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 RESEARCH ARTICLE

Compulsive sexual behavior in young adults

Brian L. Odlaug, MPH

Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark, Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA

Katherine Lust, PhD, MPH

Boynton Health Services, University of Minnesota, Minneapolis, MN, USA

Liana R.N. Schreiber, BA

Department of Psychiatry, University of Minnesota Medical Center, Minneapolis, MN, USA

Gary Christenson, MD

Boynton Health Services, University of Minnesota, Minneapolis, MN, USA

Katherine Derbyshire, BS

Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA

Arit Harvanko, BA

Department of Psychiatry, University of Minnesota Medical Center, Minneapolis, MN, USA

David Golden, BA

Boynton Health Services, University of Minnesota, Minneapolis, MN, USA

Jon E. Grant, JD, MD, MPH

Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA

BACKGROUND: Compulsive sexual behavior (CSB) is estimated to affect 3% to 6% of adults, although limited information is available on the true prevalence and impact of CSB in young adults. This epidemiological study aims to estimate the prevalence and health correlates of CSB using a large sample of students.

METHODS: The survey examined sexual behaviors and their consequences, stress and mood states, psychiatric comorbidity, and psychosocial functioning.

RESULTS: The estimated prevalence of CSB was 2.0%. Compared with respondents without CSB, individuals with CSB reported more depressive and anxiety symptoms, higher levels of stress, poorer self-esteem, and higher rates of social anxiety disorder, attention-deficit/hyperactivity disorder, compulsive buying, pathological gambling, and kleptomania.

CONCLUSIONS: CSB is common among young adults and is associated with symptoms of anxiety, depression, and a range of psychosocial impairments. Significant distress and diminished behavioral control suggest that CSB often may have significant associated morbidity.

KEYWORDS: health, hypersexuality, impulse control disorders, prevalence, sex, young adult

ANNALS OF CLINICAL PSYCHIATRY 2013;25(3):193-200

  INTRODUCTION

Although not classified as a formal psychiatric disorder according to DSM-5 or the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), non-paraphilic compulsive sexual behavior (CSB) (also referred to as sexual addiction, hypersexuality, and hypersexual disorder) has been described, in some form, in the medical literature since the 18th century.1,2 CSB has been recognized for a long time as being associated with significant distress, feelings of shame and embarrassment, and psychosocial dysfunction.2 Significant controversy exists surrounding the correct classification of CSB as a psychiatric disorder, and there are currently no agreed upon diagnostic criteria for CSB.3 Experts have yet to agree on whether it should be included as a formal disorder at all.4

Recent publication of the DSM-5 by the American Psychiatric Association shows that Hypersexual disorder is not included in this new edition, underscoring the need for research into this poorly understood condition.1 Proposed criteria have included excessive, uncontrollable, culturally abnormal sexual behavior, urges, and/or thoughts, resulting in adverse consequences, marked distress, and/or impairment in social or occupational functioning.3,5 The repetitive thoughts and excessive engagement in behavior have been likened to the symptoms often noted in the obsessive-compulsive spectrum of disorders.6 Others have argued that CSB should be classified as an addiction or failure of self-regulation based upon the impulsive, excessive, uncontrolled engagement in the behavior with deleterious outcomes.7 Regardless of classification, researchers generally agree that individuals with CSB commonly report low self-esteem, intimacy problems, social anxiety, psychological distress, interpersonal conflicts, and general impulsivity.5

No epidemiological studies of non-paraphilic CSB have been performed in the community. Estimates of CSB prevalence in the adult US population are hypothesized to range from 3% to 6%, although no data were offered to support these estimates.8 Within collegiate samples, one study assessing impulse control disorders on a private college campus (N = 791) found that 3.7% of students reported symptoms consistent with current non-paraphilic CSB.9 Another study of 240 college students found that 17.4% of students had sexually addictive traits worthy of further evaluation and treatment, although rates of CSB were not explicitly reported.10 Similar current rates (1.7% and 4.4%) have been reported in psychiatric inpatients.11,12 These studies were small and failed to examine the relationship of sexual behavior to other aspects of mental health (eg, levels of distress or depression), overall functioning, and problematic behaviors (eg, drinking, drug use, Internet use). One study of gay, lesbian, and bisexual individuals in a community sample (N = 1,543) reported a CSB rate of 27.9%, but that study included both paraphilic and non-paraphilic sexual behavior when defining CSB.13 A more accurate prevalence estimate would help indicate non-paraphilic CSB’s impact on the individual and society, and if the prevalence is substantial, potentially could intensify interest in finding treatments. In addition, ascertaining baseline prevalence would help distinguish the contributions of differing or changing social conditions from biological factors in CSB. To establish a more accurate prevalence estimate and understand the relationship between CSB and psychosocial factors in young adults in a university population, we conducted a large, Internet-based survey using a validated screening instrument embedded in a structured interview.

