Recent evidence suggests that difficulties with sexual health might serve as an early warning sign for mental health challenges. A new study published in the Journal of Psychiatric Research found that young adults who report mild, non-clinical psychotic experiences also tend to show higher rates of problematic pornography use, hypersexuality, and certain sexual dysfunctions. These findings provide evidence that screening for sexual behavioral issues could help identify individuals who might be at a higher risk of developing a severe psychiatric condition.
To understand this research, it helps to look at the different ways sexual health is defined in clinical settings. Sexual functioning generally refers to the physical and emotional processes involved in an intimate encounter. This category includes general sexual desire, psychological arousal, the physical ability to maintain an erection or natural lubrication, and the capacity to reach a satisfying orgasm.
When these natural physical processes become consistently difficult or distressing, an individual might experience a sexual dysfunction. This can lead to low self-esteem, marked personal distress, and a significant decrease in a person’s overall quality of life. On the other hand, dysfunctional sexual behavior relates more to a person’s actions and a lack of self-control.
This behavioral category includes hypersexuality, which involves an intense preoccupation with sexual fantasies and a strong urge to act on them. It also includes the problematic, compulsive consumption of pornography. Both of these behavioral issues can disrupt daily life and harm interpersonal relationships.
Scientists have observed that sexual dysfunctions are noticeably higher among people with diagnosed mental health conditions, including schizophrenia. Often, these sexual issues are viewed simply as side effects of psychiatric medications. Drugs used to treat severe mental illnesses can alter brain chemistry in ways that negatively affect a person’s sexual desire and physical arousal.
However, researchers are beginning to suspect that sexual difficulties are not just side effects of clinical treatments. Some scientists propose that a decline in sexual health might be an inherent feature of the psychiatric illnesses themselves. They suggest that these sexual issues could appear early on, before a full psychiatric disorder ever takes root.
Giacomo Ciocca, an associate professor of clinical psychology and sexual psychopathology at Sapienza University of Rome, explained the team’s motivation for looking into this dynamic. “The main reason that led us to explore the eventual relationship between problematic sexuality and psychosis onset is the prevention of psychotic risk,” Ciocca said. “In many cases, psychosis is preceded by several subclinical conditions that the literature defines as at-risk mental states. However, sexual problems and problematic sexuality are scarcely included in these pre-clinical categories.”
Psychotic-like experiences provide a unique window into this early stage of psychological vulnerability. These experiences are mild, subclinical symptoms that resemble psychosis, such as hearing brief whispers or harboring unusual, paranoid thoughts. People who have these mild symptoms do not have a diagnosed psychotic illness, but they are at a higher risk of developing one later in life.
Studying people with psychotic-like experiences allows scientists to observe the psychological factors associated with psychosis risk without the confusing influence of heavy psychiatric drugs. Because these individuals are not taking medication that alters their sexuality, they provide a much purer picture of how mental health and sexual health intersect. The authors of the current study wanted to explore if these mild psychotic symptoms are linked to specific sexual problems.
To test their ideas, the researchers recruited a sample of 582 young adults through an online survey platform. The participants ranged in age from 18 to 35 years old, with an average age of 24.5 years. The sample included 404 individuals assigned female at birth and 178 individuals assigned male at birth.
To ensure their findings were not influenced by existing psychiatric treatments, the researchers applied strict inclusion rules. They excluded anyone who was currently taking medication for a mental health condition. They also removed any participants who had a history of psychiatric hospitalization or who were currently receiving formal care from mental health services.
Participants completed a series of five detailed questionnaires for the research project. First, they took a 16-item test designed to measure the presence and intensity of psychotic-like experiences over the past month. This questionnaire asked participants to answer true or false to statements about unusual perceptions or beliefs, and then rate how much distress each experience caused them.
The researchers used three other assessments to evaluate sexual habits and physical functioning. They used a 19-item test to measure hypersexual behavior, which looked at how often participants used sex to cope with emotional distress, their ability to control sexual impulses, and the negative consequences of their sexual actions. A separate five-item scale evaluated the severity of problematic pornography use over the past six months, which helped identify individuals at risk of compulsive consumption.
To measure physical sexual functioning, the scientists used a standardized scale that looks at five core elements of human sexual response. These elements included general sexual desire, psychological arousal, physical lubrication or penile erection, the ability to easily reach an orgasm, and the level of satisfaction felt during that orgasm. Finally, the participants completed a comprehensive 53-item survey to measure recent symptoms of depression.
After collecting the data, the scientists divided the participants into two distinct groups. The first group consisted of 197 individuals who scored high enough on the psychotic-like experiences questionnaire to be considered at an elevated clinical risk. The second group consisted of 385 control subjects who reported very few or no psychotic-like experiences.
