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Emotional intimacy is the best predictor of sexual satisfaction of men and women with sexual arousal problems

Abstract

This study investigates the association between variables related to individual body appearance and relationship variables with sexual satisfaction (SS) in a sample of men and women with sexual arousal problems (SAP). An anonymous cross-sectional survey was conducted in a clinical setting with a non-representative sample of people diagnosed (DSP) with SAP and with a sample of people who identified themselves (SISP) as having a SAP. A total of 193 participants was recruited. SS and variables related to body appearance and relationship were measured. Hierarchical regression was used to study the contribution of different sets of variables on SS of men and women. No differences were found in terms of demographic variables, except for gender. Women in the SISP group presented significantly higher levels of SS than women in the DSP group. The predictive models proved to be statistically significant and explained many of the variance of SS in both men (R2=0.44) and women (R2=0.40). In both genders, emotional intimacy was revealed to be the main predictor of SS. Our results support the need to address relationship variables in patients diagnosed with SAP, specifically intimacy. This latter component must be considered for assessment, intervention and referral.

Introduction

Sexual arousal problems (SAP) are a common sexual problem (SP) presented in urological patients.1 In Portugal, the only prevalence estimates that could be obtained were from primary care: ED affects 13% of men and sexual interest/arousal disorder affects 32% of women.2, 3 SAP is associated with a decrease in the quality of life.4 Sexual satisfaction (SS) is essential for the sexual well being of people with and without SP because it is tightly associated with sexual health and is a sexual right.5 As such, SS constitutes an important goal in the treatment of SAP.4, 6, 7, 8 Researchers found evidence that cognitive, emotional and behavioral dimensions are strongly linked to SS in people with SAP.9 However, little is known about the role that of relationship variables have in the SS of people with SAP. The DSM-5 development10 acknowledges that individual factors (for example, body image) and relationship factors (for example, conflict) should be specified for SAP, so that better insight into the impact of these variables can be understood. However, even though relational factors are considered important in diagnosis, assessment and clinical intervention with people with SAP,11, 12 we found no recent research on the role that both individual and relationship factors have on SS of people with SAP. We define SS as ‘…an affective response arising from one’s subjective evaluation of the positive and negative dimensions associated with one’s sexual relationship…’,13, p 268, as we will focus on the emotional aspects of SS. Based on existing research,14, 15, 16, 17, 18 we aim in the current study to explore the role that body appearance-related factors (individual level) and intimacy, satisfaction with physical characteristics, number of children and conjugal status (relational level) have on the SS of both men and women with SAP.

We will use both a sub-group of people self-identified with a SAP and a clinical sub-group diagnosed by a clinician because studies on SP conducted with data collected in clinical settings miss those people in the population that self-identify and are distressed by a SAP and that tend not to seek formal help (medicine, psychotherapy).19, 20, 21, 22, 23, 24 Therefore, we hypothesize that people self-identified with a SAP have higher levels of SS than those who seek help and are diagnosed by a clinician.

Materials and methods

Population and sampling

The final sample aggregates two distinct groups: one with participants who self-identify as having a sexual problem (SISP) and another one diagnosed with a sexual dysfunction (DSP). The sampling procedure took place after it received approval from the institutional ethical review boards involved, and after the survey was pilot tested for face validity, comprehension and length. We developed different procedures for each group and will therefore describe each one in greater detail.

Sampling procedures for SISP

A web site was developed and linked to a secure server that was assessed through username and password and regularly checked and updated for security. Participants were recruited through snowball sampling, which was open between January and April 2008. Participants had to be heterosexual, above the age of 18, in a committed relationship; and not to be pregnant or breastfeeding. The self-identification of SAP was obtained by the person ticking the box indicating that, for a period of at least 6 months during the previous year, the person had experienced SAP. The person indicated their specific SAP, choosing from a range of SPs listed: this procedure was similar to that used by McCabe and Goldhammer.25 For those who ticked the box identifying a SAP, we asked whether people were distressed by the SAP. Those who answered yes were eligible for the present study. The first page had a consent form explaining the nature and goal of the study, the researchers involved, guarantee of anonymity and confidentiality, average duration, inclusion criteria, inexistence of financial compensation, as well as information on acceptance from the Board of Ethics and funding. The dropout rate was 40%.

