Journal of Affective Disorders 281 (2021) 631–637

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

Hypersexuality and Trauma: a mediation and moderation model from

psychopathology to problematic sexual behavior
Lilybeth Fontanesi a, Daniela Marchetti a, Erika Limoncin b, Rodolfo Rossi c, Filippo M. Nimbi d,
Daniele Mollaioli b, Andrea Sansone b, Elena Colonnello b, Chiara Simonelli d,
Giorgio Di Lorenzo c, Emmanuele A. Jannini b, Giacomo Ciocca b, d, *
a
Department of Psychological, Health and Territorial Sciences, University G. D’Annunzio of Chieti-Pescara, Chieti, Italy
b
Chair of Endocrinology & Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
c
Chair of Psychiatry Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
d
Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: . Hypersexuality is a clinical condition regarding the psychopathology of sexual behavior. In this
Hypersexuality study, we aimed to investigate the role of trauma, through the post-traumatic stress-disorder (PTSD), depression,
Trauma shame and guilt on the hypersexual behavior.
Depression
Methods: . Through an online platform, a convenience sample of 1025 subjects was recruited (females: n=731;
Shame
Guilt
71.3%; males: 294; 28.7%; age: 29.62±10.90). Recruited subjects compiled a psychometric protocol composed
by the Hypersexual Behavior Inventory (HBI) to assess hypersexuality, the International Trauma Questionnaire
(ITQ) for PTSD, the Patient Health Questionnaire (PHQ-9) to evaluate depression and the State Shame and Guilt
Scale (SSGS) for shame and guilt. Then a mediation/moderation model was performed for the data analysis.
Results: . There was a statistically significant direct effect of post-traumatic symptoms (ITQTotal) on hypersexual
behavior (HBTotal). Furthermore, indirect effects were also statistically significant, providing support to the
hypothesis that depression and guilt would be serial mediators of trauma-hypersexual behavior relations. The
paths through depression and guilt have been found to be the most significant with moderate and high indirect
effects on hypersexuality. Moreover, male gender, as covariate variable, is a relevant risk factor for hypersexual
behavior.
Conclusion: . We found the relationship between hypersexuality and trauma describing a possible etiological
pathway mainly involving depression, shame and guilt. Hypersexuality can be considered as a reactive form of a
major affective psychopathology representing a tip of the iceberg hiding the real issues of a suffering personality.
Clinicians and researchers should therefore consider hypersexual behavior in the light of a symptomatic mani­
festation of a major psychopathology involving the affective aspects of personality.

1. Introduction categorize hypersexuality as a disease per se. Conversely, in the eleventh

Hypersexuality is the excess of sexual activities, the obsession of sex
and the related consequences. This condition includes the over­
indulgence to compulsive masturbation, pornography, sexual behavior
with consenting or paid adults, cybersex or telephone sex use, and strip
clubs frequentation (Ciocca et al., 2018b; Kaplan and Krueger, 2010).
The American Psychiatric Association (APA) in the last version of the
Diagnostic and Statistical Manual of Mental Disorder (DSM-5) did not
version of the International Classification of Diseases (ICD-11) hyper­
sexuality was classified as sexual compulsive behavior disorder (CSBD)
(WHO, 2018). These different visions of main nosographic systems
generate a diagnostic mismatch, therefore and clinicians and researchers
are called to better investigate hypersexuality from many points of view
(Ciocca et al., 2018b), such as the comorbid conditions and the concept
of dual diagnosis. For the purposes of this investigation, hypersexuality
is defined as a compulsive attitude towards sexual activities derived

* Corresponding author: Giacomo Ciocca, Researcher of Clinical Psychology, Department of Dynamic and Clinical Psychology, Sapienza-University of Rome, Via
degli Apuli, 1, 00185, Rome, Italy.
E-mail address: giacomo.ciocca@uniroma1.it (G. Ciocca).

