Giulio Perrotta
The Concept of “Hypersexuality” in the Boundary between Physiological and Pathological Sexuality
hypersexuality,nymphomania,satyriasis,personality disorders,bipolarism,sexual arousal
Introduction: The concept of hypersexuality belongs to modern parlance, according to a predominantly clinical meaning, and is understood as a psychological and behavioural alteration as a result of which sexually motivated stimuli are sought in inappropriate ways and often experienced in a way that is not completely satisfactory. Methods: Literature up to February 2023 was reviewed, with 25 searches selected. Results: Forty-two articles were included in the review. Conclusion: Hypersexuality is a potentially clinically relevant condition consisting of one or more dysfunctional and pathological behaviours of one’s sexual sphere and graded according to the severity of impairment of subjective acting out; for this reason, the Perrotta Hypersexuality Global Spectrum of Gradation (PH-GSS) is suggested, which distinguishes high-functioning forms (pro-active and dynamic hypersexuality) from those of attenuated and corrupted functioning (dysfunctional and pathological hypersexuality of grades I and II). Future research is hoped to address the practical needs of this condition, such as the exact etiopathology, the role of oxytocin in dopaminergic hypotheses (and its ability to attenuate the symptomatology suffered by the patient in terms of manic drive), the best structural and functional personality framing of the subject, and the appropriate therapy to pursue.
The Concept of “Hypersexuality” in the Boundary between Physiological and Pathological Sexuality

Introduction: The concept of hypersexuality belongs to modern parlance, according to a predominantly clinical meaning, and is understood as a psychological and behavioural alteration as a result of which sexually motivated stimuli are sought in inappropriate ways and often experienced in a way that is not completely satisfactory. Methods: Literature up to February 2023 was reviewed, with 25 searches selected. Results: Forty-two articles were included in the review. Conclusion: Hypersexuality is a potentially clinically relevant condition consisting of one or more dysfunctional and pathological behaviours of one’s sexual sphere and graded according to the severity of impairment of subjective acting out; for this reason, the Perrotta Hypersexuality Global Spectrum of Gradation (PH-GSS) is suggested, which distinguishes high-functioning forms (pro-active and dynamic hypersexuality) from those of attenuated and corrupted functioning (dysfunctional and pathological hypersexuality of grades I and II). Future research is hoped to address the practical needs of this condition, such as the exact etiopathology, the role of oxytocin in dopaminergic hypotheses (and its ability to attenuate the symptomatology suffered by the patient in terms of manic drive), the best structural and functional personality framing of the subject, and the appropriate therapy to pursue.

The concept of “hypersexuality” belongs to modern parlance, according to a predominantly clinical meaning, understood as a psychological and behavioural alteration as a result of which sexually motivated stimuli are sought in inappropriate ways, often experienced in a way that is not completely satisfactory; it is a psychopathological label strongly desired by the scientific community to replace terms previously used in other areas of study as well, such as nymphomania and satyriasis, the former referring to the female sexual gender and the latter to the male sexual gender [1]. Such terminologies draw on Greek mythological culture, referring to the nymphs, who were young and beautiful maidens whose beauty attracted the desire of many men. In fact, according to mythological tradition, it was they who first used the art of seduction to continually procure new sexual partners and thus the satisfaction of their pleasures. However, the nymphs, like the sirens, hid a dark side: their company was as deadly as it was pleasurable. They often fell prey to the satyrs, bearded beings who were half-man, half-animal (goat or horse), and also devoted to lustful wildlife. The dances of the satyrs and nymphs are depicted in very famous works, which capture precisely the peculiarity and complementarity of their sexual behaviour. Nymphomania and satyriasis are, therefore, the female and male equivalents of today’s hypersexuality, which, in the past, was considered a morbid accentuation of sexual impulses. In later centuries, popular tradition extolled these aspects in many artistic representations, thus giving rise to myths and stories, widely using the terms now replaced with hypersexuality beginning in 1771 A.D. in the edited work “Nymphomania. Treatise on Uterine Fury” by French physician Giambatist De Bienville [2].

