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Background:
This study examines sexual functioning in adults with trichotillomania and skin picking disorder. To our knowledge, no study has examined sexual functioning in either of these disorders.
Methods:
334 adults (mean age=30.21, SD = 8.23, 83.5% cisgender women, 67.6% sexually active with another person in the past month) were recruited from online Reddit communities. Participants completed surveys assessing demographics, sexual functioning, and current and lifetime pulling and picking severity. Comorbidities and treatment history were assessed via dichotomous variables. Sexual functioning was assessed via the Changes in Sexual Functioning Questionnaire – Short Form (CSFQ-14).
Results:
27.1% (n=85) of the sample met criteria for sexual dysfunction. After controlling for relationship status, participants who rated their picking as currently at its worst had significantly lower scores on the Orgasm/Completion subscale. Sexual dysfunction, the total score, and subscales scores were not significantly associated with any current comorbidities or treatment variables.
Conclusions:
It is difficult to compare rate of sexual dysfunction in adults with trichotillomania and skin picking disorder with the rate in the general population given the homogeneity of this study’s sample. However, worse skin picking symptoms appear to be associated with worse sexual functioning, particularly in the orgasm domain. Since severity of comorbidities was not assessed in this study, further research is needed to determine whether comorbid disorders have an effect on sexual functioning in this population.
1 IntroductionThis study aims to examine sexual functioning in adults with trichotillomania and skin picking disorder. To our knowledge, no study has examined sexual functioning in either of these disorders.
The most frequent sexual problems in women tend to be low sexual interest, issues with arousal and lubrication, and orgasmic dysfunction. In men, they are premature ejaculation and orgasmic dysfunction (1). Common cross-cultural predictors of sexual dysfunction include relationship dissatisfaction, older age, lower educational attainment, negative experiences in sexual relationships, reduced quality of life, and physical and mental health problems (2–6).
Systematic reviews and meta-analyses show that people with psychiatric disorders generally have a greater rate of sexual dysfunction, although the prevalence and types of sexual problems vary depending on the disorder (7–9). Risk factors found to be associated with sexual dysfunction in psychiatric populations include longer duration of illness, history of relapse, and use of antipsychotic medications (7). A meta-analysis of studies on sexual functioning and depression also demonstrated that there is a bidirectional relationship between depression and sexual dysfunction, which suggests that psychiatric illness may be both a cause and an effect of sexual dysfunction (10).
The specific mechanics by which psychiatric disorders affect sexual dysfunction and vice versa is unclear. For example, in OCD—a closely related disorder to trichotillomania and skin picking disorder—it does not appear that the severity or type of OCD is correlated with sexual dysfunction (11, 12). Some have attributed increased sexual dysfunction in those with OCD to lower frequency of sexual experiences with others (13, 14). Moreover, because better mental health predicts entry into romantic relationships, those with psychiatric disorders may overall be less likely to be in relationships and have sexual experiences with others (15). However, Vulink et al. (12) still reported higher rates of sexual problems in women with OCD compared to a healthy control group with similar levels of sexual experiences with others, including lower sexual desire, more sexual disgust, less sexual arousal, and less satisfying orgasms.
Researchers have also suggested that psychiatric medications may be a cause of sexual dysfunction in psychiatric populations, considering that many patients begin reporting sexual problems after starting medication (13). However, existing studies show that the prevalence of sexual dysfunction is elevated even in those with psychiatric disorders who are not taking any medications (8, 9, 12, 16). Further research is still needed here given that these results could be explained by medications preventing improvements in sexual functioning in treated patients (16).
There may also be third factors contributing to sexual dysfunction in those with psychiatric disorders. Psychiatric populations have more relationship problems, and relationship satisfaction is most likely the strongest predictor of sexual functioning (13, 15, 17). Relationship satisfaction, psychiatric symptoms, and sexual dysfunction may all have both direct and indirect effects on each other. It could also be that there are certain traits associated with psychiatric disorders that affect sexual performance itself or lead to sexual dysfunction because of their effect on relationships. For example, in those with OCD, a need for certainty, perfectionism, and avoidance of potentially distressing experiences may lead to relationship problems and subsequently sexual dysfunction (13, 14, 18). There is some evidence that those with OCD have a higher rate of sexual dysfunction even before the onset of OCD symptoms (19). Therefore, one potential explanation of this phenomenon is that there are related traits that are present before the onset of psychiatric symptoms which affect sexual functioning. Another possible explanation is that the developmental course of OCD affects sexual development, given that one study found that men with OCD have a lower age at first masturbation and first nocturnal emission (13). These differences in sexual development may then affect sexual functioning, although more research is necessary in this area.