The researchers found that the mere presence of psychotic-like experiences was strongly associated with dysfunctional sexual behaviors. Specifically, individuals in the high-risk group reported higher levels of hypersexuality compared to the control group across all measured areas. This included using sex as a coping mechanism for bad moods, struggling to control sexual urges, and suffering negative life consequences due to their sexual actions.
The high-risk group also showed much higher rates of problematic, compulsive pornography consumption. When looking at physical sexual functioning, the researchers found that people with a high number of psychotic-like experiences reported more difficulties in actually reaching an orgasm. Other functional areas, like general sexual desire, did not show the same strong connection to these mild psychotic symptoms.
“Our results clearly demonstrate that sexual problems, such as sexual dysfunctions, sexual dysregulations, and sexual compulsivity, can be considered as risk factors for psychosis in more vulnerable people,” Ciocca said. “Hence, from a clinical point of view, it is important to assess during the prevention programs and during counseling the sexual health of youth. Problematic sexuality, therefore, could also be inserted into the other clinical criteria to identify the psychotic risk.”
He added that mental health professionals should pay close attention to these warning signs. “Readers of our paper, psychologists and psychiatrists particularly, should take into consideration the sexological assessment during their clinical practice,” Ciocca said. “Sexual function and sexual behavior are pivotal aspects of psychological functioning. About this, our perspective can be considered Freudian. Therefore, a dysregulation of sexuality is an indicator of an eventual psychological suffering before it is manifest.”
Interestingly, the researchers noticed slightly different patterns when they looked at the personal distress caused by psychotic-like experiences, rather than just the number of symptoms. Participants who felt highly distressed by their unusual thoughts and perceptions reported additional physical sexual difficulties. Along with struggling to reach an orgasm, these distressed individuals also had trouble maintaining an erection or producing natural lubrication, and they felt less satisfied with their orgasms overall.
Because depression and age can heavily influence a person’s sex life, the scientists ran additional mathematical models to control for these two factors. Even after adjusting for age and depression, the differences in hypersexuality and problematic pornography use remained significant between the two groups. The difficulty in reaching an orgasm also remained higher for the group with more psychotic-like experiences.
The authors broke the data down further by biological sex to see if the trends held true for both men and women. Among the female participants, those with high levels of psychotic-like experiences continued to show greater hypersexuality and more compulsive pornography use than female control subjects. After controlling for depression and age, the female high-risk group did not show a significantly worse ability to reach an orgasm compared to the female control group.
Among the male participants, the high-risk group demonstrated higher hypersexuality than the male control group. Curiously, the male high-risk group actually reported slightly fewer difficulties with sexual arousal than the healthy male controls. The researchers suggest that this unexpected finding might reflect an overall heightened or poorly regulated sexual drive, which sometimes accompanies the early stages of a psychotic episode.
While these findings provide helpful insights, they are subject to a few limitations. The study relied on a specific type of online sampling, which resulted in a group made up largely of Italian university students. This means the findings might not accurately represent older adults, people from different cultural backgrounds, or the broader global population.
Additionally, the researchers relied entirely on self-reported questionnaires. People are sometimes hesitant to answer questions about their sexual behavior or unusual mental experiences honestly, which can introduce inaccuracies. The cross-sectional design of the study also means the researchers only captured a single snapshot in time.
Because the data was collected all at once, scientists cannot prove that psychotic-like experiences directly cause sexual problems, or vice versa. It is entirely possible that an unmeasured third factor is responsible for both the sexual issues and the unusual mental experiences. For example, the researchers did not account for anxiety symptoms or the use of recreational substances, both of which can heavily impact mental and sexual health.
Future research could follow participants over a long period to see how early sexual difficulties might predict the actual development of severe mental illnesses. Scientists could also include a wider range of psychological factors in their models to rule out other potential causes.
“Our auspice is the inclusion of sexual assessment into the prevention program for mental disorders, particularly psychosis,” Ciocca said. “When an adolescent suffers from specific sexual issues, such as sexual compulsivity, problematic use of pornography, and also the obsession with sexual function or performance, likely there is also psychological suffering. From this point of view, problematic sexuality should be considered as a marker for a mental disorder in both clinical and research fields.”
This line of inquiry remains a major focus for Ciocca and his team at the Department of Wellbeing, Health and Environmental Sustainability. “I would like to thank my collaborator Doctor Davide Doroldi,” Ciocca noted. “He, together with me, conducted a large part of this research, from formulating the hypotheses to interpreting the results. The study about the relationship between sexuality and psychopathology is the main object of our research group at Sapienza University of Rome.”
The study, “Is problematic sexuality a marker for the onset of mental disorders? A cross-sectional study on psychotic-like experiences and sexual behaviour in a non-clinical sample,” was authored by Davide Doroldi, Giulia Origlia, Tessa Giannini, Tommaso B. Jannini, Tommaso Boldrini, Antonio Del Casale, Gabriele Lo Buglio, Grazia Spitoni, Erika Limoncin, Lorenzo Pelizza, and Giacomo Ciocca.
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