Today, hypersexuality is proposed differently and with a predominantly clinical connotation; in fact, it is present in the two main diagnostic manuals of psychiatric problems: the International Classification of Diseases (ICD) [3] and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) [4]. The ICD is the international classification proposed by the World Health Organization; it is not specific to mental disorders alone, to which, however, a section is dedicated anyway, and it encapsulates the diagnostic criteria for all possible organic disorders. The DSM-5-TR, on the other hand, is the proposal from the American Psychiatric Association group and, currently, the most widely used classification in the international scientific community, being devoted entirely to psychopathologies. However, if the two classification systems are equivalent in terms of formulation and representation, this is not true for several clinical hypotheses, including hypersexuality itself; this is an expression of a difficulty on the part of the expert editors to frame this particular clinical case in a structural and sharable way. Hypersexuality falls under “Sexual Compulsive Behaviour Disorder” (code 6C72) for ICD-11, while for DSM-5 it is considered a behavioural addiction that can characterise the subject’s pathological conduct and even be a dysfunctional trait in other disorders. The diagnostic criteria advanced by the World Health Organisation on the subject of hypersexuality are: (A) for at least six months, recurrent and intense sexual fantasies, sexual urges, or sexual behaviour in association with three or more of the following: time spent in repetitive sexual fantasies, impulses, or behaviours that interfere with other important (non-sexual) goals, activities, or obligations; repetitive engagement in sexual fantasies, impulses, or behaviours in response to dysphoric mood states (e.g., anxiety, depression, boredom, or irritability); repetitive engagement in sexual fantasies, impulses, or behaviours in response to stressful life events; repetitive but unsuccessful efforts to control or significantly reduce such fantasies, impulses, or behaviours; repetitive engagement in sexual behaviours, disregarding the risk of physical or emotional harm to self or others; (B) there is clinically significant personal distress or impairment in social, work, or other important areas associated with the frequency and intensity of these sexual fantasies, impulses, or behaviours; (C) these sexual fantasies, impulses, or behaviours are not a direct result of medical conditions (e.g., brain tumours or dementia) or substance intake (e.g., a substance of abuse or medication) [3,5].

A review was conducted to determine as precisely as possible the exact aetiology of pathological hypersexuality in its various meanings. The object of this discussion is to try to determine whether, in the current state of scientific knowledge, the following research questions can be answered: Is it possible to distinguish one or more forms of hypersexuality? And if so, is there a pathological form, and how does it differ from the other hypotheses? Is it possible to say that pathological hypersexuality is a clinical condition that is medically relevant, or is it a subjective maladaptive behaviour? And if it is a condition, is it primary or secondary? Is it possible to identify the etiological hypotheses of pathological hypersexuality?

Literature up to February 2023 was reviewed.

To identify the important aspects of the examination, the writer focused on the elements that could determine whether or not pathological hypersexuality could be considered a nosographic category in its own right or whether it could fall under obsessive-compulsive disorders, impulsive conduct disorders, or behavioural addictions, up to the hypothesis that interprets hypersexuality as one of the typical features of certain psychiatric disorders (e.g., bipolar, borderline personality disorder, and pathological narcissism).

The author searched PubMed until April 2023 for systematic reviews, clinical trials, and randomised controlled trials using the keyword “hypersexuality”, selecting 245 useful results. To have a greater and more complete overview of the topic, we ultimately selected a total of 25 studies, still adding 26 more reviews to be able to argue the elaborated content (to more easily contextualise definitions and clinical-diagnostic profiles), for an overall total of 51 results (Figure 1). Simple reviews, opinion contributions, or publications in popular volumes were excluded because they were not relevant or redundant for this work. The search was not limited to English-language papers (Table 1).

