Spotlight on Compulsive Sexual Behavior Disorder: A Systematic Review of Research on Women.

PURPOSE OF REVIEW: World Health Organization recently included compulsive sexual behavior disorder (CSBD) to the upcoming 11th edition of International Classification of Diseases (6C72). Despite the potential benefits of this decision (eg, the acceleration of research in the field will allow the development of effective treatments), previous research focused mainly on men, and as a result, we do not have an accurate clinical picture of compulsive sexual behavior (CSB) among women. Therefore, in this systematic review, we aim to present available knowledge on this topical subject. Literature search was conducted in the guideline of PRISMA methodology. Studies were identified from multiple databases including Academic Search Ultimate, SocINDEX, PsycARTICLES, PsycINFO, PubMed, and MEDLINE. Out of a total of 10,531 articles identified and screened, 58 were included in this review. Included studies covered the following topics: prevalence and etiology of CSB, behavioral and cognitive processes involved, comorbidities, personality traits, psychosocial and interpersonal difficulties, traumatic experiences, and treatments. RECENT
FINDINGS: Available studies indicate that CSB symptom severity is lower in women than in men. Overall, women reported consuming pornography less often than men and exhibit lower rates of feeling urges to these materials. CSB symptoms (including problematic pornography use) have been found to be positively related to trait psychopathy, impulsivity, sensation seeking, attention-deficit/hyperactivity disorder symptoms, obsessive-compulsive disorder, pathological buying, sexual dysfunctions, general psychopathology, child sexual abuse, while negatively related to dispositional mindfulness.
SUMMARY: Conclusions that can be drawn from prior studies are considerably limited. There are no accurate estimates of the CSB prevalence or severity among women, and studies have been mostly conducted on non-clinical populations, which has limited application for women diagnosed with CSBD.

Introduction

Compulsive sexual behavior (CSB) such as excessive pornography use and masturbation, uncontrolled use of paid sexual services, and impulsive/compulsive engagement in risky sexual contacts, is an emerging topic in science and psychiatry.1 Research within the last decade has provided data showing some similarities of neuronal mechanisms underlying CSB (in men), and substance and behavioral addiction,2–9 proposed therapeutic interventions10–13 and conceptualization,14–18 what resulted with the inclusion of compulsive sexual behavior disorder (CSBD) in the 11th edition of the International Classification of Diseases (6C72).19 According to ICD-11, CSBD is characterized by a persistent pattern of failure to control intense, sexual impulses or urges, resulting in repetitive sexual behavior over an extended period (eg, 6 months or more) that induces marked distress or impairment in personal, family, social, educational, occupational, or other important areas of functioning.15 Human sexuality is a complex phenomenon, containing biological, psychological, social, and cultural components. It encompasses various aspects of our being, such as attitudes and behaviors toward our sexual health as well as values, feelings, and experiences. Men and women differ in many aspects of their sexuality – such as sexual reactivity20–22 and preferences.23,24 For example, gender differences (both intergroup and intragroup) are visible in the context of the sexual response cycle. The classic linear model of four consecutive stages (excitation, plateau, orgasm, resolution)25 better describes the male sexual response cycle, while a greater variability of the female sexual response led researchers to the introduction of a different circular model.26,27 Due to these peculiarities in the male/female sexual response cycle, one can also expect gender differences in the CSBD-related features.

Despite the body of research regarding CSB on men, there are little data on these behaviors among women. The focus on men was based on the agreement among researchers that CSB is substantially more frequent among men than women.28–30 According to available statistics, CSB affects from 3% to 6% of people in the United States.31–34 The precise prevalence estimates of CSB for women remain uncertain, but available studies thus far including both women and men report a proportion of 8% to 40% female.29 The wide discrepancy in prevalence rates of CSB in women likely reflects the use of imprecise measurement instruments. Perhaps the best estimation of CSB among women comes from the DSM-5 field trial (which is controversial due to the lack of evidence of its conduct35). Researchers found that 5.3% of total samples of specialized outpatient clinics patients who seek treatment for CSB were women.36 Most recent data on pornography use collected on representative samples in the United States of America (USA)14 and Poland37 show that approximately 11% of adult men and 3% of women consider themselves to some extent “addicted to pornography”.

Previous research indicates that among men the dominant clinical presentation of CSB is problematic pornography use usually coupled with masturbation.28,36,38,39 Given the paucity of science, we do not have an accurate clinical picture of what CSB looks like in women. This systematic review aims to summarize the current state of knowledge about CSB among women and to critically analyze the strengths and weaknesses of the current research findings. Further, through this process, we will accomplish three goals: 1.) identify key differences in clinical picture of CSB between men and women, 2.) formulate practical implications (eg, for diagnosis, therapy, prevention) for clinical work with women, and 3.) generate directions for future research. For the present work, we use Compulsive Sexual Behavior (or CSB) to refer to out-of-control or dysregulated sexual behavior patterns, despite past literature’s use of such terms as sexual addiction, compulsive sexual behavior, hypersexuality, and similar terms. The research described later in this review comes from the period before CSBD criteria were established, and the term CSB in this review refers to symptoms (often understood according to various conceptualizations – sex addiction, sexual compulsivity, etc.) rather than a clinical diagnosis consistent with the operationalized criteria.

Methodology

Search Strategy

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.40 To identify studies examining CSB among women we searched for articles using multiple databases including Academic Search Ultimate, SocINDEX, PsycARTICLES, PsycINFO, PubMed, and MEDLINE. Our search included the following terms: (compulsive sexual behavior* OR hypersexual* OR pornography OR porn OR sexually explicit materials OR compulsive masturbation OR excessive masturbation OR masturbation) AND (women OR woman OR females OR female). The electronic databases were searched for titles or abstracts containing these keywords in published articles between January 1, 2015, and December 31, 2019.

Inclusion Criteria

We excluded articles if they: (1) were not published in the past 5 years, (2) were not scientifically peer-reviewed, (3) were not published in English, (4) did not present empirical data, (5) were not collected from humans, (6) did not assess compulsive sexual behaviors, and (7) did not present separate results on females. Of 10,531 articles found, 58 papers were included in the final review. Details concerning the method of literature search are shown in Figure 1.

