Sexual Dysfunctions and Problematic Sexuality in Personality Disorders and Pathological Personality Traits: A Systematic Review

Study Selection

The database search identified 123 records. After the removal of 6 duplicates, 117 studies were screened for title and abstract. The screening process led to 101 studies excluded. The full text of the remaining studies was assessed. Finally, 17 studies were included into the database of the present review following the aforementioned inclusion criteria. The study selection process is depicted in Fig. 1 (PRISMA).

Fig. 1figure 1

PRISMA 2020 flow diagram of included studies

All the included studies were observational studies published in a period from 1 January 2019 to 25 April 2022. The main characteristics of the analyzed studies are summarized in Table 1.

Table 1 Main findings and characteristics of included studies

Key: LS, longitudinal study; CS, cross-sectional study.

Adverse Childhood Sexual Experiences as Predictive Factor of Personality Disorders

A study by DeLisi and colleagues points out that having a sexual trauma during childhood predicts the development of a future PD, besides the well-known link with psychotic spectrum disorders [29••]. Accordingly, Hemmati and colleagues investigated the relationship occurring between childhood sexual abuse (CSA) and pathological traits of the alternative model of personality disorders (AMPD) in section III of DSM-5, evaluating a sample of 433 Iranian college students. Forty-three individuals in the sample experienced a CSA. The study showed greater pathological trait domains of the Personality Inventory for DSM-5 (PID-5) in individuals with a CSA experience [18]. Similarly, Flynn and colleagues analyzed the association between adverse childhood experiences (ACEs), PDs symptoms and health risk behaviors (HRB). ACEs positively predicted the latent HRB variable and PD symptomatology. At high levels of ACEs, childhood resiliency did not function as a protective factor for HRBs and PD symptoms [30].

In a study by Kahn et al., 317 adult males who had committed sexual offenses were analyzed to verify the frequency of ACE in their history. A statistically significant correlation was found between total ACE scores and the diagnosis of antisocial personality disorder (ASPD). The odds of having ASPD increased by 11% for each ACE item additionally reported [19]. Likewise being physically abused during childhood predicted the onset of an ASPD [29].

The Effect of Personality Disorders on Sexual Functioning

Investigating the key role of personality in sexual functioning, Ajo et al. pointed out how dysfunctional traits may influence patients’ sexual health.

The study observed the influence of PDs on the response to andrological treatment of 62 male patients with erectile dysfunction (ED) and chronic non-cancer pain (CNCP). The patterns of PDs were investigated using the Millon Clinical Multiaxial Inventory (MCMI-III). The presence of features of PDs was significantly associated with worse sexual life quality, anxiety, and depression. Self-defeating feature was correlated with more severe ED, while individuals with narcissistic features showed a better response to andrological treatment [20].

Miano and colleagues conducted a cross-sectional study about the interpersonal relationships in individuals affected by BPD. Scales were administered to 31 heterosexual couples with BPD women and 36 healthy control (HC) couples. Among involved BPD women, 42% indicated “sexuality” as an unresolved conflict area, compared to 17% signaled by HC couples [22].

A study on 509 Polish women showed a correlation of personality types with sexual excitation (SE) and sexual inhibition (SI). More extraverted women reported higher levels of SE, while women with higher level of neuroticism reported greater SI [31].

Sanchez et al. performed an evaluation of the prevalence of high-risk sexual behaviors (HRSB), their consequences, and associated factors in 103 young individuals attending a personality disorders clinic. Among them, a total of 77.7% already was sexually active, 37.5% did not use appropriate contraceptive methods, and 25.5% tested positive for a sexually transmitted infection. Nevertheless, the study found no significant association between HRSB and clinical and demographic characteristics or symptoms severity [32].

An observational study conducted on 656 women is aimed at evaluating the association of the self-reported pathological narcissistic traits with sexual functioning. Results showed lower sexual functioning in individuals with vulnerable narcissistic traits and higher levels of body image self-consciousness. Conversely, grandiose narcissistic traits appeared to be linked to higher levels of sexual functioning and lower image self-consciousness [33].

Personality Disorder Correlation with Sexual Functioning

A cross-sectional study by Ballester-Arnal et al. explored the psychiatric comorbidities of patients affected by compulsive sexual behavior disorder (CSBD). Study found a correlation between BPD and CSBD risk profile. In the examined cohort, a high CSBD risk profile was correlated with BPD in 5.9% of participants, compared to a 0.3% in the low-risk cohort [21••].

The personality profiles of Sexual Homicide Offenders (SHOs), Violent Non-Homicidal Sex Offenders (VNHSOs), and Non-Homicidal Sex Offenders (NHSOs) were described in a study by Beauregard and DeLisi. In the study, researchers reported a link between schizoid and BPD and being a SHOs. VNHSOs are more likely to present Antisocial and Paranoid PDs instead. Finally, the NHSOs presented more frequently Avoidant and Dependent PD profiles [23•].

The association between distinct risky sexual behavior (RSB) profiles and BPD features in youth was investigated by Bégin et al. in a longitudinal study on 126 adolescents and young adults. This research found significantly higher borderline personality pathology levels in participants with impulsive sex outside relationships profile [24••].

Natoli and colleagues investigated the correlation between dependent personality profile and sexual relationships and activity. The work showed lower self-reported interpersonal dependency scores and higher healthy dependency scores in sexually active individuals and in individuals with past sexual activity. However, dependent personality style seemed to not alter the likelihood of being sexually active and is positively associated with likelihood of being in a romantic relationship [25].

The association between PDs and sexual activity and behavior in adolescents was investigated by various studies. Weltzel et al. observed the developmental link between narcissism, problematic behaviors, and adolescence in a longitudinal study on 674 adolescents aged 14 and 16 years old. Adolescent narcissistic exploitativeness at age 14 prospectively predicted sexual behavior at age 16. Adolescents with higher exploitativeness levels were more likely to have sexual intercourse and exhibit symptoms of conduct disorder than adolescents with lower levels [26]. Two other studies examined the link between BPD symptoms and SRB in a population of adolescent girls at different ages. Girls with higher levels of BPD symptoms at age 14 exhibit a greater and more precipitous overtime growth in SRB. Among them, those with steeper increase in BPD levels also showed more abrupt increase in SRBs across adolescence. Additionally, BPD symptoms seemed to be associated with heightened relational insecurity across adolescence [27, 34•]. Moreover, lower self-efficacy to refuse sex and riskier attitudes were found in the BPD group of participants in a study by Penner and colleagues [28].

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