https://doi.org/10.1016/j.jad.2020.11.100
Received 3 August 2020; Received in revised form 9 November 2020; Accepted 11 November 2020
Available online 16 November 2020
0165-0327/© 2020 Elsevier B.V. All rights reserved.
L. Fontanesi et al.
from a major psychological suffering (Ciocca, 2020; Ciocca et al.,
2018b).
Some studies, in fact, highlighted this important aspect, being hy­
persexual behavior often associated with other psychopathological
problems (Castellini et al., 2018; Reid et al., 2008).
Thus, clinicians and researchers need to carefully distinguish and
recognize hypersexuality with a correct evaluation and a differential
diagnosis. The excess of sexual activities could be caused by a mood
disorder, as depressive feelings or subclinical depression, conditions not
satisfying DSM-criteria for depressive disorder (Cuijpers et al., 2014).
In this regard, an interesting point of view was debated in the light of
the Freudian idea of life instinct and death anxiety, as profound causes of
a compulsive sexuality. The ratio between death and life drive, Eros and
Thanatos, is a fascinating and speculative theory partially describing
hypersexuality (Ciocca et al., 2018a; Watter, 2018). Moreover, hyper­
sexuality was also described as an addiction disorder, where the
dysfunctional increase of sexual activity manifests together with absti­
nence symptoms as depression and guilt (Orford, 1978). To this purpose,
another recent research has investigated guilt and shame in association
with hypersexuality revealing a contrasting, but complementary role of
these two feelings. However, other authors indicated shame as the
predominant feeling associated with hypersexual behavior (Gilliland
et al., 2011).
Therefore, depression and some related feelings, such as shame and
guilt, were found to be associated with hypersexuality, playing a role of
comorbidity and being possible causal factors of a problematic sexuality.
However, according to both a past and a contemporary psycho­
pathological perspective, the problematic sexuality is often also due to
traumatic experiences (Freud, 2004; Larsen, 2019; Weiss et al., 2019;
Werner et al., 2018). The traumatic events and the post-traumatic stress
symptoms are considered triggering factors in several behavioral dis­
orders and in many forms of psychopathologies (Fusar-Poli et al., 2017;
Rossi R, 2020). More specifically, post-traumatic stress disorder (PTSD)
is a complex psychopathological disease and its symptoms belong to the
anxious/depressive spectrum and somatic correlates (Boscarino, 2004;
Sherin and Nemeroff, 2011). Traumatic events, PTSD, and its symp­
tomatologic consequences can influence psychological well-being over
lifetime and affect many aspects of human existence, as the sexual
behavior. Accordingly, some investigations found an association be­
tween traumatic life experiences and problematic sexuality, in particular
among samples of veterans, and, therefore, in male samples with also
other psychopathological related symptoms (Scoglio et al., 2017;
Turban, 2020).
In the light of these considerations and previous literature findings,
we know peculiar psychological and moral feelings linked to hyper­
sexuality appertaining to depressive symptomatology, as shame and
guilt (Shen, 2018). In this regard, guilt is considered a more adaptative
moral emotion compared to shame. Guilt is mostly related to a specific
event or behavior, while shame is related to a general negative
perception of self (Dearing et al., 2005; Tangney, 2002). Both these
moral emotions are often in correlation with depression and traumatic
symptoms (Kealy et al., 2018; Shen, 2018).
Likewise, the depressive spectrum is a central facet of traumatic life
experience, it can represent the central core of trauma (O’Donnell et al.,
2004). In addition, consolidated evidence, as also review articles,
demonstrated strong associations among stressful traumatic events,
shame and guilt (Cunningham et al., 2018; Cunningham et al., 2017;
Pugh et al., 2015).
Therefore, it is possible to hypothesize a causal relationship between