Figure 1

Literature review process.

Results

Outcomes of Interest

The analysis of selected articles indicated several themes that were explored by the researchers in their studies on CSB in women. These themes included prevalence and concept of CSB, behavioral and cognitive processes involved, comorbidities, personality traits, psychosocial and interpersonal difficulties, traumatic experiences, and treatments.

Prevalence and Concept of CSB

Although no large epidemiological studies on CSB in women have been performed yet, some research suggests that part of the female population experience problems related to CSB.14,41-63 However, none of these studies verified how many of them met CSBD diagnostic criteria.

In a cross-sectional study conducted by Baranowski and colleagues,41 3% of a sample of German women aged 18–77 years reported problematic pornography use (PPU; considered by them as a loss of control over the time spent on pornography and feeling craving for these materials), which was further associated with the amount of time spent viewing pornography, and also greater sexual motivation and emotional avoidance. Another cross-sectional study by Rissel and colleagues with 10,131 Australian women aged 16 to 69 years showed that 41% of participants reported watching pornographic material in the past year, and 1% of them self-identified as “addicted to pornography” based on subjective feeling.42 These results are comparable to Grubbs and colleagues’14 investigation conducted on a cross-sectional US nationally representative sample of 1059 women and 1016 men, showing that 3% of women and 11% of men reported some agreement with the statement “I am addicted to pornography”, and 1% of women and 3% of men agreed with this statement strongly. Results of a study of Daspe and colleagues involving 1036 Canadian participants (565 women) aged 18–55 demonstrated a positive relationship between the frequency of pornography use and perceived lack of control for women and men.43

A French cross-sectional study of Blais-Lecours and colleagues, conducted on a community sample of 597 women and 235 men aged 18–78 years, revealed that 51% of women and 90.2% of men declared consuming cyberpornography.44 Moreover, using The Cyber-Pornography Use Inventory (CPUI),64 authors found that women (as compared to men) reported less pornography time use, perceived compulsivity to pornography, sexual compulsivity, and efforts to access cyberpornography. According to the results of Weinstein and colleagues'45 investigation conducted on a group of 192 Israeli men and 75 women, women exhibited lower rates of feeling urges to pornography and frequency of cybersex compared to men.

A study of Harper and Hodgins involving Canadian university students (105 women and 86 men) showed less frequent pornography use and later age of pornography exposure among women (as compared to men).46 Also, women were less likely to self-identify as addicted to pornography and obtained lower scores on the CPUI64 as well as the internet pornography addiction criterion questions (IP-CRIT), which have been adapted by researchers from DSM-5 preliminary set of criteria for diagnosing Internet Gaming Disorder.65

A North American cross-sectional study of Vaillancourt-Morel and colleagues47 assessing dimensions of cyberpornography indicated three distinct profiles of users – recreational, highly distressed but non-compulsive, and compulsive. The recreational profile, which consisted of a larger proportion of women (486 of 596 women aged 18–78 years) and dyadic users who spent a moderate amount of time viewing pornography, reported lower levels on three dimensions of PPU – compulsivity, efforts to access pornography and emotional distress associated with its consumption. Moreover, results taken from a Ballester-Arnal and colleagues’ cross-sectional study48 conducted on a sample of 1557 Spanish college students between 18 and 25 years of age found that 96.9% of total female sample were recreational users and only 1.7% - risky users (spending between 1 and 10 h on cybersex).66

In addition to research focusing solely on PPU, some studies have been found on CSB more broadly. Dickenson and colleagues’ results of the population-based American National Survey of Sexual Health and Behavior49 involving 1174 women and 1150 men aged 18–50 years revealed that 7% of women and 10.3% of men scored 35 or higher in Compulsive Sexual Behavior Inventory,67 which indicates a high probability of meeting diagnostic criteria of CSBD.19

In an Australian study of Walton, Cantor, and Lykins50 using Hypersexual Behavior Inventory (HBI-19),68 31 women (18.4% of total sample) and 63 men exhibited clinically significant hypersexual behavior based on Reid and colleagues’ suggested cut-off score (≥53), and results of a cross-sectional study of Kraus and colleagues51 conducted on a sample of 820 post-deployed US military veterans revealed that fewer women (4.3%) than men (13.8%) demonstrated symptoms related to CSB.

Engel and colleagues’ cross-sectional study52 examining individual characteristics and signs of coercive sexual behavior conducted on a large German-speaking population of 564 women and 630 men showed that women levels of CSB symptom severity (measured accordingly to criteria of hypersexual disorder [HD] proposed by Kafka in 201028), pornography use, masturbation, and engaging in partnered sex were lower among women than men. 13.1% of women and 45.4% of men obtained scores indicating a high level of CSB symptoms severity as assessed by HBI-19 questionnaire.68 Furthermore, 18% of women (compared to 59% of men) reported fantasies of sexual coercion, and 4% of women (compared to 20% of men) declared behaviors involving sexual coercion toward others, which turned out to be associated with CSB symptoms. Importantly, the connection of total sexual outlet as well as pornography consumption was more strongly related to the level of CSB symptom severity in women than in men. The authors also found that 61% of women from the examined sample reported at least moderate symptoms of depression (assessed by Patient Health Questionnaire),69 and that depressive symptoms were positively associated with levels of CSB symptom severity (as measured by HBI-19)68 among women and men.

