Cognitive and Behavioral Outcomes of Sexual Behavior Scale

Abstract

The Cognitive and Behavioral Outcomes of Sexual Behavior Scale (CBOSBS) is an empirically validated psychometric instrument designed to evaluate the multifaceted negative sequelae associated with sexual compulsivity and out-of-control sexual behaviors. Developed by Kimberly R. McBride, Michael Reece, and Stephanie A. Sanders at Indiana University, the CBOSBS operationalizes the outcomes-based conceptual framework advanced by the Society for the Advancement of Sexual Health (SASH). Rather than defining compulsive sexual behavior solely through subjective desires, frequency metrics, or moralized frameworks, the instrument differentiates between cognitive appraisal—specifically, prospective and retrospective worry regarding potential negative consequences—and overt behavioral outcomes realized within the previous 12-month period.

The CBOSBS comprises 36 items structured across two distinct subscales: a 20-item Cognitive Outcomes Scale assessed via a 4-point Likert-type response format (ranging from 0 = Never to 3 = Always; score range: 0–60), and a 16-item Behavioral Outcomes Scale measured dichotomously (0 = No, 1 = Yes; score range: 0–16). Both components assess six core functional domains: (1) physical/medical, (2) social/interpersonal, (3) psychological/emotional, (4) financial/occupational, (5) legal, and (6) spiritual/existential. A composite CBOSBS score is derived by summing the two subscales (range: 0–76), with the 80th percentile serving as an empirical threshold indicative of clinically significant sexual compulsivity.

Psychometric evaluation in a nonclinical cohort of young adults (N = 390) demonstrated strong internal consistency reliability, yielding a Cronbach’s alpha of α = .89 for the cognitive subscale and α = .75 for the dichotomous behavioral subscale. Principal component analysis (PCA) with varimax rotation supported a six-factor structural solution mirroring the SASH multidimensional framework, accounting for 74.8% of the total variance among cognitive items. The CBOSBS provides researchers and clinicians with a nuanced, harm-focused diagnostic and evaluative tool that disentangles cognitive distress from overt functional impairment, facilitating targeted intervention and objective longitudinal tracking.

Keywords

Cognitive and Behavioral Outcomes of Sexual Behavior Scale, CBOSBS, sexual compulsivity, hypersexual disorder, compulsive sexual behavior disorder, Society for the Advancement of Sexual Health, psychometrics, sexual risk taking, harm reduction, outcome assessment

Authors

The Cognitive and Behavioral Outcomes of Sexual Behavior Scale was developed by a team of researchers specializing in human sexuality, public health, and behavioral science at Indiana University Bloomington:

• Kimberly R. McBride, Ph.D.: Department of Applied Health Science and Department of Psychological and Brain Sciences, Indiana University Bloomington; also affiliated with The Academic Edge, Inc., Bloomington, Indiana. Her scholarship centers on sexual risk reduction, sexual health disparities, and measurement models of compulsive sexual behavior. Contact: Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN 47405; Email: [email protected].
• Michael Reece, Ph.D., MPH: Professor of Applied Health Science and Founding Director of the Center for Sexual Health Promotion at the School of Public Health, Indiana University Bloomington. An internationally recognized public health researcher, Dr. Reece has authored extensive literature on HIV/STI prevention, sexual well-being, and community-based health interventions.
• Stephanie A. Sanders, Ph.D.: Provost Professor of Gender Studies and Senior Scientist at The Kinsey Institute for Research in Sex, Gender, and Reproduction, Indiana University Bloomington. Dr. Sanders is an authority on human sexual behavior, endocrinology, sexual psychophysiology, and psychosexual health assessment.

Purpose

The primary clinical and empirical purpose of the Cognitive and Behavioral Outcomes of Sexual Behavior Scale (CBOSBS) is to provide an objective, outcomes-based assessment of the degree to which an individual experiences functional impairment, psychological distress, and adverse events secondary to their sexual activities. Historically, the clinical identification of out-of-control sexual behavior has suffered from confounding moral biases, religious prescriptivism, and an over-reliance on quantitative behavior counts (such as orgasm frequency or partner numbers). The CBOSBS was explicitly formulated to overcome these limitations by measuring sexual compulsivity through real-world and perceived negative outcomes rather than sexual desire or identity alone.

