Полуструктурированный клинический интервью для оценки компульсивного сексуального поведения (SSCI-CSB): Развитие, надежность и валидность.

Introduction

Compulsive Sexual Behavior (CSB)
1
is a clinical phenomenon characterized by a persistent pattern of failure to control sexual impulses (Kraus et al.  2018 ). As a result, patients with CSB often engage in multiple out‐of‐control sexual behaviors, including excessive pornography use (typically accompanied by compulsive masturbation), casual sex with multiple partners, excessive engagement in paid sexual services, or compulsive sexual intercourse within a stable relationship, among others (Reid et al.  2012 ; Wéry et al.  2016 ). CSB produces a significant personal and psychological distress (Reid et al.  2009 ), as well as problems on various aspects of daily living (McBride et al.  2008 ), ultimately requiring psychiatric and/or psychological treatment to gain control over their sexual behavior (Derbyshire and Grant  2015 ). In recognition of the relevance of this condition and its biopsychosocial impact, The World Health Organization (WHO) included CSB as an impulse‐control disorder in the ICD‐11 (Stein et al.  2020 ).

No consensus exists on the appropriate diagnostic framework for CSB, as this clinical condition has been conceptualized as an addictive disorder (operationalized as SA) (Potenza et al.  2017 ), a sexual disorder (HD) (Kafka  2010 ; Walton et al.  2017 ), an impulse‐control disorder (CSBD) (Kraus et al.  2018 ), an impulsive/compulsive sexual behavior (ICSB) (Coleman et al.  2018 ), or not considered a disorder at all (Moser  2013 ). As a result, various researchers and clinicians have proposed different criteria for the diagnosis of this condition (each proposal emphasizing the hallmarks of their theoretical positions [Carnes et al.  2014 ]). This lack of uniformly agreed‐upon criteria for the diagnosis of CSB hinders its assessment and diagnosis.

Assessment and Diagnosis of CSB

Patients with CSB constitutes a very heterogeneous group in terms of clinical presentation and comorbid features (Kaplan and Krueger  2010 ). The literature has described multiple typologies of patients seeking treatment for out‐of‐control sexual behavior (Reid and Carpenter  2009 ; Sutton et al.  2014 ), in some cases do not qualifying for an actual diagnosis of CSB (e.g., in the cases of moral disapproval of sexual behavior [Bőthe et al.  2025 ]). This means that a subset of patients complaining of out‐of‐control sexual behaviors may do not exhibit the control problems required for a CSB diagnosis, whereas those qualifying for a CSB diagnosis may differ in a myriad of clinical aspects (e.g., main manifestations of CSB, symptoms, clinical course, severity of consequences, response to treatments, comorbid psychopathology, personality profiles, or readiness to change, among many others [Reid  2013 ; Tacchino et al.  2025 ]). This challenges the notion of “ one‐size‐fits‐all ” that has dominated the clinical approaches to CSB diagnosis (i.e., the assumption of CSB as a unitary phenomenon rather than an heterogeneous clinical experience) (Sutton et al.  2014 ). The prime example of this approach is the pervasive clinical and research practice of identifying clinical cases of CSB through self‐report measures assessing a set of pre‐stablished clinical symptoms (Montgomery‐Graham  2017 ). Whereas these instruments are useful as a first approach to the screening of CSB, their use for diagnostic purposes is prone to a variety of issues, including a low diagnostic accuracy (Maraz et al.  2015 ), the difficulty to establish clinically reliably cut‐off scores (Billaux et al.  2023 ), or the overreporting of CSB among those prone to report feeling dysregulated and compulsive in their sexual behavior due to their moral or religious beliefs (Bradley et al.  2016 ).

Against this background, the assessment of symptoms, clinical manifestations, and course of CSB requires fine‐grained assessment approaches to prevent potential problems leading to misdiagnosis (both over‐ and under‐diagnosis) of this condition (Briken et al.  2024 ), ideally through clinical interviews (Kafka  2007 ). Clinical interviews have several advantages in the diagnosis of CSB over other assessment approaches (Womack et al.  2013 ). First, clinical interviews allow a more personal communication between the interviewer and the patient, fostering rapport and more honest answers (Hook et al.  2010 ). Second, the format of a clinical interview lets to obtain more detailed responses and thorough explanations of the patients’ symptoms. Third, in a clinical interview, interviewers are able to ask for clarification using a language near to the patients’ experience, by providing examples, or asking using other words. Fourth, clinicians administering an interview are able to use their clinical judgment to decide whether the patient's symptoms qualify for a CSB diagnosis and determine its severity (instead of using non‐clinically meaningful cut‐off scores, such as in the case of self‐reports). Similarly, the degree to which subjective experience of sexual distress stems from genuine problems in controlling sexual behavior (i.e., dysregulation) rather than from a misalignment between sexual behavior and personal values (i.e., moral incongruency) is more accurately assessed through clinical interview (Kraus and Sweeney  2019 ). As a result, clinical interviews are better suited to diagnose this condition than any other instrument (Womack et al.  2013 ).

Despite their considerable advantages, there are few validated clinical interviews for assessing and diagnosing CSB in the round (Hook et al.  2010 ; Womack et al.  2013 ), and those available are limited in several ways. Extant clinical interviews for assessing CSB include the: (a) Minnesota Impulse control Disorders Interview (MIDI) (Grant  2008 ), (b) Diagnostic Interview for Sexual Compulsivity (DISC) (Morgenstern et al.  2011 ), and (c) HD Diagnostic Clinical Interview (HD‐DCI) (Reid et al.  2012 ). The MIDI barely employs four questions to assess CSB (Odlaug et al.  2013 ), thus calling into question the thoroughness of the symptoms’ examination. A more sound alternative to the MIDI is the DISC (Morgenstern et al.  2011 ). However, temporal stability for the DISC has not been examined yet, and the validation sample used to test its psychometric properties (a community sample of gay and bisexual men in New York) calls into question how this interview would perform in a different and more general sample. The HD‐DCI (Reid et al.  2012 ) is the most recently developed clinical interview for the assessment of CSB. The HD‐DCI was designed to assess the proposed DSM‐5 criteria for HD and presents adequate inter‐rater reliability and test‐retest reliability over a 2‐week period ( r of 0.81). Unfortunately, the HD‐DCI is also limited in several ways: the HD‐DCI is not publicly available (it is only available by personal request) and is mainly focused on examining the presence of CSB symptoms (overlooking important aspects, such as the exploration of the clinical course of the condition). What is more, the HD‐DCI explores which sexual behaviors are problematic based on the DSM‐5 specifiers for HD, a proposal that is outdated (the DSM‐5 specifiers for HD includes sexual behaviors that are uncommon nowadays, such as having telephone sex or visiting strip clubs). Finally, the HD‐DCI is based on the DSM‐5 proposal of criteria for HD. Despite the common use of these criteria in clinical settings (Grubbs et al.  2020 ), HD was finally rejected for inclusion in the DSM‐5 by the Board of Trustees of the APA (Kafka  2014 ), meaning that the HD‐DCI explores a set of criteria that have been not officially recognized.