No work appears in the literature that clearly and precisely differentiates the different forms of hypersexuality. Although the shared use of this terminology has replaced the previous terms “nymphomania” and “satyriasis”, no one has ever put in place a real classification capable of differentiating and grading hypersexuality. This first limitation thus confuses both the structure and function of the term concerning the clinical profiles investigated here. It could be argued that the concept of hypersexuality in itself is too general and does not apply exclusively to pathological hypotheses; it is, therefore, necessary to expand the knowledge derived from the current definitions and try to derive from them what is necessary to arrive at a possible separation of terms. We know that hypersexuality becomes pathological: (a) when the subject experiences clinically significant discomfort concerning his or her sexual conduct, which, however, does not always coincide with an inner discomfort in realising one’s urges but depends on the social judgement of the community in which he or she lives (be it the couple, friendship, family, work or social nucleus); (b) when the subject manifests the presence of a significant and disproportionate increase in the sexual drive for at least 6 months, which, however, does not always correspond to the satisfaction of one’s sexual desire, and consisting of recurrent and intrusive fantasies and thoughts, excessive sexual behaviour, and an inability to control one’s sexuality, despite the negative consequences resulting from it; (c) when the subject, in the realisation of one’s sexual drives, engages in paraphiliac dysfunctional conduct, thus in comorbidity with them or with sexual dysfunction [14,28,29] (Table 2).

There is still debate in the scientific community about the age-old question of whether hypersexuality is a maladaptive subjective behaviour due to a traumatic psychophysical event or is rather a clinical condition. There is no definitive answer, and this gap prevents further exploration of the issue; however, by reviewing what is in the literature, it is possible to define hypersexuality as a psychological and behavioural alteration as a result of which people seek sexually motivated stimuli in inappropriate ways, often in a manner that is not completely satisfactory [1]. This definition indirectly allows hypersexuality to be labelled as a potentially clinically relevant condition, the result of one or more subjective behaviours that are maladaptive to the expected statistical mean. By this assumption, there is always debate in the literature as to whether hypersexuality is a primary or secondary condition—that is, whether or not it depends on other causes. Today, the majority position seems to reasonably lean towards the secondary hypothesis, as it appears to be a dysfunctional adaptation to a primary fact that secondarily induces the onset of the hypersexual condition. In fact, all etiological hypotheses underlying hypersexuality confirm this reasoning: (a) neurological syndromes [7,8,10,13,16,20,23,30,31,32,33,34], such as Klüver-Bucy syndrome (consisting of a bilateral lesion of the amygdala), typical and atypical dementias with temporo-frontal involvement, Pick’s dementia, Kleine-Levin syndrome (or recurrent hypersomnia), autism, and attention-deficit/hyperactivity disorder (ADHD); (b) psychiatric forms [9,11,12,21,24,25,27,35,36,37,38,39], such as bipolar disorder and borderline disorder (in their euphoric/sub-euphoric components typical of manic and/or hypomanic), sub-obsessive forms, sexually oriented behavioural addictions, and high-functioning personality disorders, such as covert-type narcissism; (c) traumas of the encephalon [40], in the regions used for rationality and impulse control (temporofrontal and limbic system in general); (d) implications arising from the use of excitatory drugs (such as methamphetamine, cocaine, synthetic drugs, and hallucinatory drugs) and from the therapeutic use of certain drugs, such as the use of L-dopa and prolactin inhibitors in Parkinson’s dementia (indeed, dopaminergic drugs have been shown to influence conscious processing of rewarding stimuli and are associated with impulsive-compulsive behaviours, such as hypersexuality, by going on to activate the nucleus accumbens and dorsal anterior cingulate when shown subliminal sexual stimuli), anabolic drugs, and testosterone and other sex hormone products [17]. It is precisely in the presence, therefore, of the fulfilment of generally accepted diagnostic criteria, out of any other physiological condition (albeit deviating from the statistical mean of the reference population) that the diagnosis of sexual conduct dysfunction due to hypersexuality is reached, resulting in the evaluation of a multidisciplinary therapeutic approach considering individual and/or group psychotherapy, mainly of cognitive-behavioural or constructivist-strategic approach (to correct reinforcers and coping strategies, work on one’s emotions, motivational recovery and metacognitive functions), and psychopharmacological treatment based on symptomatology, with anxiolytics, antidepressants, mood stabilisers, and antipsychotics [15,18,19,41] (Table 2).

