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The association between sexual costs and sexual satisfaction in women: an exploration of the Interpersonal Exchange Model of Sexual Satisfaction.

Abstract: Recent research has suggested that female sexual functioning may be strongly tied to sexual satisfaction in some cases and weakly tied in others. The Interpersonal Exchange Model of Sexual Satisfaction (IEMSS) constitutes a validated theoretical framework within which to explore this complex association. The aim of the current study was to explore whether sexual functioning represents an important sexual cost that is closely linked to sexual satisfaction, and for whom. Data from 200 female undergraduates were analyzed to determine If sexual functioning accounted for the association between sexual costs and sexual satisfaction in women and whether this indirect effect was dependent on adult attachment anxiety. We found a significant simple indirect effect wherein sexual functioning accounted for the association between sexual costs and sexual satisfaction for the sample as a whole. However, attachment anxiety moderated this indirect effect: sexual functioning accounted for the association between sexual costs and satisfaction for women reporting low levels of attachment anxiety, but not for women reporting high levels of attachment anxiety. These findings suggest that, depending on individual attachment orientation, difficulties with sexual functioning may or may not represent key sexual costs that are associated with levels of sexual satisfaction. Theoretical and practical implications are discussed.

Introduction

Sexual satisfaction has been defined as "an affective response arising from one's subjective evaluation of the positive and negative dimensions associated with one's sexual relationship" (Byers, 1999, pg. 98). Sexual satisfaction has been linked to a number of important variables including relationship satisfaction (Byers, 2005) and self-esteem (Hally & Pollack, 1993), and is one of the strongest predictors of marital stability for both men and women (Karney & Bradbury, 1995). Thus, it is not surprising that sexual satisfaction is an important component of well-being for most individuals (Mulhall, King, Glina, & Hvidsten, 2008).

Despite its importance, measures of subjective sexual well-being are rarely included in epidemiological studies of female sexual dysfunction (e.g., Shifren, Monz, Russo, Segreti, & Johanes, 2008), even though difficulties with sexual functioning must be detrimental to personal and/or interpersonal well-being to be considered clinically relevant (Ferenidou, et al., 2008; King, Holt, & Nazareth, 2007). Additionally, when sexual satisfaction is measured, the conceptualization and method of assessment varies widely across studies (Ahrold, Stephenson, & Meston, in press), ranging from single item measures assessing only global sentiments to more comprehensive and specific measures that often include related but distinct constructs such as sexual functioning and sexual distress (Stephenson & Meston, 2010). These inconsistencies in the study of sexual satisfaction underscore the fact that we currently have few organized theories within which to study factors that determine how satisfied individuals are with their sex lives.

However, one validated theory in this area is the Interpersonal Exchange Model of Sexual Satisfaction (IEMSS). The IEMSS posits that sexual satisfaction is a product of four primary factors: the balance of sexual rewards and sexual costs in the relationship, the way that sexual rewards and costs compare to one's expected level of sexual rewards and costs, the perceived equality of sexual rewards and costs between partners, and the quality of the nonsexual aspects of the relationship (Lawrance & Byers, 1992). This model has been partially validated in a number of studies (e.g., Byers & MacNeil, 2006) and can account for up to 79% of the variance in sexual satisfaction ratings.

Although the IEMSS provides a potentially useful framework within which to study sexual satisfaction, relatively few researchers have utilized it to guide research and even fewer have used it to study questions related to the treatment of sexual dysfunction. One possible reason for this neglect is that the components of the model have not yet been comprehensively described. For example, while the model is essentially based on levels of sexual rewards and costs, it is not clear exactly what constitutes a reward or cost and which types of rewards and costs are most important in determining levels of satisfaction. In proposing the IEMSS, the authors suggested a number of potential costs and rewards including foreplay, physical or emotional expressions of love, and various aspects of sexual functioning (Lawrance & Byers, 1992) and a list of other potential factors is included in the IEMSS questionnaire (Lawrance & Byers, 1998). However, we are aware of only three studies that empirically identified particular sexual rewards and costs. Specifically, studies have suggested that self-disclosure positively affects levels of sexual satisfaction through its beneficial effects on the perceived balance of rewards and costs in the relationship (Byers, Demmons, & Lawrence, 1998) and/or its beneficial effect on the relationship in general (MacNeil & Byers, 2009). Also, Lawrence and Byers (1995) found that women were more likely than men to identify relational qualities of the sexual relationship (e.g., how one's partner treats you when having sex) as rewards, and physical aspects of sexual interactions (e.g., difficulty reaching orgasm) as costs.