Theoretical Rationale

The theoretical architecture of the scale is anchored in the premise that sexual behavior transitions into a clinically relevant or compulsive phenomenon when it circumvents an individual’s volitional control and triggers substantial impairment across vital life domains. Drawing from criteria established by the Society for the Advancement of Sexual Health (SASH), the authors operationalized sexual compulsivity not as an intrinsic pathology of high sexual libido, but as an etiology characterized by persistent escalation despite collateral harm. By systematically evaluating six distinct domains—physical, psychological, social, financial/occupational, legal, and spiritual—the CBOSBS separates the subjective, internal experience of anxiety, shame, and prospective worry from the objective, retrospective documentation of actual negative events.

Research Applications

In academic and epidemiological settings, the CBOSBS serves multiple critical functions:

• Differentiating Symptom Dimensions: It allows researchers to disaggregate cognitive preoccupation and worry from actual behavioral consequence rates, enabling precise modeling of how distress mediates sexual risk taking.
• Harm-Reduction Evaluation: The scale enables public health investigators to monitor reductions in real-world harms (e.g., unintended pregnancy, STI transmission, legal jeopardy) independently of whether sexual frequency declines, aligning with contemporary harm reduction paradigms.
• Cross-Scale Validation: The CBOSBS provides an external criterion measure to validate screening instruments such as the Sexual Compulsivity Scale (SCS) and the Compulsive Sexual Behavior Inventory (CSBI).

Clinical Applications

In clinical psychology, sex therapy, and psychiatric settings, the CBOSBS addresses vital assessment needs:

• Comprehensive Functional Assessment: Clinicians can identify which specific functional domains are collapsing under the weight of sexual behavior, guiding targeted systemic, legal, medical, or vocational interventions.
• Deconstructing Moral Incongruence: By evaluating spiritual, religious, and psychological worry alongside objective consequences, clinicians can distinguish individuals experiencing severe religious or moral incongruence (high subjective cognitive guilt without objective negative life outcomes) from those exhibiting severe executive dysregulation and physical hazard.
• Treatment Progress Monitoring: Tracking shifts from baseline across the 12-month behavioral index and the continuous cognitive index allows therapists to assess whether psychological restructuring and behavioral self-regulation strategies are attenuating functional impairment over time.

Psychological Construct

The psychological construct evaluated by the CBOSBS is sexual compulsivity-induced functional impairment, framed through a dual-axis structure: prospective/retrospective cognitive apprehension and realized behavioral sequelae across six ecological spheres of human functioning. This conceptualization reflects an integrative model where sexual compulsivity is defined not by the sexual acts themselves (e.g., solo masturbation, partnered intercourse, cybersex), but by their failure to be contained within boundaries that preserve the individual’s physical health, interpersonal networks, financial stability, and self-integrity.

Cognitive vs. Behavioral Manifestations

The scale posits that the negative sequelae of sexual compulsivity operate along two temporal and cognitive axes:

• Cognitive Appraisal and Worry: An affective-cognitive dimension characterized by persistent anxiety, rumination, anticipatory fear, and retrospective dread regarding potential crises generated by one’s sexual behaviors over the preceding year. This dimension captures the intrapsychic burden of out-of-control sexual behavior, including moral anguish, guilt, shame, and apprehension of social exposure or health destruction.
• Objective Behavioral Manifestations: A discrete, event-based index of tangible, empirical occurrences that took place during the preceding 12 months. This axis measures actual collateral damage, removing subjective distortion by focusing on verified life events such as arrest, STI diagnosis, occupational sanctions, or partner estrangement.

The Six Dimensional Domains

The CBOSBS operationalizes both cognitive worry and behavioral occurrence across six explicit life domains derived from SASH clinical guidelines:

1. Physical/Medical Domain:

   This dimension encompasses health-compromising outcomes. Cognitively, it assesses the frequency of worry regarding unintended pregnancy, contraction of HIV, exposure to common sexually transmitted infections (such as herpes, gonorrhea, or pubic lice), physical trauma, or catastrophic bodily harm and mortality. Behaviorally, it records verified occurrences: actual pregnancy (personal or partner), clinical diagnosis of an STI, contraction or transmission of HIV, and self-inflicted or partner-inflicted physical injuries sustained during sexual acts.