The Present Study

Given the heterogenous clinical presentation of CSB, the notable complexity of its assessment and diagnosis, and the limitations of the few available clinical interviews, the development of a new clinical interview for CSB was warranted. To address this limitation, we developed the Semi‐Structured Clinical Interview for the assessment of Compulsive Sexual Behavior (SSCI‐CSB), an interview that gathers information on the main manifestations, symptoms, and clinical course of CSB. The aim of this study is to describe the development of the SSCI‐CSB and present data on its reliability and validity in a sample of patients seeking treatment for out‐of‐control sexual behavior.

Materials & Methods

Development and Characteristics of the SSCI‐CSB

The primary purpose of the SSCI‐CSB was to design a comprehensive measure of CSB that fully covered all the symptoms of this condition, that minimized the likelihood of false‐positive diagnoses, and individually administrable in no more than a 90‐min session. To address these aims, we used the following procedure. In 2017, one of the authors with both clinical and research experience in CSB (JCC) reviewed available measures of out‐of‐control sexual behavior and the different proposals of diagnostic criteria, with a particular focus on the symptoms covered and wording. The main goal of this review was to identify the CSB symptoms typically covered by the existing instruments and the items formats in order to inform the design of the SSCI‐CSB. Based on this review, a first version of the SSCI‐CSB was generated. This first draft was revised by the principal investigator of the study (RBA) and then distributed among four experts with experience in the assessment and treatment of CSB. The resulting preliminary version of the SSCI‐CSB was administered to a reduced group of patients seeking treatment for CSB, who provided feedback regarding the clarity, understandability, and face validity of the interview (i.e., the extent to which they considered that the SSCI‐CSB fully covered the manifestation of their condition). This pilot testing produced minor changes on the wording of the SSCI‐CSB and resulted in its definitive version (the SSCI‐CSB is publicly available on https://osf.io/hfu3y [Spanish and English version] 2 and in supplemental material).

The SSCI‐CSB is broken down into four separate sections: (a) section I (focused on the assessment of the patient's sexual outlet during the last 6 months), (b) section II (assessing the diagnostic criteria for CSB), (c) section III (exploring the onset and clinical course of the condition), and (d) section IV (summary of results and diagnosis).

The SSCI‐CSB first investigates the patient's sexual outlet in order to determine which sexual behaviors should be the focus of the assessment. Individuals with CSB usually display a variety of sexual behaviors, of which only a subset constitutes the actual focus of sexual problems (Wéry et al.  2016 ). As we cannot assume that CSB involves all the sexual behaviors displayed by the patients, we may first characterize their sexual behavior and determine which may be problematic. To address this aim, the SSCI‐CSB covers eight sexual behaviors: (1) pornography use, (2) sexual exchanges with other users (including chat or webcam), (3) searching for romantic or sexual partners online (e.g., dating apps), (4) masturbation while sexual fantasizing, (5) casual sex offline, (6) casual sex offline with someone other than their monogamous partner (i.e., infidelity), (7) sexual intercourse within a stable relationship, and (8) engagement in paid sexual services. These sexual behaviors constitutes the more common behavioral manifestations of CSB (Ballester‐arnal et al.  2021 ; Gola et al.  2022 ; Kafka  2010 ; Reid et al.  2012 ; Wéry et al.  2016 ). To determine whether these behaviors may—or not—be potentially problematic, the SSCI‐CSB asks the following questions for each sexual behavior: (a) engagement in the sexual behavior in the last 6 months (“Yes/No;” if the patient answers negatively, the interviewer skips to the next sexual behavior); (b) percentage of sexual behavior (subjective estimation of the percentage of the whole sexual behavior that represents the engagement in this activity); (c) time invested per week (in minutes); (d) orgasms per week (frequency of weekly orgasms resulting from this particular behavior); (e) subjective appraisal of discomfort with the sexual behavior (from 0 [“total comfort”] to 10 [“total discomfort”]); and (f) subjective appraisal of control over the sexual behavior (from 0 [“total lack of control”] to 10 [“total control”]). These questions provide critical information about the sexual behaviors most relevant to the respondent's current sexual problems.

Section II is focused on the assessment of core and peripheral criteria for CSB. This section of the SSCI‐CSB parallels the format of well‐stablished structured clinical interviews (such as the Structured Clinical Interview for DSM [First et al.  2016 ]). The interview questions are worded mirroring the diagnostic criteria aimed to assess, but in a format that is easy to understand and near to the patient's experience. Each criterion is explored by a central question and multiple follow‐up questions. The SSCI‐CSB assesses all the criteria proposed by the three most prominent conceptualizations of CSB (i.e., the DSM‐5 criteria for HD [Kafka  2010 ], the ICD‐11 diagnostic guidelines for CSBD [Kraus et al.  2018 ], and the SA criteria proposed from the addiction framework [Carnes et al.  2014 ; Goodman  1992 ]). The 16 criteria assessed by the SSCI‐CSB and the rationale behind their inclusion are presented in Table  1 .

TABLE 1 Diagnostic criteria for CSB assessed in the SSCI‐CSB and their correspondence to different conceptual frameworks. Domain Description of the criteria DSM‐5 criteria for HD (Kafka  2010 ) ICD‐11 diagnostic guidelines for CSBD (Reed et al.  2022 ) Carnes's et al. criteria for SA (Carnes et al.  2014 ) Goodman's criteria for SA (Goodman  1992 ) Excessive dedication to sexual behavior
Criterion 1. Excessive investment of time and/or effort on the problematic sexual behavior to the point of interfering with or neglecting important goals, activities, and responsibilities.
√

√

√

√
Loss of control over sexual behavior
Criterion 2. Recurrent failure to resist impulses to engage in the problematic sexual behavior. □
√

√

√

Criterion 3. Repeated but unsuccessful efforts to control, significantly reduce, or stop the problematic sexual behavior.
√

√

√

√

Criterion 4. Frequent engagement in the problematic sexual behavior to a greater extent or over a longer period than initially planned. □ □
√

√
Interference due to the sexual behavior
Criterion 5. Clinically significant personal distress and impairment in important areas of functioning associated with the frequency and intensity of the problematic sexual behavior.
√

√

√
□
Criterion 6. Continuous engagement in the problematic sexual behavior despite knowledge of the adverse consequences caused or exacerbated by this behavior.
√

√

√

√

Criterion 7. Giving up or limiting social, occupational, or recreational activities because of the problematic sexual behavior. □
√