post-traumatic symptoms related to traumatic events in the past and
hypersexual behavior, with the possible mediation of depressive symp­
tomatology and its related feelings. In other words, post-traumatic
symptoms could affect hypersexuality through different levels of medi­
ation of depression, shame and guilt.
In this study, we aim to evaluate hypersexual behavior starting from
the role of trauma, depression, shame and guilt in a large sample of
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Journal of Affective Disorders 281 (2021) 631–637
young adults.
2. Methods
2.1. Recruitment
Through an online platform, forwarded on the main social networks,
a convenience sample of 1025 people was recruited (females, males, 18-
60 years of age). Subjects have compiled a sociodemographic chart and
five psychometric tests to assess hypersexuality, trauma, depression,
shame and guilt. All participants were informed about the research and
did not receive any financial remuneration for their participation in this
study. Each participant, therefore, gave the own consent for the study
responding to a specific item on the online platform. The entire protocol
was anonymous and our ethics committee approved this study protocol.
2.2. Measures
2.2.1. Sociodemographic characteristics
We collected some basic sociodemographic information about
gender, age, education, nationality, relational status, sexual orientation,
as also anthropometric parameters to assess body mass index (BMI).
2.2.2. Hypersexuality
Hypersexuality was evaluated with the Italian version Hypersexual
Behavior Inventory (HBI)(Ciocca, 2020). The HBI comprises 19 items
along a 5-point Likert scale (1 = Never; 5=Very often). HBI assesses
hypersexuality via three factors. The coping factor (seven items) assesses
sex and sexual behaviors as a response to emotional distress such as
sadness, restlessness, or daily life worries. The control factor (eight
items) assesses the lack of self-control in sexuality-related behaviors,
such as an individual’s attempt to change his or her sexual behavior
fails. The consequences factor (four items) assesses the diverse conse­
quences of sexual thoughts, urges, and behaviors, such as sexual activ­
ities that interfere with educational or occupational duties. An overall
total score is also calculated (HBITotal), where more high scores indicate
a major tendency towards the hypersexual behavior (Bothe et al., 2019;
Reid, 2011).
2.2.3. Post-traumatic symptoms and PTSD
Post-traumatic symptoms and PTSD were evaluated through Inter­
national Trauma Questionnaire (ITQ), a brief self-report which focuses
on post-traumatic stress disorder and complex post-traumatic stress
disorder. The ITQ was developed to be consistent with the organizing
principles of the ICD-11, as set forth by the World Health Organization,
which are to maximize clinical utility and ensure international appli­
cability through a focus on the core symptoms of a given disorder.
ITQ evaluates post-traumatic symptoms referred to a traumatic
event, through six items along a 5-point Likert scale assessing a total
score and the following three domains: Re-experiencing in the here and
now (Re), Avoidance (Av) and Sense of current threat (Th) (Cloitre et al.,
2018; Somma A., 2019).
2.2.4. Depression
Depression is evaluated by the Patient Health Questionnaire (PHQ-
9). It is composed of nine items along a 4-point Likert scale, “0” (not at
all) to “3” (nearly every day). It is one of the most validated tools in
mental health and can be a powerful tool to assist clinicians with diag­
nosing depression (Kroenke et al., 2001; Mazzotti, 2003). It is a useful
tool also to assess the effect of treatments through different levels of
cut-off scores.
2.2.5. Shame and Guilt
Shame and Guilt were assessed with State Shame and Guilt Scale
(SSGS, SS Shame, and SG is for Guilt) a psychometric test evaluating
with eight items along a 5-point Likert scale (1 = not feeling in this way;
L. Fontanesi et al. Journal of Affective Disorders 281 (2021) 631–637

