Psychometric Evaluation and Adaptation of the Five-Factor Sexual Satisfaction Scale (SSS-W) for Use in Men: The Sexual Satisfaction Scale (SSS).

The Sexual Satisfaction Scale for Women (SSS-W) is a psychometrically sound, widely used instrument for assessing sexual satisfaction and distress in women. Because the majority of scale items are gender nonspecific, numerous researchers have adapted this scale for use in male samples. The goal of the current study was to assess the reliability and validity of a slightly modified version of the SSS-W in a male sample (N = 268). A Confirmatory Factor Analysis of five previously established factors provided evidence for consistency of internal structure in men. The adapted scale (SSS) exhibited acceptable test-retest reliability, as well as evidence for validity based on relationships with theoretically predicted variables. Taken together, there is evidence to suggest that the SSS may be a reliable and valid psychometric tool for the measurement of sexual satisfaction and distress in both men and women.

History of Sexual Assault as a Predictor of Response to a Self-Guided Online Program for Sexual Desire and Arousal Difficulties in Women.

Sexual Interest/Arousal Disorder (distressing, long-lasting impairments in sexual desire and/or arousal) is common in women, but few have access to efficacious psychotherapies, including cognitive-behavioral therapy (CBT) and mindfulness-based therapy (MBT). eSense, an online program meant to maximize treatment access, has been shown to be a feasible, satisfactory, and potentially efficacious intervention. However, subpopulations such as sexual assault survivors may find the program less usable or efficacious. The current study compared women with and without a history of sexual assault (SA) regarding their ability to use and benefit from eSense. Forty-four women (22 with a history of SA; M age = 34.20 years) used eSense (CBT or MBT) and completed validated self-report scales of sexual function, sexual distress, treatment satisfaction, and homework compliance. A history of SA did not predict differences in attrition or changes in clinical outcomes. Exploratory analyses suggested that women with a history of SA reported slightly higher difficulty completing homework assignments, but also slightly higher treatment satisfaction. These preliminary results suggest that eSense may be usable and helpful for women with a history of SA. We discuss ways to maximize the acceptability and efficacy of online programs for women with a history of SA.

Feasibility of a cognitive behavioral online intervention for women with Sexual Interest/Arousal Disorder.

OBJECTIVES: Difficulties with sexual desire and arousal are common in women, but most lack access to effective treatment such as cognitive-behavioral therapy (CBT). eSense is a recently created online CBT intervention for sexual difficulties with promising evidence of usability. The current study assessed the feasibility of women completing the full eSense CBT program without guidance. METHODS: Eleven women with Sexual Interest/Arousal Disorder completed eSense and provided feedback via semi-structured interviews. RESULTS: Participants reported high satisfaction with eSense's functionality, improved knowledge about sexuality, greater awareness of their thought patterns, and better perspective around their sexual difficulties. Despite some difficulty completing homework, participants exhibited statistically significant pre-post improvements in sexual desire (d = 1.04), sexual arousal (d = 1.83), sexual satisfaction (d = 1.35), and sexual distress (d = 1.79). CONCLUSION: The findings add to the growing evidence that self-guided online interventions are feasible and potentially efficacious in treating female sexual dysfunction.

Feasibility of a Brief Online Psychoeducational Intervention for Women With Sexual Interest/Arousal Disorder.