Lower prevalence of CSB symptoms among women than men was also found in a Bőthe and colleagues’ cross-sectional study53 on a large, diverse, non-clinical sample of 6132 women and 11,902 men using HBI-1968 questionnaire. Gender and Sexual Orientation-Based Comparisons showed that LGBTQ (lesbian, gay, bisexual, transgender, and queer) men scored the highest on each HBI-19 subscale,68 while heterosexual women scored the lowest. Moreover, LGBTQ men had the highest outcomes on other indicators of CSB, such as frequency of masturbation, number of sexual partners, or frequency of pornography use. In turn, LGBTQ women had the highest scores on the subscale related to coping with unwanted feelings and stress. Similar results have been shown in a study of Tripodi and colleagues conducted on two non-clinical Italian and Swedish samples consisting of 433 women and 414 men aged 20–30 years.54 Women spent less time on online sexual activities (including pornography viewing) as well as scored lower on instruments measuring problematic cybersex behavior (Internet Sex Screening Test)70 and sexual compulsivity (Sexual Addiction Screening Test-Abbreviated).70

Results from a study by Mulhauser, Short, and Weindtock55 conducted on a group of 134 women and 235 men above the age of 18 from the US general population showed gender differences in scores obtained on measures of CSB, such as HBI-19,68 Pornography Consumption Inventory (PCI),71 CPUI,64 and Problematic Pornography Use Scale (PPUS),72 with women scoring significantly lower than men.

Among 216 addicted (to alcohol, drugs, gambling, or sex) participants from a study of Zilberman and colleagues56 carried out on Israeli sample, 57 men and 4 women exhibited high levels of CSB symptom severity, as assessed by the Individual-Based Compulsive Sexual Behavior Scale (I-CSB).73 Lower scores among women (as compared to men) on the I-CSB73 were also observed in a study by Efrati on a group of 310 high school Israeli adolescents (127 teen girls) aged 16–18.57

Some research that has been found during the selection process focused on the concept of CSB. Werner and colleagues’ study58 on a Croatian sample of 1786 women and 1242 men aged 18–60 years, testing the concept of CSB from a perspective of network analytic approach to psychopathology74 assuming that CSB symptoms and related behaviors are represented as inter-connected nodes, revealed similar structure for women and men. For both women and men, the central positions in the networks were occupied by psychological distress and sexuality-related negative emotions (eg, depression, anxiety, shame), along with a loss of control over sexual feelings (eg, pleasure, desire). Interestingly, pornography use was positioned peripherally regardless of gender, but in women, the relationship between pornography use and shame was present.

Additionally, another two studies sought to answer a question of whether CSB may be best represented dimensionally or categorically, determined the latent structure of a construct using taxometric methods. Analyses of Graham and colleagues’ study was performed on a group of 1112 US individuals (53.6% women), while a study of Kingston and colleagues involved 915 Canadian individuals (671 women). Results from both studies were indicative of the dimensionality of CBS in the case of women.59,60

Carvalho and colleagues,61 in a study exploring the overlap between problematic sexuality and high sexual desire, conducted on a Croatian non-clinical sample of 4597 men and women aged 18–60 years (age over 18 was the only inclusion criterion), extracted two clusters. Cluster one, named “control/consequences cluster”, represents a lack of control over one’s sexuality and negative outcomes, while the other cluster, named “desire/activity cluster”, reflects the high sexual desire and frequent sexual activity. Authors found that women included in the “control/consequences cluster” showed a higher level of depression and neuroticism, and they reported more often co-existing the consequences of substance abuse (such as feeling guilty, neglecting of duties, forgetfulness of facts that happened under the influence) than women in “desire/activity cluster”. In turn, Štulhofer and colleagues62 examining a combination of CSB (according to HD criteria)28 and high sexual desire on a group of 2599 Croatian women aged 18–60, found that 178 women from the studied sample were classified in the high sexual desire group, 239 women – in the hypersexuality group, and 57 women met criteria for both groups. Furthermore, high sexual desire and high sexual desire and hypersexuality groups reported more negative consequences related to their sexuality.

Gender differences were also found in studies of Efrati and Gola63 on a sample of 1800 Israeli adolescents (841 teen boys and 959 teen girls aged 14–18 years). The authors, using a latent profile analysis, revealed three clusters of CSB: abstainers, sexual fantasizers, and individuals with CSB (based on criteria of HD).28 Teen girls were more likely included in a group of abstaining adolescents, characterized by low scores in all subscales of the I-CSB,73 such as sexual fantasies, obsessive sexual thoughts, and spending more time watching pornography.

Behavioral and Cognitive Processes

Our search also revealed three articles describing attentional biases to sex-related stimuli,75–77 which are understood as unconscious processes that lead individuals to focus and sustain attention on addiction-relevant cues in their naturalistic environment.78,79 According to incentive sensitization theory by Robinson and Berridge,80 addicted individuals exhibit fast shifts of attention to stimuli related to their addiction (eg, alcohol), because of the cue’s incentive salience.

Pekal and colleagues75 conducted a study on a group of 174 participants aged 18–52 years (87 females) to investigate the role of attentional biases in the development of excessive and addictive usage patterns of internet pornography. Tendencies toward uncontrolled use of internet pornography were assessed by the Short-Internet Addiction Test adapted to online sexual activities (s-IATsex),81 while attentional bias was measured using the Visual Probe Task.82 Women (as compared with men) had lower mean scores in s-IATsex and – based on cut-off scores – the sample consists of two problematic female users. In addition, women exhibited lower attentional biases toward sexual cues compared to men. The results of this investigation also revealed a relationship between attentional bias and symptom severity of the addictive use of pornography. Although women and men differ in reaction times to pornographic stimuli, the analysis showed that attentional biases occur independently of sex within the framework of excessive pornography use symptoms.

An Albery and colleagues’ study76 using a modified Stroop task did not show gender differences in attentional biases for sex-related words among 55 sexually active individuals (28 male and 27 female aged 20–69). Regardless of gender, among participants with a higher level of sexual compulsivity assessed by the Sexual Compulsivity Scale (SCS),83 greater attentional bias was linked with lower levels of sexual experience. In turn, among those with a low level of sexual compulsivity, levels of sexual experience did not differentiate the levels of attentional bias. These findings indicated that attentional preference for concern-related stimuli might be dependent on the interaction between time to remain sexually active and the level of sexual compulsivity.