  METHODS

Design of 2011 College Student Computer Use Survey

As a collaboration between the Department of Psychiatry and Boynton Health Service at the University of Minnesota, the College Student Computer Use Survey (CSCUS) was designed to assess a variety of physical and mental health behaviors. The survey included questions about sexual behaviors and their consequences, stress and mood states, overall functioning, and the respondent’s demographic information. A clinically validated screening instrument, the Minnesota Impulse Disorders Interview (MIDI), also was included to classify respondents as either having CSB or not. (See the assessment section for CSB criteria.) All study procedures were carried out in accordance with the Declaration of Helsinki and were approved by the institutional review board of the University of Minnesota, Human Subject Code number 1005M81734.

Subjects

A random sample of students at a large public Midwestern university was recruited to complete the 2011 CSCUS. Between April 2011 and May 2011, these randomly selected students received an email inviting them to participate. The email contained a link to a webpage that displayed the IRB-approved informed consent page for the on-line survey. After viewing a webpage displaying the informed consent document, students either could continue with the survey if they indicated participant consent or opt out. As an incentive for participation, all participants were entered into a drawing for gift certificates valued at $1,000, $500, and $250 at a variety of stores. In addition, for those who fully completed the survey, 3 portable music players were awarded by random selection. Surveys were completed anonymously. A total of 6,000 students were invited to participate in the survey; 2,108 completed the survey, a response rate of 35.1%, which compares favorably with rates in national health surveys.14 A respondent was defined as a person who fully or partially completed the survey.

Assessments

The survey consisted of 54 questions concerning demographic characteristics, physical and mental health behaviors including stress, depression, body mass index (BMI), exercise habits, as well as perceived attractiveness and academic performance variables such as grade point average (GPA). In addition to formal mental health diagnoses, participants were presented with a list of mental health conditions and asked if they ever had been diagnosed with a mental health disorder.

To estimate the prevalence of CSB, we used the Minnesota Impulsive Disorders Interview (MIDI).15 The MIDI screens for CSB, compulsive buying, kleptomania, trichotillomania, intermittent explosive disorder, and pathological gambling. We also screened for excoriation (skin picking disorder) using criteria established by Arnold et al.16 Questions about CSB, based on previous research,5 included: 1) Do you or others that you know think that you have a problem with being preoccupied excessively with some aspect of your sexuality or being overly sexually active; 2) Do you have out-of-control or distressing sexual fantasies; 3) Do you have out-of-control or distressing sexual urges; 4) Do you engage in repetitive sexual behavior that you feel is out of control or causes you distress. Subjects were considered to be a positive CSB screen if they answered “yes” to question 1 and either question 2, 3, or 4. For purposes of this study, we used the MIDI as a self-report screen for current ICDs, similar to a survey conducted in a previous college sample study.9 In adults and adolescents, the MIDI has demonstrated excellent classification accuracy compared to diagnostic instruments.11,17 Diagnostic criteria for trichotillomania, gambling disorder, intermittent explosive disorder, and kleptomania are consistent with the DSM-5, and criteria for compulsive buying18 and excoriation (skin picking) disorder16 are consistent with previous research. Subjects were characterized as having a formal impulse control disorder if they met full criteria for that disorder.

In addition to the MIDI, we used the following instruments to survey respondents:

Patient Health Questionnaire (PHQ-9).19 The PHQ-9 is a 9-item, client-administered scale based directly upon the diagnostic criteria for major depressive disorder in the DSM-IV. It assesses current symptoms and functional impairment to aid in making a preliminary diagnosis of depression. It also provides a measure of depression severity.

Perceived Stress Scale (PSS).20 The PSS is a 10-item, valid and reliable, self-report measure assessing the degree to which individuals find their lives to be unpredictable, uncontrollable, and stressful. Respondent answered each question on a 5-point Likert scale (ranging from “never” to “very often”) based on experiences of the previous month. Scores range from 0 to 40 with higher scores indicating greater life stress.