Sampling procedures for DSP

The participants were recruited from two public sexology clinics and two private offices. Two urologists and two psychologists confirmed a DSM-IV-TR26 diagnosis of SAP in men and women. In the line of recent developments on the DSM-5 criteria for SAP10 and based on the review on the literature, which shows a significant overlap between ‘arousal’ and ‘desire’ disorders in women,27 we considered desire and arousal disorders in women as the same clinical condition. There were 90% eligible participants that completed and returned the questionnaires. Participants with psychiatric comorbidity were excluded as these conditions affect SS and could bias the results.4, 28 In total, 91 participants self-perceived as having a SP for at least 6 months (SISP) completed the questionnaire online (32 men and 59 women) and 102 (65 men and 37 women) completed the questionnaire in a clinical setting (DSP). Regarding demographic variables, there were no statistically significant differences among DSP and SPSP groups. We found statistically significant differences for gender, χ2(1, N=93)=15.693, P=0.001, with more women participants in the SISP group. Most participants were living in the Greater Lisbon Area (n=127; 67%). The mean age of participants was 36.51 years (s.d.=10.24, age range: 19–73). Ninety-one (47.4%) were living in a common law (mean length=3.5 years, s.d.=8.2, range: 1–17), and 101 (52.6%) were married (mean length=12.78 years, s.d.=10.63, range: 1–48). Most participants held a high-school degree (n=123; 64.1%).

Measures

The survey included a general questionnaire designed to address socio-demographic questions.

Outcome measure

Sexual satisfaction

We used the Global Measure of Sexual Satisfaction (GMSEX) that evaluates SS within the context of present relationship.13 It is a five item scale with 7-point bipolar adjectives. Higher scores indicate greater satisfaction. The scale showed good reliability and validity in previous research.29 In the current study, the instrument showed good reliability, with Cronbach’s alpha (CA) of α=0.93 and average inter item correlation (AIIC)=0.73.

Predictors

Body-related predictors

Body satisfaction. We assessed body satisfaction using a single question (‘How satisfied are you with your physical appearance?’). Participants rated their satisfaction on a Likert scale from 1 (‘not satisfied’) to 5 (‘completely satisfied’).

Body dissatisfaction. We used the Global Body Dissatisfaction Scale (GBD), which is part of the Body Attitudes Test30 to assess body dissatisfaction based on the frequency of negative perceptions, behaviors and feelings about one’s body. Participants rated their answers in a 6-point Likert scale (ranging from 1 ‘never’ to 6 ‘always’). Higher scores indicated higher body dissatisfaction. The scale has had good reliability and validity in previous research.30, 31 In the current study, the CA was α=0.82 and AIIC=0.52.

Focus on body parts. Participants were asked if they worried about the negative appearance of specific body part(s) and answered ‘no’ or ‘yes’.

Body appearance cognitive distraction. This variable was evaluated with the Body Appearance Cognitive Distraction Scale, which is a 10-item subscale of the Cognitive Distraction Scale.31 Participants rated their answers in a 6-point Likert scale (ranging from 0 ‘never’ to 5 ‘always’). Higher scores indicate higher cognitive distraction. Past research showed good reliability and validity.16, 31, 32 In the present study, the CA was α=0.93 and the AIIC was 0.57.

Relationship predictors

Number of children. Participants answered the question: ‘How many children do you have (please consider any children you and your partneŕs have from previous relationships)?’.

Conjugal status. Participants were asked: ‘Are you married?’ and were offered the possibility to answer ‘no’ or ‘yes’.

Physical characteristics. Satisfaction regarding physical characteristics, the satisfaction with the opinion of a participant’s partner toward the participant and the satisfaction of a participant towards their partner, was also explored within the context of the present relationship and assessed with a two-item subscale of the Evaluation Scale of Marital Life Areas Satisfaction (EASAVIC), scale measuring satisfaction with areas of a couple’s life.33 The items are rated on a Likert scale from 1 (‘not satisfied’) to 6 (‘completely satisfied’). In the present study, the CA of the subscale was α=0.79 and the AIIC was 0.66.

Intimacy. The satisfaction with emotional intimacy was evaluated with 23 items that constituted the subscale of intimacy of the EASAVIC. This subscale evaluates satisfaction with different components of emotional intimacy, such as expressing feelings, communication, sharing and conflict management. In the current study, the CA was α=0.98 and the AIIC was 68.

