Introduction

The intimate relationship between sexuality and health is well recognized. Sexual behaviours are considered a culmination of a plethora of biological factors that are related to excitement, plateau, orgasm, and resolution phases¹. Sexual dysfunctions could result from excessive sympathetic arousal and are sometimes mediated by chronic anxiety and suppression or expression of anger². The inability to attain erection leads to anxiety and sympathetic arousal, thus serving as components of a vicious cycle and has a solid psychological component³. Anxiety-related sexual activity may be the final pathway through which all sexual dysfunctions occur, though the centrality of anxiety in no manner implies causality⁴. Sexual Dysfunction depends on various aspects that can be divided into predisposing, precipitating, and maintaining factors. Cultural factors (beliefs, norms, and attitudes towards sexuality, personality) may serve as vulnerability factors, while anxiety and guilt related to performance, higher relationship conflicts, etc., may serve as some intrapersonal factors in sexual dysfunction. Loss of sexual chemistry, fear of intimacy, restricted foreplay, poor communication between partners, and lack of privacy may also influence Sexual dysfunction⁶.

Studies linking personality and sexuality suggest that people with neuroticism would have higher feelings of disgust regarding sexual activity due to their highly labile emotions and lasting fear and anxiety⁷. Men adhering to androgynous sex roles tend to be more comfortable and have positive attitudes towards sex ⁸; stereotypic masculine men would be at risk of suffering from exaggerated concerns about their sexual performance⁹ and may develop sexual anxieties. Eroto-phobic people tend to have higher chances for sexual dysfunction¹⁰that studies suggest that affective responses related to sexuality get conditioned to several erotic cues. In contrast, informational responses are associated with beliefs, expectancies, and attitudes¹¹. Conservative/restrictive sexual attitudes were found to be significant predictors of sexual distress¹². The prevailing cultural beliefs about masculine sexuality emphasize strength, competence, and assertiveness, and men who endorse them would have more trouble enjoying sex when their body starts ageing¹³.

The presence of sexual self-schemas in sexual dysfunctions has been highlighted^14, and associated beliefs may increase their tendencies of catastrophic misinterpretations and subsequent activation of negative self-schemas¹⁵. Identification of “Centerfold syndrome” has led to further attention to the role of masculinity socialization in the development of sexual self-schemas in men¹⁶. Traditional heterosexual men may be predisposed to shame-related schemas and show features related to vanity, exhibitionism, and a vulnerability similar to narcissistic individuals¹⁷.

Such Narcissistic and Egocentric patterns of behaviour have been found in the literature, termed Sexual Narcissism (SN), and its role has been validated in Borderline Personalities¹⁸Histrionic Personality Disorder¹⁹ and Narcissistic Personality disorder²⁰. These individuals could constantly be prone to intimacy issues, and extramarital issues are common among this population²¹. Two constant sources of relationship distress are neuroticism and attachment insecurity, both identified in the vulnerable type of narcissism²². SN is an egocentric pattern of sexual behaviour characterized by Sexual Exploitation, Sexual Entitlement, Sexual Skills, and Low Sexual Empathy²³. Individuals with higher levels of narcissism tend to have higher levels of need for agency within relationships related to power, status, intelligence, attractiveness etc²⁴. It is then possible that men with narcissistic patterns of sexual behaviour and sexual dysfunction may experience a significant amount of distress beyond what they experience through their inadequate sexual functioning.

Attitudes towards sex differ significantly between men and women, and they remain traditional in India²⁵. Refusing sex was one of the significant predictors for aggressive and forced sex among Indian men, emphasizing the need for policies in the sense of entitlement that traces back to the cultural norm of being a ‘dutiful son²⁶.’ Further, endorsement of ‘machismo,’ or traditional masculine beliefs towards their gender role is also seen, which further strengthens the possibility of prevailing narcissistic traits among the population.