Internet Addiction Test (IAT).21 The IAT is a 20-item, self-report assessment that measures the impact of Internet use on various life domains. It has demonstrated high validity, reliability, and good internal consistency. Subjects answer items on a 5-point Likert scale with higher scores suggesting greater Internet use problems. Research has indicated that Internet users with complete control over their usage score between 0 to 19 points, while those with mild, moderate, and significant Internet use problems score between 20 to 49, 50 to 79, and 80 to 100 points, respectively. In addition to the IAT, subjects were asked about time spent engaging in various Internet activities. For the purpose of this study, we examined Internet pornography use among individuals screening positive for CSB vs non-CSB students.

Data analysis

We examined distribution characteristics of all variables. Only participants with complete data on the dependent variable were included in analyses (n = 1,837; 30.6%). Baseline demographic data were evaluated for differences between those with complete data and those without complete data using t tests for parametric data and Mann-Whitney U tests for nonparametric data. Participants were divided into 2 groups: CSB and no CSB. The analyses included: 1) descriptive and comparison statistics for the sample’s demographics, 2) the prevalence of CSB, and 3) cross-tabulation and t test comparisons of those classified as having CSB vs the remaining respondents in terms of demographics, health behaviors, and functioning. As an exploratory study, significance was set to P ≤ .05. For clinically significant results at the .05 level, Cohen’s d effect sizes are reported where 0.2, 0.5, and 0.8 are generally considered to be small, medium, and large effect sizes, respectively.

  RESULTS

Of the 6,000 students who received the invitation to participate in the survey, 2,108 completed the survey (35.1% response rate). The mean age was 22.6 ± 5.02 [range 18 to 58]. Although most subjects were white (n = 1,650; 78.3%), 229 (10.9%) identified themselves as Asian American, 42 (2.0%) as Hispanic, 25 (1.2%) as African American, 26 (1.2%) as African, 85 (4.0%) as “other,” and 51 (2.4% non-responders.

For the purpose of this study, analysis is based on only respondents who identified themselves as male or female, responded to the questions related to impulse control, and provided valid responses to the questions about being diagnosed with a psychiatric disorder within their lifetime. As such, the final sample used in this study included 1,837 students, 1,075 (58.5%) of which were women and 762 (41.5%) male. Sex distribution in this study was consistent with the overall prevalence of males (42.4%) and females (57.6%) attending the university in the spring of 2011.

Of the 1,837 subjects included in this analysis, 36 (2.0%) met criteria for current CSB. Rates of CSB differed significantly between men (n = 23; 3.0%) and women (n = 13; 1.2%) (P = .006; d = .06) (TABLE 1). All 36 (100%) of the subjects with CSB reported having “out-of-control sexual fantasies,” “out-of-control sexual urges,” and more than one-half (n = 19; 54.3%) reported out-of-control sexual behaviors (TABLE 2). Furthermore, 8 (22.3%) of the CSB group reported Internet pornography use of ≥1 hour each day.


TABLE 1

Demographics of 1,837 university students grouped by compulsive sexual behavior

Variable CSB
(n = 36)
No CSB
(n = 1,801)
Statistic P Effect size
Age, Mean ( ± SD) [range], years 23.64 ± 6.16
[18 to 53]
22.64 ± 5.12
[18 to 58]
0.6965a,b
.4862  
Sex, (% male) 23 (63.9) 739 (41.0) 7.596c .006 0.06
Race/ethnicity, n (%)          
  White 24 (66.7) 1,438 (79.8) 3.337c .052  
Marital status, n (%)          
  Single/divorced/widowed/separated 21 (58.3) 1,063 (59.2) 0.01c .921  
  Married/partner/engaged/committed Relationship 15 (41.7) 735 (40.8)      
aPearson’s chi-squared.
bn = 1,807.
cDegrees of freedom.

Effect size: d = Cohen’s d.