5 = feeling this way very strongly). The sum of four specific items can be variables were all statistically significant amongst them, with positive
used to be detect shame and guilt, respectively, as two different domains correlation. The Pearson correlation coefficient among HBITotal, HBI­
(Cavalera, 2017). Coping, HBIControl, HBIConsequences, ITQTotal, ITQRexeperience,
ITQAvoidance, ITQThreat, PHQ-9, SG and SG were all positive and
2.2.6. Statistical Analysis statistically significant with r values range from medium to small
Continuous variables were statistically represented as means and (Table 2). In particular, the higher correlation of different tests was
standard deviations (SD). Variances of the controls and experimental between ITQTotal and PHQ-9 (r=.440; p<.01), the lower correlation
groups were compared using Student’s T-test for non-matched data, was between HBIConsequences and ITQRexeperience (r=.092; p<.01)
assuming equal variance. Dichotomic variables were represented sta­ (Table 2).
tistically as absolute and percentage frequencies. The difference be­
tween categorical variables was tested using the Chi-Square test or the 3.1. Serial Mediation Model
Fisher’s exact test when appropriate.
A bivariate Pearson correlation was performed to test the level of The model is significant, F(5.1018) = 64.288, p < .001, and
association among the different variables based on psychometric tests explained 24% of the HBITotal variance. There was a statistically sig­
with the related scales and subscales. nificant direct effect of post-traumatic symptoms on hypersexual
A serial multiple mediator model, with three mediators (depression, behavior, confirming our hypothesis that past traumatic events would
shame and guilt), and gender as a covariate was run using Model 6 of predict hypersexuality. Furthermore, indirect effects were also statisti­
PROCESS, Version 2 (Hayes, 2013), as developed by Preacher and Hayes cally significant, except for shame, providing support to the hypothesis
(Preacher, 2004) for SPSS, version 25 (IBM, Armonk, NY), to assess the that depression and guilt would be serial mediators of trauma-
relation between trauma and hypersexual behavior. Serial mediation hypersexual behavior relations, as reported in Table 3 and Fig. 1.
model tests whether multiple mediators account for some or all of the Gender, inserted in the model as covariate, had a direct impact on HBI,
relationship between two other variables. The model with 3 mediators suggesting that the male gender is a risk factor in the rise of hypersexual
(Concept Diagram number 6, Hayes, 2013) representing eight distinct behavior. The paths through depression and guilt have been found to be
effects of X (ITQ) on Y (HBI), seven indirect effects and one direct effect. the most significant with moderate and high indirect effects on hyper­
The seven indirect paths are found by outlining every possible way of sexuality (Table 3).
getting from X to Y through at least one M (PHQ9, SS and SG). All
measures were treated as continuous variables, except for the dichoto­ 4. Discussion
mic covariate “gender” (male/female). PROCESS estimates indirect ef­
fects using bootstrap confidence intervals. In the present study, the This study revealed in a cohort of young adults the predictive role of
bias-corrected 95% confidence interval (CI) was calculated with 5,000 post-traumatic symptoms on hypersexual behavior through the media­
bootstrapping resamples. Theeffects were considered significant when tion roles of depression and guilt. Hypersexual behavior could originate
the resulting confidence interval did not contain 0. Each alpha error from a traumatic core and related symptomatology, as avoidance, re-
lower than 5% indicated statistical significance. experiences, hyperarousal, although our statistical model revealed that
depression feelings play an important role together with a greater
3. Results involvement of the male gender.
Furthermore, the relationship between hypersexuality and depres­
The analysis of data shows in Table 1 the sociodemographic char­ sion is well known by some studies (Kopeykina et al., 2016; Watter,
acteristics together with the mean scores and standard deviations on the 2018), as also the evidence about a greater presence of hypersexuality
total sample at our psychometric considered measures. The socio­ among the male population (Engel et al., 2019a; Engel et al., 2019b),
demographic aspects revealed that the sample is mainly composed of while the association between hypersexuality and post-traumatic
women (71.3%) and subjects in a relationship (65.8%). Through a symptoms was less studied and it results unclear.
pairwise correlation matrix, we found that the considered psychometric On the whole, the relationship between depression and trauma is
strong, as largely demonstrated by other previous investigations (Man­
delli et al., 2015; O’Donnell et al., 2004; Vibhakar et al., 2019), and the
Table 1
Demographics and psychometric characteristics of sample (n=1025).
response to a traumatic event is often characterized by depressive feel­
ings, as in separation or mourning experiences (Bose, 1995; Rotermann,
Variables n;% / mean±SD
2007). Based on these considerations, our research clarifies the trajec­
Gender
Women 731; 71.3 tory from trauma to hypersexual behavior through depression and guilt.
Men 294; 28.7 In other words, if hypersexuality is derived from chronic, transitory or
Relational Status subclinical depressive states, post-traumatic symptoms related to a
Single 351;34.2 traumatic event should be considered the first and main cause deter­
In a relationship 674;65.8
Age 29.62±10.90
mining a problematic sexuality. In fact, the a-specific impact of trauma
Hypersexual Behavior Inventory or childhood trauma on behavioral dependences, through alcohol,
HBITotal 33.15±13.07 drugs, internet, gambling characterized by emotional dysregulation and
HBICoping 14.09±6.46 a lack of impulses control was largely demonstrated (Choi et al., 2014;
HBIControl 11.20±5.34
DK, 2020; Estévez et al., 2017). In this regard, the addiction model is
HBIConsequences 7.86±3.55
International Trauma Questionnaire considered the most valid theory to explain the hypersexual disorder.
ITQTotal 9.30±5.80 The parallelism between hypersexuality and the common addiction
ITQRexeperience 2.90±2.29 disorders was made in the past to demonstrate, as in other forms of
ITQAvoidance 3.39±2.40 addiction, that the hypersexual subject spends a lot of time looking for
ITQThreat 3.01±2.57
Patient Health Questionnaire
novel sexual partners compromising the social and relational life,
PHQ-9 10.44±6.03 without taking into account potential negative consequences as the
State Shame and Guilt Scale sexually transmitted diseases (Ciocca et al., 2018b; Orford, 1978). These
SS 7.53±3.96 dysfunctional phenomena together with risky behaviors related to
SG 7.63±4.37
addiction and hypersexuality have a strong link with the traumatic ex­
SD=standard deviation. periences, as magisterially shown in the famous film “Fathers and

