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Psycho-affective responses to sexual situations constitute one of the most notable and reliable psychological differences between sexually dysfunctional and functional men [1–4]. Not surprisingly, dysfunctional men tend to report higher negative affect and lower positive affect than functional men. However, even within samples of sexually dysfunctional men, significant variation in emotional response occurs: some dysfunctional men show high levels of distress and negative affect while others show little or none [4,5]. Some such variation can be accounted for by the importance the patient ascribes to his sex life, in fact more so this factor than the severity of the dysfunction itself .
Men's emotional experience, along with sexual response itself, is clearly affected by the cognitive framework and expectations they bring to a sexual situation. Specifically, how they use the information about the situation to understand their actions and attribute cause to them affects their interpretation of and response to the sexual situation [7–9].
Broadly speaking, studies on cognitive attribution of cause have found that people tend to make internal-self attributions for personal positive behaviours or outcomes, and external-other attributions for negative behaviours or outcomes . Such attribution processes might apply to sexual situations as well: for example, externalized, self-serving attributions may be adaptive when dealing with failed sexual experiences such as premature ejaculation, erectile dysfunction or lack of orgasm, as they would help ensure positive feelings toward future sexual experiences. In contrast, internal, self-serving attributions may be more typical for successful sexual experiences.
Yet, the attribution process surrounding successful (or unsuccessful) sexual responses, first, appears to be quite different for sexually functional vs sexually dysfunctional men and women, and second, is not fully consistent with general predictions made by attribution theory. Men with erectile disorder, for example, tend to make internal (self-blaming) attributions for negative sexual events, whereas men without erectile disorder do not ; women with low orgasm rates show a similar pattern, adopting a self-handicapping interpretation of placing blame on themselves for their lack of orgasm and giving credit for orgasm to an outside source such as a partner . As noted, such patterns contrast with attribution theory expectation: one might anticipate that sexually dysfunctional individuals would not blame themselves but rather make a self-serving attribution by blaming their partner or outside circumstances [9,13].
Internal attribution for the cause of sexual inadequacy has the potential to precipitate a cycle of failure and create a self-fulfilling prophesy, thus making attribution processes relevant to understanding men with sexual problems. Men who attribute their failure to internal causes (i.e. to something about themselves rather than to the partner or situation) typically report a diminished sense of self-efficacy, and as such come to expect similar negative outcomes across future sexual situations. This predisposition may become a major factor in maintaining or intensifying the sexual problem [14–18].
The above studies suggest that men with sexual problems are more likely to assume an internal attribution (i.e. ‘something is wrong with me’), assigning blame (and by implication ‘control’ over the problem) to themselves, thereby setting up a negative orientation regarding future sexual situations. Indeed, men with sexual problems are known to approach sexual situations more negatively than their functional counterparts, giving support to this assumption . However, not all internal attributions are the same. For example, internal attributions – ones where men feel both personally responsible and presumably in control – are likely to be different from those that, although internal (i.e. directed toward the self), absolve men from assumptions regarding personal responsibility and control.
In this study, we were interested in investigating the relationship between the psycho-affective response of men with a sexual dysfunction and their attributions/assumptions about the cause of their dysfunctional sexual response. Specifically, we hypothesized that men who attributed their sexual failure to a physical/medical condition (although an internal attribution, not one for which the man must assume responsibility and control) would respond more positively emotionally than men who attributed their problem to a psychological/relationship problem or to an unknown cause (internal attributions over which an individual might assume greater responsibility and control). Our analysis included two additional factors: (i) an index of clinician-diagnosed ‘somatic risk’, a variable that assessed the likelihood that the man's sexual problem was actually due to a physical/medical problem; and (ii) the patient's self-reported ‘importance of sex’, a factor which, when strongly endorsed, has been shown to exacerbate dysfunctional men's negative emotional response within the sexual situation .
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This study is, to our knowledge, the first to investigate the relationship between causal attribution of sexual dysfunction in men and how it affects their emotional response in a sexual situation with their partner. Three broad findings are apparent. First, men that have a clear physical/medical cause to which they can attribute their problem experience less negative and greater positive emotion in the sexual situation. Second, ‘diagnosed’ somatic risk for sexual dysfunction, although having some predictive potential regarding emotional response, was less relevant than the participant's beliefs regarding the cause of his sexual problem. Third, the greater the importance of sex to the participant, the lower his positive affect and the higher his negative affect – an effect identified in a previous study and, from this analysis, shown to affect emotional response independent of causal attributions or diagnosed somatic risk.
It is not surprising that men with sexual dysfunction report overall more negative affective responses than functional men, a finding that has been demonstrated repeatedly [4,5]. More interesting is the effect that the man's attribution of cause of the sexual problem had on his emotional response. Specifically, men who can attribute their sexual dysfunction to a medical or physical condition do much better emotionally (higher positive affect and lower negative affect) than those who attribute the problem to unknown or psychological factors.