√

√

Criterion 8. Frequent engagement in the problematic sexual behavior when expected to fulfill occupational, academic, domestic, or social obligations. □ □
√

√
Coping through sexual behavior
Criterion 9. Repetitively engaging in the problematic sexual behavior in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability).
√
□ □ □
Criterion 10. Repetitively engaging in the problematic sexual behavior in response to stressful life events.
√
□ □ □ Criteria recycled from substance use disorders
Criterion 11. Tolerance (i.e., need to increase the intensity or frequency of the problematic sexual behavior in order to achieve the desired effect, or diminished effect with continued sexual behavior of the same intensity). □ □
√

√

Criterion 12. Abstinence (i.e., distress, anxiety, restlessness, or irritability if unable to engage in the problematic sexual behavior). □ □
√

√

Criterion 13. Craving (i.e., strong desire or urge to engage in the problematic sexual behavior) □ □
√

√
Cycle of addiction
Criterion 14. Increasing sense of tension and arousal immediately prior to initiating the problematic sexual behavior (anticipation of pleasure). □ □ □
√

Criterion 15. Intense pleasure or relief at the time of engaging in the sexual behavior followed by a significant worsening of emotional experience (guilt, shame, etc.) shortly after. □ □ □
√
From gratification to compensation
Criterion 16. Continues engagement in the problematic sexual behavior even when the individual derives little or no satisfaction. Engagement in the problematic sexual behavior is explained by a need for relief from the upset of not doing so (transition from a reward‐seeking sexual behavior [gratification] to a compensation sexual behavior). □
√
□
√
John Wiley & Sons, Ltd.

Diagnostic criteria for CSB assessed in the SSCI‐CSB and their correspondence to different conceptual frameworks.

Section III explores the clinical course of CSB. Questions in this section inquire about the age in which the problematic sexual behavior(s) were first conducted, the escalation in the severity of their presentation (“ Insidious ” vs. “ Acute ”), and the subjective appraisal of discomfort and control during the first stages (same format as in the first section of the SSCI‐CSB). Items also ask about the age at which sexual behavior started to be perceived as problematic, awareness of the actual severity of CSB at first stages (“ Yes/No ”), and whether the escalation occurred among four features of CSB (“ Time invested on sexual behavior ,” “ Frequency or intensity of sexual behavior ,” “ Manifestations of sexual behavior ,” and “ Risk related to sexual behavior ”). Finally, items inquire about the presentation of CSB over time (“ Continuous ” vs. “ Episodic ”), severity of current episode (“ Serious ” vs. “ In remission ”), previous experience seeking for counseling and/or professional help for CSB, and previous experience with psychological/psychiatric treatments for CSB. Questions in section III were partially based on the «HD Course Questionnaire» (Reid et al.  2012 ) and the few available studies exploring the natural course of CSB (Castro‐Calvo et al.  2023 ).

Section IV is aimed to guide clinicians in the analysis of the results of the SSCI‐CSB and the establishment of an accurate diagnosis of CSB. The SSCI‐CSB includes a table in which interviewers transfer the results of the interview. To simplify this process, users only indicate whether each criterion is met or not (i.e., the information required to make a diagnosis). The same table includes a decision tree indicating which criteria are required for the diagnosis of CSB according to three most prominent conceptualizations of CSB (i.e., the DSM‐5 criteria for HD [Kafka  2010 ], the ICD‐11 diagnostic guidelines for CSBD [Kraus et al.  2018 ], and the SA criteria proposed from the addiction framework [Carnes et al.  2014 ; Goodman  1992 ]), thus facilitating the elaboration of an accurate diagnosis. Through this decision tree, interviewers are able to verify whether a patient meets or not the symptoms required for a CSB diagnosis according to these diagnostic frameworks. This section of the SSCI‐CSB parallels the format of the section “Summary of results” from the Structured Clinical Interview for DSM (First et al.  2016 ).

Participants and Procedure

Data acquisition for the estimation of the psychometric properties of the SSCI‐CSB was conducted between 2019 and 2022. Participants were patients of a randomized controlled trial (RCT) examining the effectiveness of an Internet‐delivered CBT treatment for CSB. Patients were recruited through referral from psychologists or psychiatrists familiar with the RCT or by self‐referral via promotional pamphlets, newspaper articles, other media coverage, or by the website of the RCT ( https://adiccionalsexo.uji.es/ ). All the patients were: (a) actively seeking treatment for out‐of‐control sexual behavior; (b) Spanish‐speaking (from different Spanish‐speaking countries); and (c) aged 18 years and older.

Respondents to the call for participation in the RCT were screened for eligibility via an initial online survey to determine if they were likely to meet the criteria for taking part in the study. If the initial survey indicated that they were eligible, an appointment for a videoconference was set up for them to meet with one of the clinicians conducting the RCT. Six clinicians (the two authors of the SSCI‐CSB and four therapists previously trained in the administration and correction of the SSCI‐CSB) participated in patients’ assessment. All the therapists were doctoral‐level psychologists working at a university‐based sexual disorder specialty clinic (Salusex). The SSCI‐CSB was administered as a routine assessment during the online admission interviews of the RCT (T1). Patients were encouraged to attend the videoconference from a quiet and private room. On average, the SSCI‐CSB took 90 min to administer, yet patients with more severe clinical pictures or more problematic sexual behaviors may require more time to complete the interview. Participants screening positive for CSB at this initial screening or displaying a high‐risk profile (i.e., patients that did not meet criteria for the diagnosis of CSB but experienced subthreshold symptoms of CSB) were accepted in the RCT. To check test‐retest reliability of the SSCI‐CSB over a 3‐month period, a subset of patients screening positive at the initial screening was included in a waiting list and reassessed 3 months later (T2). Figure  1 provides a detailed description of the study recruitment enrollment.

Flowchart of participants’ recruitment.

A total of 85 patients seeking treatment for CSB (81 men and four women aged between 22 and 67 years old [ X
age  = 36.0]) completed the SSCI‐CSB at the initial screening interview (T1, whole validation sample). Participants’ characteristics at baseline are displayed in Table  2 . Of these patients, 22 were randomly selected and reassessed 3 months later (T2, test‐retest subsample).

TABLE 2 Participants’ characteristics at baseline (T1) ( n  = 85). % ( n ) or M (SD) Sex Male 95.3% ( n  = 81) Female 4.7% ( n  = 4) Age (range 22–67) 36.00 (9.74) Country of residence  a
Spain 70.6% ( n  = 60) Colombia 5.9% ( n  = 5) Mexico 5.9% ( n  = 5) Argentina 3.5% ( n  = 3) Peru 3.5% ( n  = 3) Ecuador 2.4% ( n  = 2) Occupational status Student 9.4% ( n  = 8) Active worker 78.8% ( n  = 67) Unemployed 9.4% ( n  = 8) Other (retired, disabled, etc.) 2.4% ( n  = 2) Religious beliefs Atheist 57.6% ( n  = 49) Practicing believer 12.9% ( n  = 11) Non‐practicing believer 29.4% ( n  = 25)
a
Categories with less than 2% of responses were not included in the table. John Wiley & Sons, Ltd.

