Scoring and Interpretation of the FSFI: What can be Learned From 20 Years of use?

INTRODUCTION: Over the past 20 years, the Female Sexual Function Index (FSFI) has been considered the gold standard for the measurement of sexual function in women, with over 1,000 published manuscripts citing the article. Despite the measure's widespread usage and excellent psychometric properties, there has been some confusion over how to best implement and score the measure and interpret corresponding findings. AIM: The aim of the current article is to provide guidance, drawing from 20 years of use, on how to best implement the FSFI in research settings and interpret results based on the validation studies that have been conducted to date. METHODS: The overview of scoring and interpretation procedures found in this article is drawn from a review of the published literature on the psychometric properties of the FSFI. MAIN OUTCOME MEASURE: The measure of interest for the present review is the FSFI. RESULTS: This review article provides information about implementing, scoring, and interpreting the full-scale FSFI. Domain-level scoring and interpretation procedures are also discussed across the 5 domains of the FSFI: arousal, satisfaction, desire, pain, and lubrication. Additionally, guidance is provided for evaluating translated versions of the FSFI and using the measure to examine sexual function in culturally diverse populations. CLINICAL IMPLICATIONS: Guidance on appropriately scoring and interpretating the FSFI has the potential to strengthen our empirical understanding of sexual function, and consequently, to guide theory-driven treatment development and clinical practice. STRENGTH & LIMITATIONS: The present review provides applied guidance for the appropriate use of the FSFI specifically, but does not cover other common measures of sexual function or adaptations of the original measure. CONCLUSION: It is our hope that the guidance found in this review will ultimately lead to more rigorous and appropriate usage of the FSFI in research settings. Meston CM, Freihart BK, Handy AB, et al. Scoring and Interpretation of the FSFI: What can be Learned From 20 Years of use? J Sex Med 2020;17:17-25.

Facilitating Erotic Connection: The Relationship Shared Values Primer (RSVP) to Sex and Relationship Therapy in the Context of Sexual Trauma History.

There are few models of sex therapy designed specifically for working with relationships in which one or more partners have a history of sexual trauma. The Relationship Shared Values Primer (RSVP) to sex and relationship therapies is a pre-sex therapy psychoeducation with the goal of promoting buy-in and reducing attrition by fostering safety and connection prior to beginning the therapeutic work through a dialogue of four key values: (1) Intimate Justice, (2) Non-linear Healing, (3) Mindful Acceptance, and (4) Erotic Empathy. We discuss research support for the rationale of the RSVP, how the RSVP can mitigate current obstacles to working with this population, and present a case study of the RSVP application.

Why Humans Have Sex: Development and Psychometric Assessment of a Short-Form Version of the YSEX? Instrument.

Research has documented 237 distinct reasons for engaging in sex, which have been clustered into the 141-item, 13 subscale YSEX? instrument. Although the YSEX? has impressive psychometric properties, the required completion time is a barrier to its use in time-constrained contexts. The current studies develop and validate a short-form version of the instrument. The new 28-item, 14 subscale YSEX?-SF demonstrates acceptable model fit and good internal-reliability, with evidence for cross-form and construct validity. The YSEX?-SF maintains the original instrument's sound psychometric properties with a significantly shorter completion time, which may facilitate the study of sexual motivation.

Identification of Nonconsensual Sexual Experiences and the Sexual Self-Schemas of Women: Implications for Sexual Functioning.