The third study, conducted on a group of 47 women and 48 men by Stark and colleagues,77 demonstrated that symptoms of internet PPU (assessed by s-IATsex)81 and daily time spent on watching these materials were less pronounced in women than in men. In addition, they found a linear relationship between the approach-avoidance score towards pornography (measured by Approach-Avoidance Task) and internet PPU among women and men, which indicated that participants characterized by greater problems while adjusting for the internet pornography consumption was associated with only approach biases for pornography.

Comorbidity and Predisposing Factors

Identified studies were focused on the relationship between CSB and substance-use disorders,84–88 compulsive buying disorder or compulsive buying behavior,89–91 ADHD,92 obsessive-compulsive disorder,93 Parkinson’s disease,94 borderline personality disorder,95 and autism spectrum disorder.96

Brem and colleagues84–86 in the three articles described their studies conducted on groups of adults in residential treatment for substance-use disorders (SUDs). In the first study, the authors examined dispositional mindfulness as a potential protective factor for CSB on a group of 446 women (at least 18 years old) diagnosed with one or more SUDs.84 Dispositional mindfulness is defined as a tendency to have open and receptive awareness and attention towards present moment experiences.97 The results of this investigation showed a negative relationship between dispositional mindfulness and CSB among women with SUDs. After adding dispositional mindfulness as a predictor, alcohol problems (not drug problems) proved to be a significant predictor of CSB among women. Furthermore, 53.2% of women reported at least one concern with CSB, gaining 1 point out of 20 on the Sexual Addiction Screening Test-Revised (SAST-R),98 and 12.6% of a sample scored six or higher on the SAST-R, thus being within the at-risk range of CSB. Results of the second investigation85 carried out on 446 women in residential treatment for SUDs showed a positive relationship between CSB symptoms and defectiveness/shame, PTSD symptoms, and alcohol/drug use and problems. Furthermore, experiential avoidance defined as a tendency to avoid, escape, or change one’s experience of aversive internal events (eg, thoughts, feelings),99 was positively related to CSB symptoms, PTSD symptoms, defectiveness/shame, and drug use and problems. Finally, the relationship between PTSD symptoms, defectiveness/shame, and CSB symptoms may be partially explained by experiential avoidance. In the third study,86 Brem and colleagues using the same methods examined gender differences in the relationship between CSB and dispositional mindfulness on a large group of 1993 adults (22.4% female) in residential treatment for SUDs. For women with SUDs, results revealed negative relationships between CSB indicators (assessed by SAST-R)98 and two dimensions of dispositional mindfulness – acting with awareness and non-judging of inner experience. Moreover, two SAST-R subscales – affect disturbance and preoccupation – have been found to be negatively associated with alcohol use and problems, but positively associated with drug use and problems. In addition, three SAST-R dimensions – internet problems, preoccupation, and relationship disturbance – were positively related to depression symptoms among women.

Another set of studies on a group of women and men admitted to a 12-step-based private, residential treatment program for SUDs have been conducted by Elmquist and colleagues.87,88 The first one,87 which involved 120 women, showed that after adjusting for alcohol/drug use and problems, age, and positive impression management, CSB symptoms were positively associated with borderline personality symptoms. The second study,88 conducted on a sample of 198 men and 62 women, revealed that five early maladaptive schemas domains (disconnection and rejection, impaired autonomy and performance, other-directedness, impaired limits, over vigilance and inhibition) assessed by the Young Schema Questionnaire – Long Form, Third Edition (YSQ-L3)100 were positively associated with CSB symptoms assessed by SAST-R98 in a group of individuals with SUDs. No gender differences were found between CSB and non-CSB groups.

Using a Brazilian sample, de Mattos, Kim, and Requião examined psychiatric co-morbidities in compulsive buying disorder (CBD) on a group of 151 women and 20 men with CBD and found that women were less likely to be diagnosed with sexual addiction.89 However, it is worth emphasizing that drawing strong conclusions about gender in the context of co-occurrence of CBD and CSB on such a small sample of men is unwise. Müller and colleagues90 examined the risk for exercise dependence, eating disorder pathology, and other addictive behaviors among 128 fitness centers clients (28.3% females). The authors found a positive relationship between CSB symptoms (assessed by HBI-19)68 and symptoms of pathological buying (assessed by Compulsive Buying Scale)101 in both women and men. In addition, women exhibited fewer symptoms of CSB as compared to men. Finally, an investigation of Granero and colleagues91 focused on compulsive buying behavior (CBB) and CBD comorbidity involved a sample of 3324 patients divided into five groups according to their diagnosis: CBB (n=110; 71.8% females), sexual addiction (n=28; 3.6% females), internet gaming disorder (n=51; 5.9% females), internet addiction (n=41; 26% females), and gambling disorder (n=3094; 10.1% females). Overall, they found that the combination of impulsive/compulsive symptoms was particularly visible in patients with CBB and sexual addiction.

To identify possible similarities and differences in the relationship between ADHD and CSB (according to HD criteria)28 and PPU, Bőthe and colleagues92 conducted a study on a large, non-clinical sample of 4237 women and 9806 men. Among women, CSB was found to be positively associated with PPU and ADHD symptoms, while PPU was weakly associated with ADHD symptoms. As interpreted by the authors, results suggest that among women ADHD symptoms would lead to CSB rather than to PPU.

Fuss and colleagues93 examined the association between CSB and obsessive-compulsive symptoms on a sample of 279 women and 260 men aged 18–75 years. Fuss and colleagues found that in patients with current OCD a lifetime prevalence of CSBD was 5.6%, and significantly lower in women than men. In turn, El Otmani and colleagues94 conducted a study on 125 patients diagnosed with Parkinson’s disease to determine the prevalence of current impulse control disorders (ICDs) among this group. Results of an analysis using Questionnaire for Impulsive-Compulsive Disorders in Parkinson’s Disease Rating Scale102 identified ICDs in 28% of patients (15 women and 20 men), of which 2 women and 8 men reported CSB symptoms.

