What happens in the brains of sexually compulsive women? An fMRI study on compulsive sexual behavior disorder in women

Background and aims The neural mechanisms of compulsive sexual behavior disorder (CSBD), included in ICD-11, remain uninvestigated in women. Men with CSBD show increased reward-circuit reactivity to sexual cues; whether this extends to women is unknown. Methods Twenty-nine treatment-seeking heterosexual women with CSBD and twenty healthy, heterosexual control women (HC) completed a modified Incentive Delay Task with erotic and monetary cues and rewards during fMRI. A priori analyses tested group × cue interactions in eight regions of interest and brain-symptom associations. Results Women with CSBD responded more slowly overall and less accurately to erotic cues than HC women, and rated erotic rewards as more pleasant (group × cue interaction). Group × cue interactions in cue-related activity showed higher reactivity to erotic than monetary cues in women with CSBD (left amygdala, posterior orbitofrontal cortex [pOFC], precentral gyrus) and the reverse pattern in HC women (ventral striatum [VStr], putamen). For rewards, women with CSBD showed higher reactivity in the anterior orbitofrontal cortex (aOFC) and precentral gyrus, and symptom severity correlated positively with cue reactivity of the VStr, putamen and pallidum. Exploratory analyses additionally differentiated women with and without problematic pornography use (PPU) in the pOFC and aOFC. Discussion and Conclusions As in men, reward-system reactivity was linked to symptom severity, but cue reactivity did not by itself distinguish the groups. Most women reported compulsive sexual encounters, whereas prior male samples predominantly involved PPU. Whether findings from men generalize to non-PPU presentations remains open, underscoring the need for more inclusive research.