Statistical analysis

We conducted independent t-tests to compare groups. Effect size was determined by calculating η2. We studied predictors of SS through multiple hierarchical regression analysis and verified whether or not assumptions were violated. In order to control for the effect of belonging to a self-identified or a clinically diagnosed sample, source of the sample was introduced as a dichotomous control variable by forced entry at step 1. We evaluated two sets of predictors of SS: one set of body-related variables (frequency of global dissatisfaction, body appearance, cognitive distraction and focus on or concern with specific body parts during sexual activity), and another set of relationship variables (intimacy, physical characteristics, relationship status and number of children). Stepwise method was used at each step. We did not use Bonferroni correction for alpha levels due to the exploratory nature of the study. Missing values were deleted pairwise. CA, AIIC, Pearson’s correlations, t-tests and hierarchical multiple regression were performed with SPSS statistics 19 (SPSS Inc., Chicago, IL, USA).

Results

Differences among subgroups

The final sample had 193 heterosexual participants, 97 men and 96 women. We only found statistically significant differences on the total SS scores between women in the DSP (n=37; M=18 94; s.d.=8.45) and women in the SISP group (n=59; M=24.135; s.d.=6.71); t(63.952)=3.161, P<0.001. The magnitude of the differences in the means (mean differences=5, 19, 95% CI: 1.11 to 8.47) was large (η2=0.37, Cohen’s d=0.80) with SISP women presenting higher SS. No statistically meaningful differences between men and women in SS scores were found.

Intercorrelations among measures

We computed Pearson product-moment correlation coefficients among all variables under study separately for the SISP and DSP samples (see Tables 1 and 2). Satisfaction with intimacy and physical characteristics presented strong positive correlation indexes (r>0.50) in both men and women in the DSP sample, indicating that the higher the intimacy the higher the physical satisfaction in this sample. Except for men in the SISP, GBD and BACD (body appearance cognitive distraction) presented strong positive correlations in both samples (r>0.50, P<0.01), indicating that the higher the dissatisfaction with body appearance, the higher the BACD. All other significant correlations were moderate to weak.

Table 1 Pearson correlations (zero order) between predictors and outcome variable in the clinical sample (N=102)
Table 2 Pearson correlations (zero order) between predictors and outcome variable in the sample self-identified as having a SAP (N=91)

Predictors of SS

Because we aimed at looking at predictors of SS in men and women, we conducted a hierarchical multiple regression analysis for men (n=97) and women (n=96) separately. For men, in step 1 the source of sample (SISP or DSP) did not prove to be a significant predictor of SS. In the final model, step 2, there was a significant increase of 40% of the variance of SS explained by the only predictor, satisfaction with intimacy. The R2 change was significant and the variance explained by model 2 was good (R2=0.44), indicating that higher levels of satisfaction with intimacy predict higher SS for men with erectile disorder in the current study.

For women, the results were slightly different. First, at step 1, the source of the sample was a significant predictor of SS explaining 11% of the variance of SS, which means that for women being either self-identified or diagnosed with SAP predicts levels of SS. In step 2, an additional 5% of variance is explained by inclusion of BACD as a significant negative predictor of SS, implying that the higher the cognitive distraction with body appearance during sexual activity the lower the SS. However, BACD did not prove to be a significant predictor in the final model, step 3. The variable satisfaction with intimacy entered as significant positive predictor in the final model, explaining a 32% increase of variance in SS scores, which supports that higher intimacy predicted higher SS. The adjusted R2 for model 3 is bigger than R2 at model 2 and 1 and the R2 change is also significant at each model. The source of the sample remained a significant predictor at each step. Thus, for women included in this study, the final model explains 48% of the variance of SS and has two significant predictors, the source of the sample and satisfaction with intimacy.

Discussion

Women and men with SAP presented similar SS levels. This finding differs from previous research with community samples17 where women tend to present lower SS than men.2, 3, 34 This result seems to suggest that for people with SAP, the level of SS might be similar in men and women. Women in the DSP sample present lower levels of SS. A low level of SS associated with SAP in women might be a motive to seek treatment.6

Our prediction models establish intimacy as the main predictor of SS. However, there are differences in the models for men and women. In men, body-related variables did not prove to be significant predictors. Previous research has demonstrated that performance-related cognitive distraction has a role on men’s SAP. However, recent researchers have argued that both men and women presented similar content on cognitive distraction, which affects SS.16 Our results do not support that individual body-related variables (body dissatisfaction or focus during sexual activity) had a role in men’s SS. As for relationship variables, intimacy was the only predictor of men’s SS. Previous transcultural research had already established that physical intimacy (for example, cuddling) is a significant predictor of SS in men,35 but our study establishes emotional intimacy (not including physical intimacy) to also be a strong predictor of SS in men with SAP. The amount of variance explained (40%) suggest that relational variables have an important role in men’s SS. Clinicians should therefore address dyadic dimensions in both assessment and intervention in SAP to promote SS in the male population with SAP.

