Sexual stigma, attachment difficulties, and emotional dysregulation among patients with severe mental illness

Sexual behavior is directly affected by mental illness sexual stigma (MISS). Previous studies have shown high rates of MISS¹ and a correlation with high-risk sexual behavior.² However, those studies enrolled predominantly psychiatric outpatients. So far, little is known about the relationship between stigmatization, love life, and sex life in highly dysfunctional psychiatric patients. This pilot study, conducted with full Ethics Committee approval, described the sexual behavior and romantic relationships as well as investigated the correlation among depression, anxiety, type of attachment, and MISS in patients referred to treatment for severe mental illness (SMI) at the day hospital of a tertiary care center in São Paulo, Brazil.

The inclusion criteria were a diagnosis of SMI, age 18 years or older, literacy, cognitive ability to complete the study instruments, and absence of organic neurologic conditions, current schizophrenic crisis, or current manic episode. Overall, 27 outpatients met these criteria and provided written informed consent for participation.

The sample was composed of 18 men and 9 women. On the Structured Clinical Interview for DSM (SCID), 18 (66.7%) met criteria for schizophrenia, seven (25.9%) for mood disorder, and two (7.4%) for schizoaffective disorder. The age of the participants ranged between 21 and 59 years (mean, 37; SD, 11.7). Fourteen participants (51.8%) reported a secondary education or less, while 13 (48.2%) reported at least some higher education. Sixteen (59.3%) were Caucasian, five (18%) reported current employment, and only one (3.7%) was married. Regarding lifetime romantic and sexual relationships, 20 (74.1%) participants reported at least one romantic relationship in the past, and 15 (57.7%) reported having had sexual intercourse at least once. On the other hand, only one (3.9%) reported a current romantic partner, five (18.6%) reported engaging in sexual intercourse in the preceding 6 months, and 11 (42.3%) reported masturbation.

Table 1 shows the correlation matrix of the measures. The Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and Mental Illness Sexual Stigma Questionnaire (MISS-Q) individual domain presented strong, statistically significant correlations between them, as did the anxious adult attachment style and BAI score. These findings are probably related to the internalization of MISS and diminished self-esteem, and suggest that patients with low self-esteem would also be more likely to feel socially inadequate, resulting in anxious symptoms.³ The MISS-Q social domain exhibited a high correlation with the Adult Attachment Scale (AAS) dependent score, while the BDI score presented a negative correlation with the AAS secure score. These findings suggest possible emotional dysregulation among the patients, which may be related to dysfunctional attachment.⁴,⁵

Table 1
Correlation matrix of depression, anxiety, adult attachment, sexual experience, and mental illness stigma

Scale	BDI	BAI	AAS Anxious	AAS Dependent	AAS Secure	ASES	MISS-Q Individual	MISS-Q Social	MISS-Q Structural	MISS-Q Total
BDI	1
BAI	0.57*	1
AAS Anxious	0.28	0.56†	1
AAS Dependent	-0.27	-0.30	-0.07	1
AAS Secure	-0.43†	-0.05	-0.21	0.25	1
ASES	0.32	0.03	-0.03	0.05	-0.23	1
MISS-Q Individual	-0.63*	-0.55†	-0.2	0.24	0.40†	-0.05	1
MISS-Q Social	-0.23	-0.43	-0.3	0.58†	0.34‡	0.16	0.51†	1
MISS-Q Structural	0.10‡	-0.34‡	0.06	0.16	-0.11	0.24	0.25	0.32	1
MISS-Q Total	-0.37‡	-0.57†	-0.23	0.5†	0.33‡	0.14	0.78*	0.89*	0.57†	1

• AAS = Adult Attachment Scale (Secure, Dependent, and Anxious are domains of the AAS); ASES = Arizona Sexual Experience Scale; BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; MISS-Q = Mental Illness Sexual Stigma Scale (Individual, Social, and Structural are the MISS-Q domains; their sum score corresponds to the total MISS-Q score).
• ^*
  p < 0.001,
• ^†
  p < 0.05,
• ^‡
  p < 0.10.

This study sheds light on the connections among negative emotion states, insecure attachment, and MISS among highly dysfunctional patients with SMI, who reported low rates of romantic and sexual experiences. However, a new study with a larger sample is necessary to confirm the internal validity and increase external validity. Subsequently, interventions focused on diminishing MISS and anxious attachment may have a positive impact on emotional status and increase opportunities for affectionate and sexual relationships in this population.

Acknowledgments

To all participants and professionals involved in the project, especially to Julie C. Vieira, Osvaldo H. Takeda, Ana L. A. Alves, Karen M. G. Mattos and Michele S. Cruz.

References

• ¹
  Wainberg ML, Cournos F, Wall MM, Norcini Pala A, Mann CG, Pinto D, et al. Mental illness sexual stigma: implications for health and recovery. Psychiatr Rehabil J. 2016;39:90-6.
• ²
  Elkington KS, McKinnon K, Mann CG, Collins PY, Leu CS, Wainberg ML. Perceived mental illness stigma and HIV risk behaviors among adult psychiatric outpatients in Rio de Janeiro, Brazil. Community Ment Health J. 2010;46:56-64.
• ³
  Bonfils KA, Firmin RL, Salyers MP, Wright ER. Sexuality and intimacy among people living with serious mental illnesses: factors contributing to sexual activity. Psychiatr Rehabil J. 2015;38:249-55.
• ⁴
  Collins NL. Working models of attachment: implications for explanation, emotion, and behavior. J Pers Soc Psychol. 1996;71:810-32.
• ⁵
  Marganska A, Gallagher M, Miranda R. Adult attachment, emotion dysregulation, and symptoms of depression and generalized anxiety disorder. Am J Orthopsychiatry. 2013;83:131-41.

Publication Dates

• Publication in this collection
  03 Feb 2020
• Date of issue
  Jan-Feb 2020

History

• Received
  2 Aug 2019
• Accepted
  1 Oct 2019