Participants’ characteristics at baseline (T1) ( n  = 85).

Categories with less than 2% of responses were not included in the table.

Secondary Measures

Besides the administration of the SCI‐CSB, a comprehensive test battery lasting approximately 45–60 min was administered to all patients at each assessment point. The test battery was administered through Qualtrics via personalized link in order to connect the results from the SCI‐CSB (administered via videoconference) and the results from the test battery (completed online).

The test battery included an ad hoc scale assessing basic sociodemographic information (sex, age, country of residence, education, occupational status, and religiosity), offline sexual behavior (marital status, sexual orientation, engagement in different sexual practices, and frequency of sexual activity), and online sexual behavior (time per week online for sexual purposes, self‐perceived excessive use, and self‐perceived addiction), the Internet Sex Screening Test (ISST) (Ballester‐arnal et al.  2010 ); the Hypersexual Behavior Inventory (HBI) (Ballester‐arnal et al.  2019 ), the Sexual Addiction Screening Test (SAST) (Castro‐Calvo et al.  2018 ), and the Sexual Compulsivity Scale (SCS) (Ballester‐arnal et al.  2013 ). The ISST is a scale focused on measuring compulsive engagement in online sexual activities (Delmonico and Miller  2003 ). The SCS, the HBI, and the SAST are three of the most widely used scales for the assessment of CSB (Turner et al.  2022 ). The HBI and SAST were designed for diagnostic purposes, and have a cutoff score for the identification of patients with a potential clinical picture of CSB (Carnes  1983 ; Reid et al.  2011 ). On the contrary, the SCS conceptualizes CSB as a dimension (a continuum of proclivity to loss control over sexual behavior) (Kalichman and Rompa  1995 ), and its use for diagnostic purposes is less common. All these scales have been translated into Spanish, and different validation studies support their psychometric properties in Spanish samples.

Data Analyses

Data derived from the SSCI‐CSB were analyzed at three levels: (a) at a criterion level (i.e., rating of each criterion as present or absent), (b) at a diagnosis level (i.e., participants’ classification as with or without CSB according to the different diagnostic frameworks included in the SSCI‐CSB), and (c) at a dimensional level (i.e., sum of the number of CSB criteria endorsed [Total SSCI‐CSB score]). The criteria and diagnosis levels implied a categorical approach to data analyses, whereas the total SSCI‐CSB score was analyzed through a dimensional approach.

First, descriptive analyses were conducted to characterize participants in terms of their clinical profile. Second, reliability was evaluated by examining the internal consistency and intra‐rater test‐retest reliability of the SSCI‐CSB. To calculate internal consistency for the entire set of 16 criteria (i.e., at a criterion level), two reliability indices were computed: the ordinal Cronbach's alpha (a) and McDonald's Omega (ω). Both indices were computed on the basis of the polychoric correlation matrix (advised when modeling dichotomous data) through the «Psych» R package.

Intra‐rater test‐retest reliability was examined using the percentage of agreement and the Cohen's Kappa coefficient (or proportion of agreement beyond that expected by chance) (Sim and Wright  2005 ). Both indices were used to assess the agreement between the SSCI‐CSB ratings at T1 and T2 at a criterion level (whether rating of a criterion as present/absent at T1 was consistent at T2) and a diagnosis level (whether classification of a participant as with/without CSB diagnosis at T1 was consistent at T2). Kappa coefficients were interpreted using standard cut‐offs for level of agreement (i.e., 0< poor, 0.01–0.20 slight, 0.21–0.40 fair, 0.41–0.60 moderate, 0.61–0.80 substantial, and >0.81 almost perfect) (Landis and Koch  1977 ). Test–retest reliability was also examined from a dimensional approach correlating (Pearson's r ) the total number of CSB criteria endorsed at T1 and T2.

Third, validity of the SSCI‐CSB was tested by estimating the diagnostic performance of CSB criteria and diagnoses against two external criteria (or reference standards): the HBI and the SAST. Typically, reference standards are tests that provide authoritative—and presumably indisputable—evidence that a condition does or does not exist (Trevethan  2017 ). In the case of CSB, none of the available assessment instruments have enough level of evidence to be considered a “gold standard” (Briken et al.  2024 ). In this context, we relied on some of the most widely employed scales for the assessment of CSB to test the diagnostic performance of the SSCI‐CSB: the HBI and the SAST (Turner et al.  2022 ). Patients scoring ≥ 53 on the HBI (Reid et al.  2011 ) and ≥ 13 on the SAST (Carnes  1983 ) were classified as “with CSB.” Diagnostic performance was assessed with the following indices: (a) sensitivity (i.e., proportion of participants testing positive in the reference standard that are correctly identified by the SSCI‐CSB as having the criterion or the diagnosis); (b) specificity (i.e., proportion of participants testing negative in the reference standard that are correctly identified by the SSCI‐CSB as not having the criterion or the diagnosis); (c) positive predictive value (PPV, i.e., proportion of participants meeting the criterion or the diagnosis in the SSCI‐CSB who also test positive according to the reference standard); and (d) negative predictive value (NPV, proportion of participants do not meeting the criterion or the diagnosis in the SSCI‐CSB who also test negative according to the reference standard) (Trevethan  2017 ).

In a second step, the known‐groups validity of the SSCI‐CSB was examined by comparing the sexual and clinical profile of participants classified as “with” or “without CSB diagnosis.” To compare participants’ characteristics in each group, we performed t tests (continuous variables) and chi‐square tests (categorical variables). Two effect size indices (Cohen's d and Cramer's V ) were computed by using G*Power (version 3.1). For Cohen's d , effect sizes of about 0.20 were considered small, close to 0.50 moderate and greater than 0.80 large (Cohen  1988 ); for Cramer's V , these effect sizes corresponded to values of 0.10, 0.30 and 0.50 (Ellis  2010 ).

Results

Clinical Characteristics

Participants’ clinical characteristics at T1 are displayed in Tables  3 and  4 . The most common problematic sexual behaviors were predominantly online: pornography use (70.6%), use of chat for sexual purposes (47.1%), and use of webcam for sexual purposes (35.3%). Among participants engaging in these sexual behaviors, pornography use and use of chat and webcam for sexual purposes represented the 41.7%, 22.1%, and 18.04% of their sexual outlet and a time investment of around 7.4, 6.46, and 4.29 h per week respectively. The average number of orgasms per week resulting from these three sexual behaviors were 5.96, 2.87, and 2.94 (equaling around 12 orgasms per week). Subjective discomfort associated with these sexual behaviors ranged between 6.15 and 8.05, whereas self‐perceived control was notably low (between 3.18 and 3.99).