Several etiopathological theories in the literature try to explain hypersexuality, but all of them do not seem to be fully satisfactory enough to answer the question in a supportable and reproducible way. However, if the compulsive, impulsive, and psycho-traumatic models can partially explain the hypersexual condition, the neurobiological model manages to be more precise. Below is a schematization of the main etiopathological theories (Table 3).

The pathological concept of “hypersexuality” and its clinical reference are well established in the literature; however, it is not possible to clarify whether only that person who manifests such behaviours because of his promiscuity or even if he enacts them exclusively with one person, but with amplified frequency mode, should be considered “hypersexual.” In fact, at present, it is not even possible to clarify whether pathological hypersexuality depends only on the number of relationships (understood in a quantitative sense) or also on the intensity of them (understood in a qualitative sense), because of the time spent and resources used. Although there are no established criteria for hypersexuality, traits that are commonly seen in a hypersexual person or sexual addict include [46]: Sex obsession. Spending a lot of time fantasising about sexual urges and enacting sexual behaviours. Compulsive and frequent masturbation (one to several times a day). Use of virtual pornography. Sources include videos, adult magazines, and the Internet (websites, webcams). Masturbation with virtual material is practised with repeated and systematic frequency. Massive dedication in a daily time frame, planning sexual activity. One spends several hours deciding where and how to get the next sexual “pleasure”. Use of sexual services. This already represents a more structured and pathologically dysfunctional behaviour, as sexual activities now involve direct or indirect human interaction. Behaviours may include phone sex, connections via Internet chat rooms, paying for sexual encounters, visits to strip clubs, multiple partners, or frequent one-night stands. Degeneration of behaviour into reckless, socially objectionable, or illicit sexual activity. Substance abuse, sexual assault, or dangerous sexual activity (such as autoerotic asphyxiation) may be added to sexual activity. Engaging in sexual behaviour that goes against one’s values, religious beliefs, or what society deems appropriate, experiencing helplessness, or inability to restrain oneself. Manifesting paraphiliac attitudes or behaviours. These are sexual behaviours that result in psychological distress, injury, or the death of another person. Examples include exhibitionism (exposing genitals to strangers), voyeurism (watching or participating in sexual activity with others), sadomasochism (sexual pleasure in inflicting pain or humiliation on others), and paedophilia (sexual feelings towards children). Inability to stop one’s sexual behaviour despite negative consequences in other areas of personal life, such as emotional, love, family, social, professional, or health-related relationships. The physiological and pathological boundary seems to be marked exclusively by adherence or non-adherence to the shared and widely used diagnostic criteria in psychiatric practise, but such a view seems overly stringent and impractical concerning the subjective emotional universe of the person. “Hypersexual” should therefore be considered those who, in compliance with the above diagnostic criteria, present an accentuation of the individual sexual dynamic plot of a presumed neuropsychiatric matrix of dimensional type (and not purely categorical) [47,48], such as to condition one’s own and others’ lives according to sexual activity; the more it presents itself as conditioning and limiting concerning other spheres of life (family, work, social relations, affective and sentimental relationships), in reason of its qualitative and quantitative manifestation, the more hypersexuality presents dysfunctional pathological connotations, deserving of clinical intervention. Another issue that is not unanimously answered in the literature concerns the relationship between hypersexuality and paraphilia. It is unclear whether hypersexuality can be considered paraphilia or is simply the summation of behaviours aimed at intensifying sexual activity beyond the limits predetermined by the reference context. In this regard, the inference that seems most consistent with the topic analysed is to consider hypersexuality as a behavioural status with a strong emotional impact that can manifest itself with or without the presence of one or more paraphilias; in essence, paraphilias become the means used by the hypersexual to fuel his dysfunctional state, but they may not be present, may be limited to a precise context, or still be attenuated or nuanced concerning the main conduct of seeking sexual activity. A hypersexual who has one or more paraphilias structured into a paraphiliac disorder is markedly pathological, compared to a hypersexual who does not have such a disorder in his or her personological profile. Yet another issue concerns the relationship between hypersexuality and mental disorders as nosographically framed in psychiatry. The literature here is rich on this topic, and hypersexuality is always associated with pathological and dysfunctional personality frameworks, as is the case with borderline, histrionic, narcissistic, and antisocial disorders, but also with markedly manic bipolar profiles, in obsessive-compulsive disorder, sadistic and masochistic personalities, and in psychosis with erotically motivated features; however, it is not clear whether hypersexuality is the factor that fuels dysfunctionality in these morbidities or is rather a constitutive element of them [49,50]. No research in the literature has focused on the possible role of oxytocin in hypersexuality, and thus the neurobiological relationship with dopaminergic accesses is instead widely studied in sexual conduct-related disorders; however, some authors have hypothesised this correlation on the basis of oxytocin effects on brain areas involved in emotional processes [51,52]. Various psychometric instruments are used to assess the degree of functional impairment of hypersexual individuals, such as in the case of the Sex-relation Evaluation Schedule Assessment Monitoring (SESAMO), which explores sexual and relational aspects, the Sexual Addiction Screening Test (SAST) and the Sexual Compulsivity Scale (SCS), which investigate the compulsive component of dependent sexuality, of the Hypersexual Behaviour Inventory (HBI), which investigates hypersexual behaviours, and the Childhood trauma questionnaire (CTQ), which investigates psycho-traumatic profiles of the infant; however, none of these instruments clearly and comprehensively define a graded scale of hypersexuality capable of distinguishing between highly functional and dysfunctional forms. Because of these limitations, it was decided to propose a scale to comprehensively assess the severity of the symptoms of hypersexuality, capable of collecting the range of the main hypotheses and thus grading the behaviour according to the different factors involved. This classification (Perrotta Hypersexuality Global Spectrum of Gradation, PH-GSS) therefore intends to fill the content gap found here in the literature and propose a comprehensive measure, pending validation using a representative sample. The following table shows the content of the PH-GS (Table 4).