Many individuals who experience nonconsensual sexual experiences (NSEs) do not identify their experiences with common sexual violence labels (e.g., sexual assault, rape, or abuse), and cognitive mechanisms of identification have yet to be examined. Identification may involve the integration of the experience into sexual self-schemas, which would have implications for sexual well-being. Women were recruited through Amazon's Mechanical Turk (N = 818) to take part in an anonymous online study of sexual experiences. The current study assessed the relationship between textually derived sexual self-schemas and sexual function (measured by the Female Sexual Function Index) in women (M = 35.37 years, SD = 11.27) with NSEs who both did (identifiers, n = 305) and did not (non-identifiers, n = 176) identify with common sexual violence labels, in comparison with those with no NSEs (n = 337). Text analyses revealed nine sexual self-schema themes in participants' essays: Virginity, Openness, Erotophilia, NSEs, Romantic, Sexual Activity, Warmth, Relationships, and Reflection. Analyses demonstrated that identifiers reported significantly poorer sexual functioning and less use of both the Warmth and Openness themes than those with no NSEs. Identifiers also invoked the NSE theme more frequently than both those with no NSE histories and non-identifiers. While greater prominence of the Warmth theme was predictive of greater sexual functioning for both non-identifiers and those with no NSEs, this was not true for identifiers. Instead, the NSE theme was significantly predictive of lower sexual functioning in identifiers. The results suggest that NSE identification may result in greater internalization of the NSE into one's sexual self-schema and, in turn, predict decrements in sexual functioning. The results are discussed in relation to identification interpretation and clinical intervention.

Opinion Paper: On the Diagnosis/Classification of Sexual Arousal Concerns in Women.

BACKGROUND: In the professional literature and among our professional societies, female sexual dysfunction nomenclature and diagnostic criterion sets have been the source of considerable controversy. Recently, a consensus group, supported by the International Society for Women's Sexual Health, published its recommendations for nosology and nomenclature, which included only one type of arousal dysfunction, female genital arousal disorder, in its classification system. Subjective arousal was considered an aspect of sexual desire and not part of the arousal phase. AIM: To advocate for the importance of including subjective arousal disorder in the diagnostic nomenclature in addition to the genital arousal subtype. METHODS: We reviewed how the construct of subjective arousal was included in or eliminated from the iterations of various diagnostic and statistical manuals. The Female Sexual Function Index (FSFI) was used to examine the relations among subjective arousal, genital arousal, and desire in women with and without sexual arousal concerns. MAIN OUTCOME MEASURES: Sexual arousal through a self-report Film Scale, physiologic sexual arousal through vaginal photoplethysmography in response to an erotic film, and the FSFI. RESULTS: The clinical literature and experience support differentiating subjective arousal from desire and genital arousal. Correlations between the FSFI domains representing desire and subjective arousal, although sufficient to suggest relatedness, share approximately 58% of the variance between constructs-a lower shared variance than FSFI domains representing subjective arousal and orgasm. Similarly, when looking at FSFI individual items best representative of sexual desire and subjective arousal, the large majority of the variance in subjective arousal was unexplained by desire. A third line of evidence showed no significant difference in levels of subjective arousal to erotic films between sexually functional women and women with desire problems. If desire and subjective arousal were the same construct, then one would expect to see evidence of low subjective arousal in women with low sexual desire. CLINICAL IMPLICATIONS: Optimized treatment efficacy requires differentiating mental and physical factors that contribute to female sexual dysfunction. STRENGTHS AND LIMITATIONS: Support for our conclusion is based on clinical qualitative evidence and quantitative evidence. However, the quantitative support is from only one laboratory at this time. CONCLUSION: These findings strongly support the view that female sexual arousal disorder includes a subjective arousal subtype and that subjective arousal and desire are related but not similar constructs. We advocate for the relevance of maintaining subjective arousal disorder in the diagnostic nomenclature and present several lines of evidence to support this contention. Althof SE, Meston CM, Perelman M, et al. Opinion Paper: On the Diagnosis/Classification of Sexual Arousal Concerns in Women. J Sex Med 2017;14:1365-1371.

Role of Body Esteem in the Sexual Excitation and Inhibition Responses of Women With and Without a History of Childhood Sexual Abuse.

