The Diagnostic and Statistical Manual (DSM-5) (1) introduced a new sub-category named “Non-substance-related disorders” included in the category “Substance-Related and Addictive Disorders.” This sub-category includes an addictive disorder not involving substance use, the Gambling Disorder. Apart from the inclusion of the “Gambling Disorder” (F63.0), the DSM-5 committee members considered other conditions such as Internet-gaming disorder (2) or hypersexuality disorder (3, 4). Finally, although several DSM-5 working groups (5) proposed to include the Hypersexual Disorder in the manual. Its inclusion was rejected, and nor was this nosological entity incorporated in the Section III (reserved for conditions that require further study), due to multiple reasons, including the lack of data in important areas (6).

Hypersexuality has been described as a non-controlled pattern of recurrent, intense, and excessive preoccupation with sexual behavior, urges and fantasies that causes adverse consequences and significant psychological distress (5, 7). However, the research suggests the theoretical conceptualizations of hypersexuality, are unlikely to provide a complete description to the diverse presentations and experiences of the condition, and that hypersexuality is diverse, complex and most likely relate to a range of risk factors present across individuals (8).

Similarly, compulsive sexual behavior (CSB) was defined classically as repetitive behaviors mediated by the behavioral attempts to reduce anxiety and other dysphoric affects (e.g., shame and depression) with an underlying obsessive component (9). Despite of the active scientific discussion about whether disorder constitutes a behavioral addiction (10), it has not been included in the International Classification of Diseases 11th (ICD-11) addictive disorders category but in the Impulse Control Disorder category (11). In this classification, the problem is defined as a persistent pattern of failure to control sexual impulses, resulting in repetitive sexual behavior over a prolonged period (6 months or more) that causes marked discomfort in personal, family, social, school, work, or in other functional areas (12).

Mental health professionals recognize the problematic sexual behavior as a problem with clinical relevance. The increase in this demand is congruent with the increased awareness shown by different groups such as health workers, politicians, educators, and researchers. There is a lack of studies involving large samples and the real prevalence of CSB remains unclear. However, according to the Society for the Advancement of Sexual Health (2012), the prevalence of CSB among the general United States population is between 3 and 6%. In line with this, some studies estimate rates of 3–6% (5), mainly affecting adult males (80% or more) (13). Moreover, there is growing evidence of the potentially serious consequences of not treating this condition (14), including emotional and relational problems and risky sexual behaviors leading to sexually transmitted infections such as HIV/AIDS, as well as physical injuries (15, 16). Among male treatment seekers, the most reported clinical associated behaviors are pornography use, compulsive masturbation, various sexual partners, casual/anonymous sex encounters with strangers, and prostitution consumption (13, 17, 18).

Since the popularization of the Internet, new forms of sexual behaviors have emerged (10). This technology has allowed the practice or consumption of sex in new ways (such as online pornography, online sexual chatting, and sexting), causing problems among a small but significant part of the population. Consequences of the problematic online sexual practices are similar to the in-person form and include risky sexual behaviors (19), professional and financial problems (20), interpersonal isolation (21), and online compulsive sexual behavior (OCSB) (22, 23). Less clear is the relationship between problematic online sexual practices and offline sexual difficulties (such as erectile disorder, premature ejaculation, excitation disorder, sexual pain disorder, or orgasmic disorder), some reviews finding that the use of online sexual content can condition sexual arousal causing difficulties (24), while others showing contradictory data and no causal relationship (25).

Although several studies have explored CSB (26–28), the correlates among OCSB symptoms and sociodemographic, psychopathology, and personality variables has rarely been investigated in clinical groups. The few studies analyzing this question have found that, with respect to demographics, CSB is associated with being male (29). Despite these results in clinical population, it is not clear if CSB is gender–specific, the majority of research in general population is based on studies with male samples, and little studies has been performed on CSB in women (30–32). When gender-representative studies have been done in general population, that gender differences are less pronounced (2–3 men with CSB to every 1 woman ratio).

Regarding psychopathology, although studies focusing on CSB or “sex addiction” do not consider whether the behavior is in-person or online, results show comorbidity with anxiety and depression (33, 34), and with other addiction problems, including substance abuse or problem gambling (13, 35). Post-traumatic stress and traumatic episodes also seem to be related to excessive sexual behavior (35). Finally, with respect to personality traits associated to CSB, some authors have related the disorder with high novelty seeking and low self-directedness (36). However, the personality factors involved in its development and maintenance remain scarcely explored.

Taking into account the existing literature with respect to CSB, we can conclude that most of the previous studies did not separate in-person from online behavior. Moreover, most of the previous data have been conducted in non-clinical settings and is based on surveys. Given the scarcity of research performed in clinical samples, the purpose of this study was to identify socio-demographic, sexual behaviors, sexual problem severity, psychopathology, and personality characteristics associated with CSB and OCSB patients from a clinical setting, as well as to compare them with a healthy control group. These analyses can help in the conceptualization of patients consulting for CSB, and these comparisons among individuals can contribute to clarifying some of the results found in previous research regarding clinical profiles, and can help to improve the clinical treatments.

The purpose of this study was to evaluate the clinical, personality and socio-demographic characteristics of patients diagnosed with CSB or with OCSB using a case-control design; and to compare both clinical groups on socio-demographics, sexual behavior, sexual problem severity, psychopathology and personality characteristics. A sample of 87 patients was recruited from a Behavioral Addictions unit at an urban mental health center in Barcelona.

As in previous studies (18), when compared to healthy controls, both experimental groups showed higher psychopathology, psychological problems in all measures and higher CSB. As observed in other studies (51), it may be that the reason for consultation is sexual behavior and, after psychopathological examination, a psychiatric pathology is detected. According to this, the presence of CSBs might be indicative of the need of an in-depth examination of other Axis-I pathologies that might otherwise go unnoticed.

