Assessing compulsive sexual behavior disorder: The development and international validation of the compulsive sexual behavior disorder-diagnostic inventory (CSBD-DI).

Background and aims: The World Health Organization's International Classification of Diseases (ICD-11) includes Compulsive Sexual Behavior Disorder (CSBD), a new diagnosis that is both controversial and groundbreaking, as it is the first diagnosis to codify a disorder related to excessive, compulsive, and out-of-control sexual behavior. The inclusion of this novel diagnosis demonstrates a clear need for valid assessments of this disorder that may be quickly administered in both clinical and research settings. Design: The present work details the development of the Compulsive Sexual Behavior Disorder Diagnostic Inventory (CSBD-DI) across seven samples, four languages, and five countries. Setting: In the first study, data were collected in community samples drawn from Malaysia (N = 375), the U.S. (N = 877), Hungary (N = 7,279), and Germany (N = 449). In the second study, data were collected from nationally representative samples in the U.S. (N = 1,601), Poland (N = 1,036), and Hungary (N = 473). Findings: Across both studies and all samples, results revealed strong psychometric qualities for the 7-item CSBD-DI, demonstrating evidence of validity via correlations with key behavioral indicators and longer measures of compulsive sexual behavior. Analyses from nationally representative samples revealed residual metric invariance across languages, scalar invariance across gender, strong evidence of validity, and utility in classifying individuals who self-identified as having problematic and excessive sexual behavior, as evidenced by ROC analyses revealing suitable cutoffs for a screening instrument. Conclusion: Collectively, these findings demonstrate the cross-cultural utility of the CSBD-DI as a novel measure for CSBD and provide a brief, easily administrable instrument for screening for this novel disorder.

Orgasm Frequency (Total Sexual Outlet) in a National American Sample.

There has been renewed interest in the conceptualization and diagnosis of conditions marked by excessive sexuality. Researchers and clinicians have often utilized orgasm frequency (e.g., total sexual outlet) as an indicator of hypersexuality. Indeed, some have proposed seven or more (7+) orgasms by any means in a typical week as indicating hypersexuality. Most studies utilizing this criterion, however, have examined clinical or judicial samples of men, as opposed to general population samples. The purpose of the current study was to provide representative population data of total sexual outlet (TSO) for people varying in age, relationship status, and sex, while also examining the impact of the phrasing of the questions (i.e., time frame). A total of 1029 participants were recruited online via a Qualtrics panel, consisting of 442 males and 587 females, from diverse regions across the USA. Results indicated that between 10.3 and 16.7% of the sample met the 7+ criterion for hypersexuality, with considerable variation by age, relationship status, sex, and less variation by wording of the question. Results are discussed in terms of the applicability of the 7+ cut-off for identifying elevated TSO. Results from this survey could be useful to researchers and clinicians looking for comparison data for their research and clinical assessment results.

Psychometric Properties of Common Measures of Hypersexuality in an Online Canadian Sample.

BACKGROUND: Hypersexuality has been posited as the central defining feature of Compulsive Sexual Behavior Disorder, and although the acceptance and inclusion of this construct in psychiatric nosologies provides some legitimacy, concerns surrounding terminology, assessment, and diagnosis remain. AIM: The present study was an independent psychometric examination of 2 of the most commonly used measures of Compulsive Sexual Behavior Disorder; specifically, the gender invariance of the latent structure, reliability (test retest, internal consistency), and external correlates (concurrent validity) of these measures. METHODS: The Sexual Compulsivity Scale and the Hypersexual Behavior Inventory were completed by 2 nonclinical online community samples of cisgender women (ns = 525 and 359), cisgender men (ns = 419 and 364), and transgender or non-binary individuals (ns = 38 and 11). OUTCOMES: Criterion based measures of sexual history and total sexual outlet (number of orgasms per week) were gathered to validate Sexual Compulsivity Scale and Hypersexual Behavior Inventory total and factor scores. RESULTS: Results supported the factorial validity of both assessment measures: correlated 3 factor solutions were established through exploratory factor analysis of 1 sample, and confirmatory factor analysis in the second sample. Multiple group confirmatory factor analysis, conducted on the 2 combined samples, also supported the gender invariance of the 3-factor solutions. Additional basic psychometric indices of test-retest and internal consistency reliability and criterion-related (concurrent) validity conducted across the 2 online samples were supported. CLINICAL IMPLICATIONS: Common measures of hypersexuality have potential for use in its assessment, treatment, and management. STRENGTHS & LIMITATIONS: Study strengths include: the inclusion of 2 fairly large and diverse online samples, thorough checks for insufficient effort/validity of responding, validity and reliability methodology (ie, measurement at multiple time points, obtaining behavioral indicators of sexual health), and a comprehensive set of psychometric analyses to inform conclusions regarding the external validity, reliability, and latent structure of hypersexuality measures across gender groups. Study limitations include: potential concerns related to validity and accuracy of responding owing to a reliance on self-report, the potential for selection bias, and limiting the examination of the latent structure of hypersexuality to cisgender men and women such that the results may not generalize to gender diverse populations. CONCLUSION: Hypersexuality is a multidimensional construct, with a common latent structure among cisgender men and women, consistency in measurement over time, and meaningful concurrent associations with behavioral criteria that have relevance for sexual health. Olver ME, Kingston DA, Laverty EK, et al. Psychometric Properties of Common Measures of Hypersexuality in an Online Canadian Sample. J Sex Med 2022;19:331-346.