The link between physical aspects of sexual interactions (i.e. sexual functioning: sexual desire, sexual arousal, orgasm, and sexual pain) and sexual satisfaction has been an important target of recent research. Specifically, although past studies have established an association between sexual functioning and sexual satisfaction (Hoon, 1983; Hurlbert, Apt, & Rabehl, 1993), a number of studies have found that difficulties with sexual functioning are not always associated with low levels of satisfaction in women. For example, a study by Ferenidou and colleagues (Ferenidou et al., 2008) found that 72.5% of women who score below the clinical cut-off score of the Female Sexual Function Index report high levels of sexual satisfaction. Other researchers have identified moderators of the association between sexual functioning and subjective sexual well-being, showing that sexual functioning is strongly tied to distress in some cases and weakly tied in others (Stephenson & Meston, 2010).

The IEMSS provides a convenient framework within which to explore this connection between difficulties with sexual functioning and sexual satisfaction. Specifically, difficulties with sexual functioning may constitute one of the sexual "costs" that is most closely associated with sexual satisfaction. Indeed, for many women sexual functioning may be one of the primary determinants of sexual satisfaction and, thus, difficulties in this area would account for much of the association between sexual costs and sexual satisfaction. One way to test this hypothesis is through testing ma indirect effect model wherein the association between two factors is accounted for by a third factor. In this case, if difficulties with sexual functioning constitute a sexual cost that is closely associated with sexual satisfaction, then controlling for sexual functioning should weaken or eliminate the association between reported sexual costs and sexual satisfaction. Alternatively, if difficulties with sexual functioning are a cost weakly tied to sexual satisfaction, then controlling for sexual functioning should minimally affect the association between reported costs and satisfaction.

It is likely that difficulties with sexual functioning may not be an equally important sexual cost for all women (i.e., for some women, difficulties with sexual functioning may not be a sexual cost closely tied to sexual satisfaction). One moderating variable that may be important in this regard is adult attachment anxiety. Modern iterations of attachment theory suggest that an adult's method of relating to romantic partners can be placed along two independent continua: attachment anxiety and attachment avoidance. A number of recent studies have suggested that adult attachment anxiety in particular, which can be understood as the degree to which individuals fear neglect and abandomnent in romantic relationships, is important in shaping women's sexual experiences (Birnbaum, 2007; Bimbaum, Reis, Mikulincer, Gillath, & Opraz, 2006; Butzer & Campbell, 2008). Specifically, studies have shown that anxiously attached women are more likely to have sex to meet attachment needs (e.g., increasing closeness and intimacy) as opposed to reasons such as experiencing pleasure (Davis, Shaver, & Vernon, 2004; Impett, Gordon, & Strachman, 2008) and that some difficulties with sexual functioning are distressing for anxiously attached women only in the context of relationships with little intimacy (Stephenson & Meston, 2010).

Based on these findings, we can predict that difficulties with sexual functioning may be of relatively less importance in determining levels of sexual satisfaction for women who report high attachment anxiety because they are less likely to be motivated by factors such as sexual pleasure that are disrupted as a result of sexual functioning difficulties. On the other hand, women reporting low attachment anxiety are more likely to have sex to experience physical pleasure and tend to be similarly distressed by difficulties with sexual functioning regardless of levels of relational intimacy (Davis, et al., 2004; Stephenson & Meston, 2010), suggesting that the sexual costs most closely tied to sexual satisfaction for these women may be sexual functioning.

The goal of the current study was to test whether sexual functioning accounts for the association between sexual costs on sexual satisfaction in women, which would suggest that sexual functioning is a key sexual cost that is closely tied to sexual satisfaction.