INTRODUCTION: Women's sexuality is influenced by their perceptions of their bodies. Negative body appraisals have been implicated in the development and maintenance of sexual concerns in women with a history of childhood sexual abuse (CSA). The sexuality of these women is often expressed in extremes of approach and avoidant sexual tendencies, which have been related to the sexual inhibition and sexual excitation pathways of the dual control model. AIM: To test the influence of body esteem on the sexual excitation and inhibition responses of women with and without a history of CSA. METHODS: One hundred thirty-nine women with CSA and 83 non-abused women reported on their abuse history, depressive symptomology, sexual response, and affective appraisals of their body. MAIN OUTCOME MEASURES: Validated self-report measurements of sexual excitation and inhibition responses (Sexual Excitation/Sexual Inhibition Inventory for Women) and body esteem (Body Esteem Scale) were administered. RESULTS: Body esteem was significantly associated with sexual inhibition responses of women regardless of CSA history status but was significantly related only to the sexual excitation responses of women with a CSA history. Perceived sexual attractiveness was a unique predictor of sexual excitation in women with a history of CSA. CONCLUSION: Women with a history of CSA have lower body esteem than non-abused women, particularly in self-perceived sexual attractiveness, and these perceptions appear to influence their sexual responses by acting on the sexual excitation and inhibition response pathways.

Early intervention using written exposure therapy for PTSD and AUD symptoms following sexual assault: Description of design and methodology.

The co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common following sexual assault and associated with more severe symptomology and increased likelihood of sexual revictimization. Integrated interventions aimed at reducing PTSD and AUD symptoms following recent sexual assault are needed and should address barriers to care and early treatment termination. The proposed study will test a novel, brief (5 to 7 sessions) intervention that integrates Written Exposure Therapy for PTSD and Cognitive Behavioral Therapy for AUD, and is initiated within the first six weeks post-assault. In Phase 1, qualitative analysis of content gathered during focus groups with treatment providers will be conducted to inform intervention development. In Phase 2, a proof-of-concept pilot study (n = 10) of the intervention, Substance Use Skills Training and Exposure Post-Sexual Assault (STEPS), will be conducted. In Phase 3, a pilot randomized controlled trial (RCT) among 54 recent sexual assault survivors will be implemented using the updated manualized STEPS intervention to evaluate feasibility and preliminary efficacy in reducing PTSD and AUD symptoms. Ecological momentary assessments will be used to assess daily alcohol use, craving, affect, intrusions and avoidance. The effects of STEPS on commonly associated symptoms (e.g., depression, substance use) will be examined. The proposed study has the potential to make a significant public health impact by advancing knowledge on the link between sexual assault and co-occurring PTSD and AUD and informing early intervention efforts for this high-risk population.

Associations among sexual assault, posttraumatic stress, drinking to cope with anxiety, and alcohol use based on gender identity and sexual orientation.

BACKGROUND: Sexual assault (SA) is experienced by a substantial proportion of emerging adult college students and is associated with elevated rates of posttraumatic stress disorder (PTSD) and alcohol use. This study examines the mediating role of posttraumatic stress symptoms (PTSS) in the associations among SA severity, drinking to cope with anxiety, and average weekly drinks while considering the moderating roles of gender identity and sexual orientation. METHODS: A total of 2160 college students who were diverse in gender (cisgender women, 64.4%; cisgender men, 30.6%, and transgender and gender diverse [TGD] individuals = 4.9%) and sexual orientation (heterosexual = 68.0%, LGBQ+ = 32.0%) completed measures of SA severity, PTSS, drinking to cope with anxiety motives, and average weekly drinks. RESULTS: The mediation model for the full sample indicated significant indirect effects of SA severity on drinking to cope with anxiety through PTSS, but not on average weekly drinks. Moderation analyses revealed differential relationships between the variables based on both gender identity and sexual orientation. For instance, the association between SA severity and PTSS was stronger for cisgender women and TGD individuals than cisgender men, and for LGBQ+ individuals than heterosexual individuals. While the association between PTSS and average weekly drinks was only significant for cisgender men, the association between PTSS and drinking to cope with anxiety was significant for both cisgender men and women but not TGD individuals. Furthermore, the association between SA severity and drinking to cope with anxiety was stronger for cisgender women than cisgender men. CONCLUSIONS: Findings from this study demonstrate sexual orientation and gender identity differences and similarities in the associations of SA severity, PTSS, drinking to cope with anxiety, and alcohol use. Results are discussed in relation to the self-medication hypothesis and tailoring interventions for diverse groups.

