on women, a previously underrepresented demographic (Grubbs et al., 2020; Kafka, 2010). However, several limitations should be noted. The high proportion of female and highly educated participants limits generalizability of results, particularly for men and gender-diverse individuals. The survey was not specifically addressed to women. This result could be partially explained by the advertisement of the survey as a “survey on sexuality and emotions”. This wording might appeal more to women than to men. This could also be explained by the general observation, that women are more likely to participate in surveys (Becker, 2022). Further studies are warranted, that include more balanced gender representations.
Moreover, as the study was advertised as a survey about sexuality and emotions, individuals with higher levels of sexual interest might be overrepresented. We aimed to minimize this effect by disseminating the study across a wide range of groups and platforms, intentionally avoiding those dedicated to specific topics such as sexuality. As actual diagnoses can only be achieved through clinical interviews, self-report questionnaires lack diagnostic precision. Results can be susceptible to social desirability bias, particularly on sensitive topics like sexual activities. Indirect questioning could reduce this bias. For a detailed discussion on the limitations related to the SDT, please refer to Finkenstaedt et al. (2024). The correlational research cannot determine the causality between sexual risk behavior, sexual sensation seeking, CSBD symptoms, and BPD. Future research should use diverse, representative samples and multiple assessment methods for a more nuanced understanding of CSBD and its correlates, allowing for interventions that are better tailored to all genders.
Future directions
Walton et al. (2017) described multiple predispositions toward CSBD, suggesting a heterogeneous presentation of the disorder. Gender disparities may also fit into this observation. This study, while not generalizable to the broader population, offers insights into how CSBD symptoms might present among women.
Currently, diagnostic criteria for CSBD do not address differences between genders. Further investigations should examine the role of impulsive sexual behavior and sensation seeking in CSBD, especially among women. Despite increasing recognition of gender differences, the existing literature remains inconclusive. While recent studies using convenience samples have included more women, clinical sample studies continue to focus on men (Kürbitz & Briken, 2021). Addressing these gaps is essential for accurately understanding and treating CSBD across genders.
Conclusion
The present study's findings reveal that higher levels of delay discounting of protected sex and lower preference for safer sex measures are associated with compulsive sexual behavior and sexual sensation seeking, especially among women. These findings align with prior research on sexual decision-making and risk-taking behaviors. Given the link between these concepts and sexual risk behavior, it is crucial, on the one hand, to focus on risky sexual behavior in the assessment of patients presenting with CSBD, on the other hand, to gain a better understanding of sexual sensation seeking in women and explore how this concept can be integrated into therapy.
Our study contributes to the growing body of research on CSBD, shedding light on its occurrence and manifestation. Further research is needed to elucidate the underlying mechanisms in order to develop targeted assessments and therapeutic interventions, potentially taking gender differences in CSBD into account.
Funding sources
This study received no external funding.
Authors' contribution
J.F. conceptualized the study. M.F. conducted the data collection. M.F. performed data analyses and wrote the original draft. D.B. assisted in data processing. J.F. and S.B. provided critical revisions and intellectual input. All authors have read and agreed to the published version of the manuscript. All authors had full access to all data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Conflict of interest
The authors declare no conflicts of interest.
Supplementary material
Supplementary data to this article can be found online at https://doi.org/10.1556/2006.2025.00028.
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