Another study by Jardin and colleagues,95 conducted on a group of 1326 female college students showed that sexual compulsivity (as assessed by HBI-19)68 may mediate the influence of borderline personality disorder features on a number of sexual partners, suggesting that women suffer from BPD may be more susceptible to the development of CSB symptoms. Lastly, a study of Schöttle and colleagues96 revealed that patients with autism spectrum disorder (90 patients with Asperger syndrome and 6 with atypical autism) reported CSB (as assessed by HBI-19)68 more frequently than those without autism spectrum disorder. However, these differences occurred only in male patients, and not among female patients.

Personality Traits

The contribution of personality factors to ratings of CSB symptoms was examined in 10 studies.77,103-110

In a study of Shimoni and colleagues,103 81 women and 186 men were recruited via internet sites used for finding sexual partners. Results of this investigation showed that women (as compared to men) obtained lower scores on Sexual Addiction Screening Test (SAST),111 they were less open to experiences and more neurotic (as assessed by the Big Five Index).112 Interestingly, higher neuroticism was related to higher scores on the SAST but only in men.

In the case of trait impulsiveness and compulsiveness, Bőthe and colleagues104 investigated its relation to PPU and CSB symptoms on a large community sample of 13,778 individuals (4151 females). Regardless of gender, PPU was weakly associated with impulsivity and compulsivity. Additionally, impulsivity was more strongly related to CSB than compulsivity. Analysis of the female sample model revealed that both traits were positively but weakly related to PPU, compulsivity was positively and weakly associated with CSB, and impulsivity was positively and moderately associated with CSB. Rømer and colleagues105 using regression analyses assessed the relationship between impulsivity traits and indicators of addiction-related behaviors on a group of 109 individuals aged 16–26 years (31% females) from a Danish nationally representative survey. It has been found that after adjusting for gender, age and education, lack of perseverance – the UPPS-P Questionnaire113 factor – was associated with PPU; however, women had significantly lower scores on the Pornography Craving Questionnaire (PCQ)114 compared to men. Finally, a study of Carvalho and colleagues106 conducted on a non-clinical sample of 235 female college students showed that motor/planning impulsiveness (assessed by the Barratt Impulsiveness Scale),115 negative affect (assessed by the positive and negative affect schedule; PANAS),116 and psychoticism (assessed by the Brief Symptom Inventory)117 significantly predicted sexual compulsivity in women. It is worth emphasizing that only 2.5% of women from this sample presented clinically relevant levels of sexual compulsivity as assessed on the SCS.83

Two studies by Sindermann and colleagues107 examined an association between specific forms of internet-use disorder and “the dark triad of personality” (measured by the Short Dark Triad Questionnaire)118 on a group of 940 individuals (667 females). Results indicated that among women (but not among men), trait psychopathy was significantly positively correlated with tendencies toward problematic internet-pornography use (measured by s-IATsex).81

Another factor raised in scientific research on CSB was sexual sensation seeking.108,109 Burri108 examined an association between sexual sensation seeking (measured by Sexual Sensation Seeking Scale),119,120 sexual compulsivity (measured by SCS)83 and gender identity, and sexual functioning (in female sample measured by the Female Sexual Function Index),121 on a population sample of 193 women and 86 men. Burri found that sexual sensation seeking was positively correlated with sexual compulsivity in women and men. Moreover, higher levels of sexual sensation seeking were related to higher levels of desire, arousal, lubrication, and orgasm and lower sexual pain among women. In turn, Chen and colleagues109 carried out a study on a group of 808 Chinese college students aged 17–22 years (42.3% female) to test a model that sexual sensation seeking may impact PPU through online sexual activities, and that this relationship may be further influenced by the third-person effect (understood as a tendency to overestimate the influence that media has on the attitudes and behaviors of others while underestimating its impact on oneself122). In addition to the results showing that women scored lower on measures of online sexual activities and PPU, authors also found that this moderated mediation model accounted for a lower variance among women than men.

Stark and colleagues’ investigation,77 aforementioned in the Behavioral and cognitive processes section, further demonstrated that greater trait sexual motivation, defined as a general motivation to be sexually active in a long-lasting perspective, was related to higher problematic internet sexually explicit material use, which may indicate that this trait is a vulnerability factor for CSB. In turn, a study of Carvalho and Nobre93 conducted on a group of 260 female college students demonstrated that sexually aggressive women presented significantly higher levels of sexual compulsivity (assessed by SCS).83

Psychosocial and Interpersonal Difficulties

Some research, including those described in the previous sections, assessed the relationship between CSB and general psychopathology and sexual functioning,123 sexual satisfaction,43 sexting behaviors,124 forming intimate relationship,45 attachment,125 sexual orientation,125 and sexual excitation/inhibition.126

The results of an Italian study by Castellini and colleagues,123 conducted on a non-clinical sample of 532 women and 243 men showed that sexual dysfunctions (in women assessed by the Female Sexual Function Index),121 as well as general psychopathology (assessed by The Symptom Checklist [SCL]-90-Revised),127 were associated with CSB symptom severity (assessed by Hypersexual Disorder Screening Inventory)128 in both women and men.

In the case of sexual satisfaction, Daspe and colleagues43 found that gender, length of the relationship, and parenthood did not moderate the interaction between frequency of pornography use and relationship and sexual satisfaction in the prediction of perceived lack of control over pornography viewing.

Another study of Morelli and colleagues,124 conducted on a sample of 610 adolescents aged 13–20 years (63% teen girls) revealed gender differences regarding sexting behaviors (measured by The Sexting Behaviors Questionnaire)129 and cyberpornography addiction (measured by CPUI),64 with teen girls showing lower means in these variables. Furthermore, sexting behaviors were correlated with alcohol consumption and pornography use among both teen boys and girls.

According to results of Weinstein and colleagues study,45 in women, no correlation was found between ratings of difficulties in intimacy (assessed by the Questionnaire on difficulties in intimacy)130 and cybersex (assessed by the Cybersex Addiction Test),131 whereas an association between pornography ratings (assessed by the Pornography Craving Questionnaire)132 and cybersex occurred on a trend level. In men, positive correlations have been found in both cases.