It is important to note that, according the IEMSS, sexual exchanges including high or low levels of sexual functioning can be viewed by the individual as either costly, rewarding, both costly and rewarding, or neither costly nor rewarding. Additionally, the IEMSS includes perceived comparison levels and the quality of non-sexual aspects of the relationship. Thus, a full exploration of the model would include not only costs and rewards, but also an individual's perception of available alternatives and many aspects of the overall romantic relationship.

In the present study, we tested a simple indirect effects model wherein sexual functioning accounts for the association between reported costs and sexual satisfaction. We also tested a moderated indirect effects model, also known as a conditional indirect effect model. Our hypotheses was that the indirect effect of sexual functioning would be moderated by attachment anxiety such that sexual functioning would account for the association between sexual costs and sexual satisfaction for women reporting low attachment anxiety, but not those reporting high attachment anxiety.

Method

Participants

Participants were 200 female undergraduates at the University of Texas enrolled in either an Introductory Psychology course (N=73) or a Human Sexuality course (N = 127). The average age of participants was 20.25 years old (SD = 2.33) and they were primarily European-American (54.5%), with 17.7% Hispanic, 16.4% Asian-American, 4.5% African American, and 5.9% mixed race or "other." All participants reported being in exclusive, sexually active (intercourse in the past month), heterosexual relationships (Mean length = 20.93 months, SD = 25.13 months) at the time of their participation. Participants reported a median of 2 lifetime sexual partners (Mean = 4.21, SD = 6.94).

Measures

Sexual satisfaction

Sexual satisfaction was measured using the contentment subscale of the Sexual Satisfaction Scale for Women (SSS-W; Meston & Trapnell, 2005), which is a 30-item self-report measure encompassing the domains of sexual contentment, communication, compatibility, personal concern, and relational concern. We chose not to use the full scale as it includes items measuring sexual distress, sexual communication, and sexual compatibility--constructs that are conceptually and empirically distinct from sexual satisfaction. For example, Stephenson and Meston (2010) have shown that, in some cases, sexual satisfaction and sexual distress are differentially related to various aspects of female sexual functioning. The Contentment subscale consists of six items such as, "In general, I am satisfied with my sex life." The contentment subscale has been shown to have excellent reliability (Cronbach's alpha = .83) and has been shown to differentiate between women with and without diagnoses of sexual dysfunction (Meston & Trapnell, 2005). Cronbach's alpha for the contentment subscale in the current sample was .82.

Sexual functioning

We assessed sexual functioning using the Female Sexual Function Index (FSFI; Rosen, et al., 2000), which is a 19-item self report measure assessing the domains of desire, arousal, lubrication, orgasm, satisfaction, and pain. The FSFI has been shown to be reliable (Cronbach's alpha = .97) and valid for use in women with and without diagnoses of female sexual arousal disorder and female orgasm disorder and hypoactive sexual desire disorder (Meston, 2003). We excluded the satisfaction subscale from analyses due to its overlap with our outcome variable. Cronbach's alpha for the FSFI in the current sample was .89.

Attachment anxiety

We assessed adult attachment anxiety using the anxiety subscale of the Experiences in Close Relationships Scale-Revised (ECR-R; Sibley, Fischer, & Liu, 2005; Sibley & Liu, 2004). Although attachment orientation is ideally assessed using clinical interviews (Mikulincer & Shaver, 2003), the ECR-R has been shown to be one of the most reliable and valid self-report measures of attachment, exhibiting excellent psychometric properties. The scale includes items such as, "I need a lot of reassurance that I am loved by my partner," and "My desire to be very close sometimes scares people away." Cronbach's alpha for the attachment anxiety subscale in the current sample was .73.

IEMSS Questionnaire

Perceived sexual costs were measured using an item included in the IEMSS Questionnaire (Lawrance & Byers, 1998) which is a 6-item self-report measure assessing perceived sexual rewards, perceived sexual costs, relative level of costs and rewards between self and partner, costs and rewards compared to expected costs and rewards. Before participants answer these questions, they were provided with an explanation for what constitute "costs" and "rewards" in sexual relationships. An excerpt from these instructions reads:
   Think about your job.