TABLE 3 Sexual behaviors assessed by the SSCI‐CSB at T1 ( n  = 85). Sexual behavior a
Engagement in the last 6 months % of sexual behavior b
Time per week (in minutes) Orgasms per week Subjective discomfort Subjective control Endorsement as the primary problematic sexual behavior c
% ( n )
M (SD)
M (SD)
M (SD)
M (SD)
M (SD) % ( n ) Online sexual behaviors Pornography use 98.8% (84) 41.72 (27.20) 443.93 (555.68) 5.96 (3.987) 6.15 (2.96) 3.99 (2.46) 70.6% (60) Use of the chat for sexual purposes 69.4% (59) 22.01 (13.59) 387.72 (680.03) 2.87 (2.67) 7.85 (1.86) 3.80 (2.82) 47.1% (40) Use of the webcam for sexual purposes 54.1% (46) 18.04 (10.74) 257.95 (317.97) 2.94 (2.71) 8.05 (2.29) 3.18 (2.26) 35.3% (30) Searching for sexual partners online 34.1% (29) 13.92 (8.57) 516.52 (900.04) 2.13 (2.07) 7.96 (2.13) 4.01 (2.89) 0% (0) Offline sexual behaviors Masturbation while sexual fantasizing 48.2% (41) 12.92 (12.03) 90.51 (95.80) 3.95 (6.44) 2.48 (2.95) 7.15 (2.52) 1.2% (1) Sexual intercourse within a stable relationship 63.5% (54) 16.73 (12.49) 135.60 (156.49) 2.08 (1.65) 0.45 (1.38) 8.58 (2.07) 0% (0) Casual sex 12.9% (11) 7.70 (5.63) 55.50 (40.03) 1.40 (1.26) 4.00 (3.88) 6.90 (3.31) 8.2% (7) Casual sex with someone other than the monogamous partner (infidelity) 5.9% (5) 6.20 (5.21) 27.00 (52.39) 0.60 (0.89) 6.10 (4.15) 5.00 (3.80) 0% (0) Engagement in paid sexual services 7.1% (6) 11.00 (10.83) 45.00 (76.48) 1.40 (2.07) 6.83 (4.11) 2.66 (2.87) 3.5% (3)
a
Categories with less than 2% of responses were not included in the table.
b
Subjective estimation of the percentage of the whole sexual behavior that represents the engagement in this activity.
c
From all the sexual behaviors endorsed, those representing the primary focus of sexual problems. John Wiley & Sons, Ltd.

Sexual behaviors assessed by the SSCI‐CSB at T1 ( n  = 85).

Categories with less than 2% of responses were not included in the table.

Subjective estimation of the percentage of the whole sexual behavior that represents the engagement in this activity.

From all the sexual behaviors endorsed, those representing the primary focus of sexual problems.

TABLE 4 Endorsement of CSB criteria and diagnoses at T1 ( n  = 85). % ( n )
Criteria endorsement
Criterion 1 (excessive time/effort investment) 52.9% (45) Criterion 2 (failure to resist) 56.5% (48) Criterion 3 (unsuccessful efforts to control) 65.9% (56) Criterion 4 (more engagement than initially planned) 67.1% (57) Criterion 5 (personal distress and impairment) 65.9% (56) Criterion 6 (engagement despite negative consequences) 48.2% (41) Criterion 7 (giving up or limiting important activities) 38.8% (33) Criterion 8 (neglect obligations) 23.5% (20) Criterion 9 (coping with dysphoric mood states) 56.5% (48) Criterion 10 (coping with stressful life events) 44.7% (38) Criterion 11 (tolerance) 52.9% (45) Criterion 12 (abstinence) 35.3% (30) Criterion 13 (craving) 42.4% (36) Criterion 14 (anticipation of pleasure) 41.2% (35) Criterion 15 (negative emotional experience after) 60% (51) Criterion 16 (lack of pleasure/need of relief) 32.9% (28)
Diagnosis endorsement
Diagnosis according to the DSM‐5 criteria 38.8% (33) Diagnosis according to the ICD‐11 diagnostic guidelines 17.6% (15) Diagnosis according to Carnes's et al. criteria 38.8% (33) Diagnosis according to Goodman's criteria 20% (17) John Wiley & Sons, Ltd.

Endorsement of CSB criteria and diagnoses at T1 ( n  = 85).

Of the 16 CSB criteria assessed by the SSCI‐CSB, four were endorsed by ≥ 60% of the participants (e.g., “ more engagement in the problematic sexual behavior than initially planned ” [67.1%] or “ unsuccessful efforts to control the problematic sexual behavior ” [65.9%]). On the contrary, four criteria were endorsed by < 40% of the participants (e.g., “ giving up or limiting important activities due to the problematic sexual behavior ” [38.8%] or “ abstinence ” [35.3%]). At a diagnosis level, between 17.6% and 38.8% of participants were classified as with CSB according to the diagnostic frameworks included in the SSCI‐CSB.

Reliability of the SSCI‐CSB

Internal consistency of the 16 criteria assessed by the SSCI‐CSB at T1 was excellent (α = 0.95; ω = 0.97). A subset of 22 participants at T1 was randomly selected and reassessed with the SSCI‐CSB 3 months later. Results from test‐retest coefficients of agreement comparing SSCI‐CSB ratings at T1 and T2 are shown in Table  5 . At a criterion level (i.e., 3‐month consistency of criteria endorsement), the percentage of agreement ranged from a low of 54.5% (consistency of “ tolerance ” ratings) to a high of 90.9% (e.g., “ neglect obligations ”). Kappa was in the range of substantial to almost perfect agreement ( κ between 0.621 and 0.812) for criterion 2, 8, 9, and 12 (meaning that these criteria were the most stable over time and/or the most consistent as assessed by the SSCI‐CSB). Furthermore, kappa coefficients indicated fair to moderate agreement (i.e., acceptable) in nine additional criteria: criterion 1, 4, 5, 6, 7, 10, 13, 14, and 15 ( κ between 0.318‐581). Finally, agreement between criteria endorsement at T1 and T2 was poor for “ unsuccessful efforts to control sexual behavior ” ( κ  = 0.182), “ tolerance ” ( κ  = 0.113), and “ lack of pleasure/need of relief ” ( κ  = 0.092).

