• Sexual behaviour

At what point does problematic or excessive sex become pathological? In STI and HIV clinic settings, we are familiar with the adverse consequences of having multiple partners which can include increased risk for STIs and HIV, unwanted pregnancies and significant relationship discord and distress. Kafka has recently reviewed the evidence for such excessive non-paraphilic behaviours with a view to a new classification in the American Psychiatric Association's Diagnostic Manual of Mental Disorders due for publication in 2012 (DSM-V).1 He uses the term hypersexual disorder (HD) to encompass all such excessive non-paraphilic behaviour.

In practice in STI clinic settings and elsewhere there is anecdotal evidence of a growing clinical need for services for men and women presenting with self-defined ‘sexual addiction’.2 Recognising an HD is obviously important—not least because therapeutic help may be offered and given. The model proposed by Kafka goes some way in offering taxonomy of how excessive sexual behaviours could be categorised. Kafka3 has reviewed the various pathophysiological models for HD, which includes sexual desire dysregulation, sexual addiction and dependence, sexual compulsivity and impulsive/compulsive disorders. Of particular therapeutic interest is the sexual desire dysregulation, where it is suggested that dysfunctional cerebral monoamines (eg, serotonin) interact with sex hormones to produce a biological substrate associated with increased sexual appetite as well as mood, anxiety and attention-deficit disorders and a propensity to substance abuse. Therapeutic options, which include cognitive-behavioural therapy (CBT) and selective serotonin reuptake inhibitor (SSRI) antidepressants, depend on clinical recognition of cases.

So how does one recognise HD? Kafka3 has suggested that the following diagnostic criteria are useful (see box 1).