Another study of Weinstein and colleagues,125 conducted on a group of 50 women and 50 men over 18 years old, showed that both anxious and avoidant attachment were positively correlated with sexual compulsivity in all participants. Moreover, the analysis revealed a significant gender by sexual orientation interaction effect on sexual compulsivity. Specifically, lesbian women reported higher levels of sexual compulsivity compared to heterosexual women. No significant difference was found in the case of men regardless of sexual orientation.

Rettenberger, Klein, and Briken126 investigating the relationship between CSB (assessed by HBI-19),68 sexual excitation and sexual inhibition (assessed by the SIS/SES-Short Form)133 on a group of 988 women and 750 men aged 18–62, found that women scored lower than men on a scale measuring sexual excitation (SES) and HBI-19,68 however, they obtained higher scores on both sexual inhibition dimensions – inhibition due to threat of performance failure (SIS1) and inhibition due to threat of performance consequences (SIS2). Moreover, gender, SES and SIS1 (reflecting inhibition due to threat of performance failure) were positively related to CSB.

Traumatic Experiences

Several studies aimed to verify whether a child sexual abuse (CSA) may play a role in the development of CSB symptoms.123,134-138 Meyer and colleagues134 examined gender differences in this area in a study on a sample of 504 women and 308 men aged 18–78 years. In addition to the result suggesting CSB (assessed by SAST-R)98 being less present among women regardless of the history of sexual abuse, authors have, however, found that participants (both men and women) with a history of CSA reported more attachment anxiety in romantic relationships than those without a history of CSA. Castellini and colleagues’ study123 revealed an association between childhood adversities (assessed by The Childhood Experience of Care and Abuse)139 and CSB (assessed by Hypersexual Disorder Screening Inventory)128 among women, but not among men.

Another four studies were carried out by Vaillancourt-Morel and colleagues on Canadian samples.135–138 The first study involved a group of 529 women and 157 men aged 18–77 years that currently were in a close relationship, of which 20% women and 19% men with a history of CSA.135 Specifically, they found that CSA was associated with a higher level of sexual avoidance and sexual compulsivity (assessed by SCS),83 which was a predictor of lower couple adjustment. In 2016, the authors conducted the second study in order to test a mediation model assuming that the relationship between CSA severity and extradyadic sexual involvement (ESI) may be explained through sexual compulsivity.136 The study sample consisted of 521 women and 148 men (aged 18–77 years) involved in a close relationship. The results were as follows: CSA severity was positively and significantly associated with sexual compulsivity, which predicted ESI; there was a direct relationship between CSA and EDI; high CSA severity led – through a high sexual compulsivity – to the highest likelihood of ESI; CSB severity was lower among women; there was no gender difference in the structural association between CSA, ESI and sexual compulsivity. The third study was conducted on a group of 756 women and 265 men aged 18–77.137 In total sample, 21.3% of women and 19.6% of men experienced legally defined CSA, of which 54 women and 10 men defined their incident as sexual abuse (self-definers). Results reveal an association between self-defined CSA and higher negative post-abuse reactions and sexual avoidance, while not identifying as sexually abused was related to higher sexual compulsion. The last study by Vaillancourt-Morel and colleagues138 involved 1033 participants aged 18–77 (760 women) and found that sexual outcomes of CSA differed according to relationship status. Regardless of gender, CSA severity was related to higher sexual compulsivity in single participants, higher sexual avoidance and compulsivity in cohabiting participants, and higher sexual avoidance in those who were married.

Treatment of CSB Among Women

Three studies conducted on groups of treatment-seeking/receiving individuals were discovered.84,86,140 Seven hundred and nineteen Polish women aged 14–63 years took part in a survey study of Lewczuk and colleagues.140 Thirty-nine of women were treatment seekers for PPU. Results showed higher scores in terms of the number of symptoms related to pornography use and the amount of pornography use among treatment seekers (compared to non-treatment seeking women). Additionally, treatment seekers reported a higher maximal number of masturbations per day and longer episodes of binge pornography watching. A path analysis model showed that the amount of pornography use was significantly related to treatment-seeking, and this relationship remained positive and significant after introducing the mediator – severity of symptoms associated with pornography consumption. Interestingly, authors found a loss of significance of the positive association between the amount of pornography use and treatment-seeking when they included two other predictors to the model: religious practices (assessed by the reported average amount of time [minutes per week] spent on practices such as prayers, participation in services, reading spiritual books, and meditations) and symptoms associated with pornography use. Finally, the authors found a correlation between depression, anxiety, and PPU among women, suggesting that a higher level of PPU may be associated with a greater level of psychopathology.

Two aforementioned studies of Brem and colleagues involving individuals in residential treatment for SUDs84,86 revealed a negative association between CSB symptom severity and dispositional mindfulness (assessed by Mindful Attention Awareness Scale)141 among women with SUD, pointing to the potential utility of using mindfulness-based approaches in treating women with CSB and SUD.

Discussion

The decision on including CSBD in the forthcoming 11th edition of the International Classification of Diseases, despite the potential benefits, remains hotly debated among scientists and clinicians.18,142-144 Whether mechanisms underlying CSBD are impulsive, compulsive, or addictive remains a contentious issue. The placement of CSBD in medical classification will undoubtedly contribute to the acceleration of research focusing on the definition, classification, and theoretical framework of CSBD, which may in turn allow for the development of effective treatments for people experiencing these problems. The current conceptualization of CSBD was preceded by numerous studies involving mainly heterosexual men; thus, applying diagnostic criteria to women or sexual minorities is short-sided. Accuracy of diagnostic criteria in the evaluation of CSBD women and non-heterosexual samples should be further evaluated in large, culturally diverse samples of men and women.

One of the missing gaps in the literature pertains to the lack of scientific investigation on CSB among women and sexual minorities,145,146 focusing on prevalence estimates, clinical patterns of sexual functioning, as well as neurobiological mechanisms. According to Bőthe and colleagues’ review of literature on LGBTQ adolescents,146 of eleven studies published in the past 5 years, only two focused exclusively on CSB among the reviewed group. Moreover, the authors pointed to the lack of quantitative investigations concentrated on comparison to heterosexual individuals and taking into account ethnic diversities.