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Table 2
Bivariate correlation between hypersexuality, trauma, depression, shame and guilt measures.
1 2 3 4 5 6 7 8 9 10
1. HBITotal
2. HBICoping .881**
3. HBIControl .829** .523**
4. HBIConsequences .828** .636** .591**
5. ITQTotal .247** .248** .199** .160**
6. ITQRexeperience .154** .160** .122** .092** .787**
7. ITQAvoidance .204** .215** .157** .124** .810** .491**
8. ITQThreat .231** .215** .194** .165** .800** .425** .455**
9. PHQ .402** .406** .288** .307** .440** .286** .337** .423**
10. SS .334** .326** .264** .237** .366** .218** .289** .363** .675**
11. SG .341** .284** .313** .266** .308** .205** .241** .287** .493** .627**
**
p<.001

Table 3
Model coefficients for the serial mediation analysis with gender as covariate.
Path Non-standardized coefficients Standardized coefficients
Estimate (SE) LLCI (95%) ULCI (95%) Estimate (SE) LLCI (95%) ULCI (95%) p
Total effect .648(.068) .515 .781 <.001
Direct effect .236(.070) .099 .373 <.001
Indirect effects:
Total indirect effect .412(.044) .329 .502 .183(.018) .148 .219
ITQ→PHQ-9→HBITotal .288(.043) .207 .376 .128(.019) .02 .160
ITQ→SS→HBITotal .005(.010) -.014 .027 .002(.004) -.006 .012
ITQ→SG→HBITotal .026(.013) .005 .055 .012(.006) .002 .024
ITQ→PHQ9→SS→HBITotal .017(.030) -.040 .077 .007(.013) -.018 .034
ITQ→PHQ9→SG→HBITotal .015(.008) .003 .033 .007(.003) .001 .014
ITQ→SS→SG→HBITotal .015(.007) .004 .030 .006(.003) .002 .013
ITQ→PHQ9→SS→SG→HBITotal .046(.015) .016 .078 .020(.007) .007 .034

Model Summary: R= .490 R2=.240, F(5.1018) = 64.288, p < .001.