Sexual Shame in the Sexual Excitation and Inhibition Propensities of Men With and Without Nonconsensual Sexual Experiences.

For men with nonconsensual sexual experience (NSEs) histories, sexual shame may play a critical role in their sexual responses. Through online surveys, the current study examined sexual shame in the sexual excitation and inhibition responses of men with NSE histories who both do (identifiers; n = 255) and do not identify (non-identifiers; n = 239) their NSEs with sexual violence labels (e.g., rape) and men with no NSEs (n = 289). Regardless of identification, men with NSEs reported greater sexual shame than men with no NSEs and higher levels of excitatory (e.g., arousability) and inhibitory (e.g., inhibitory cognitions) domains of sexual response propensities. Sexual shame predicted inhibitory domains of sexual response for all of the men. NSE history and identification moderated the relationship between sexual shame and arousability. Sexual shame had a stronger positive association with arousability for both identifiers and those with no NSEs than non-identifiers. The results provide support for the role of sexual shame in men's sexual response and suggest sexual shame is an important target for interventions with men with NSEs.

Nonconsensual Sexual Experience Histories of Incarcerated Men: A Mixed Methods Approach.

Nonconsensual sexual experiences (NSEs) may contribute to mental health concerns among incarcerated individuals, yet NSEs are understudied in this population. This study takes a novel approach in examining the prevalence of NSEs among incarcerated males by utilizing both quantitative and qualitative measures. The sample consisted of 189 men from three provincial maximum-security prisons in Ontario, Canada. Based on quantitative findings, 44.2% of the sample experienced NSEs before the age of 18, and 41.7% of the sample endorsed an experience that fit the legal definition of a NSEs as adults. Participants also responded to a qualitative open-ended question about their history of NSEs. Based on qualitative findings, a total of 23% of the men reported at least one incident of a NSE (e.g., child and adult). Based Findings highlight the high prevalence of NSEs among incarcerated men with quantitative responses demonstrating how the use of a behavioral questionnaire may, to some extent, correct for underreporting of NSEs. Qualitative responses illustrate the lived experience of incarcerated men and provide a deeper understanding of their NSEs. Responses also speak to the lack of resources and support available to these men. Findings underscore the need for proactive approaches in meeting mental health needs of incarcerated men in general and with regard to NSEs in particular. Results may inform the development of future correctional procedures (i.e., intake protocols that account for men with NSEs) and resources to support incarcerated men in navigating the psychological impact of non-consensual sexual experiences.

A Developmentally Relevant Approach to Classifying Nonconsensual Sexual Experiences in the Study of Women's Sexual Well-Being.

In this article we propose a sexual developmental approach to classifying the onset of nonconsensual sexual experiences (NSEs) that differs from the traditional age cutoff approach. Online measures of sexual self-schemas, sexual response, and sexual functioning were administered to 797 women with and without NSE histories. Women were grouped based on when their NSEs first occurred in reference to their age of menarche and age of their first consensual sexual experience (i.e., premenarche onset, postmenarche preconsensual onset, postconsensual onset, and no NSEs). Between-group analyses assessed differences in sexual well-being and structural equation modeling (SEM) assessed measurement invariance across the four groups. Women with NSE onset postmenarche but before their first consensual sexual experience reported significantly more conservative-embarrassed sexual self-schemas than did women with no NSEs. Women with NSE onset postmenarche and post-first consensual sex had significantly less sexual satisfaction than did women with no NSE histories. The other groups did not significantly differ from each other. The model demonstrated partial indicator-level metric noninvariance, suggesting that the various indicators of sexuality contributed differentially to the overall sexual well-being across these groups of women. The results support the use of the developmentally informed approach to classifying NSEs when assessing female sexual well-being.