Trichotillomania and skin picking disorder may be linked to sexual dysfunction in multiple ways. Similar to other psychiatric illnesses, distress and functional interference from these disorders could both directly lead to dysfunction and indirectly lead to dysfunction by contributing to relationship problems. Use of psychiatric medications in this population, whether for their pulling or picking behaviors or for comorbid disorders, may also increase sexual dysfunction. Finally, there are factors specific to trichotillomania and skin picking disorder that could impact sexual functioning. Both hair pulling and skin picking often lead to unwanted changes in one’s physical appearance, including visible hair loss, skin damage, and scarring. People with these disorders can feel more self-conscious about their physical appearance (20–22). Concerns about appearance may in turn lead to heightened anxiety during sexual experiences with others and thus sexual dysfunction (23, 24). Moreover, the developmental course of these disorders could be tied to sexual functioning. The age of onset for trichotillomania tends to be around puberty, which is typically also the age of onset for major aspects of sexual development (25, 26). Distress from hair pulling behaviors may impact sexual functioning at this key developmental point, which could then lead to sexual dysfunction into adulthood. It has also previously been hypothesized that lower levels of sex hormones in adolescence is a contributing factor in the development of trichotillomania, which could simultaneously affect sexual functioning (27).
Overall, the existing literature shows that psychiatric disorders are correlated with sexual dysfunction, but the nature of the relationship is complex and requires further research. Moreover, prior studies on psychiatric illness and sexual dysfunction tend to focus on depressive disorders, anxiety disorders, OCD, and schizophrenia, but there have been few studies on other disorders (9). While there are several ways that trichotillomania and skin picking disorder may be tied to sexual functioning, there is little published research to support these claims. The current study intends to add to the literature by examining sexual functioning in adults with trichotillomania and skin picking disorder and variables associated with sexual functioning in this population.
2 Methods2.1 ParticipantsAdults between the ages of 18 to 65 years were recruited from online Reddit communities for trichotillomania and skin picking disorder as well as other body-focused repetitive behaviors (e.g., nail biting). Participants completed surveys assessing demographics, sexual functioning, current and lifetime pulling and picking severity, current comorbidities, and current treatments.
Participants self-identified as having trichotillomania and/or skin picking disorder. To ensure that participants engaged in an adequate level of hair pulling or skin picking behavior, participants were only included if they endorsed pulling or picking 3 or more days in the past week, more than 15 minutes per day, and said that their pulling or picking either bothered them or interfered with their daily life over the past week (distress or interference rated at least 1 on a scale of 0 to 5). Furthermore, participants who selected “asexual” as their sexual orientation (n=12) were excluded from analyses, given that the CSFQ-14 is not intended for individuals for whom little to no sexual desire is reflective of their normal sexual functioning rather than dysfunction. This brought the final sample size to 334.
All study procedures received approval from the University of Chicago’s Institutional Review Board (IRB) and were done in compliance with ethical guidelines outlined in the Declaration of Helsinki. Participants were required to read and sign an online informed consent before they were allowed to move forward in the survey. Survey completers could enter a raffle to win a $100 virtual Visa gift card. 15 winners were randomly selected.
2.2 MeasuresParticipants self-reported demographic variables as well as current sexual activity. Current sexual activity was defined as having sexual experiences with at least one other person in the past month. Sexual experiences were defined as any kind of sexual acts with other people, including kissing, touching, intercourse, or other sexual acts.
Sexual functioning was assessed via the Changes in Sexual Functioning Questionnaire – Short Form (CSFQ-14) (28). The scale consists of 14 items that ask about sexual functioning over the past month across five domains: Desire/Frequency, Desire/Interest, Pleasure, Arousal/Excitement, and Orgasm/Completion. Participants answer questions on a Likert scale from 1 to 5. Total score ranges from 14 to 70, with higher scores representing better sexual functioning. Scores below or equal to 47 in males and below or equal to 41 in females indicate sexual dysfunction. The scale also results in five subscale scores based on its five domains.
Current pulling and picking severity was measured over the past week by number of days per week spent pulling or picking, time spent per day pulling or picking (in minutes), how much their pulling or picking bothered them on a scale of 0 to 5, and how much their pulling or picking interfered with their daily life on a scale of 0 to 5 (0=not at all, 5=very, very much). For days spent pulling or picking in the past week and time spent per day puling or picking, participants wrote in their answers. These severity items were in part based off of the National Institute of Mental Health Trichotillomania Symptom Severity Scale (NIMH-TSS), which similarly asks participants how much time they spent pulling hairs in a typical day (in minutes), how much their hair pulling bothers them on a scale of 0 to 5, and how much their hair pulling interferes with their daily life on a scale of 0 to 5 (29). To measure lifetime pulling and picking severity, participants were asked to report on the same variables when their pulling or picking was the worst in their lifetime.