To our best knowledge, this is the first review aimed at summarizing the current state of knowledge about CSB among women to elucidate current gaps as well as generate areas for future research exploration. In this section, we summarize the most important research findings for consideration.

In the context of the prevalence of CSB, research indicated that fewer women (as compared to men) reported viewing pornographic materials over the last 6 months,44 they reported less pornography time use44,46-48,77 and exhibited lower rates of feeling urges to pornography,45 a smaller percentage of them self-identified as addicted to pornography based on subjective feeling,14 and fewer women reported symptoms related to CSB, such as difficulties in controlling sexual thoughts and behaviors, engaging in sexual activity to cope with unpleasant emotional states, and experiencing negative consequences because of these sexual behaviors.50–53,55–57,63,75,77,89,90,109,111,134,136 It is worth noting that prior research focused on measuring PPU and masturbation and has been conducted almost exclusively in men, and prior work has not included a deeper analysis of patterns of sexual functioning of women who reported issues related to CSB. We also note that the subjective assessment of addiction to pornography does not necessarily reflect a CSBD diagnosis in women. CSBD diagnosis should be confirmed through clinical evaluations by trained medical professionals. Another point worth mentioning is a lack of clinically validated CSB measures for women. Many of the current CSB measures were developed using the diagnosis criteria for Hypersexual Disorder (HD) proposed to DSM-5.28 The diagnostic criteria for HD and CSB do not completely overlap in several regards. It is unknown what diagnostic criteria were used in many of the reviewed studies; hence, discrepancies in prevalence statistics exist. For example, Engel and colleagues52 used only HBI-19 questionnaire to assess CSB symptoms severity; however, in their discussion, they emphasized the need for conducting clinical interviews to classify someone with CSB.

The results of studies examining CSB from the perspective of behavioral and cognitive processes remain inconsistent, which makes it difficult to draw clear conclusions from these studies. On one hand, studies of Pekal and colleagues75 and Sklenarik and colleagues147 showed that enhanced attentional bias toward pornographic stimuli among women was associated with higher severity of symptoms related to addictive usage of pornography and higher anhedonia. These results are in line with several studies on substance-use disorders148 and behavioral addictions.149 On another hand, there are studies showing lower attentional biases in women (as compared to men) as well as studies that did not show any sex differences.150,151 The authors posited that these pornographic pictures have stronger rewarding characteristics for men than women. However, most recent research on neural correlates of erotic stimuli processing showed no sex differences.152 Therefore, it is important to investigate other factors, such as a history of exposure for erotic content or recent sexual activity. For example, in Albery and colleagues’ investigation,76 sexually active participants exhibited a greater tendency to preferentially process sex-related words than neutral stimuli. These results support prior findings indicating the existence of a similar pattern for substance-related153 and non-substance-related behavior.2,149,150,154 No effect of gender on interference scores was noted. Finally, Stark and colleagues77 found only approach biases for pornography among participants having greater problems with its consumption.

Five studies revealed that CSB symptoms may comorbid with symptoms of Substance Use Disorder (SUD).84–88 Interestingly, two of them84,86 indicated a negative relationship between CSB and tendencies to be aware of the present moment, suggesting that approach based on mindfulness techniques should be further examined in the context of its potential effectiveness in working with women. A deeper examination of the co-occurrence of CSB and SUD should be considered in women. According to Carnes,155 CSB and substance use are woven together (eg, substance use can lead to engaging in problematic sexual behavior or substance use may enhance sexual experience, reinforcing the pairing of these problematic behaviors). Preliminary evidence suggests that in women (similar to men) drug use may be a risk factor for CSB.156 Women’s problems with substance use have been found to be positively associated with negative mood states (eg, feeling depressed, degraded) after being preoccupied with sexual thoughts, fantasies, and behaviors.

Two studies87,95 indicated a relationship between CSB and borderline personality symptoms, which has been previously well documented in the literature,83,157-159 and has been found to occur more often in women compared to men.160 Interestingly, both CSB and borderline personality are characterized by the lack of impulse control,158 which is often manifested by engaging in problematic and risky sexual behavior, such as having multiple sexual partners or unprotected sex,158,161-164 as well as preoccupation with sexual fantasies165 and distress related to sexual behavior.165 In the case of women who exhibit more borderline personality features, previous studies showed that they more likely report more sexual partners,83,166,167 more casual sexual partners,167 and earlier age of sexual initiation.168 Many factors are related to increased numbers of sexual partners in people with severe psychiatric conditions (eg, substance use, childhood sexual abuse, being unmarried).169 Association between borderline personality symptoms and the numbers of sexual partners may be explained by greater substance use. For example, among individuals with BPD, those who reported using substances also reported more sexual partners.163,170 Findings from two studies included in this review are consistent with prior studies showing a strong co-occurrence between CSB and borderline personality symptoms in both non-clinical95 and clinical samples with substance-use disorder.87

Further, CSB symptoms have been found to be associated with ADHD symptoms,92 obsessive-compulsive disorder,93 and pathological buying.90 Further work is needed to identify effective treatments for CSB and other co-occurring disorders among treatment-seeking women.

In the case of personality factors in females, PPU has been positively related with trait psychopathy,107 sexual sensation seeking was positively correlated with sexual compulsivity,108 but a model assuming that sexual sensation seeking may impact PPU through online sexual activities, and may be influenced by the third-person effect applied to women less so than men.109 Another examination revealed that impulsivity was stronger (but only moderately) associated with CSB104 than was compulsivity for women. Other studies found that motor/planning impulsiveness, negative affect, and psychoticism significantly predicted sexual compulsivity.106

Additionally, CSB symptom severity has been found to be associated with sexual dysfunctions, and more generally with psychopathology.123 The results of another study showed a positive correlation between sexual compulsivity and both anxious and avoidant attachment.125 Finally, one study showed an association between childhood adversities and CSB among women,123 and another four studies revealed a relationship between sexual compulsivity and child sexual abuse (CSA).135–138 Prior works have found a significant relationship between CSA and insecure attachment171–173 and demonstrated their high prevalence among individuals with CSB symptoms. CSA is being considered as an important factor in the development of CSB.174–178 Some researchers proposed that CSB symptoms occur as a form of regulatory behavior of coping with stressors related to CSA and negative emotions.135,179-184 As noted by others,185 longitudinal studies using a cohort design are needed to assess the trajectory of sexually related responses (ie, sexual avoidance, compulsivity, and ambivalence) across the lifespan for women and men reporting histories of CSA or other forms of child maltreatment.