TABLE 2

Behaviors associated with compulsive sexual behavior (CSB)

Behavior, n (%) CSB (n = 36)
Out of control sexual fantasies 36 (100)
Out of control sexual urges 36 (100)
Out of control sexual behaviors 19 (54.3)
Time spent on online pornography (per day)  
   None 15 (41.6)
   <1 hour 13 (36.1)
   1 to 3 hours 5 (13.9)
   4 to 5 hours 1 (2.8)
   6 to 8 hours 2 (5.6)
   >8 hours 0 (0.0)

Subjects with CSB reported significantly higher stress levels as measured by the Perceived Stress Scale (P < .001; d = .79), higher depressive symptoms as measured by the Patient Health Questionnaire (P < .001; d = .54), viewed themselves as less attractive (P = .001; d = .47), and higher BMI ratings in males (P = .017; d = .29), compared with the non-CSB cohort of students. Individuals with CSB were also significantly more likely to report more days out of the past month with poor mental health compared to non-CSB students (mean 11.17 ± 17.34 days vs 6.13 ± 7.29 days; P = .0001; d = .38), including the occurrence of panic/anxiety attacks (n = 4 [11.1%]; P = .021; d = .05). Students with CSB also scored much higher on the Internet Addiction Scale (39.39 ± 16.4) compared to those without CSB (29.63 ± 10.98; P < .0001; d = .70); however, both groups scored within the mild problematic Internet use range (TABLE 3).


TABLE 3

Health and performance indices grouped by compulsive sexual behavior

Health variable CSB (n = 36) No CSB
(n = 1,801)
Statistic P Effect size
Grade point average (GPA) 3.21 ± .46 3.35 ± .47 t = 1.7458
df = 1802
SE = 0.08
.08 0.30
Body mass index (BMI)
  Males
26.57 ± 10.6 24.23 ± 4.29 t = 2.3998
df = 747
SE=0.975
.017 0.29
  Female 23.41 ± 4.49 23.34 ± 4.56 t = 0.055
df = 1062
SE=1.272
.9561  
Perceived Stress Scale 21.16 ± 6.5 15.96 ± 6.7 4.3755a,b <.0001 0.79
PHQ-9 7.71 ± 6.23 4.79 ± 4.39 3.7969a,c .0002 0.54
Internet Addiction Test 39.39 ± 16.4 29.63 ± 10.98 5.00a,d <.0001 0.70
Perceived attractiveness, (1-10 scale, 1 = least attractive; 10 = most attractive)
  Attractiveness of self
  Attractiveness to others
6.03 ± 1.93
6.92 ± 1.93
6.83 ± 1.43
7.38 ± 1.38
3.29a,e
1.955a,f
.001
.051
0.47
(N) days within the past 7 days engaged in being physically active for at least 30 minutes 3.17 ± 2.08 3.27 ± 2.18 0.2729a,g .785  
(N) days poor physical health, (past 30 days) 4.71 ± 6.39 3.35 ± 6.25 1.2744a,h .203  
(N) days poor mental health, (past 30 days) 11.17 ± 17.34 6.13 ± 7.29 t = 3.8726
df = 1706
SE=1.301
.0001 0.38
All values are mean ± SD.

aDegrees of freedom.
bn = 1,743.
cn = 1,749.
dn = 1,712.
en = 1,820.
fn = 1,812.
gn = 1,823.
hn = 1,821.

CSB: compulsive sexual behavior; PHQ-9: Patient Health Questionnaire; SD: standard deviation.

Individuals who met criteria for CSB were significantly more likely to report lifetime social anxiety disorder (n = 6 [16.7%]; P = .001; d = .09) (TABLE 4). In regard to concomitant impulse control disorders as assessed by the MIDI, CSB subjects were significantly more likely to screen positive for compulsive buying (22.2% vs 3.3%; P < .0001; d = .14), pathological gambling (8.3% vs 0.6%; P = .0022; d = .12), and kleptomania (2.8% vs 0%; P = .0196; d = .16) than non-CSB subjects, respectively (TABLE 4).