   If you're like most people, you can give
   concrete examples of positive, pleasing
   things you like about your job. These are
   "rewards."

   Most people can also give concrete examples
   of negative, displeasing things they don't like
   about their job. These are "costs ..."

   Now, instead of thinking about your job,
   think about the rewards and costs associated
   with your sexual relationship with your
   partner, and answer the questions below.


The primary item used in the current study was item four: "How costly is your sexual relationship with your partner?" Given our primary focus on the association between difficulties with sexual functioning and sexual satisfaction, we focused on sexual costs specifically rather than the other components of the model. Although inclusion of the 46-item Rewards and Costs Checklist would have also been helpful as it specifically assesses some aspects of sexual functioning, we did not include it due to its length and its incomplete assessment of sexual functioning (e.g., unlike the FSFI, it does not asses both frequency and intensity of sexual desire).

Procedure

Participants who met study inclusion criteria based on their responses to a pre-screening survey utilized by the University of Texas Psychology Department were recruited by e-mail. Interested participants gave informed consent and completed an online survey, entitled "Sexuality and Relationships" within two weeks of the beginning of the semester. Introductory psychology students received partial course credit and participants in Human Sexuality received extra credit. Those not meeting study inclusion criteria could complete similar projects for credit. All responses were anonymous. The University of Texas IRB approved all procedures.

Results

Association between study variables Sexual satisfaction was significantly correlated with all other study variables except sexual pain. Interestingly, attachment anxiety was not directly related to any aspect of sexual functioning, but was related to sexual satisfaction and sexual costs (see Table 1).

Simple indirect effects model

We tested a simple indirect effects model to determine whether sexual functioning accounted for the association between sexual costs and sexual satisfaction using the method outlined by Preacher and Hayes (2004). This method provides unstandardized estimates of each path in the model, as well as bootstrapped confidence intervals that can be used to test the significance of the overall indirect effect. The creation of bootstrapped confidence intervals is typically preferred over a Sobel test to the degree that the sampling distribution of the estimate of the indirect effect is non-normal (Preacher & Hayes, 2004).

Utilizing this method, we found that paths a (t = -4.77, p<.001), b (t = -2.53, p<.05), c (t = 7.07, p<.001), and c (t = -3.97, p<.001) were significantly different from zero (see Figure 1). Additionally, we calculated 95% and 99% confidence intervals of the overall indirect effect using bootstrapping with 5000 resamples. The 95% confidence interval did not overlap with zero (-.17, -.01), however, the 99% CI did overlap with zero (-.20, .01), suggesting that the simple indirect effect of sexual costs on sexual satisfaction through sexual functioning is statistically significant at alpha = .05, but not at alpha = .01.

Conditional indirect effects model

We tested a conditional indirect effects model in which the indirect effect described above was presumed to be moderated by attachment anxiety (We also controlled for attachment avoidance in our analysis of conditional indirect effects). To test the conditional indirect effects model, we used procedures outlined by Preacher, Rucker, and Hayes (2007), which expands on the method of testing simple indirect effects by testing for interactions between model paths and a moderator variable. Additionally, the method provides estimates of the strength of the indirect effect at multiple levels of the moderator, analogous to a simple slope method of interpreting an interaction.

Results of the analysis (see Table 2) show a significant interaction between path a and attachment anxiety (t = 2.32, p < .05), and a marginally significant interaction between path b and attachment anxiety (t = -1.88, p = .06), suggesting the presence of a conditional indirect effect. To aid in the interpretation of this interaction, we computed conditional indirect effects at three levels of attachment anxiety (Mean, + 1SD, -1SD) using bootstrapped confidence intervals (5000 resamples) and found that, at low (-1SD) or average (Mean) levels of attachment anxiety, the indirect effect was significantly different from zero. However, at high levels of attachment anxiety (+1SD), the

indirect effect was non-significant suggesting that sexual functioning accounts for the association between sexual costs and satisfaction for women with low or average levels of attachment anxiety, but not for women with high levels of attachment anxiety.