This study aims to explore the role of narcissism in sexual dysfunctions through the evaluation of sexually narcissistic behaviours, Cognitive self-schemas, and dysfunctional beliefs, thereby subjecting all the variables to find out which among them differentiated a group with sexual dysfunction from a group without sexual dysfunction.

Methods and Tools

All procedures performed in studies involving human participants were by the ethical standards of the institutional ethics committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Institutional Ethics Committee (IEC:535/2017), and written consent was obtained from all the participants.

Sample:

The sample was recruited from a tertiary care hospital in south India. A urologist screened the patients out of the study for any organic cause of the dysfunction. Thirty-one male participants with sexual dysfunctions that have the highest tendency for psychogenesis (i.e., Erectile Dysfunction and Premature Ejaculation) between the ages of 22 and 60 years were recruited from the Departments of Urology, Clinical Psychology, and the Psycho-sexual Clinic of a tertiary care university teaching hospital using convenience sampling. In addition, 31 healthy men matched for age and education, free from sexual dysfunctions, formed the controls. Controls were selected from patient bystanders and men who presented to various outpatient departments in the hospital.

(a) Tools:

The study made use of the following tools:

1. International Statistical Classification of Disorders- 10 Diagnostic Criteria for Research²⁷: The Diagnostic Criteria recommended by ICD-10 for various sexual dysfunctions (F52) were used. F52.2 and F52.4 are the specific codes for the failure of genital response and premature ejaculation, respectively.

2. The International Index of Erectile Function²⁸ (IIEF). A 15-item, 5-point Likert-type, self-administered measure provides us with domain-specific scores on Erectile functioning, Orgasmic function, Sexual Desire, Intercourse Satisfaction, and Overall satisfaction. IIEF was used to screen participants belonging to the experimental and control groups.

3. Modified MINI screen²⁹ (MMS). The MMS is a generic screening measure for mood, anxiety, and psychotic spectrum disorders and consists of twenty-two questions with yes/no responses. Totaling the number of ‘yes’ answers gives the score of MMS. 6 or greater indicates the likely presence of a psychiatric disorder. MINI was used to identify and monitor the presence of any psychiatric diagnoses that the participants presented with. However, participants who scored six or higher were not excluded from the analysis.

4. Sexual Beliefs Questionnaire (SBQ)- Male Version 30. A 40-item questionnaire assessing specific stereotypes and beliefs along six domains, viz., Sexual Conservatism, Female sexual power, Macho belief, Beliefs about women’s satisfaction, Restrictive attitude towards sex, and Sex as an abuse of man’s power.
5. The marital version of the Sexual Narcissism Scale²³. Sexual Narcissism Scale (SNS) is a 20-item scale assessing across all four domains of Sexual Narcissism. Items are written to represent one of four components of narcissism hypothesized to be active in the sexual domain and influence sexual outcomes.
6. Questionnaire of Cognitive Schema Activation in Sexual Context³¹. A 28-item instrument with a 5-point Likert scale that assesses cognitive schemas presented by the participants during sexual situations.

Questionnaires were translated into the regional language of the participants. This was done with the help of one field expert who would translate and review the translations done by another. The translated questionnaires were cross-checked to minimize loss of meanings and appropriateness. If the participants could read and write English, the original forms of the questionnaires were given to them.

(b) Statistical techniques:

The difference in the scores obtained by those having ED/PE and those free from ED/PE in the 15 variables under study (6 variables of dysfunctional beliefs, four variables of sexual narcissism, and five variables of sexual self-schemas) were subjected to a preliminary analysis using Shapiro-Wilk test to find out the normality of the score distribution. The results indicated variations from normality in some of these variables. Hence, it was decided to use a non-parametric test to assess the differences between the two groups in the dependent variables. Accordingly, the differences were analyzed using the Mann-Whitney U-test.