TABLE 4

Lifetime psychiatric diagnosis grouped by compulsive sexual behavior

SELF-REPORTED DIAGNOSES
Non-impulse control disorders
CSB
(n=36)
No CSB
(n=1,801)
Statistic P Effect size
Major depressive disorder 9 (25.0) 324 (18.0) 1.169a .279  
Bipolar disorder 1 (2.8) 20 (1.1) 0.868a .352  
Anorexia nervosa 0 (0.0) 44 (2.4) 0.901a .342  
Bulimia nervosa 0 (0.0) 33 (1.8) 0.692a .406  
Schizophrenia 0 (0.0) 1 (0.1) b 1.000  
Generalized anxiety disorder 4 (11.1) 166 (9.2) 0.151a .698  
Social anxiety disorder 6 (16.7) 73 (4.1) 13.644a .001 0.09
Substance use disorder 1 (2.8) 33 (1.8) 0.150a .699  
Obsessive-compulsive disorder 1 (2.8) 37 (2.1) 0.091a .763  
Attention-deficit/hyperactivity disorder 3 (8.3) 74 (4.1) 1.568a .210  
Posttraumatic stress disorder 0 (0.0) 38 (2.1) 0.776a .378  
Borderline personality disorder 0 (0.0) 2 (0.1) b 1.000  
Any lifetime diagnosis 15 (41.7) 494 (27.4) 3.572a .059  
RESULTS OF THE MIDI
Impulse control disorders
CSB
(n=36)
No CSB
(n=1,801)
Statistic P  
Hair pulling disorder (trichotillomania) 2 (5.6) 23 (1.3) b .0845  
Pathological gambling 3 (8.3) 11 (0.6) b .0022 0.12
Compulsive buying 8 (22.2) 59 (3.3) b <.0001 0.14
Intermittent explosive disorder 1 (2.8) 4 (0.2) b .0944  
Kleptomania 1 (2.8) 0 (0.0) b .0196 0.16
Excoriation (skin picking) disorder 4 (11.4) 73 (4.1) b .0562  
aPearson’s chi-squared.
bFisher exact test.

CSB: compulsive sexual behavior; MIDI: Minnesota Impulse Disorders Interview.

  DISCUSSION

To our knowledge, this is the first formal examination of the prevalence and health correlates of CSB in a large sample of college students. Our results suggest that 2.0% of university students report symptoms consistent with CSB, a rate slightly lower than the 3.7% found in a previous college sample study9 and lower than the speculated 3% to 6% rate proposed by other researchers (for a review, see reference 22). In our sample, and consistent with previous research,9 the majority (63.9%) of individuals meeting CSB criteria were male and reported out-of-control sexual fantasies, out-of-control sexual urges, and approximately half engaged in out-of-control sexual behaviors. These findings are of potential importance for 3 reasons: first, because if the sexual behavior is “out of control,” it may impede healthy sexual choices. Previous research has found sexually compulsive behavior is associated with higher-risk sexual behavior.23 The “out-of-control” behavior reported in this survey therefore may have resulted in transmission of sexually transmitted diseases as well as shame and poor self-respect. Second, because approximately half of the students with CSB struggled with only urges and fantasies, (albeit urges and fantasies associated with psychosocial dysfunction), they may not perceive their urges and fantasies as a legitimate reason for possible treatment. Finally, although a majority of students screening positive for CSB were male, a substantial proportion of students with CSB were female (n = 13; 36.1%). This is similar to the 22.2% of subjects who were female and screened positive for CSB in the Black et al study5 of 36 CSB subjects and 22.9% of females in the Seegers study10 of 240 college students who met criteria for a “need to seek further evaluation and treatment” for sexual addiction. Although sexual compulsivity has been shown to be higher in male college students,23 our results and previous research clearly illustrate and underscore the importance of screening both female and male students for CSB. Because proper sexual health screening is lacking in the medical field, especially in educational institutions,24 greater education around sexual compulsivity (including intrusive urges and thoughts as well as sexual behavior) in both male and female students is critical to the identification and potential treatment of CSB in this age cohort.

CSB and the Internet

Consistent with previous research, we found that individuals with CSB spend more time on the Internet, qualifying as having “mild problematic” Internet usage. This is consistent with previous research, which found that of 9,265 Internet users, 4.6% met criteria for CSB.25 Previous reports have found sexual compulsivity to have a strong link to the amount of time spent pursuing online sexual activities;25 it also has been positively associated with perceived problematic online sexual activity.25 Although a majority of subjects (58.4%) with CSB reported using Internet pornography, it was a minority (22.3%) that reported ≥1 hour of use daily. Although it is possible that Internet pornography is a main outlet for some students with CSB, the fact that such a low percentage of students reported engaging in this behavior for ≥1 hour suggests that other forms of sexual engagement or preoccupation are present in most of this cohort. It is also possible that due to the wide availability of sexual outlets on the Internet, time spent on Internet sex sites may not be a particularly useful measure of CSB symptom severity or dysfunction. For those wishing to engage in sexual behavior, sexual partners could be found with relatively little time spent on the Internet. Unfortunately, accessing the Internet for sexual behaviors may be particularly problematic and dangerous in young adults given the tremendous public health concern about sexually transmitted disease and sexual violence, as well as the well-documented association between sexual compulsivity and risky sexual behavior.26 Colleges and universities should consider using the Internet for public health announcements regarding CSB.