For the women included in our study, belonging to the SISP sample is a significant predictor of SS. As stated previously, SISP women present higher levels of SS, therefore our results suggest that the level of SS in women with SAP might be associated with seeking treatment.

As for body-related variables, only BACD seems to have a role in women’s SS. However, this effect disappears when relationship variables are considered and in the final model, only intimacy and belonging to the SISP are positively related to SS. The present study does not support that body-related variables predict SS when relationship variables are considered. Our results support previous results on the impact of emotional intimacy on women’s SS.18 Therefore, addressing both intimacy and SS issues in the context of assessment and treatment of SAP might be a valuable path to improve women’s sexual health.

The individual factors assessed do not have a role in SS in the present study, which might indicate that variables associated with sexual functioning may differ from those that are associated with SS. Furthermore, neither the presence of children nor the conjugal status or the satisfaction with the appreciation of physical characteristics in the relationship is associated with SS for both men and women. However, the inspection of correlations among measures shows that satisfaction with physical characteristics is strongly correlated with intimacy. Although not assessed, we surmised that this may indicate relationship factors concerning physical characteristics are linked to intimacy (for example, praising of partner’s body during and outside sexual activity) and might have a role on SS of people with SAP.

The present study has some clinical and research implications. Previous research demonstrated that SS is mutually determined as each partner’s SS is dependent on both his/her own characteristics and also on those of his/her partner.36 Actor-partner effects should be considered in future studies to better understand which partner variables interact with emotional intimacy satisfaction to promote SS in people with SAP. In clinical terms for men, the importance of SS and role of partners are acknowledged in guidelines for different treatments for ED. These guidelines include addressing relationship problems, but they do not include evaluation of emotional intimacy (communication, conflict management and expression of feelings) in initial assessment or follow-up.37 We think this assessment is fundamental for psycho-educational purposes in the context of intervention, to refer or involve other professionals in the intervention on SAP or to include partners in assessment and treatment of SAP.8 Future studies should include other relationship variables (for example, sexual-self disclosure), and use repeated measures of independent variables to explore the effects of changes in these key variables on SS throughout different types of intervention (for example, directed toward enhancing a couple’s emotional intimacy or aimed at sexual behavior).

This study has some limitations that constrain the generalization of our results and should be highlighted. The data collected are self-reported. As a cross-sectional study, it does not allow us to infer causal relationships among variables. The sample is a convenience sample, not representative of the Portuguese population. In this study, the average participant age was 37-years old: thus there appeared a higher prevalance of common law relationships than exist in the general population (near 50% in the study vs 7% general population).38 Although the study results may not then be representative of data that more closely resembles general population, it charts this increased common law percentage of those in their mid 30’s, providing info on an understudied phenomena in Portugal and its potential impact in the study of SAPs both now and into the future. We did not include dating relationships or other types of relationships (for example, extra-dyadic), so we do not know if these associations would be present in different cases. This should be warranted in future studies. We only examined individual, body-related factors. We think there might be other individual factors (for example, perfectionism) related to SS that should be considered in future studies. Finally, we decided to combine disorders of desire and arousal in women following the recent literature on the topic of womeńs sexual arousal and interest27 as well as the new DSM-5 proposal to combine these two previously separated SPs in one diagnostic category.10 This decision did not allow us to compare our results with previous studies done in the field.

Our results highlight the impact relational variables have on SAP. Even though intimacy had been previously established as a predictor of SS,17 we contributed to the literature on SAP by demonstrating that when considering body-related factors as well as other relational variables, it is satisfaction with emotional intimacy that explains a large percentage of the variance of SS that cannot be neglected. Our results support previous orientations that assessment of and intervention in SAP should integrate a thorough evaluation of relationship variables and these variables should be addressed in the treatment with the involvement of partners.8, 39

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Acknowledgements

We thank Marta Crawford, MSc for her precious support throughout this study. This study was supported by a grant with the reference SFRH/BD/39934/2007 from the National Foundation of Science and Technology.

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Correspondence to P M Pascoal.

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Pascoal, P., Narciso, I. & Pereira, N. Emotional intimacy is the best predictor of sexual satisfaction of men and women with sexual arousal problems. Int J Impot Res 25, 51–55 (2013). https://doi.org/10.1038/ijir.2012.38

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Keywords

  • body dissatisfaction
  • clinical sample
  • intimacy
  • sexual arousal
  • sexual satisfaction predictors

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