Fig. 1. Serial multiple mediation model.

Fig. 1. Serial multiple mediation model, with gender (male=1, female=2) as covariate. X= Independent variable (ITQ); Y= Dependent Variable (HBItot); Mediators:
M1= PHQ-9, M2= SS, M3= SG.
Numbers represent standardized coefficients. Numbers within parentheses are standardized errors. * p < 0.05. ** p < 0.01. ***p < 0.001.

Daughters” by Muccino in 2015 (Muccino, 2015). However, the trau­
matic life events became PTSD according to specific symptomatologic
domains as the re-experience, avoidance and the sense of current threat,
as we have evaluated with the ITQ.
The relationship between post-traumatic symptoms and depressive
feelings was well documented in the literature and also our findings
confirmed the association among post-traumatic stress and depression,
with clinical involvement played by guilt (Cunningham et al., 2017;
Owens et al., 2009). Into this psychopathological manifestation, PTSD
can be considered a trigger element for depression, shame, guilt, and, in
some cases, for hypersexuality, particularly in males.
This psychopathological pathway of hypersexuality is in line with

634
L. Fontanesi et al.
the systems sexology paradigm (Jannini, 2017), a theoretical perspec­
tive considering sexuality as the result of a more complex set of in­
teractions than the traditional bio-psychosocial model. The hypersexual
behavior, in fact, could be the consequence of a past trauma generating
post-traumatic symptoms depressive states and related social impair­
ment. Our data revealed both a direct and an indirect effect of trauma on
hypersexuality with mediation factors of depression and guilt (Sekowski
et al., 2020).
In this regard, the Freudian idea about the strong link between
trauma and sexual behavior is once again confirmed by this study in the
light of many perspectives of contemporary psychopathology affirming
the etiopathogenetic role of trauma (Freud and Breuer, 1895; Kraan
et al., 2015; van der Kolk et al., 1996). In our research, PTSD plays an
impacting and predictive role on hypersexual behavior both alone and
with the mediation role of depression and guilt. A controversial role is
instead played by shame in relation to trauma and hypersexuality.
Shame correlates with both PTSD and hypersexuality, but it has no
mediation role among our main outcome measures.
On the contrary, an influence of shame was found on the guilt
feeling, confirming the more painful role of shame into the moral
emotions that could hierarchically influence guilt and then the sexual
behavior, as our statistical model revealed (Shen, 2018).
However, the most relevant pathway that we found is the trajectory
of trauma towards hypersexuality through the mediation role of
depression. The correlation coefficients among PTSD, depression and
hypersexuality resulted significant in a small-medium range, if consid­
ering the conventional Pearson’s effect size. Moreover, as mentioned,
our analysis demonstrated the etiological link between trauma,
depression and hypersexuality.
A secondary pathway generating hypersexual behavior is related to
guilt. Guilt is a feeling strictly related to both PTSD syndrome and
depression feelings, as literature and clinical practices have often
revealed (Nishith et al., 2005; Owens et al., 2009). Our results suggest
hypersexuality as a possible consequence or pathological evolution of
the correlation among trauma, depression and guilt. On the basis of this
psychopathological perspective, hypersexuality can be considered a
behavioral symptom strongly related to an affective disorder with a
traumatic origin (Kopeykina et al., 2016). Hypersexual behavior is
confirmed to be a tip of the iceberg triggered by a stressful life event
through the mediation of depression and guilt. Then again, other evi­
dence revealed hypersexuality as a consequence of traumatic experi­
ences, such as the exposition to dramatic war or terroristic attack
scenarios, as in the case of veterans or survivors (Moisson et al., 2019;
Turban, 2020). Hypersexuality is in fact considered as a dysfunctional
coping strategy in response to psychological suffering, as PTSD and
depression, especially (Larsen, 2019; Watter, 2018). Therefore, in
several cases, hypersexual behavior should be considered a reactive