Health correlates and CSB

We also found that CSB students had lower GPAs, more problems with anxiety disorders, and were more likely to have higher levels of stress compared to non-CSB university students. This is consistent with previous research on clinical samples of individuals with CSB that found high rates of anxiety and ADHD in individuals with CSB.27 Past work also suggests that poor mental health can have a significant impact on overall academic performance28 and underscores a public health need for academic institutions to provide awareness and treatment resources for students endorsing compulsive sexual symptoms. A limited amount of research has investigated the concept of perceived attractiveness and BMI in CSB. We found that individuals with CSB believed themselves less attractive, and that males with CSB have higher BMIs. Research on Internet addiction has found that a preoccupation with being overweight was a predictor of problematic Internet use29 and therefore, it is possible that perceived appearance or low self-esteem factors into the development of CSB. Further exploration of this topic is merited in future research projects.

The exclusion of hypersexual disorder from DSM-51 is an acknowledgement to our limited understanding of the course, prognosis, and treatment of this disorder in the psychiatric community and continued skepticism over the legitimacy of hypersexuality as a disorder at all. While not formally indicated for further study, advancements in our understanding of this complex, heterogeneous, and often controversial disorder would undoubtedly benefit both clinicians and patients.

Limitations

Several limitations must be acknowledged in this study. First, CSB rates were based on a self-report scale without a formal, in-person clinical evaluation and thus, CSB rates may be under- or over-reported. Follow-up interviews with students screening positive for CSB on the self-report measure would likely result in the exclusion of some of the cohort from having CSB. Due to the potential shame and embarrassment involved in endorsing CSB, an anonymous survey may provide more accurate prevalence estimations due to the anonymity of completing the assessment.

Second, the proportion of our sample that was white was significantly higher than recent US census data, making the interpretation of results to the general population difficult. Future research in university and college settings should strive for a more population-representative sample in an effort to generalize results to a wider young adult audience.

Finally, given the heterogeneity of sexual compulsivity, future research should examine the many religious, moral, and cultural differences in college and community samples as considerations for perceived uncontrolled sexual behavior.

  Conclusions

The relative paucity of information surrounding CSB, especially in young adults, coupled with the significant potential for chronic medical consequences resulting from engaging in these behaviors is a cause of concern. Public health initiatives directed at adolescents and young adults that illustrate the consequences of unfettered sexual activity and the existance of viable treatments are important. These initiatives should target educators and administrators who have direct contact with this population so that they may better recognize and intervene with young adults who may be struggling. Finally, because of the heterogeneity of sexual compulsivity, future research should examine the many religious, moral, and cultural differences among college and community samples as considerations for perceived uncontrolled sexual behavior.

DISCLOSURES: Mr. Odlaug receives grant support from the Trichotillomania Learning Center, is a consultant to Lundbeck Pharmaceuticals, and receives honoraria and royalties from Oxford University Press. Dr. Grant receives grant/research support from the National Institute of Mental Health, the National Institute on Drug Abuse, the National Center for Responsible Gaming, Forest Pharmaceuticals, Roche Pharmaceuticals, Transcept Pharmaceuticals, Psyadon Pharmaceuticals and the University of South Florida, and receives honoraria/royalties from Springer, Oxford University Press, American Psychiatric Publishing, Inc., Norton Press, and McGraw Hill. Dr. Lust, Ms. Schreiber, Dr. Christenson, Ms. Derbyshire, Mr. Harvanko, and Mr. Golden report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

ACKNOWLEDGEMENTS: This research was supported, in part, by a Center for Excellence in Gambling Research grant by the National Center for Responsible Gaming, an American Recovery and Reinvestment Act (ARRA) Grant from the National Institute on Drug Abuse (1RC1DA028279-01) to Dr. Grant, and internal funding from Boynton Health Services, University of Minnesota.

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CORRESPONDENCE: Brian L. Odlaug, MPH Department of Public Health, Faculty of Health and Medical Sciences University of Copenhagen Øster Farimagsgade 5A, DK-1014 Copenhagen K, Denmark E-MAIL: brod@sund.ku.dk; odlaug@uchicago.edu