An examination of latent constructs of dynamic sexual violence risk and need as a function of indigenous and nonindigenous ancestry.

The present study examined latent constructs of dynamic sexual violence risk and need, as measured by the Violence Risk Scale-Sexual Offense version (VRS-SO), as a function of Indigenous ancestry among a Canadian federal sample of 1,063 treated men convicted for a sexual offense. Multigroup confirmatory factor analysis of VRS-SO dynamic items ratings supported a correlated 3-factor oblique solution across Indigenous (n = 393) and nonindigenous (n = 670) groups, corresponding broadly to the domains of sexual deviance, criminality, and treatment responsivity. Associations examined between pre- and posttreatment rated factor scores and sexual and violent recidivism were moderated less by Indigenous ancestry and more by victim profile. Specifically, sexual deviance scores were significantly associated with 5- and 10-year sexual recidivism outcomes among both ancestral groups, but only among men with exclusively child victims. Further, criminality was predictive of all outcomes, particularly violent recidivism, irrespective of ancestry or victim type. Treatment responsivity was significantly predictive of sexual and violent recidivism, but only among men who had an adult victim. Change scores on all 3 factors, while controlling for pretreatment score, were significantly associated with decreased sexual and violent recidivism across ancestry and victim groups. Results underscore a common structure to sexual violence risk that emerges from the VRS-SO for Indigenous and non-Indigenous men and that risk and change scores from the three factor domains have comparable predictive properties across these broad ancestral groups. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A prospective multisite examination of dynamic sexual violence risk: Extension and update to Olver, Nicholaichuk, Kingston, and Wong (2014).

OBJECTIVE: The present study is an extension and update of Olver, Nicholaichuk, Kingston, and Wong's (2014) prospective multisite examination of sexual violence risk and treatment change on a large federal Canadian sample of 570 treated sexual offenders rated pretreatment and posttreatment on the Violence Risk Scale-Sexual Offense version (VRS-SO). METHOD: The present study featured the clinical application of a risk assessment and treatment planning tool, the VRS-SO, with recidivism outcome data updated by 4 years to a total of 10.2 years. VRS-SO change scores, representing reductions in sexual violence risk from treatment or other change agents (e.g., aging), were reanalyzed in terms of their associations with community sexual, violent, and general recidivism postrelease. RESULTS: Recidivism base rates increased with the concordant increase in follow-up time. VRS-SO risk scores significantly predicted all recidivism outcomes, whereas change scores were consistently associated with decreases in sexual and violent recidivism after controlling for baseline risk through bivariate (d = -.24 to -.61) and Cox regression survival analyses (eB = .878 to .938). CONCLUSIONS: The results affirm the dynamic nature of sexual violence risk and demonstrate that structured assessments of change, linked to participation in sexual offense specific treatment, to be associated with decreases in future sexual offending as well as other recidivism outcomes. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

What should be included in the criteria for compulsive sexual behavior disorder?

Compulsive sexual behavior disorder (CSBD) is currently defined in the eleventh revision of the International Classification of Diseases (ICD-11) as an impulse control disorder. Criteria for hypersexual disorder (HD) had been proposed in 2010 for the fifth revision of Diagnostic and Statistical Manual (DSM-5). In this article, we compare differences between HD and CSBD and discuss their relevance.Significant differences between HD and CSBD criteria include: (1) the role of sexual behavior as a maladaptive coping and emotion regulation strategy listed in criteria for HD but not in those for CSBD; (2) different exclusionary criteria including bipolar and substance use disorders in HD but not in CSBD, and (3) inclusion of new considerations in CSBD, such as moral incongruence (as an exclusion criterion), and diminished pleasure from sexual activity. Each of these aspects has clinical and research-related implications. The inclusion of CSBD in the ICD-11 will have a significant impact on clinical practice and research. Researchers should continue to investigate core and related features of CSBD, inlcuding those not included in the current criteria, in order to provide additional insight into the disorder and to help promote clinical advances.