[FIGURE 1 OMITTED]

Discussion

While it is well established that sexual costs are associated with sexual satisfaction, less is known about which costs are most closely linked to satisfaction and for whom. One way to examine this question is by utilizing indirect effect models wherein the link between reported costs and satisfaction is examined while statistically controlling for a potentially important cost. Our results suggest that sexual functioning may account for the association between sexual costs and satisfaction, and that the importance of sexual functioning may be dependent on individual attachment anxiety. Specifically, we found a statistically significant indirect effect of sexual costs on sexual satisfaction through sexual functioning suggesting that, in general sexual functioning may account for the association between sexual costs and satisfaction. However, we also found a significant conditional indirect effect wherein sexual functioning accounted for this association for women in the mid to low range of attachment anxiety, but not women in the high range of attachment anxiety. These findings suggest that, for women low in attachment anxiety, difficulties with sexual functioning may represent an important sexual cost that is closely tied to sexual satisfaction whereas for women high in attachment anxiety, difficulties with sexual functioning may not represent an important sexual cost.

These results correspond well with recent research on the complex link between sexual functioning and subjective sexual well-being. Specifically, recent studies have suggested that, while sexual functioning and sexual well-being are closely related in some cases, these factors are weakly related in other cases (Ferenidou, et al., 2008; King, Holt, & Nazareth, 2007). Individual attachment anxiety has been identified as an important moderator of this association in a number of studies (Birnbaum, 2007; Birnbaum, Reis, Mikulincer, Gillath, & Opraz, 2006; Davis et al., 2006; Stephenson & Meston, 2010), suggesting that "the status of the overall relationship may be of primary importance to anxiously attached women ... [whereas] for securely attached women, the physical pleasure of sexual interactions may be important independently of the quality of their relationships." (Stephenson & Meston, p. 3692) The current findings add to this developing concensus using concepts included in the IEMSS by suggesting that the importance of sexual functioning as a sexual cost may depend partially on one's level of attachment anxiety.

This concordance of findings lends additional support the usefulness of the IEMSS (Lawrance & Byers, 1992) for measuring women's sexual complaints. While the model may be viewed as difficult to put into use given the potential number of possible costs and rewards (as evidenced by the small number of researchers that utilize it), our results suggest that the widely studied factor of sexual functioning may account for the effects of one of the model's key components: sexual costs. As such, the IEMSS may provide a useful and practical theoretical framework to integrate the diverse findings regarding the associations between sexual functioning and sexual satisfaction.

These findings also speak to the potential diversity of etiological and maintaining factors of female sexual dysfunction (FSD), suggesting that the most important sexual costs for women may be related to sexual functioning specifically only in certain situations. One important aspect of the "medicalization of FSD" (e.g., Bancroft, Loftus, & Long, 2003; Fagan, 2007; Tiefer, Hall, & Tavris, 2002) has been an increased focus on pharmacological interventions to treat FSD by directly changing levels of sexual desire, arousal, etc. However, it is important for researchers and treatment providers to consider that while sexual costs and the resultant sexual dysfunction can stem directly from problems with sexual functioning, they do not always do so. In many cases, the most important factors influencing sexual satisfaction in women may be only tangentially related to physiological phenomena, such as genital arousal, and that both medical and/or psychological treatments may be appropriate in different circumstances.

Given that the current study included a non-clinical population, our ability to translate these findings to clinical populations is quite limited. However, a potential implication of our findings is that, when selecting women with "sexual complaints" for clinical trials of treatments for FSD, it may be important to specify which types of complaints can realistically be ameliorated by the treatment under investigation. For example, a drug that increases blood flow to the genitals may be quite effective for women whose sexual complaints center around sexual functioning only (possibly women with low levels of attachment anxiety), but much less effective for women whose most important sexual complaints are unrelated to sexual functioning (possibly women with high levels of attachment anxiety). Future research on the interplay between sexual costs and sexual functioning in clinical populations will allow us to make such distinctions with much greater confidence and potentially increase the power and specificity of clinical trials in the field of female sexuality.