Hypersexuality is the term that describes a series of heterogeneous conditions, substantiated by behaviours of a sexual nature, that must be graded according to their severity of impairment of subjective agency. If the terms nymphomania and satyriasis now appear judgmental, it is only correct to speak of hypersexuality if a grading scale is put in place to help the practitioner distinguish between the different hypotheses. For this reason, the Perrotta Hypersexuality Global Spectrum of Gradation (PH-GSS) is suggested, which distinguishes high-functioning forms (pro-active and dynamic hypersexuality) from those of attenuated and corrupt functioning (dysfunctional and pathological grade I and II hypersexuality). Hypersexuality, therefore, is a potentially clinically relevant condition secondary to another medical condition and consisting of one or more dysfunctional and pathological behaviours of one’s sexual sphere, which can be explained in a more shareable and reproducible way according to the neurobiological theoretical model. Future research is hoped to address the practical needs of this condition, such as the exact etiopathology, the role of oxytocin in the dopaminergic hypotheses (and its ability to attenuate the symptomatology suffered by the patient in terms of manic drive), the best structural and functional personality framing of the subject, and the appropriate therapy to be pursued.

Systematically defining the gradation of hypersexuality means being able to frame the subject more structurally and functionally by choosing the most appropriate treatment and avoiding letting the therapist decide based on his or her subjective assumption or interpretation of the patient’s symptomatic experience. It is therefore extremely important to be able to complete such an operation to give clinical dignity to a condition that, to date, has not been fully explained and is often interpreted only as a personality trait or accentuation of the sexual pattern because of the primary medical condition.