To evaluate comorbidities, participants were asked “Have you ever been diagnosed with any of the following disorders (check all that apply)?” The options were, “I have never had a psychiatric disorder,” “depression,” “any anxiety disorder (e.g., generalized anxiety, social anxiety, panic disorder, phobias),” “PTSD,” “ADHD,” “OCD,” “bipolar disorder,” “schizophrenia,” “any personality disorder (e.g., borderline, narcissistic, avoidant),” “eating disorder,” “alcohol use disorder,” “substance use disorder,” and “other.” Participants were then asked if they were currently experiencing symptoms of each disorder that was checked. To assess current treatments, participants were asked to indicate if they were currently taking psychiatric medications, hormonal medications, and if they were in psychotherapy. If they indicated that they were currently taking psychiatric medications, they were asked to write out what medications they were taking. This data was then coded into medication classes (e.g., antidepressants, stimulants).
2.3 Statistical analysesThis study aimed to identify variables associated with sexual dysfunction based on the CSFQ-14 cutoff scores. It also aimed to identify variables associated with the degree of overall sexual functioning according to the CSFQ-14 total score and the degree of sexual functioning in each domain of sexual functioning according to the subscale scores. T-tests, ANOVAs, chi-square tests, and Pearson correlations were conducted for these statistical analyses. When it was necessary to control for demographic variables, ANCOVAs and partial correlations were performed as applicable. Effect sizes were categorized using cutoffs into either small (d=0.20, φ=0.10, ηp2 = 0.01), medium (d=0.50, φ=0.30, ηp2 = 0.06), or large (d=0.80, φ=0.50, ηp2 = 0.14).
There is some missing data in this study, given that participants were allowed to skip items they did not feel comfortable answering. This includes the CSFQ-14, where 20 participants did not answer at least 1 item. Therefore, these participants’ data is analyzable for some subscales but not others, and it was not analyzable for the total score. Given our large sample size, we do not believe missing data introduced bias into the results.
IBM SPSS Version 31.0 was used for all data analysis. Considering that this study is exploratory, it was determined that a Bonferroni correction would be overly restrictive to control for multiple comparisons. Instead, the significance level was set at p-values <0.01 to be considered statistically significant.
3 Results3.1 DemographicsThe final sample consisted of 334 participants ages 18 to 65 (mean age=30.21, SD = 8.23). 27.2% of the sample had trichotillomania, 56.0% had skin picking disorder, and 16.8% had both. 83.5% were cisgender women, 9.0% were cisgender men, and 7.5% were gender minorities who were assigned female at birth. 71.8% were non-Hispanic White, 59.0% were heterosexual, 59.0% worked full-time, and 68.5% had a bachelor’s degree or higher. 64.7% were in a relationship, 10.2% were dating or “hooking up” (having sexual experiences with others outside of the bounds of dating or a relationship), and 25.1% were single (not dating or having sexual experiences with other people). In the past month, 63.4% had sexual experiences with one person, 4.2% with multiple people, and 32.4% with no one. Therefore, 67.6% of the sample were considered currently sexually active.
Based on the CSFQ-14, 27.1% of the full sample met criteria for sexual dysfunction. There was no significant difference in rates of sexual dysfunction between those who had trichotillomania (22.5%), skin picking disorder (25.9%), and both (38.2%). There were also no significant differences in the total or subscale scores by disorder. The mean total score was 46.30 (SD = 9.27), 95% CI [45.27, 47.33] (Figure 1). There was no significant difference in age between those who met criteria for sexual dysfunction (M = 31.72, SD = 10.75) than those who did not (M = 29.61, SD = 7.08). Age was also not associated with the CSFQ-14 total or subscale scores.
CSFQ-14 total scores for 314 participants with trichotillomania, skin picking disorder, or both.
There was no significant differences in rates of sexual dysfunction by sex and gender (cisgender women: 28.6%, gender minorities: 25.0%, cisgender men: 14.3%). Cisgender women had significantly lower total scores (M = 45.65, SD = 9.48) than cisgender men (M = 53.32, SD = 5.82), t(44.069)=-6.157, p<.001, d=-.835, (large effect size). Gender minorities also had significantly lower total scores (M = 45.25, SD = 6.65) than cisgender men (M = 53.32, SD = 5.82), t(50)=4.667, p<.001, d=1.298, (large effect size). In terms of the specific domains on the CSFQ-14, cisgender women had significantly lower scores on the Desire/Frequency [t(306)=-3.163, p=.002, d=-.608], Desire/Interest [t(305)=-4.792, p<.001, d=-.921], and Arousal/Excitement [t(299)=-6.448, p<.001, d=-1.260] subscales than cisgender men. Gender minorities also had significantly lower scores on the Arousal/Excitement subscale than cisgender men, t(51)=5.139, p<.001, d=1.418.
