Etiology and Terminology

We mentioned earlier that at the opposite end of the sexual desire continuum from hypoactive sexual desire is a very small minority of individuals who have extremely high levels of sexual desire. Most such individuals adapt to their high levels of sexual desire, can exert a high degree of control over their sexual needs, and derive satisfaction from orgasmic experience. There are other individuals, however, who are preoccupied with sexual feelings and thoughts; they are insatiable, often respond to a variety of erotic stimuli, and continually seek sexual activity. Their behavior may involve unconventional sexual activity, such as paraphilias, or criminal activities, including rape. However, in our experience, it is mainly conventional sexual practices (i.e., masturbation and intercourse), undertaken with high frequency and without consideration of the consequences, that characterize such hypersexual individuals.

Controversy centers on the terminology and conceptualization of hypersexuality. The terms “nymphomania” and “satyriasis” were frequently and are now sometimes used to describe excessive and insatiable sexual impulses in women and men, respectively. While there can be no doubt that some people who indulge in high-frequency sexual activity are driven to such behavior by excessively high sexual drive, this is not always the case. Excessive sexual behavior may originate from processes - such as a relatively unusual psychological response to particular patterns of life circumstances - unrelated to biological sexual drive. Hence, hypersexuality better describes excessive sexual behavior than excessive sexual drive. On this basis, hypersexuality has been variously conceptualized as a behavior addictive disorder (sexual addiction), a dependence syndrome (sexual dependence), a compulsive disorder (sexual compulsiveness), and an atypical impulse-control disorder (sexual impulsivity). In discussing the strengths and weaknesses of these various conceptualizations of hypersexuality, Rinehart and McCabe pointed out that there is considerable overlap in the descriptive criteria of each label. They concluded that there is no consensus in the literature about what constitutes hypersexuality. DSM-IV does not recognize the problem of hyperactive sexual desire as sufficiently distinct in nature from paraphilia, mania, and personality disorder to warrant a separate diagnostic category.

If hypersexuality refers to excessive sexual desire or behavior, the major questions are 1) what constitutes “excessive”? and 2) can “excessive” sexual behavior be considered pathological? Although some authors have defined excessive sexual behavior in terms of weekly number of orgasms experienced (e.g., more than 21), there is no generally accepted definition as to what constitutes excessive, or even normal, levels of sexual behavior. Indeed, M. P. Levine and Troiden pointed out that what may appear excessive in one society may be normal in another. They argued against pathologizing sexual practices, including hypersexuality, that do not follow the majority norms of society, an argument that the present authors endorse, except when the sexual behavior in question leads to personal or interpersonal distress or causes physical or psychological trauma to the person or others.

Perhaps the most helpful diagnostic criterion of hypersexuality is that the (excessive) sexual behavior disrupts the person’s life or causes interpersonal distress. For example, we described the case of a 22-year-old secretary who lost her job because she experienced, during the premenstrual phase of her cycle, such a frequent and intense need for orgasm that she absented herself from her workstation up to 12 times a day to go to the washroom to masturbate. She would also masturbate in her car on her way to and from work. The hypersexuality was confined to the 3 or 4 days preceding the onset of her menstrual period. Suppression of menstruation for 6 months solved the problem, and at follow-up 2 years later, there had been no relapse.