Though the U-test can bring out the differences between the groups in the different variables under consideration, being a univariate technique, it fails to consider the possibility that the predictor variables could be inter-correlated. Hence, there could be some redundancy in the results obtained through the analysis. Multivariate techniques like discriminant analysis could be gainfully employed in such situations to control for the redundancy, if any, among the variables and to identify the most relevant variables that can differentiate between the groups. However, violating normality assumptions reported earlier about some variables calls for caution in applying this powerful parametric technique in the present case. Detailed examination of the Q-Q plot relating to many statistically significant Shapiro-Wilk values showed that the normality violations were generally minor. Because discriminant analysis is generally robust against minor violations of normality³², it was decided to use the procedure as an exploratory follow-up analysis, the results of which could be considered suggestive.

Results

None of the study participants had a comorbid psychiatric condition as assessed by the Modified MINI questionnaire. Table 1 shows the participants' demographic details regarding age and education. The mean age of the participants in the group with Sexual Dysfunction was 37.7, and the mean age of participants in the group without Sexual Dysfunction was 36.1. The average Erectile Functioning score of the Experimental group was 10.7, and the control group was 20.1

It may be seen from Table 2 that out of the total of 15 variables, 12 variables have produced significant differences between the two groups under study. The three variables that failed to make a substantial difference between the groups included two variables of sexual narcissism (viz., low empathy and high perceived sexual skills) and one variable of sexual self-schema (viz., self-depreciation).

As can be seen from Table 3, the discriminant analysis indicated that the differences between the group having ED/PE and those not having ED/PE in dysfunctional beliefs, sexual narcissism, and sexual self-schemas could be summarized in terms of 3 variables, viz., Female Sexual Power (a dysfunctional belief variable with a coefficient of 0.61), Helplessness schema (a cognitive schema variable with a coefficient of 0.57) and Exploitation (a sexual narcissism variable with a coefficient of 0.49). The classification scores obtained by unstandardized function coefficients indicated that 87.1% of original cases could be correctly classified using the function (see Table 4).

Spearman’s rho computed using the data (table 5) indicated that erectile functioning had a significant negative correlation with all the other variables, viz., Female Sexual Power (r=-0.57; p<.01), Exploitation (r=-0.42; p<.01), and Helplessness (r=-0.39; p<.01). Considering the intercorrelations among the predictor variables, it was found that Female Sexual Power had a significant positive correlation with Exploitation (r=0.32; p<.05) and Helplessness (r= 0.33; p<.01), while the latter two variables were unrelated to each other (r=0.23; p>.05).

Discussion

The construct of sexuality is built around cultural attitudes, beliefs, and norms, and it is imperative to look at sexuality from the socio-cultural point of view. According to Social Dominance Theory³³, Social Dominance Orientation (SDO) is a crucial factor in determining the self-efficacy of women and men. Specific to the backdrop of Indian culture, women are challenged to pose the power to control their sexual behaviour. In such a scenario, if women believe that men should dominate them sexually, it would only contribute to their self-efficacy. However, the belief that men should dominate sexually may prevent men from feeling open and comfortable discussing their sexual behaviour. They may tend to avoid addressing their sexual dysfunctions, which may lead to reduced self - efficacy³⁴. A Strong association between self-efficacy, level of confidence, and power-related issues has been repeatedly demonstrated by the previous research³⁵.

These traditional gender roles among men are also linked to authority, dominance, a rigid internal structure, and, most importantly, evaluative negativity towards sex³⁶. It may be possible to assume that other dysfunctional beliefs that were assessed along with Female Sexual Power failed to get included in the function because of the shared variance of these variables. Discrimination analysis, a multivariate procedure, ensures that among a set of variables with a high amount of shared variance, only the most relevant variables having unique information are selected, and the remaining ones are dropped to avoid redundancy.