The Impact of Childhood Sexual Abuse on Women's Sexual Health: A Comprehensive Review.

INTRODUCTION: Childhood sexual abuse (CSA) has been identified as a potent risk factor for sexual dysfunction. Certain characteristics of the abuse experience, such as repeated abuse, appear to affect the risk of developing sexual dysfunction. Despite the robust findings that CSA can be detrimental to sexual function, there is little consensus on the exact mechanisms that lead to these difficulties. AIM: To summarize the most up-to-date research on the relation between CSA and women's sexual function. METHODS: The published literature examining the prevalence of sexual dysfunction among women with CSA histories, various types of sexual dysfunctions, and mechanisms proposed to explain the relation between CSA and later sexual difficulties was reviewed. MAIN OUTCOME MEASURES: Review of peer-reviewed literature. RESULTS: Women with abuse histories report higher rates of sexual dysfunction compared with their non-abused peers. The sexual concerns most commonly reported by women with abuse histories include problems with sexual desire and sexual arousal. Mechanisms that have been proposed to explain the relation between CSA and sexual dysfunction include cognitive associations with sexuality, sexual self-schemas, sympathetic nervous system activation, body image and esteem, and shame and guilt. CONCLUSION: Women with CSA histories represent a unique population in the sexual health literature. Review of mechanisms proposed to account for the relation between CSA and sexual health suggests that a lack of positive emotions related to sexuality, rather than greater negative emotions, appears to be more relevant to the sexual health of women with CSA histories. Treatment research has indicated that mindfulness-based sex therapy and expressive writing treatments are particularly effective for this group. Further research is needed to clarify the mechanisms that lead to sexual dysfunction for women with abuse histories to provide more targeted treatments for sexual dysfunction among women with abuse histories. Pulverman CS, Kilimnik CD, Meston CM. The Impact of Childhood Sexual Abuse on Women's Sexual Health: A Comprehensive Review. Sex Med Rev 2018;6:188-200.

Methodologic Considerations for the Study of Childhood Sexual Abuse in Sexual Health Outcome Research: A Comprehensive Review.

INTRODUCTION: Childhood sexual abuse (CSA) has been a topic of interest in sexual health research for decades, yet literature on the sexual health correlates of CSA has been hindered by methodologic inconsistencies that have resulted in discrepant samples and mixed results. AIM: To review the major methodologic inconsistencies in the field, explore the scientific and clinical impact of these inconsistencies, and propose methodologic approaches to increase consistency and generalizability to the general population of women with CSA histories. METHOD: A comprehensive literature review was conducted to assess the methodologic practices used in examining CSA and sexual health outcomes. MAIN OUTCOME MEASURES: Methodologic decisions of researchers examining sexual health outcomes of CSA. RESULTS: There are a number of inconsistencies in the methods used to examine CSA in sexual health research across the domains of CSA operationalization, recruitment language, and measurement approaches to CSA experiences. CONCLUSION: The examination of CSA and sexual health correlates is an important research endeavor that needs rigorous methodologic approaches. We propose recommendations to increase the utility of CSA research in sexual health. We recommend the use of a developmentally informed operationalization of childhood and adolescence, rather than age cutoffs. Researchers are encouraged to use a broad operationalization of sexual abuse such that different abuse characteristics can be measured, reported, and examined in the role of sexual health outcomes. We recommend inclusive recruitment approaches to capture the full range of CSA experiences and transparency in reporting these methods. The field also could benefit from the validation of existing self-report instruments for assessing CSA and detailed reporting of the instruments used in research studies. The use of more consistent research practices could improve the state of knowledge on the relation between CSA and sexual health. Kilimnik CD, Pulverman CS, Meston CM. Methodologic Considerations for the Study of Childhood Sexual Abuse in Sexual Health Outcome Research: A Comprehensive Review. Sex Med Rev 2018;6:176-187.