Understanding the Latent Structure of Hypersexuality: A Taxometric Investigation.

We examined the latent structure and taxonicity of hypersexuality in large university and community samples of male and female respondents. Participants completed the Hypersexual Behavior Inventory (HBI) and Sexual Compulsivity Scale (SCS), each as part of larger anonymous online surveys of sexual behavior. Exploratory factor analyses (EFA) were performed in part to prepare the data for taxometric analysis and also to identify the putative dimensions underpinning each measure. Three latent dimensions were identified from each of the Sexual Compulsivity Scale (dyscontrol, consequences, and preoccupation) and Hypersexual Behavior Inventory (coping, dyscontrol, and consequences). Taxometric analyses of the generated factors using mean above minus below a cut (MAMBAC), maximum covariance (MAXCOV), and latent mode factor analysis (L-Mode) broadly supported a dimensional latent structure for hypersexuality, particularly in female participants. Implications pertaining to the assessment of hypersexuality are discussed.

Diagnostic Issues in the Paraphilias.

PURPOSE OF REVIEW: To examine the empirical bases underlying the diagnoses of the paraphilias. We address issues concerning the reliability of these diagnoses and their implications for etiology, treatment, and prognosis. RECENT FINDINGS: Research on these issues with the paraphilias is quite limited except for those paraphilics whose interests lead them to sexually offend. Even among these clients, research has, for the most part, failed to distinguish those who meet criteria for a paraphilia from those who do not, thereby limiting the possibility of drawing firm conclusions regarding the value of a paraphilic diagnosis. Speculations regarding the etiology of the paraphilias are for the most part limited to those who sexually offend and these theories do not distinguish those who do, or do not, meet paraphilic criteria. Treatment of sex offenders, when effective, appears to have the same impact regardless of whether or not clients meet criteria for a paraphilia. In terms of prognosis, it was only among untreated child molesters that a paraphilic diagnosis (in this case "pedophilia") predicted long-term outcome. In the face of these problems, we suggest a dimensional approach to diagnoses may represent an improvement over the current categorical model.

Using the Violence Risk Scale-Sexual Offense version in sexual violence risk assessments: Updated risk categories and recidivism estimates from a multisite sample of treated sexual offenders.

The present study sought to develop updated risk categories and recidivism estimates for the Violence Risk Scale-Sexual Offense version (VRS-SO; Wong, Olver, Nicholaichuk, & Gordon, 2003-2017), a sexual offender risk assessment and treatment planning tool. The overarching purpose was to increase the clarity and accuracy of communicating risk assessment information that includes a systematic incorporation of new information (i.e., change) to modify risk estimates. Four treated samples of sexual offenders with VRS-SO pretreatment, posttreatment, and Static-99R ratings were combined with a minimum follow-up period of 10-years postrelease (N = 913). Logistic regression was used to model 5- and 10-year sexual and violent (including sexual) recidivism estimates across 6 different regression models employing specific risk and change score information from the VRS-SO and/or Static-99R. A rationale is presented for clinical applications of select models and the necessity of controlling for baseline risk when utilizing change information across repeated assessments. Information concerning relative risk (percentiles) and absolute risk (recidivism estimates) is integrated with common risk assessment language guidelines to generate new risk categories for the VRS-SO. Guidelines for model selection and forensic clinical application of the risk estimates are discussed. (PsycINFO Database Record

A randomised controlled trial of a cognitive skills programme for offenders with mental illness.

BACKGROUND: Interventions for offenders with mental illness have tended to be confined to treatment of illness, with the expectation that symptom reduction will be accompanied by reduced criminal recidivism, but recent evidence suggests that other treatment targets may be more effective against recidivism. AIM: The aim of this study was to examine the effect of a cognitive skills programme (Reasoning and Rehabilitation 2: Short Version for Adults [R&R2]) among offenders with mental illness. Our first hypothesis was that participation in this programme would result in significantly greater improvement in antisocial attitudes than among similar prisoners who did not participate; both groups received "treatment as usual" (TAU). Our second hypothesis was that those receiving R&R2 would show less post-treatment violent or general recidivism than those receiving TAU alone. METHOD: Incarcerated offenders with serious mental illness (N = 101) were randomly assigned to R&R2 or TAU alone. Criminal attitudes and mental state were examined before and after treatment. Violent and non-violent recidivism was measured, on average, 18 months after release. RESULTS: In both intervention and TAU alone trial arms, there were significant pre- to post-treatment changes in criminal attitudes and symptoms or signs of mental disorder. There was no difference between groups in these respects. These pre/post changes were not associated with reductions in recidivism over time, whether or not controlling for baseline risk. CONCLUSIONS: Although there was no demonstrable advantage of R&R2 over TAU alone, non-significant trends towards lower violent recidivism in the R&R2 group and general recidivism in the TAU group suggest that it may be worth repeating the trial in a larger sample with more differentiated control groups.