BACKGROUND: Low sexual desire and arousal are the most common sexual concerns in women, but most women lack access to effective treatment such as cognitive behavioral therapy. Web-based psychological interventions, which are economical, private, easily accessible, and potentially effective, may increase the reach of evidence-based treatment. AIM: To determine the feasibility of translating cognitive behavioral therapy for the most common female sexual dysfunction, Female Sexual Interest/Arousal Disorder, into an online format. The present study examined the feasibility of an introductory psychoeducational module of eSense, an online program currently being developed that is based on existing empirically supported in-person treatments, which delivers content to the user in a visually appealing and interactive manner. METHODS: Sixteen cisgender women (M age = 31.9) with female sexual arousal/interest disorder worked through a pilot module of eSense inperson at a sexual health laboratory. OUTCOMES: Qualitative semistructured interviews and online questionnaires were used to assess participants' experiences of usability of the platform, clarity/relevance of the content, satisfaction with the experience, and any changes in clinical outcomes of sexual function and distress. RESULTS: Participants reported a high level of satisfaction with the website's functionality and presentation. They reported greater knowledge, felt validated and more hopeful, and were eager to continue the remaining modules. Participants also reported notable prepost improvements in sexual desire, arousal, and satisfaction. CLINICAL IMPLICATIONS: Initial user-experience assessment may represent a method of simultaneously improving online interventions and providing therapeutic education to participants. STRENGTHS & LIMITATIONS: This is one of the first studies, to our knowledge, to test a graphics-rich, interactive online intervention for sexual difficulties that does not require direct contact with expert providers or support groups. Limitations include the high level of education, motivation, and technical fluency of the sample and the potentially confounding effect of the researcher's presence during interviews. Because this was a feasibility study, the sample size was small, and no control group was included, limiting conclusions about efficacy and generalizability. CONCLUSION: The format of eSense appears to be feasible and usable, lending support to the growing evidence that it is possible to take in-person therapeutic interventions online. Zippan N, Stephenson KR, Brotto LA, Feasibility of a Brief Online Psychoeducational Intervention for Women With Sexual Interest/Arousal Disorder. J Sex Med 2020;17:2208-2219.

Statistical Mediators of the Association Between Mindfulness and Sexual Experiences in Men with Impaired Sexual Function.

Mindfulness-based therapy has shown promise as a treatment for female sexual dysfunction and has the potential to be an efficacious treatment for male sexual dysfunction. However, there has been little empirical evidence regarding the mechanisms through which mindfulness may improve sexual experiences, especially for men. Recent theoretical reviews have suggested potential mediators that may explain the beneficial effects of mindfulness on symptoms of male sexual dysfunction, including reduced avoidance of sex, reduced distraction during sex, and/or reduced activation of negative sexual schemas. We attempted an initial statistical test of these factors as potential mediators of the association between trait mindfulness and multiple sexual outcomes (sexual function, sexual satisfaction, and sexual distress) using a cross-sectional correlational design. A total of 163 men with self-reported current impairments in one or more aspects of sexual function completed self-report scales using a secure online survey. Bivariate correlations indicated that mindfulness was significantly associated with sexual satisfaction, sexual distress, and premature ejaculation, but not other aspects of sexual function. Sexual avoidance statistically mediated the link between mindfulness and sexual satisfaction, both distraction and activation of negative schemas statistically mediated the link between mindfulness and premature ejaculation, and all three factors statistically mediated the link between mindfulness and sexual distress. These results generally supported previous theoretical work and have implications for future treatment outcome research.

Why Is Impaired Sexual Function Distressing to Men? Consequences of Impaired Male Sexual Function and Their Associations With Sexual Well-Being.

INTRODUCTION: According to theoretical models of sexual dysfunction, the complex association between male sexual function and subjective sexual well-being (ie, sexual satisfaction and distress) may be partially mediated by specific "consequences" of impaired function, but little research has assessed the frequency of specific consequences or their association with well-being. AIM: To pilot a scale assessing consequences of impaired male sexual function, and test whether specific consequences (eg, disruption of sexual activity, negative partner responses) mediated the association between sexual function and well-being. METHODS: 166 men in sexually active heterosexual relationships completed self-report measures. A majority of men self-identified as experiencing impaired sexual function in the past month. MAIN OUTCOME MEASURE: Sexual Satisfaction Scale, International Index of Erectile Function, and Measure of Sexual Consequences. RESULTS: 17 specific consequences were reported with at least moderate frequency and were rated at least somewhat distressing. A factor analysis suggested 3 distinct categories of consequences: barrier to sex and pleasure, negative partner emotional responses, and impaired partner sexual function. These factors and the overall scale exhibited acceptable internal and test-retest reliability and each was significantly associated with multiple facets of sexual function and well-being. Frequency of sexual consequences significantly mediated the association between sexual function and well-being, with the strongest and most consistent indirect effects being found for the barrier to sex and pleasure factor. CLINICAL IMPLICATIONS: Consequences of impaired sexual function on one's sexual experiences may be an important maintaining factor of sexual dysfunction and reduction in these consequences may represent a mechanism of action for psychological treatments. STRENGTH AND LIMITATIONS: Strengths included a relatively large sample with a diverse range of sexual function and well-being, as well as modern statistical analyses to assess factor structure and mediation effects. Limitations included the use of self-report scales with limited independent evidence of validity and reliability for use with male samples, as well as the cross-sectional methods that preclude strong conclusions regarding causal relationships. CONCLUSION: Sexual consequences represent potential maintaining factors of male sexual dysfunction and may represent key targets of cognitive behavioral treatments. Stephenson KR, Truong L, Shimazu L. Why is impaired sexual function distressing to men? Consequences of impaired male sexual function and their associations with sexual well-being. J Sex Med 2018;15:1336-1349.