No studies are assessing the effectiveness of treatment in women with CSB, only gender differences in predictors of treatment-seeking have been identified so far38,140. For women, the mere amount of pornography use, symptoms related to its consumption, as well as religiosity were associated with treatment-seeking behavior,140 while among men symptoms of pornography use predicted treatment-seeking behavior more strongly than the quantity of consumption.38

Limitations

Little scientific attention devoted to the issue of CSB in women resulting in a paucity of accurate estimates of the prevalence and the problem in this group. Moreover, prior studies mostly included measurement of characteristics and CSB behavior in general populations (non-clinical), with a lack of research carried out on the population of women diagnosed with CSBD. A study on the prevalence of CSB among patients with Parkinson’s disease94 did not provide information on whether the effects of L-Dopa and dopamine agonists that may cause CSB were considered. Given the absence of clinically relevant research on women with CSB, the current state of the data does not provide adequate treatment guidelines for women suffering from this condition. Due to these limitations, we cannot draw conclusions regarding best clinical practices for medical providers working with women reporting issues with CSB.

An additional point worth emphasizing is that many of the reviewed studies were conducted on Western, educated, industrialized, rich, and democratic (WEIRD) societies.186 As participants from these societies (predominantly college students) represent approximately 80% of all study participants, they are unrepresentative of most people living with CSB. Results from studies using WEIRD samples do not generalize well for clinical populations or those from non-Western societies or individuals from culturally diverse backgrounds. We hope that generalization drawn from our review will help inform the next steps for CSB research in women, but do caution the reader about making strong conclusions from our systematic review.

Future Directions

Our first recommendation is for future investigations to concentrate on obtaining accurate epidemiological data on women with CSB. The aforementioned prevalence estimates are derived from research involving mostly heterosexual men, which limits generalizability for women. There is also a need for conducting studies in clinical samples of women in order to identify patterns of their sexual functioning, the occurrence of sexual dysfunctions, possible co-occurrence of CSB with other impulse control disorders, addictive or mental health disorders, and specific personality profiles. Since we do not have a clinical picture of women experiencing CSB, it is recommended that future research assess the psychological role of certain behaviors, and its impact on various aspects, including relationships, sexual and psychosocial functioning. Such data would allow for developing culturally appropriate CSB treatment for women with diverse life experiences. Furthermore, it is important to verify the potential difference in neuronal mechanisms underlying CSB between women and men, as well as examine genetic vulnerability factors for the development and maintenance of CSBD in this group. Future research should also concentrate on testing therapeutic interventions for women reporting issues with CSB, albeit in its various forms (ie, repetitive pornography use, masturbation, casual and risky sexual encounters, etc.). Our recommendation for future studies with women reporting issues with CSBD are presented in Table 1.

Table 1

Recommendations for Future Studies of Compulsive Sexual Behavior Disorder Among Women

Data	Goal
ClinicalSelf-report	Conduct large epidemiological studies
ClinicalBehavioralSelf-reportNeurobiological	Assess and validate proposed CSBD diagnostic criteria in the context of women in clinical settings Identify (dominant) patterns of sexual functioning of CSBD women Examine the occurrence of sexual dysfunctions among women with CSBD Examine possible co-occurrence of CSB with other impulse control disorders, addictive/mental health disorders and specific personality profiles Identify the clinical picture of women with CSBD (eg, psychological role of certain behaviors, its impact on relationships and sexual and psychosocial functioning) Examine the role of impulsivity/compulsivity in the development and maintenance of CSBD Examine the relationship between neuronal mechanisms and treatment outcomes for treatment-seeking women with CSBD
ClinicalPharmacologicalNeurobiological	Conduct randomized clinical trials to identify efficacious pharmacological and behavioral treatments/interventions
Neurobiological	Investigate structural, functional, neurochemical and other data and their integration Verify potential differences in neuronal mechanisms of CSBD between women and men Examine neurobiological mechanisms underlying specific aspects of CSBD
Genetic	Conduct genome-wide association studies (GWAS) on women with CSBD Examine vulnerability genetic factors for the development and maintenance of CSBD Examine environmental and epigenetic influences on processes in CSBD

Note: Compulsive sexual behavior disorder (CSBD).

Conclusions

To summarize the reviewed literature, available studies indicate that CSB symptom severity is lower in women than in men. The following indicators have been examined in terms of their relationships with CSB symptoms among women and men: attentional bias toward sex-related stimuli, substance use and problems, depression symptoms, early maladaptive schemas, compulsive/pathological buying, ADHD symptoms, obsessive-compulsive disorder, Impulsive-Compulsive Disorders, Autism Spectrum Disorder, trait impulsiveness, compulsiveness and motivation, “the dark triad of personality”, sexual sensation seeking, gender identity, sexual dysfunctions, “third-person effect”, general psychopathology, sexual satisfaction, sexting behaviors, difficulties in intimacy, insecure attachments, sexual excitation and sexual inhibition, child sexual abuse, dispositional mindfulness, and treatment-seeking behavior. Studies assessing the relationship between CSB and borderline personality features, sexual aggression, and negative affect-have been conducted on female samples only, therefore, it is difficult to establish a gender-specific relationship. Overall, the results of the research described in this paper do not provide a clear understanding of the patterns of sexual functioning in women with CSB. Further research is needed to address gaps in understanding about possible gender differences in the clinical manifestation of CSB in women and men.