A common theme of all three variables that were found as a significant discriminator between populations with sexual dysfunction and those without was found to be one associated with power. Female Sexual Power is also looked into as a need for control in sex³⁷, one of the strongest beliefs among a clinical sample of patients with erectile dysfunction in the analysis. Power has consistently been associated with sexual aggression in literature³⁸. Traditional gender roles could play a significant role in the need for power among men. Exploitative behaviors by men, such as forced sex, are also influenced by traditional gender roles of male sexual dominance³⁹and has an effect associated with a desire for control and self-monitoring⁴⁰. Males tend to use other manipulation techniques that involve direct and bilateral strategies such as reasoning, persuasion, bargaining, talking, stating importance, etc., to influence the partner⁴¹. This could reduce the interpersonal quality of the relationship that results from aggressive, exploitative, and maybe even coercive acts. Lack of intimacy and love is consistently proven as a significant variable within patients of sexual dysfunction, and clinicians have reported reduced effectiveness of treatment within cases that have limitations in this region⁶.

A helpless nature develops from the Dependence / Incompetence schema⁴². Though the Incompetence schema was included as a separate variable in the analysis, the Helplessness schema was identified as more important in the present study. This could be because the individual may be experiencing the surrendering effect towards the schema and the negative impact following a dysfunctional episode. Fear of incompetence during sexual activity could serve as a source of anxiety, and feelings of helplessness could be a result of not being able to fulfill the demands of the gender identity that an individual closely attaches themselves to, though this needs further research. Schemas have a predisposing effect, yet the failure of previous encounters of dysfunction maintains it, as schemas also have a maintenance component. Hence, the helplessness variable does not need a significant role in exploitative behaviours. Yet, both could be related to a need for power, attempts to dominate, and a subsequent episode of dysfunction. This could explain the high correlation of ‘Helplessness’ with Female Sexual Power (FSP), as it fits well with the contention that having a dominating female sexual partner could affect the individual with sexual dysfunction by making them feel incompetent and powerless, eventually resulting in a sense of helplessness.

Culturally established gender and sex roles may play a part in the development of FSP, which may contribute to an intra-psychic evaluation of sex roles and self-view and further contribute to negative effects. A negative experience in a sexual context may lead to evaluative negativity, which may also be influenced by a reduced interpersonal quality. FSP may also pave the way to an expression of power, such as attempts to seek control and other exploitative behaviours⁴³, though this needs further research. If true, sexually narcissistic traits could contribute to these behaviours. Negative evaluations may contribute to schema maintenance through feelings of helplessness or otherwise.

Conclusion

A variable of sexual narcissism is found relevant in the population with sexual dysfunction for the first time. People who score high on Female Sexual Power, Helplessness Schema and Exploitation tended to score low on Erectile Functioning, suggesting the need for a broader, flexible parameter for male gender roles to maintain a healthy sex life. Mental health providers need to look into the feeling of helplessness in a sexual context that may be rooted within an incompetent and inadequate aspect of the self-concept of an individual. While themes related to power are suggested in the form of turn-taking in sexual activities, cognitions and vulnerabilities in the transference of power are often ignored. Within individual and couple therapy and sex therapy, dysfunctional beliefs related to sex roles and schematic vulnerabilities related to incompetence and sexual scripts may also be addressed, challenged, cognitively disputed, and behaviourally experimented to enhance effectiveness.

Whether sexual narcissism plays a mediating or moderating role in this is to be studied in further research, and the current study does not suggest any cause-effect inferences. Traditional gender and sex roles vary according to culture, and it may be worthwhile to compare and contrast different populations with a larger sample to see if there is an effect. It may also be noted that while the two groups were matched on age, education, and, through the sampling criteria, sex, there may be other factors such as the number of years in marriage, substance use, or sub-clinical psychiatric aspects (it may be noted that clinical comorbidity was assessed) to be taken into consideration to increase the generalizability of the results. These may be taken up by future studies that focus on the variable further rather than from an exploratory paradigm.

Acknowledgements

The authors thank Dr. Laura Widman, Associate Professor in the Department of Psychology North Carolina State University, for supporting this research and permitting us to use the Sexual Narcissism Scale.

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