Previous research has shown that men with a sexual dysfunction who experience sexual failure are more likely to internalize the cause (self-blame) than men without sexual dysfunction . Furthermore, these men have greater difficulty with sexual functioning in the future than men who externalize the problem . Our study, however, clearly differentiates between types of ‘internal’ attributions, suggesting that the critical factor with respect to attribution is not merely its reference to something about ‘oneself’ (vs something about an external factor), but rather its reference to situations where the individual can assume responsibility and control. That is, the key distinction is not external vs internal, but rather control/efficacy vs lack of control/efficacy. Specifically, those men who can attribute their problem to a physical/medical issue are able to ‘externalize’ the problem – needing to assume less responsibility for and/or control over the problem. In doing so, they reduce the burden of responsibility on themselves and thus, even though sexual performance itself may be unaffected, tend to have a more positive affective experience – lower insecurity and stronger feelings of arousability and affection – during sex with their partner. In contrast, men with a sexual dysfunction who attribute their problem to an internal factor for which they feel responsible respond more negatively emotionally (and less positively), a pattern of responding that is likely to maintain or even intensify the problem. Such men, for example, less confident in their ability to perform and possibly more distracted during sexual experiences , may be less mindful of the moment with their partner, a situation that in turn is likely to further affect performance. Furthermore, because feelings of insecurity (i.e. low confidence and trust), arousability and affection are grounded in the dyadic relationship, this attributional pattern may well affect overall relationship functioning and quality. By implication, such men are probably less likely to overcome the effects of sexual dysfunction through medication alone, a conclusion similar to one that we reported previously based on a sample of men with premature ejaculation .
Men having greater ‘diagnosed’ somatic risk for developing a sexual dysfunction reported higher feelings of insecurity and, to a lesser extent, lower feelings of affection. Two points are notable. First, the correlation between attribution of cause and diagnosed somatic risk was lower than anticipated; we had actually expected near redundancy in these two variables. Clearly, what men believe to be the cause of their sexual problem, and what the actual probable cause is, are quite different. Hence, a differential diagnosis may continue to have value, even in an era of patient-centred approaches where patients' goals and ways to achieve them are given priority and where the establishment of aetiology is often de-emphasized. Second, the importance of clear communication between the clinician and patient about probable cause is obvious, as dysfunctions due to a medical or physical problem (assuming such a diagnosis is valid) weigh less heavily emotionally on the patient – the patient's perception of his situation is more important to his emotional response to sex than the actual situation.
Finally, the higher the dysfunctional man rated the importance of sex with his partner, the less positive his emotional experience, specifically in the areas of pleasantness, affection and arousability. Previous research has demonstrated the importance of ‘soft’ variables – including individual expectations, needs and desires – on a man's emotional response within the context of a partnered sexual experience . This relationship persisted when variables on attribution and somatic risk were introduced into the analysis.
The findings of this study have specific implications for the treatment of men with sexual dysfunctions. Men who place a high value on their sex lives but who cannot attribute sexual failure to a physical/medical aetiology represent a particularly vulnerable group. Such men need to be given a clear route to understanding their physical/medical cause (assuming one actually exists), or they may be considered for more in-depth treatment that enables them to adopt a less self-blaming perspective and a more self-protective attribution process in future sexual experiences. One approach to treatment, for example, might include a biopsychosocial model that emphasizes individual vulnerability in any one of the major domains that affect sexual functioning – biological, psychological and relational – with the concomitant message that some individuals, while healthy biologically, may have an inherent psychological vulnerability within sexual situations. Such vulnerability might, however, stem from desirable personality characteristics such as sensitivity to the partner, valuing sex and intimacy with the partner, taking responsibility for one's actions and so on. That is, the same attributes that are important to a well functioning relationship and valued by society in other situations may increase psychological vulnerability in situations involving sexual ‘performance’.
Several sampling and other methodological issues may have affected the conclusions of this study. First, our sample consisted of men with a mix of sexual dysfunctions; although most had erectile dysfunction or combined erectile dysfunction with premature ejaculation, several had just premature ejaculation. Second, the study lacks an index of the quality of relationship functioning and an assessment of the partner's emotional response. Both measures would probably contribute to our understanding of variation in men's emotional response during sex with their partner. Finally, we did not distinguish between types of depression, whether clinical, event-related, sex-related and so on. Such a distinction might affect attribution categories – e.g. clinical (true psychopathological) depression may be considered a biological/medical cause rather than a psychological cause. Unless the patient's medical history indicated otherwise, the absence of this level of detailed information led us to classify any mention of depression as a psychological cause. On the positive side, few participants constituted an ‘undifferentiated’ depression attribution.
This study shows that causal attributions for dysfunctional response affect psycho-affective response to a partnered sexual situation and may, in turn, contribute to the development, maintenance and intensification of a sexual dysfunction. These findings further suggest that treatment focused on medication alone may be inadequate, and that a comprehensive strategy should include the development of internal positive self-serving attributions and feelings surrounding sexual activity.