2. Social and Interpersonal Domain:

   Human sexual expression is embedded within relational networks. This domain measures the erosion of interpersonal bonds. The cognitive component gauges worry that sexual activities are causing conflicts, distance, or rupture with platonic friends, family members, or primary romantic/marital partners. The behavioral component records documented ruptures, such as estrangement from family, dissolution of friendships, or formal relationship/marriage breakdown directly attributable to sexual conduct.

3. Psychological and Emotional Domain:

   Compulsive behaviors frequently induce internal dysregulation. This dimension evaluates internal psychological toxicity. Cognitively, it measures chronic states of self-directed moral condemnation, acute guilt, and profound shame regarding sexual practices. Behaviorally, it reflects pervasive subjective states of severe guilt, acute embarrassment, and debilitating psychological distress recognized as major emotional crises resulting from sexual conduct.

4. Financial and Occupational/Educational Domain:

   Sexual compulsivity can consume substantial temporal, cognitive, and monetary resources. Cognitively, it captures worry about squandering personal financial capital, incurring destabilizing debt, losing employment, being placed on academic probation, or facing expulsion from academic institutions due to sexual preoccupation or neglected duties. Behaviorally, it records concrete consequences: catastrophic financial loss, workplace disciplinary actions, termination of employment, and academic failure or administrative sanctions.

5. Legal Domain:

   This dimension evaluates the intersection between sexual behaviors and civic statutes (e.g., public solicitation, illicit pornography, trespassing, exposure). Cognitively, it tracks the frequency with which an individual worries that their private or public sexual behaviors violated criminal laws or put them at imminent risk of arrest. Behaviorally, it documents whether the individual was subjected to formal law enforcement intervention, criminal citation, or actual arrest within the prior year.

6. Spiritual and Existential Domain:

   Many individuals construct their personal identity, life meaning, and community membership around spiritual, philosophical, or religious frameworks. This domain measures internal value dissonance. Cognitively, it addresses anxiety that sexual behaviors are diametrically opposed to one’s spiritual beliefs, ethical principles, or religious tenets. Behaviorally, it records the subjective crystallization of this crisis as acute spiritual distress and perceived alienation from one’s faith or existential value system.

Theoretical Framework

The development of the CBOSBS is informed by a confluence of behavioral addiction theory, cognitive-behavioral models of psychopathology, and the public health harm-reduction framework. It represents a significant methodological evolution away from purely moralizing or non-empirical constructs of sexual deviance toward an evidence-based clinical science of behavioral regulation.

The SASH Outcomes-Based Paradigm

During the late 1990s and early 2000s, clinical consensus within the Society for the Advancement of Sexual Health (SASH) evolved toward defining sexual compulsivity through its collateral consequences. In this framework, sexual compulsivity is not defined by specific sexual tastes, paraphilic interests, or partner counts, as such definitions inevitably reflect normative cultural biases. Instead, SASH formulated an objective diagnostic paradigm stating that sexual behavior becomes compulsive when:

• It is engaged in repeatedly despite demonstrable negative consequences;
• The individual experiences an inability to diminish, modify, or cease the behavior volitionally; and
• The behavior systematically impairs functioning across biological, psychological, sociological, legal, economic, or spiritual domains.

The CBOSBS serves as the direct psychometric translation of this SASH framework, establishing standardized empirical markers for each identified area of functioning.

Cognitive-Behavioral and Executive Dysfunction Models

From a cognitive-behavioral perspective, compulsive sexual behavior operates within a self-reinforcing feedback loop. Sexual activity is frequently deployed as an emotional regulation strategy to alleviate negative affect (e.g., anxiety, loneliness, depression, or stress). However, when the behavior conflicts with personal values or incurs risks, it generates acute cognitive distress (guilt, shame, prospective anxiety regarding STI transmission, legal exposure, or job loss). Within an executive dysfunction framework, diminished prefrontal inhibitory control prevents the individual from suppressing the sexual impulse despite anticipating these harms. Ironically, the resulting cognitive distress elevates negative affect, which triggers further sexual behavior as a maladaptive coping mechanism. By isolating cognitive worry from behavioral sequelae, the CBOSBS allows researchers to model how the internal cognitive load interacts with executive behavioral breakdown.