Statistical and Epistemological Issues in the Evaluation of Treatment Efficacy of Pharmaceutical, Psychological, and Combination Treatments for Women's Sexual Desire Difficulties.

We were grateful to receive responses from Leonore Tiefer, Anita Clayton and Robert Pyke, and Richard Balon and Robert Segraves, to our commentary (Brotto et al., 2016 ) on Pyke and Clayton ( 2015 ). These commentaries raise a number of substantive statistical and epistemological issues relating to the evaluation of treatment efficacy in pharmaceutical, psychological, and combination treatments for sexual desire difficulties and caution researchers to remain mindful of sources of bias as we do the science. In what follows, we discuss each of these issues in turn in hopes of encouraging our field to adopt the highest possible standards when carrying out and interpreting treatment outcome research.

Changes in Mindfulness and Posttraumatic Stress Disorder Symptoms Among Veterans Enrolled in Mindfulness-Based Stress Reduction.

OBJECTIVES: The current study assessed associations between changes in 5 facets of mindfulness (Acting With Awareness, Observing, Describing, Non-Reactivity, and Nonjudgment) and changes in 4 posttraumatic stress disorder (PTSD) symptom clusters (Re-Experiencing, Avoidance, Emotional Numbing, and Hyperarousal symptoms) among veterans participating in mindfulness-based stress reduction (MBSR). METHOD: Secondary analyses were performed with a combined data set consisting of 2 published and 2 unpublished trials of MBSR conducted at a large Veterans Affairs hospital. The combined sample included 113 veterans enrolled in MBSR who screened positive for PTSD and completed measures of mindfulness and PTSD symptoms before and after the 8-week intervention. RESULTS: Increases in mindfulness were significantly associated with reduced PTSD symptoms. Increases in Acting With Awareness and Non-Reactivity were the facets of mindfulness most strongly and consistently associated with reduced PTSD symptoms. Increases in mindfulness were most strongly related to decreases in Hyperarousal and Emotional Numbing. CONCLUSIONS: These results extend previous research, provide preliminary support for changes in mindfulness as a viable mechanism of treatment, and have a number of potential practical and theoretical implications.

Further Validation of the Female Sexual Function Index: Specificity and Associations With Clinical Interview Data.

Female sexual function is a multi-faceted psychophysiological construct. The Female Sexual Function Index (FSFI) is considered a "gold standard" self-report instrument that assesses the various aspects of sexual function. However, researchers have recently proposed potential limitations of the FSFI, highlighting the need for continued validation research. The aims of the current analyses were (a) to assess the correlations between FSFI scores and information regarding specific rates of functional impairment gained via clinical interview; and (b) to assess the specificity of FSFI subscale scores in reflecting corresponding aspects of sexual function (e.g., whether the Sexual Desire subscale reflects sexual desire specifically rather than sexual arousal, orgasm, etc.). The participants were 97 sexually active women who reported impairments in sexual function. Clinical interview data exhibited moderate-to-strong correlations with FSFI scores. Additionally, FSFI subscales generally exhibited adequate specificity in terms of reflecting their corresponding aspects of sexual function more strongly than other aspects. The results generally supported the validity of the FSFI. Implications for the measurement and conceptualization of female sexual function are discussed.