form of an affective disorder, although it also represents a dysfunctional
strategy to cope with the psychological internal suffering, related to a
traumatic life event. The hypersexual subject copes the psychological
distress, depression and related feelings, and, obviously the traumatic
experiences and related consequences, as PTSD and guilt, with a dys­
regulated sexual behavior and a problematic sexuality (Ciocca et al.,
2018a). Nosography is controversial in regards to sexual addiction and
sexual compulsivity, as a per se category, but the strong correlation that
we found with PTSD and depression indicates hypersexual behavior as a
symptom and not as a separate disease (Ciocca et al., 2018b; Kafka,
2010, 2014; Potenza, 2017). Therefore, we suggest to consider the true
hypersexuality as a symptomatologic phenomenon of a traumatic con­
dition or a depressive disease, or both of these psychopathologies
together.
On the whole, when researchers and clinicians study or assess a
patient with hypersexual behavior, it is fundamental to thoroughly
investigate the history of traumatic life events, PTSD, depression and
related feelings. In particular, some psychodynamic perspective pointed
out on the treatment focused on the traumatic core and the related
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Journal of Affective Disorders 281 (2021) 631–637
intrapsychic conflicts and defense mechanisms. In this clinical approach
and in the therapeutic relationship the transference plays a pivotal role
to elaborate negative feelings as mistrust, angry, guilt and shame related
to trauma (Busch and Milrod, 2018).
The psychopathological variables correlated to hypersexuality need
to be studied in clinical samples, preferably with case-control designs, to
provide solid evidence. The non-clinical sample that we recruited rep­
resents a limitation of our study together with an unbalanced gender
distribution, although the male-female ratio is comparable to the re­
cruitments on convenience samples. The gender imbalance in the pre­
sent study has been consistently demonstrated, reported, and addressed
in previous research which highlights the proneness of women to
participate in psychological surveys (Saleh and Bista, 2017; Slauson-­
Blevins and Johnson, 2016). Women in fact, give more importance to
their own internal experiences and show more willingness to show their
feelings and emotions. On the other hand, men show relatively less in­
terest in psychological surveys and to open up to others about their in­
ternal states (Galdas et al., 2005; Seidler et al., 2016). However, future
studies on this field of research should also consider the role of
emotional dysregulation in the relationship between trauma and
hypersexuality.
5. Conclusions
In conclusion, our investigation found the relationship between hy­
persexuality and PTSD describing a possible etiological pathway mainly
involving depression, with a secondary role of guilt. Depression and
related feelings seem to be the central core in the relationship between
PTSD and hypersexuality and the clinical interventions should be mostly
addressed towards the internal depressive suffering related to trauma,
although the manifested symptom is the hypersexual behavior. Hyper­
sexuality can be considered now as a reactive form of a major affective
psychopathology derived from a trauma, hiding the real issues of a
suffering personality. Hence, the psychopathology of trauma should be
the main target for the treatment in many cases of hypersexual behavior.
6. Author statement
Fontanesi and Ciocca designed the study and wrote the protocol.
Fontanesi, Ciocca, Marchetti, Limoncin, Colonnello managed the liter­
ature searches and analyses. Ciocca, Fontanesi, Rossi, Mollaioli, San­
sone, and Nimbi undertook the statistical analysis. Ciocca and Fontanesi
wrote the first draft of the manuscript. Jannini, Di Lorenzo, Simonelli
and Ciocca supervised the manuscript. All authors contributed to and
have approved the final manuscript.
7. Role of the funding source
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
None.
Acknowledgments
The authors would like to thank all the University students who
participated at data collection for this study.
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