TABLE 5 Concordance of results from the SSCI‐CSB at T1 and T2 ( n  = 22). % of agreement Kappa (95% CI)
Concordance at criterion level
Criterion 1 (excessive time/effort investment) 63.7% 0.318 (0.000–0.645) Criterion 2 (failure to resist) 81.8% 0.621 (0.288–0.908) Criterion 3 (unsuccessful efforts to control) 59.1% 0.182 (0.000–0.486) Criterion 4 (more engagement than initially planned) 72.7% 0.377 (0.000–.744) Criterion 5 (personal distress and impairment) 81.8% 0.506 (0.000–0.879) Criterion 6 (engagement despite negative consequences) 77.3% 0.466 (0.020–0.818) Criterion 7 (giving up or limiting important activities) 72.7% 0.455 (0.032–0.812) Criterion 8 (neglect obligations) 90.9% 0.771 (0.396–1.000) Criterion 9 (coping with dysphoric mood states) 90.9% 0.812 (0.522–1.000) Criterion 10 (coping with stressful life events) 72.8% 0.459 (0.084–0.814) Criterion 11 (tolerance) 54.5% 0.113 (−0.273 to 0.488) Criterion 12 (abstinence) 86.4% 0.723 (0.384–1.000) Criterion 13 (craving) 72.8% 0.455 (0.068–0.814) Criterion 14 (anticipation of pleasure) 81.8% 0.581 (0.140–0.899) Criterion 15 (negative emotional experience after) 77.2% 0.396 (−0.082 to 0.790) Criterion 16 (lack of pleasure/need of relief) 59.1% 0.092 (−0.360 to 0.504)
Concordance at diagnosis level
Diagnosis according to the DSM‐5 criteria 100% 1.000 (1.000–1.000) Diagnosis according to the ICD‐11 diagnostic guidelines 77.3% 0.304 (−0.158 to 0.699) Diagnosis according to Carnes's et al. criteria 72.7% 0.455 (0.039–0.814) Diagnosis according to Goodman's criteria 90.9% 0.614 (−0.065 to 1.000) John Wiley & Sons, Ltd.

Concordance of results from the SSCI‐CSB at T1 and T2 ( n  = 22).

At a diagnosis level (i.e., 3‐month consistency of CSB diagnosis), the percentage of agreement on participants’ classification as with or without CSB at T1 and T2 was appropriate to excellent (between 72.7% and 100% depending on the particular diagnostic framework). In the case of the CSB diagnosis according to the DSM‐5 criteria, all the participants initially classified as with or without CSB at T1 met the same diagnostic category at T2 (100% agreement, κ  = 1.000), thus supporting the robustness of this set of criteria and the temporal stability of its diagnosis through the SSCI‐CSB. Agreement on CSB diagnosis according to the ICD‐11 diagnostic guidelines was lower yet acceptable (77.3% agreement, κ  = 0.304).

The correlation between the number of CSB criteria endorsed at T1 and T2 was positive and significant ( r  = 0.882; p  < 0.001), supporting the temporal stability of the overall results of the SSCI‐CSB when scored dimensionally.

Validity of the SSCI‐CSB

Table  6 gives an overview of the diagnostic performance of each CSB criterion and CSB diagnosis against two reference standards: the diagnosis of CSB according to the HBI and the SAST. At a criterion level, the SSCI‐CSB showed more specificity (average specificity of 71.43% and 63.71%) and PPV (95.25% and 84.54%) than sensitivity (50.88% and 52.52%) and NPV (11.85% and 27.13%). In other words, the SSCI‐CSB criteria performed well at avoiding false positives, but negative results according to the SSCI‐CSB contained positive results according to the HBI and SAST.

TABLE 6 Diagnostic performance of CSB criteria and diagnoses at T1 ( n  = 85). Diagnostic performance against the HBI cut‐off score a
Diagnostic performance against the SAST cut‐off score b
Sensitivity Specificity PPV NPV Sensitivity Specificity PPV NPV
Diagnostic performance at a criteria level
Criterion 1 (excessive time/effort investment) 55.13% 71.43% 95.56% 12.5% 58.21% 66.67% 86.67% 30% Criterion 2 (failure to resist) 61.54% 100% 100% 18.92% 62.69% 66.67% 87.5% 32.43% Criterion 3 (unsuccessful efforts to control) 69.23% 71.43% 96.43% 17.24% 71.64% 55.56% 85.71% 34.48% Criterion 4 (more engagement than initially planned) 67.95% 42.86% 92.98% 10.71% 67.16% 33.33% 78.95% 21.43% Criterion 5 (personal distress and impairment) 67.95% 57.14% 94.64% 13.79% 71.64% 55.56% 85.71% 34.48% Criterion 6 (engagement despite negative consequences) 51.28% 85.71% 97.56% 13.64% 55.22% 77.78% 90.24% 31.82% Criterion 7 (giving up or limiting important activities) 41.03% 85.71% 96.97% 11.54% 43.28% 77.78% 87.88% 26.92% Criterion 8 (neglect obligations) 24.36% 85.71% 95% 9.23% 26.87% 88.89% 90% 26.62% Criterion 9 (coping with dysphoric mood states) 58.97% 71.43% 95.83% 13.51% 61.19% 61.11% 85.42% 29.73% Criterion 10 (coping with stressful life events) 46.15% 71.43% 94.74% 10.64% 46.27% 61.11% 81.58% 23.4% Criterion 11 (tolerance) 53.8% 57.1% 93.3% 10% 58.21% 66.67% 86.67% 30% Criterion 12 (abstinence) 37.18% 85.71% 96.67% 10.91% 37.31% 72.22% 83.33% 23.64% Criterion 13 (craving) 46.15% 100% 100% 14.29% 46.27% 72.22% 86.11% 26.53% Criterion 14 (anticipation of pleasure) 41.03% 57.14% 91.43% 8% 38.81% 47.06% 74.29% 16.33% Criterion 15 (negative emotional experience after) 58.97% 28.57% 90.02% 5.88% 61.19% 44.44% 80.39% 23.53% Criterion 16 (lack of pleasure/need of relief) 33.33% 71.43% 92.86% 8.77% 34.33% 72.22% 82.14% 22.81% Average 50.88% 71.43% 95.25% 11.85% 52.52% 63.71% 84.54% 27.13%
Diagnostic performance at a diagnosis level
Diagnosis according to the DSM‐5 criteria 41.03% 85.71% 96.97% 11.54% 43.28% 77.78% 87.88% 26.96% Diagnosis according to the ICD‐11 diagnostic guidelines 19.2% 100% 100% 10% 20.9% 94.4% 93.3% 24.29% Diagnosis according to Carnes's et al. criteria 41.03% 85.71% 96.97% 11.54% 43.28% 77.78% 87.88% 26.92% Diagnosis according to Goodman's criteria 21.79% 100% 100% 10.29% 22.39% 88.89% 88.24% 23.53% Average 30.76% 92.86% 98.49% 10.84% 32.46% 84.71% 89.33% 25.43% Abbreviations: NPV, Negative Predictive Value; PPV, Positive Predictive Value.
a
Cut‐off score of HBI ≥ 53 (Reid et al.  2011 ).
b
Cut‐off score of SAST ≥ 14 (Carnes  1989 ). John Wiley & Sons, Ltd.