With regard to personality, compared to healthy controls, patients scored higher in harm avoidance and self-transcendence, and lower in self-directness and cooperativeness. This is in line with what was found in the few articles analyzing the personality of this type of patient (52). High harm avoidance has been associated with affective disorders, anxiety disorders, and substance abuse (41). Moreover, these personality profile, combined with high impulsivity, is similar to those found in other behavioral addictions and substance addictions, where the results of many studies showed that patients with gambling disorder scored significantly higher on the temperament dimension harm avoidance; whereas they scored significantly lower on the character dimensions Self-Directedness and Cooperativeness (53–55). Even so, there are some differences with gambling disorder patients, for example, there is no difference with respect to controls on the novelty seeking scale. Other authors (52) have found a similar results in CSB subjects where openness to experience was not found to predict hypersexual behavior. This personality profile could indicate that compulsive sex could be more related to a coping strategy than to an intention to live new experiences, that these types of patients have little control regarding their sexual behaviors, and that they will continue to carry out these behaviors to in spite of the negative consequences that can be caused to them.

In respect of, self-transcendence, which measures the spiritual behavior of each individual (characteristics of spirituality, mysticism, magical, and religious thoughts) has been found to be higher in the clinical groups. This result is in line with other studies where the authors found higher religious believes in CSB population (56), and in contrast with authors founding a total absence of religious beliefs in similar samples (57). The restrictive morality of some religions with respect to sexual behavior could cause the individual to consider their sexual behavior out of control when compared with the “rules” of the religion that is lived. In this sense, some authors have suggest that emotions like guilt and shame may temporarily inhibit some sexual behaviors in hypersexual persons’, but those only act as inhibitors in a short-term due the increased sexual urge and the difficulties in the suppression of this desire (8). It would be of interest to study whether it is morality itself that facilitates this experience, or it is personality traits and their coping strategies that determine the way in which the person understands and incorporates their beliefs.

Finally, the clinical group scored higher in all impulsivity scales. Other authors have found links between CSB and self-report or task related measures of impulsiveness and impulsivity scores (8, 58, 59). Although some authors defend that the CSB is an impulse control disorder, and that the behavior in these patients may be a consequence of a deficit in the inhibitory control system, this type of impulsiveness has also been found in other behavioral additions, specifically in gambling disorder. Therefore, in the future it would be interesting to further explore the mediating relationship of impulsivity in the uncontrolled sexual behavior.

When comparing OCSB patients with non-OCSB, the differences were limited to non-OCSB exhibiting higher physical sexual diseases presence and higher percentage of homosexual and bisexual orientation. Moreover, non-OCSB obtained higher scores in anxiety and in sexual impulse control failure.

In the actual literature, few is known about the relationship between sexual orientation and sexual behaviors in CSB, with some authors finding lower levels of capability to control sexual urges and fantasies, and higher negative consequences of this behavior in gay, bisexual, transgender, and queer (LGTBQ) males (60). Easier access to casual sexual encounters (through cruising, saunas, sex parties…) would facilitate the appearance of the problem, as occurs in other behavioral addictions (e.g., gambling disorder), where it has been found that countries with easier access to this content has higher prevalence of problematic gambling (61).

Even so, considering our findings, the higher percentage of males consulting for any type of CSB were heterosexual. This result is in line with previous studies, suggesting that CSB is more prevalent among men than women, but differs from those authors finding in general population, more prevalence among LGBTQ men than heterosexual men (60, 62–64). It is possible that the stigmatization associated with homosexuality and that the more liberal sexual behaviors that are usually associated with this sexual orientation, lead these people to seek less treatment for this problem, consulting for other comorbid symptoms (i.e., anxiety).

Non-online compulsive sexual behavior patients showed more sexually transmitted diseases (STD). It is plausible that the effortless accessibility, high variety, and the large number of unknown sexual partners that implies the non-OCSB contribute to the uncontrollable engagement in risky sexual activities that lead these patients to develop STD.

Finally, our results have implications for clinical practice. First, both CSB (online and non-online) patients may experience a variety of comorbid psychological and medical problems. Second, the few differences between OCSB and non-OCSB personality traits suggest underlying common vulnerabilities and nosological similarities independently of the sexual behavior type. Even so, our results seem to indicate that people with non-OCSB may suffer more consequences that are negative, and that these may cause more severe comorbid symptoms, therefore, the clinical approach should have these repercussions into account. Whether sexual orientation plays a role in treatment response in CSB, and whether treatment needs differ based on sexual orientation, necessitates further inquiry.

Several methodological limitations to this study need to be taken into account. First, the results are based on a small sample. It is therefore difficult to generalize the conclusions. Second, the participants in the sample are only representative of people who seek treatment, and therefore the findings obtained may not apply to all individuals with CSB. Even so, these results may be of value for patients seeking treatment in relation to CSB. Third, the assessment trough standardized self-administered questionnaires did not allow for in-depth evaluation of specific Axis I and II comorbid disorders, although it should be noted that patients were supervised by a trained psychologist to ensure the highest quality of data collection. Fourth, the retrospective design to determine some sexual behaviors might be confounded by memory biases of the patients.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Ethics Committee of CEIC Fundació Unió Catalana d’Hospitals (CEIC14/71). The patients/participants provided their written informed consent to participate in this study.

DF, VG-B, and JS conceived and planned this manuscript. VG-B and JS carried out the search and revision of the literature, and drafted the study. DF and OC-P analyzed the data. VG-B, JS, OC-P, DF, MB-A, SJ-M, AH, AP-G, and JR revised the manuscript critically for important intellectual content, and commented on and approved the final manuscript and were accountable for all aspects of the work. All authors have read and agreed to the published version of the manuscript.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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