The Dual-Process and Harm Reduction Perspectives

The scale aligns closely with dual-process models of human self-regulation. The Cognitive Outcomes subscale captures the reflective system’s post-hoc evaluation and anticipatory apprehension, whereas the Behavioral Outcomes subscale records the failures of the reflexive, impulsive system to modulate action in high-arousal contexts. Moreover, the scale operationalizes public health harm reduction principles: by measuring discrete damages (e.g., HIV transmission, arrest, financial ruin) rather than sexual frequency, it shifts clinical attention toward mitigating verifiable physical, legal, and relational devastation.

Validity

The psychometric validity of the CBOSBS was rigorously evaluated during its initial design and subsequent cross-sectional studies conducted by McBride, Reece, and Sanders (2007, 2008), as well as in associated investigations by Perera et al. (2009a, 2009b).

Construct and Structural Validity

Construct validity for the 20-item cognitive outcomes scale was established via principal component analysis (PCA) with orthogonal (varimax) rotation among an initial validation sample of 390 nonclinical young adults. Because items were formulated to reflect the six theoretical domains established by SASH, an a priori six-factor solution was extracted. The resulting six-factor structure explained an impressive 74.8% of the total cumulative variance. All items demonstrated robust factor loadings corresponding to their intended theoretical domains (physical health risks, relational disruptions, legal hazards, financial/occupational impairments, spiritual conflicts, and psychological distress).

Convergent and Concurrent Validity

The CBOSBS demonstrated strong convergent validity when benchmarked against established measures of sexual compulsivity and sexual addiction:

• Sexual Compulsivity Scale (SCS): Total CBOSBS scores correlated significantly and positively with the Kalichman Sexual Compulsivity Scale (McBride et al., 2008). Individuals scoring high on the SCS reported significantly elevated cognitive worry and a higher incidence of past-year behavioral harms.
• Compulsive Sexual Behavior Inventory (CSBI): In regression models evaluating the predictive utility of the CSBI (McBride et al., 2007), CBOSBS scores were strongly associated with CSBI control failure and sexual obsession dimensions, validating that greater subjective compulsivity directly corresponds to higher rates of experienced life disruptions.
• Substance Use and Impulsivity: In studies by Perera et al. (2009a, 2009b), the CBOSBS correlated positively with measures of alcohol abuse, illicit substance involvement, and childhood behavioral dispositions toward behavioral undercontrol, confirming convergent validity with the broader spectrum of impulse-control and addictive disorders.

Discriminant Validity

Analysis of inter-item correlation matrices confirmed that the CBOSBS does not capture a generic, unidimensional construct of high sexual frequency, high libido, or healthy erotophilia. Individuals reporting high sexual frequency without executive dysregulation or high-risk contexts did not elevate on legal, occupational, or psychological distress factors. A small number of items within specific subscales exhibited high collinearity (such as worry about “financial problems” versus “wasting money”), indicating slight content redundancy within individual sub-domains, but the overall matrix supported divergent operational spheres across the six life domains.

Reliability

The reliability of the CBOSBS has been demonstrated across multiple psychometric investigations, reflecting robust internal consistency across its multi-tiered scoring architecture.

Internal Consistency Reliability

The scale authors calculated Cronbach’s alpha separately for the cognitive and behavioral components in a validation sample of 390 young adults (McBride, Reece, & Sanders, 2007, 2008):

• Cognitive Outcomes Scale (20 items): Exhibited high internal consistency with a coefficient of α = .89. This confirms that the 4-point Likert items measure prospective and retrospective worry across life domains with exceptional psychometric cohesion.
• Behavioral Outcomes Scale (16 items): Yielded an internal consistency coefficient of α = .75. Although slightly lower than the cognitive scale, this represents an acceptable and robust level of reliability for a 16-item scale utilizing a strictly dichotomous (Yes/No) response format, particularly given the low base rate of severe adverse events (e.g., HIV infection, arrest) in a nonclinical young adult cohort.
• Domain-Specific Subscales: When evaluated independently, the Cronbach’s alpha estimates for the six extracted factor subscales remained consistently high across both cognitive and behavioral divisions, validating the internal reliability of the individual sub-domains.