Diagnostic performance of CSB criteria and diagnoses at T1 ( n  = 85).

Abbreviations: NPV, Negative Predictive Value; PPV, Positive Predictive Value.

Cut‐off score of HBI ≥ 53 (Reid et al.  2011 ).

Cut‐off score of SAST ≥ 14 (Carnes  1989 ).

Previous observations are confirmed when exploring the diagnostic performance of the SSCI‐CSB at a diagnosis level. Whereas average sensitivity and NPV of the four CSB diagnosis according to the SSCI‐CSB was low (between 30.76%–32.46% and 10.84%–25.43% respectively), average specificity and PPV was almost perfect (between 84.71%–92.86% and 89.33%–98.49%).

As for known‐groups validity, results comparing the sexual and clinical profile of participants categorized as with or without CSB according to the SSCI‐CSB are displayed in Table  7 . Participants with CSB showed an increased frequency of sexual activity (as expressed by a higher prevalence of participants reporting a TSO ≥ 7 [26.3% vs. 63.4%; V  = 0.37]), scored significantly higher in a scale assessing excessive and problematic engagement in online sexual activities (ISST, d  = 0.56), and showed greater levels of CSB as measured by the HBI ( d  = 0.45), SAST ( d  = 0.52), and SCS ( d  = 0.72).

TABLE 7 Known‐groups validity of the SSCI‐CSB at T1 ( n  = 85). Symptoms scale Without CSB ( n  = 42) With CSB  a ( n  = 43) Inferential statistic Effect size
M (SD) or %
M (SD) or %
Sexual profile: frequency of sexual activity (including masturbation) Total Sexual Outlet (TSO) ≥ 7 26.3% 63.4% χ 2  = 10.94 ***

V  = 0.37 Sexual profile: Online Sexual Behavior Minutes per week devoted to cybersex 571.95 (548.11) 762.81 (743.88)
t  = −1.34
d  = 0.29 Internet Sex Screening Test (ISST, range between 0 and 25) 15.74 (3.02) 17.49 (3.20)
t  = −2.58 **

d  = 0.56 Self‐perceived excessive use (yes) 87.8% 97.7% χ 2  = 3.08
V  = 0.19 Self‐perceived interference (yes) 92.9% 100% χ 2  = 3.18
V  = 0.19 Self‐perceived addiction (yes) 100% 97.7% χ 2  = 0.98
V  = 0.10 Sexual dispositional traits Hypersexual Behavior Inventory (HBI, range between 19 and 95) 69.26 (17.33) 75.93 (11.66)
t  = −2.05 *

d  = 0.45 Sexual Addiction Screening Test (SAST, range between 0 and 25) 15.36 (5.24) 17.86 (4.14)
t  = −2.44 **

d  = 0.52 Sexual Compulsivity Scale (SCS, range between 10 and 40) 24.24 (7.86) 29.53 (5.55)
t  = −3.59 ***

d  = 0.77
a
Participants with a CSB diagnosis according to at least one of the diagnostic frameworks included in the SSCI‐CSB. *
p < 0.05 **
p < 0.01 ***
p < 0.001. John Wiley & Sons, Ltd.

Known‐groups validity of the SSCI‐CSB at T1 ( n  = 85).

Participants with a CSB diagnosis according to at least one of the diagnostic frameworks included in the SSCI‐CSB.

p < 0.05

p < 0.01

p < 0.001.

Discussion

The purpose of this research was to develop a semi‐structured clinical interview for the assessment of CSB (the SSCI‐CSB) and then examine its reliability and validity. To address this aim, the SSCI‐CSB was administered to 85 participants seeking treatment for out‐of‐control sexual behavior. The results from this study lend us to provide data on the psychometric robustness and validity of the SSCI‐CSB, but also to discuss the nature, structure, and clinical expression of CSB.

The examination of the sexual and clinical profile characterizing the 85 patients seeking treatment for CSB offers interesting insights into the clinical presentations of this condition. In terms of sexual outlet, participants in this study engaged in a myriad of online and offline sexual behaviors, yet only a minority constituted the actual focus of sexual problems. This finding resonates with previous studies with clinical samples of patients with CSB (Wéry et al.  2016 ), supporting the inclusion in the SSCI‐CSB of a first section aimed to determine which particular sexual behaviors should be the focus of the assessment rather than examining sexual behavior in general. In particular, we found that offline sexual behaviors were problematic only for a minority of patients (between 0% and 8.2%), while out‐of‐control sexual behaviors were predominantly online (in particular, problematic pornography use [70.6%], problematic use of sexual chats [47.1%], and problematic use of webcams for sexual purposes [35.3%]). This prominence of the Internet as the medium for the expression of CSB may be explained by the structural characteristics of sex online (accessibility, anonymity…) and by certain design features of sexual websites and apps, potentially promoting loss of control and dysregulated engagement (Flayelle et al.  2023 ).

Surprisingly, only a small proportion of these participants seeking treatment for CSB met the threshold for the diagnosis of this condition according to the SSCI‐CSB (between 17.6% and 38.8%). This means that most participants experienced subthreshold symptoms of CSB. This low proportion of positive diagnosis warrants a more in‐depth examination of the causes of this underdiagnosis. While it is relatively common that some patients seeking treatment for CSB experience distress because their sexual behavior does not align with their moral, ethical, or religious values (i.e., moral incongruency) (Grubbs and Floyd  2025 ) or because of a flawed self‐identification as “sex addicts” (Cantor et al.  2013 ) (in both cases, without experiencing actual problems to control their sexual behavior), this low proportion of positive diagnosis warrants a more in depth examination of the potential causes of this underdiagnosis. A potential explanation emerges after examining the endorsement of the different CSB diagnostic criteria. Four out of the 16 criteria screened by the SSCI‐CSB were endorsed by < 40% of the participants. Two of these criteria were related to the consequences of CSB. While experiencing negative outcomes derived from sexual activity constitutes an important feature for the diagnosis of CSB (McBride et al.  2008 ), the ability of some patients to conceal their sexual problems may explain the low proportion of reported consequences, even in the presence of severe symptoms of lack of control. This result is consistent with prior interview studies with clinical samples (Morgenstern et al.  2011 ). Another criterion with a low proportion of endorsement was abstinence. The applicability of “abstinence” criterion to CSB has not been sufficiently studied (Castro‐Calvo et al.  2018 ; Fernandez et al.  2021 ). Our results a priori support researchers that have cautioned against the use of the “abstinence” criterion to characterize CSB (Castro‐Calvo et al.  2022 ), but more research is needed examining the centrality of this criterion. The last criterion with a low percentage of endorsement was “lack of pleasure/need of relief.” A recent opinion paper have noted the contradictory nature of this criterion (suggesting that CSB is driven by a compulsive component, yet the general diagnostic framework for this criterion conceptualizes CSB as an impulse‐control disorder) (Bőthe et al.  2022 ). In any case, the fact that this criterion was endorsed by 33% of our patients seeking treatment for CSB means that, at least for a subset of patients presenting with this condition, the lack of pleasure linked to the sexual activity constitutes a feature of their dysregulated sexual experience.