Heterosexual Women's Causal Attributions Regarding Impairment in Sexual Function: Factor Structure and Associations with Well-Being.

Theory and interventions for female sexual dysfunction typically emphasize the role of cognitions, including the perceived causes of impaired sexual function (causal attributions). Although causal attributions have been extensively studied in the context of mood disorders and relational distress, research in the area of sexual dysfunction has been limited. The current study explored the factor structure of women's causal attributions regarding their impaired sexual function and the association between these attributions and multiple indicators of subjective well-being. Women in heterosexual relationships reporting current impairments in sexual function (N = 147) completed self-report scales assessing 13 distinct causal attributions, sexual function, and subjective well-being. Results suggested moderately reliable patterns of attributions regarding responsibility (e.g., self vs. partner), specificity to sexual activity, and the degree to which women could effectively address the causes of their difficulties. Beliefs that impaired sexual function was the fault of one's self or one's partner, caused by wider issues in the relationship, and difficult to effectively address were generally associated with lower well-being over and above severity of functional impairment. These findings support multiple theories of sexual dysfunction, and highlight the potential importance of cognitive factors in understanding and treating female sexual dysfunction.

Why is impaired sexual function distressing to women? The primacy of pleasure in female sexual dysfunction.

INTRODUCTION: Recent research has highlighted a complex association between female sexual function and subjective distress regarding sexual activity. These findings are difficult to explain given limited knowledge as to the mechanisms through which impaired sexual function causes distress. AIM: The current study assessed whether a number of specific consequences of impaired sexual function, including decreased physical pleasure, disruption of sexual activity, and negative partner responses, mediated the association between sexual function and distress. METHODS: Eighty-seven women in sexually active relationships reporting impairments in sexual function completed validated self-report measures and daily online assessments of sexual experiences. MAIN OUTCOME MEASURES: Participants completed the Sexual Satisfaction Scale for Women, the Female Sexual Function Index, and the Measure of Sexual Consequences. RESULTS: Results suggested that decreased physical pleasure and disruption of sexual activity, but not partner responses, statistically mediated the association between sexual function and distress. CONCLUSION: Sexual consequences represent potential maintaining factors of sexual dysfunction that are highly distressing to women. Results are discussed in the context of theoretical models of sexual dysfunction and related treatments.

The conditional importance of sex: exploring the association between sexual well-being and life satisfaction.

Leaders in the field of sexuality have called for additional research examining the link between sexual well-being and life satisfaction in women in order to expand knowledge regarding the important consequences of a satisfying sex life. Participants in the present study were sexually active women reporting a wide range of sexual difficulties who completed an in-person interview, validated self-report measures, and daily online assessments for 4 weeks. Sexual well-being was related to life satisfaction both cross-sectionally and within individuals over time. In addition, high relational satisfaction and low attachment anxiety served as protective factors, decreasing the degree to which unsatisfying sexual experiences were associated with decreases in life satisfaction. These results extend previous findings by confirming a strong association between sexual well-being and overall life satisfaction within individuals over time. The strength of this association is moderated by a number of intra- and interpersonal factors. Implications for healthcare providers are discussed.

A pilot trial of telephone-based collaborative care management for PTSD among Iraq/Afghanistan war veterans.

BACKGROUND: Collaborative care and care management are cornerstones of Primary Care-Mental Health Integration (PC-MHI) and have been shown to reduce depressive symptoms. Historically, the standard of Veterans Affairs (VA) collaborative care was referring patients with posttraumatic stress disorder (PTSD) to specialty care. Although referral to evidence-based specialty care is ideal, many veterans with PTSD do not receive such care. To address this issue and reduce barriers to care, VA currently recommends veterans with PTSD be offered treatment within PC-MHI as an alternative. The current project outlines a pilot implementation of an established telephone-based collaborative care model-Translating Initiatives for Depression into Effective Solutions (TIDES)-adapted for Iraq/Afghanistan War veterans with PTSD symptoms (TIDES/PTSD) seen in a postdeployment primary care clinic. MATERIALS AND METHODS: Structured medical record extraction and qualitative data collection procedures were used to evaluate acceptability, feasibility, and outcomes. RESULTS: Most participants (n=17) were male (94.1%) and white (70.6%). Average age was 31.2 (standard deviation=6.4) years. TIDES/PTSD was successfully implemented within PC-MHI and was acceptable to patients and staff. Additionally, the total number of care manager calls was positively correlated with number of psychiatry visits (r=0.63, p<0.05) and amount of reduction in PTSD symptoms (r=0.66, p<0.05). Overall, participants in the pilot reported a significant reduction in PTSD symptoms over the course of the treatment (t=2.87, p=0.01). CONCLUSIONS: TIDES can be successfully adapted and implemented for use among Iraq/Afghanistan veterans with PTSD. Further work is needed to test the effectiveness and implementation of this model in other sites and among veterans of other eras.