Measurement Stability Considerations

Because the behavioral component measures retrospective occurrences over an explicitly defined period (“in the past year”), standard short-term test-retest reliability reflects episodic event recall stability. The scale functions as an evaluative state/index inventory for behavioral events and a trait-like measure for cognitive preoccupation and worry. Due to the relatively low base-rate occurrence of catastrophic sexual outcomes (e.g., felony arrest, physical incapacitation) in general collegiate and community samples, the scale authors recommend utilizing the composite total scale score (α composite > .88) when conducting standard parametric modeling in nonclinical cohorts.

Factor Analysis

The structural dimensionality of the Cognitive and Behavioral Outcomes of Sexual Behavior Scale was empirically derived through rigorous factor analytic methods on the 20 cognitive items.

Exploratory Factor Structure (PCA)

Using a validation dataset of young adults (N = 390), McBride, Reece, and Sanders subjected the 20 cognitive outcomes items to a principal component analysis (PCA) utilizing an orthogonal varimax rotation. Because the scale was constructed deductively around the six SASH diagnostic domains, the factor extraction was set a priori to evaluate a six-factor model. The results strongly supported this theoretical architecture:

• Total Variance Explained: The extracted six-factor solution accounted for 74.8% of the total cumulative variance in cognitive outcomes.
• Factor 1: Physical / Health Consequences: Comprising items 1, 2, 3, 4, 5, and 6 (worry regarding pregnancy, STI transmission, HIV infection, physical pain/injury to partner, physical pain/injury to self, and serious physical injury/death). Factor loadings ranged from .68 to .84.
• Factor 2: Interpersonal / Relational Ruptures: Comprising items 7, 8, and 9 (worry regarding friction or breakdown with friends, family members, and primary romantic/marital partners). Factor loadings exceeded .72.
• Factor 3: Occupational and Academic Disruption: Comprising items 14, 15, and 16 (interference with task completion at school/work, potential job termination, and school-related disciplinary probation or expulsion). Factor loadings ranged between .70 and .86.
• Factor 4: Financial Distress: Comprising items 12 and 13 (worry about broad financial problems and squandering/wasting monetary resources). These items exhibited high reciprocal loadings (> .80).
• Factor 5: Spiritual and Religious Conflict: Comprising items 17 and 18 (worry regarding inconsistency with personal spiritual beliefs and religious values). Both items loaded heavily on this distinct latent factor (> .85).
• Factor 6: Legal Exposure: Comprising items 10 and 11 (worry regarding criminal arrest and engaging in unlawful acts). Items loaded at .78 and .82, respectively.
• Emotional Items (Items 19 and 20): Items capturing guilt and shame loaded strongly onto the psychological/affective component, cross-loading moderately with the spiritual conflict domain due to shared moral affect.

Inter-Item Dynamics and Dimensionality

Inspection of the inter-item correlation matrix revealed that while the scale demonstrates cohesive global reliability, it is definitively multidimensional. Inter-factor correlations were low to moderate, confirming that individuals can experience severe impairment in one domain (e.g., spiritual conflict or health anxiety) without necessarily experiencing impairment in another (such as legal sanctions or financial ruin). However, high collinearity was noted between specific item dyads—such as item 12 (financial problems) and item 13 (wasting money)—suggesting that in abbreviated clinical protocols, these items could be streamlined without compromising structural integrity.

Instrument / Measurement Tool

The CBOSBS is a standardized, self-administered psychometric assessment that captures the adverse consequences of solo and partnered sexual behaviors over the preceding 12 months.

Instrument Specifications

• Total Item Count: 36 items
  • Cognitive Outcomes Subscale: 20 items (assessing prospective and retrospective worry)
  • Behavioral Outcomes Subscale: 16 items (assessing actual realized occurrences)
• Administration Format: Self-report paper-and-pencil or secure computer-assisted digital assessment.
• Administration Time: Approximately 10 minutes to complete.
• Target Population: Adolescents and adults (ages 18 and older) in clinical, forensic, or research settings.
• Temporal Frame: Evaluates experiences occurring specifically within the past year (12 months).