Heterosexual participants (33.5%) had significantly higher rates of sexual dysfunction than non-heterosexual participants (17.8%), X2(1)=9.470, p=.002, φ=-.174 (small effect size). Non-heterosexual participants had significantly higher total scores (M = 48.05, SD = 7.76) than heterosexual participants (M = 45.08, SD = 10.03), t(308.563)=-2.963, p=.003, d=-.325 (small effect size). In particular, non-heterosexual participants had significantly higher scores on the Desire/Frequency [t(331)=-3.278, p=.001, d=-.365] and Desire/Interest [t(318.257)=-4.612, p<.001, d=-.500] subscales than heterosexual participants. There was no significant difference in rates of sexual dysfunction or total or subscale CSFQ-14 scores between gay or lesbian and bisexual or pansexual participants.
Relationship status was not significantly associated sexual dysfunction. Relationship status was significantly associated with the CSFQ-14 total score (relationship: M = 47.10, SD = 8.90; dating or hooking up: M = 48.30, SD = 7.77; single: M = 43.32, SD = 10.21), F(2)=5.657, p=.004, ηp2 = .035 (small effect size). Specifically, relationship status was significantly associated with the Pleasure subscale, F(2)=53.434, p<.001, ηp2 = .245. Those who were in a relationship had similar Pleasure subscale scores to those who were dating or hooking up, and both had higher scores than those who were single.
Participants who were currently sexually active (had sexual experiences with at least one other person in the past month) were significantly less likely to meet criteria for sexual dysfunction (22.4%) than those who were not currently sexually active (37.4%), X2(1)=7.641, p=.006, φ=-.156 (small effect size). Participants who were currently sexually active had significantly higher CSFQ-14 total scores (M = 47.61, SD = 8.68) than those who were not (M = 43.43, SD = 9.93), F(1)=14.296, p<.001, ηp2 = .044 (small effect size). In particular, those who were currently sexually active had significantly higher scores on the Pleasure [F(1)=182.309, p<.001, ηp2 = .356] and Orgasm/Completion [F(1)=8.395, p=.004, ηp2 = .026] subscales than those who were not.
Educational achievement was not associated with rates of sexual dysfunction. However, educational achievement was significantly associated with the CSFQ-14 total score (less than bachelor’s: M = 44.82, SD = 9.47; bachelor’s: M = 48.20, SD = 8.20; master’s or higher: M = 44.84, SD = 10.23), F(2)=5.274, p=.006, ηp2 = .033 (small effect size). Educational achievement was also significantly associated with the Desire/Interest [F(2)=5.875, p=.003, ηp2 = .034], Arousal/Excitement [F(2)=6.223, p=.002, ηp2 = .037], and Orgasm/Completion [F(2)=6.109, p=.002, ηp2 = .037] subscales. Participants with a bachelor’s degree had higher scores on all three of these subscales than those with less than bachelor’s degree and those with a master’s degree or higher.
Hispanic/Latino participants had significantly higher scores on the Desire/Frequency subscale than non-Hispanic/Latino participants, t(331)=-2.594, p=.010, d=-.458. Race and employment status were not significantly associated with rates of sexual dysfunction or CSFQ-14 total or subscales scores (Table 1).
Demographic variableFull sampleSexual dysfunctionCSFQ-14 scoresAll M (SD) or %Dysfunctional M (SD) or %FunctionalDemographics for 334 participants with trichotillomania, skin picking disorder, or both.
Ns may vary depending on whether there was missing data from participants not answering certain items. *Current sexual activity is defined as having sexual experiences with at least one other person in the past month. Sexual experiences is defined as any kind of sexual acts with other people, including kissing, touching, intercourse, or other sexual acts.
3.2 Pulling and picking detailsThere were no significant differences in pulling or picking variables between those who met criteria for sexual dysfunction and those who did not. The total CSFQ-14 score was also not significantly related to any pulling and picking variables.
Functional interference from pulling when pulling was at its worst was weakly negatively associated with the Pleasure subscale, r=-.224, p=.007, n=144. However, with controlling for relationship status, this result was no longer significant. After controlling for relationship status, participants who rated their picking as currently at its worst had significantly lower scores on the Orgasm/Completion subscale (M = 9.68) than those who said their picking had been worse before (M = 10.87), F(1)=6.838, p=.010, ηp2 = .029 (small effect size) (Table 2).
Pulling or picking variableFull sampleSexual dysfunctionCSFQ-14 scoresAll
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