Focusing now on the psychometric robustness of the SSCI‐CSB, this study demonstrates that the SSCI‐CSB is a reliable scale for the assessment and diagnosis of CSB. Cronbach's α and Ω of the 16 criteria assessed by this interview was 0.95 and 0.97 respectively, meaning that the entire set of criteria are consistent when measuring the clinical picture of CSB. These values are even higher to those reported in previous validation studies of widely used screening scales for CSB (Montgomery‐Graham  2017 ) and the few available diagnostic interviews (Turner et al.  2022 ; Womack et al.  2013 ), thus positing the SSCI‐CSB as a solid alternative for the measurement of this construct. In addition, we tested the temporal stability of both the SSCI‐CSB criteria and diagnoses, demonstrating that 13 of the 16 criteria (κ between 0.318 and 0.812) and the four diagnoses of CSB included in the interview (κ between 0.304 and 1.00) were consistent after 3 months.

As for the diagnostic performance of the SSCI‐CSB, derived scores at both a criterion and a diagnosis level presented a high specificity and PPV, yet a notably lower sensitivity and NPV. These results are explained by the level of diagnostic stringency of the SSCI‐CSB. The SSCI‐CSB was designed to minimize false‐positive diagnoses. As a result, qualifying for a CSB criterion or diagnosis according to the SSCI‐CSB required higher levels of severity than doing so according to the HBI or the SAST (the reference standards). In this context, the central question is whether sensitivity and NPV should be sacrificed in favor of reducing false positives. Diagnostic performance of a given instrument depends on the prevalence of the target condition: when the prevalence of the target condition is low (as is the case of CSB [Walton et al.  2017 ]), the proportion of false positives tend to be high (Streiner  2003 ), leading to its overdiagnosis. Most available scales for CSB do not provide data on their diagnostic accuracy (Fernandez and Griffiths  2021 ), but given their screening nature, we may expect that they would be characterized by a low specificity and PPV (and therefore, are useful only at an initial assessment stage—that is, for identifying individuals at‐risk but not for their diagnosis—) (Womack et al.  2013 ). On the contrary, the SSCI‐CSB contributes to the evaluation of CSB by constituting a robust diagnostic instrument at later assessment stages (when the assessment is focused on elaborating an accurate diagnosis according to a more strict, comprehensive, and fine‐grained approach). This is particularly relevant considering that, when confronted with a subclinical presentation of CSB, half of the mental health professionals employing the ICD‐11 diagnostic guidelines assigned a CSB diagnosis even though this diagnosis should not be assigned (Fuss et al.  2024 ). Another way to test the validity of the SSCI‐CSB was to examine known‐groups validity (Davidson  2014 ). In particular, participants with and without CSB according to the SSCI‐CSB were compared to test whether these groups differed in terms of variables that are known to express differently according to the level of CSB. As expected, participants with CSB showed a sexual and clinical profile characterized by an increased frequency of sexual activity, more symptoms of excessive and problematic use of the Internet for sexual purposes, and greater severity of CSB as measured by three independent dimensional scales. This profile matches with that observed in individuals with CSB (Castro‐Calvo et al.  2020 ), thus confirming the ability of the SSCI‐CSB to discriminate between clinical and non‐clinical expressions of CSB.

Limitations and Future Directions

This study is not without limitations. First, the lack of a uniformly agreed‐upon criteria for the diagnosis of CSB challenged its operationalization and assessment through the SSCI‐CSB. Second, the sample employed for the examination of the psychometric properties of the SSCI‐CSB was limited in terms of number of participants ( n  = 85), meaning that further replication of the study in larger samples is required to confirm our preliminary results. Linked to this observation, our study only included four women seeking treatment for CSB. Even though CSB is less prevalent in women (and therefore, their presence in studies with clinical samples is usually low), we are increasingly aware of gender‐specific features in terms of clinical characteristics and associated features (Kowalewska et al.  2025 ). Thus, future studies testing gender invariance of the SSCI‐CSB are warranted. Furthermore, our sample did not include patients with other mental health conditions, meaning that we did not examine the specificity of CSB diagnosis derived from the SSCI‐CSB against other psychopathologies. Fourth, inter‐rater reliability of the SSCI‐CSB is yet to be tested. Finally, our study did not include measures directly aligned with the ICD‐11 criteria for CSBD (e.g., the CSBD‐19/CSBD‐7 [Bőthe et al.  2023 ] or the CSBD‐DI [Grubbs et al.  2023 ]) as external criteria or reference standards to further evaluate the validity of the SSCI‐CSB. This is because the development of the SSCI‐CSB predates the publication of any assessment scale aligned with the ICD‐11 criteria for CSBD. Instead, we used measures such the SAST. While the SAST is one of the most widely used measures of out‐of‐control sexual behavior (Montgomery‐Graham  2017 ), it has been criticized for including items without clinical utility in the assessment and diagnosis of CSB (e.g., the item related to childhood sexual abuse) (Castro‐Calvo et al.  2018 ). This limitation may also explain the lower rates of CSB identified using the SSCI‐CSB compared to the measures used as reference standards.

Conclusion

The SSCI‐CSB represents a promising step forward in the clinical assessment of CSB, offering an interview‐based tool with strong internal consistency and encouraging reliability indices. Its development addresses a critical gap in the field, where clinicians have largely depended on screening self‐reports with limited diagnostic utility and prone to misdiagnosis (Briken et al.  2024 ). Nevertheless, key aspects from the SSCI‐CSB such as inter‐rater reliability and replication across diverse samples (in particular, women and sexual minorities) remain to be tested. For this reason, the SSCI‐CSB should be considered a preliminary yet valuable contribution, warranting further evaluation in future studies both by the current research team and, ideally, by independent research groups.

Author Contributions

R.B.A. was the PI for the study. J.C.C. and RBA were involved in the development of the SSCI‐CSB. J.C.C., R.B.A., C.G.G., E.R.P., B.G.G., and M.G.B. participated in recruiting participants and collecting data. J.C.C. conducted the analysis and interpretation of data and wrote the first draft of the paper. R.B.A. revised the first draft. All authors contributed to and approved the final version of the paper.

Ethics Statement

The study procedures were carried out in accordance with the Declaration of Helsinki. The Institutional Review Board of the Jaume I University approved the study.

Consent

Patients involved in the research were informed about the study aim and they provided informed consent.

Supporting information

SSCI‐CSB (Supplemental Material).