Response Format and Scoring Protocols

• Cognitive Subscale Response Format: 4-point Likert-type scale scored as:
  • 0 = Never (Option A)
  • 1 = Sometimes (Option B)
  • 2 = Often (Option C)
  • 3 = Always (Option D)

  Cognitive Subscale Score Range: 0 to 60.

• Behavioral Subscale Response Format: Dichotomous categorical scale scored as:
  • 0 = No
  • 1 = Yes

  Behavioral Subscale Score Range: 0 to 16.

• Total Composite Score Calculation: The global CBOSBS score is calculated by summing the Cognitive Subscale score and the Behavioral Subscale score:

  $$\text{Total Score} = \text{Score}_{\text{Cognitive}} (0–60) + \text{Score}_{\text{Behavioral}} (0–16)$$

  Total Score Range: 0 to 76.

• Clinical Threshold and Interpretation:
  • Empirical Cutoff: Consistent with validation guidelines, the threshold for clinically significant sexual compulsivity (SC) is reached when an individual’s total score meets or exceeds the 80th percentile relative to established reference norms.
  • Profile Interpretation: Clinicians are advised to evaluate the cognitive and behavioral scores both independently and in conjunction. A substantial discrepancy (e.g., high cognitive score with zero behavioral outcomes) typically indicates moral/spiritual distress, severe health anxiety, or obsessive-compulsive symptomatology rather than behavioral behavioral dyscontrol. Conversely, an elevated behavioral score with a low cognitive score may reflect profound executive undercontrol, antisocial personality traits, or emotional detachment/denial.

Permissions & Fee and Test Year

The Cognitive and Behavioral Outcomes of Sexual Behavior Scale (CBOSBS) was developed and validated between 2006 and 2008 by Kimberly R. McBride, Michael Reece, and Stephanie A. Sanders at Indiana University Bloomington. Initial baseline psychometrics and validation studies were formally published in peer-reviewed scientific literature in 2007 and 2008.

Copyright and Licensing

The CBOSBS is considered an academic, non-commercial measurement tool. The scale was made available through academic publications and scholarly compendia (such as the Handbook of Sexuality-Related Measures) for empirical research and educational usage without mandatory licensing fees. Researchers and clinicians may utilize the instrument provided that proper academic attribution is maintained and the scale is cited in accordance with standard scientific conventions.

Permissions Contact

For commercial applications, clinical electronic health record (EHR) integration, or permission to modify or translate the instrument, inquiries should be directed to the primary author:

Kimberly R. McBride, Ph.D.
Department of Psychological and Brain Sciences
Indiana University, Bloomington, IN 47405
Email: [email protected]

References

• McBride, K. R., Reece, M., & Sanders, S. A. (2007). Predicting negative outcomes of sexuality using the Compulsive Sexual Behavior Inventory. International Journal of Sexual Health, 19(4), 51–62. https://doi.org/10.1300/J514v19n04_06
• McBride, K. R., Reece, M., & Sanders, S. A. (2008). Using the Sexual Compulsivity Scale to predict outcomes of sexual behavior in young adults. Sexual Addiction & Compulsivity: The Journal of Treatment & Prevention, 15(2), 97–115. https://doi.org/10.1080/10720160802029220
• Perera, B., Reece, M., Monahan, P., Billingham, R., & Finn, P. (2009a). Childhood characteristics and personal dispositions to sexually compulsive behavior among young adults. Sexual Addiction & Compulsivity, 16(2), 131–145. https://doi.org/10.1080/10720160902905753
• Perera, B., Reece, M., Monahan, P., Billingham, R., & Finn, P. (2009b). Relations between substance use and personal dispositions towards out-of-control sexual behaviors among young adults. International Journal of Sexual Health, 21(2), 87–95. https://doi.org/10.1080/19317610902903254
• Reece, M., Dodge, B., & McBride, K. (2006). Sexual compulsivity: Issues and challenges. In R. McAnulty & M. Burnette (Eds.), Sex and sexuality: Volume 2. Sexual health and sexual disorders (pp. 213–231). London: Praeger Press.

13. Items of the Scale (Questionnaire)