Construct Validity of the Violence Risk Scale-Sexual Offender Version Instrument in a Multisite Sample of Treated Sexual Offenders.

The present study examined the construct validity of the Violence Risk Scale-Sexual Offender version (VRS-SO) through an examination of its factor structure and convergence with psychological measures assessing conceptually relevant constructs in a sample of 732 treated incarcerated adult male sex offenders. The VRS-SO was rated prospectively pre- and posttreatment by service providers, and several of the men had completed a psychometric battery at each time point. Prospective Stable 2000 ratings were examined for comparison purposes. Results of exploratory longitudinal factor analysis, performed on VRS-SO pre- and posttreatment dynamic item scores, supported a three-factor model (comparative fit index = .990) and the measurement invariance of the loadings over time. A stringent longitudinal confirmatory factor analysis of the VRS-SO items also supported the three-factor structure. Scores from the three factors (Sexual Deviance, Criminality, and Treatment Responsivity) were correlated in conceptually meaningful ways with scores from the Stable 2000 and selected psychometric measures. The results provide evidence for the construct validity of VRS-SO test scores as providing an index of sex offender risk and, more specifically, that its item content and factor domains measure psychological constructs pertinent to sex offender risk and need.

Predictive Accuracy of Violence Risk Scale-Sexual Offender Version Risk and Change Scores in Treated Canadian Aboriginal and Non-Aboriginal Sexual Offenders.

The present study examined the predictive properties of Violence Risk Scale-Sexual Offender version (VRS-SO) risk and change scores among Aboriginal and non-Aboriginal sexual offenders in a combined sample of 1,063 Canadian federally incarcerated men. All men participated in sexual offender treatment programming through the Correctional Service of Canada (CSC) at sites across its five regions. The Static-99R was also examined for comparison purposes. In total, 393 of the men were identified as Aboriginal (i.e., First Nations, Métis, Circumpolar) while 670 were non-Aboriginal and primarily White. Aboriginal men scored significantly higher on the Static-99R and VRS-SO and had higher rates of sexual and violent recidivism; however, there were no significant differences between Aboriginal and non-Aboriginal groups on treatment change with both groups demonstrating close to a half-standard deviation of change pre and post treatment. VRS-SO risk and change scores significantly predicted sexual and violent recidivism over fixed 5- and 10-year follow-ups for both racial/ancestral groups. Cox regression survival analyses also demonstrated positive treatment changes to be significantly associated with reductions in sexual and violent recidivism among Aboriginal and non-Aboriginal men after controlling baseline risk. A series of follow-up Cox regression analyses demonstrated that risk and change score information accounted for much of the observed differences between Aboriginal and non-Aboriginal men in rates of sexual recidivism; however, marked group differences persisted in rates of general violent recidivism even after controlling for these covariates. The results support the predictive properties of VRS-SO risk and change scores with treated Canadian Aboriginal sexual offenders.

Relations Between Self-Reported Adverse Events in Childhood and Hypersexuality in Adult Male Sexual Offenders.

Hypersexuality, or extreme normophilic sexual urges and behaviors, is a controversial construct that was recently considered as a candidate disorder for the DSM-5 and was rejected. It was also rejected for inclusion in Section III (Conditions for Further Study). Nonetheless, it has been found to be an important predictor of recidivism among sex offenders, and it continues to be discussed widely in the literature. In the present study, we investigated the developmental roots of this construct in a sample of 529 adult male sexual offenders, who were administered the Multidimensional Assessment of Sex and Aggression. Physical, psychological, and sexual abuse experiences were estimated using several scales of early development. Psychological abuse in childhood and adolescence, especially by a father, was found to be the most prominent predictor of subsequent hypersexual thoughts and behaviors. The accumulation of abuse types, however, was also associated with a monotonic increase in the latent trait of hypersexuality. The consequences of these results for conceptualizations of the construct are discussed.

Sex Offender Risk Assessment and Management.