Assessing the association between childhood sexual abuse and adult sexual experiences in women with sexual difficulties.

Self-report instruments for assessing sexual well-being in women with sexual difficulties have not to date been explicitly validated among women with a history of childhood sexual abuse (CSA). Given an extensive literature suggesting psychological differences between women with and without a history of CSA, it is possible that sexual well-being has a different meaning for these groups. Without validated scales, it is difficult to evaluate the impact of early sexual trauma on adult sexuality. The present study assessed whether the factor structure of widely used measures of sexual well-being were consistent across women experiencing sexual difficulties, with and without an abuse history, and to estimate effect sizes for the statistical effect of CSA on sexual well-being in this population. A sample of women with and without a history of CSA (N = 238) completed the Female Sexual Function Index and the Sexual Satisfaction Scale for Women. Structural equation models indicated generally consistent factor structures across groups, suggesting good construct validity. Effect size estimates indicated medium to large (0.53-0.72) effects of CSA on sexual well-being for women with sexual difficulties. These findings support and extend research regarding the potential effects of CSA that may inform treatment for this population.

Effects of expressive writing on sexual dysfunction, depression, and PTSD in women with a history of childhood sexual abuse: results from a randomized clinical trial.

INTRODUCTION: Women with a history of childhood sexual abuse (CSA) have high rates of depression, posttraumatic stress disorder, and sexual problems in adulthood. AIM: We tested an expressive writing-based intervention for its effects on psychopathology, sexual function, satisfaction, and distress in women who have a history of CSA. METHODS: Seventy women with CSA histories completed five 30-minute sessions of expressive writing, either with a trauma focus or a sexual schema focus. MAIN OUTCOME MEASURES: Validated self-report measures of psychopathology and sexual function were conducted at posttreatment: 2 weeks, 1 month, and 6 months. RESULTS: Women in both writing interventions exhibited improved symptoms of depression and posttraumatic stress disorder (PTSD). Women who were instructed to write about the impact of the abuse on their sexual schema were significantly more likely to recover from sexual dysfunction. CONCLUSIONS: Expressive writing may improve depressive and PTSD symptoms in women with CSA histories. Sexual schema-focused expressive writing in particular appears to improve sexual problems, especially for depressed women with CSA histories. Both treatments are accessible, cost-effective, and acceptable to patients.

Relationship satisfaction as a predictor of treatment response during cognitive behavioral sex therapy.

Although recent research suggests that individual cognitive behavioral therapy (CBT) may be an effective treatment for female sexual dysfunctions, we have little information regarding predictors of treatment response. The goal of the current study was to assess the degree to which pre-treatment relationship satisfaction predicted treatment response to cognitive behavioral sex therapy. Women with sexual dysfunction (n = 31, M age = 28 years, 77.4 % Caucasian) receiving cognitive-behavioral sex therapy with or without ginkgo biloba, as part of a wider randomized clinical trial, were assessed pre- and post-treatment using validated self-report measures of sexual satisfaction, sexual distress, sexual functioning, and relationship satisfaction. Pre-treatment relationship satisfaction predicted changes in sexual satisfaction and distress, but not sexual functioning. Women with higher relationship satisfaction at intake experienced larger gains in sexual satisfaction and distress over the course of treatment. Pre-treatment relationship satisfaction also moderated the association between changes in sexual functioning and changes in sexual distress, such that improved functioning was associated with decreased distress only for women entering therapy with high relationship satisfaction. These findings suggest that, for women with low relationship satisfaction before entering treatment, improvement in sexual functioning may not be enough to alleviate their sexual distress.