Sexual violence is common and can have profound effects on victims compared with other forms of violence. This violence includes unwelcome and forced sexual contact on adults or children. Assessment of individuals who perpetrate sexual violence starts with a comprehensive biopsychosocial evaluation after a finding of guilt. Clinicians should then evaluate risk. Based on this assessment, a risk management plan should be developed, directed at the specific risk of the offender. Management options include external control (eg, incarceration, probation), psychotherapeutic interventions, pharmacologic interventions, and treatment of comorbidity. This organized approach aids in reducing the risk of future sexual violence.

Nudity as a Disinhibiting Cue in a Date Rape Analogue.

Situational factors likely play a role in date rape. The sexual inhibition hypothesis suggests that men are typically sexually inhibited by violence and non-consent, but that inhibition can also be disrupted. We attempted to determine if female nudity reduces inhibition of sexual arousal to non-consensual cues in sexually non-aggressive men. In two studies, heterosexual men (aged 18-25) were presented with six 2-min audiotaped narratives depicting consensual sexual interactions, non-consensual sexual interactions (rape), and non-sexual interactions (neutral) involving a man and a woman. In the first study, 20 participants saw pictures depicting nude or clothed women while listening to the stories. In the second study, 20 other participants saw videos depicting nude or clothed women exercising, also while listening to the stories. Genital responses and subjective sexual arousal were measured. Results suggested that nudity may have a disinhibitory effect on sexual arousal to non-consensual cues, but only when presented in the form of moving images.

A psychometric examination of treatment change in a multisite sample of treated Canadian federal sexual offenders.

In the present study, we examined the degree of change and predictive accuracy of a number of well-known psychological self-report measures intended to identify treatment targets for sexual offenders. Participants included 392 federally incarcerated sexual offenders who participated in low, moderate, or high intensity sexual offender programs offered within penitentiaries under the jurisdiction of the Correctional Service of Canada. These men were followed in the community for an average of 5.42 years postrelease. Very small to moderate pretreatment and posttreatment changes were found on measures of cognitive distortions, aggression/hostility, empathy, loneliness, social intimacy, and sex offender acceptance of responsibility. However, pretreatment and posttreatment scores on these measures frequently demonstrated weak and inconsistent relationships to sexual, violent, and general recidivism. In addition, within-treatment change on these measures bore little relationship to outcome. However, when statistically corrected for pretreatment score the relationship of treatment change to outcome frequently improved, particularly on measures of physical aggression and anger, even after controlling for Static-99R score. Clinical and research implications are discussed regarding the assessment and evaluation of change on psychological risk factors in treated sexual offenders.

Assessment of the paraphilias.

Paraphilias are recurrent, persistent, and intense sexual interests in atypical objects or activities. The most commonly encountered paraphilias in sexological or forensic settings are pedophilia, sexual sadism, exhibitionism, and voyeurism. Paraphilias are often comorbid with other sexual, mood, and personality disorders. Assessment and diagnosis require an integration of multiple sources of clinical information, given the limits and biases of self-report (through clinical interview or questionnaires). Clinicians ideally have access to more objective assessment methods, such as phallometric testing of sexual arousal. The accurate assessment and diagnosis of paraphilias is essential to effective treatment and management.

A multisite examination of sexual violence risk and therapeutic change.

OBJECTIVE: We conducted a prospective multisite examination of sexual offender risk and treatment change on a large federal Canadian sample of 676 treated sex offenders followed up for an average of 6.31 years post release. METHOD: The present study featured the clinical application of a risk assessment and treatment planning tool, the Violence Risk Scale-Sexual Offender version (VRS-SO; Wong, Olver, Nicholaichuk, & Gordon, 2003). The VRS-SO was rated pre- and posttreatment by sex offender treatment providers on the sample of men who were attending institutionally based sex offender programs across the 5 regions of the Correctional Service of Canada. The Static-99 (Hanson & Thornton, 1999) was also rated as part of routine services, and the Static-99R was used for substantive analyses. RESULTS: The VRS-SO dynamic factors and the Static-99R demonstrated significant predictive accuracy for sexual, violent, and general recidivism (area under the curve = .65 to .78). Significant pre-post changes on the VRS-SO dynamic factors were observed, ranging from small to moderate in magnitude (d = 0.22 to 0.62) across low, moderate, and high intensity programs. The change scores, in turn, were associated with decreases in the 3 recidivism outcomes; the majority of relationships examined attained significance after partialing out of pretreatment scores. Cox regression survival analyses, controlling for pretreatment risk, further demonstrated change scores to have associations with postrelease recidivism outcomes to varying degrees. CONCLUSIONS: The results are consistent with the dynamic nature of sexual violence risk and suggest that risk-relevant changes associated with participation in sexual offender treatment are linked to reductions in sexual offender recidivism.