Feasibility of an Online Mindfulness-Based Intervention for Women with Sexual Interest/Arousal Disorder.

Objectives: Difficulties with sexual desire impact up to a third of women and most do not seek or receive appropriate care for these complaints, in part due to stigma, embarrassment, and limited availability of treatment. In-person mindfulness-based interventions have lasting benefits to sexual desire and sex-related distress in controlled clinical trials but are difficult to access. Online cognitive-behavioral interventions for sexual concerns have shown promising findings, but online mindfulness interventions have received little testing. The current study assessed the feasibility of an online program (called eSense-Mindfulness) adapted from an effective face-to-face intervention for women with Sexual Interest/Arousal Disorder. Methods: Thirty cisgender women (M age = 35.3) with Sexual Interest/Arousal Disorder consented and completed at least one of the eight modules of eSense-Mindfulness while providing weekly feedback regarding their experience. Feasibility was assessed via attrition rates and participant self-report regarding challenges of using the program. Limited efficacy testing was based on effect sizes for changes in sexual response and sex-related distress. Results: Participants (n = 25 who completed all testing) reported high levels of usability and ease of understanding content and reported the mindfulness exercises as well as the information on partner communication to be the most relevant. Limited efficacy testing showed large effect sizes for reductions in sex-related distress, and improvements in sexual desire, arousal, and satisfaction whereas there were smaller effect sizes for improvements in lubrication, orgasm, and vaginal pain. Conclusions: The findings suggest that efficacious face-to-face mindfulness interventions for sexual dysfunction in women show excellent evidence of feasibility when delivered online without personalized guidance.

The association between sexual motives and sexual satisfaction: gender differences and categorical comparisons.

Past research suggests that sexual satisfaction may be partially dependent on sexual motives (the reasons people have sex). The primary goal of this study was to determine which of a wide range of empirically derived sexual motives were related to sexual satisfaction, and whether gender differences existed in these relationships. Examining data from 544 undergraduate participants (93 men, 451 women), we found that certain types of motives predicted levels of sexual satisfaction for both genders. However, a greater number of motive categories were related to satisfaction for women than for men, and sexual motives were a more consistent predictor of satisfaction in general for women than for men. We also found that empirical categories of motives predicted more variance in satisfaction ratings than did previously used theoretical categories. These findings suggest that a wide range of sexual motives are related to sexual satisfaction, that these connections may be moderated by gender, and that empirically-constructed categories of motives may be the most effective tool for studying this link.

When are sexual difficulties distressing for women? The selective protective value of intimate relationships.

INTRODUCTION: Recent studies have shown that sexual functioning and sexually related personal distress are weakly related in women, with only a minority of sexual difficulties resulting in significant levels of distress. However, there has been little systematic research to date on which factors moderate the relationship between sexual functioning and sexual distress. AIM: To assess the degree to which relational intimacy and attachment anxiety moderate the association between sexual functioning and sexual distress in college-age women. METHODS: Two hundred women (mean age=20.25) completed surveys assessing sexual functioning, relational intimacy, attachment anxiety, and sexual distress. MAIN OUTCOME MEASURES: Participants completed the Sexual Satisfaction Scale for Women, the Female Sexual Function Index, the Dimensions of Relationship Quality Scale, and the Revised Experiences in Close Relationships Measure of Adult Romantic Attachment. RESULTS: Relational intimacy and attachment anxiety moderated the association between multiple aspects of sexual functioning and sexual distress. For lubrication and sexual pain, functioning was more strongly associated with distress in low-intimacy vs. high-intimacy relationships, but only for women with high levels of attachment anxiety. Results regarding desire were mixed and neither intimacy nor attachment anxiety interacted with subjective arousal or orgasm in predicting distress. CONCLUSION: Both relational intimacy and attachment anxiety are important moderators of the association between sexual functioning and subjective sexual distress in women. Theoretical and practical implications are discussed.