Limitations and future research

The current study had a number of limitations. Participants in the study were young, female college students and tended to report high levels of sexual functioning, relational quality, and sexual satisfaction. Thus, great care must be taken in applying these findings to older women and to those seeking treatment for sexual dysfunction. Future research utilizing clinical populations will be helpful in verifying whether these findings apply to women experiencing clinically diagnosable sexual dysfunction. Additionally, the current study relied on self-report data, which is potentially limited by social desirability (Meston, Trapnell, & Gorzalka, 1998) and retrospective recall biases (Levine & Safer, 2002). The limitation of self-report measures is especially important in the area of adult attachment, which is a notably complex construct that is best assessed by in-person interviews. Also, as mentioned above, the current study examined only one aspect of the IEMSS: sexual costs. Future research that incorporates additional aspects of the model has the potential to more fully illuminate the association between sexual functioning and sexual satisfaction.

Despite these limitations, the current study provides us with initial evidence that sexual functioning may represent an important sexual cost for women that strongly influences satisfaction levels, but that it may not do so in all cases. For women who report high levels of attachment anxiety, difficulties with sexual functioning may be of relatively less importance. Future research that extends these findings to clinical populations will be useful in determining the clinical utility of these findings which could potentially improve our ability to provide more focused and effective treatments for the diverse forms of female sexual dysfunction.

Acknowledgement: This publication was supported by Grant Number R01 HD51676 from the National Institute for Child Health and Human Development to Cindy M. Meston.

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Kyle R. Stephenson (1) and Cindy M. Meston. (1)

(1) The University of Texas at Austin

Correspondence concerning this article should be addressed to Kyle Stephenson, The Sexual Psychophysiology Lab, The University of Texas at Austin, 2400 Inner Campus Drive, Austin, TX 78712. E-mail: krstephenson@gmail.com
Table 1 Correlation matrix

                         Sexual       Sexual    Attachment   Desire
                      Satisfaction    Costs      Anxiety

Sexual satisfaction        1         -.278 **   -.165 *       .173 *
Sexual costs                         1           .148 *      -.154 *
Attachment anxiety                              1             .041
Desire                                                       1
Arousal
Lubrication
Orgasm
Pain

                      Arousal    Lubrication    Orgasm      Pain

Sexual satisfaction    .505 **    .327 **       .454 **    .112
Sexual costs          -.275 **   -.143         -.192 *     .031
Attachment anxiety    -.135       .036         -.123       .040
Desire                 .478 **    .228 **       .135       .069
Arousal               1           .576 **       .511 **    .121
Lubrication                      1              .243 **    .381 **
Orgasm                                         1.000       .000
Pain                                                      1.000

                        M      SD

Sexual satisfaction   23.28   5.47
Sexual costs          6.32    2.14
Attachment anxiety    20.20   6.62
Desire                4.19    0.99
Arousal               5.09    0.92
Lubrication           5.42    0.77
Orgasm                4.74    1.37
Pain                  5.42    0.92

* p<.05, ** p<.0l

Ranges for measures are as follow: desire, arousal, lubrication,
orgasm, and pain: 1-6; sexual satisfaction: 6-30;
sexual costs: 1-9; attachment anxiety: 7-42

Table 2 Regression results for sexual functioning as moderated
mediator

Mediator variable model
Predictor                       B         SE      t         p

Constant                      -0.06      0.24   -0.24
Sexual costs                  -0.86      0.26   -3.32       **
Attachment anxiety            -0.09      0.25   -0.38
Attachment avoidance           0.55      0.24    2.32       *
Sexual costs X
Attachment anxiety             0.55      0.24    2.32       *

Dependent variable model
Predictor                       B         SE       t        p

Constant                       0.04      0.06    0.74       **
Sexual costs                  -0.22      0.07   -3.23
Attachment anxiety            -0.04      0.06   -0.53
Attachment avoidance          -0.05      0.06    -0.8
Sexual costs X
Attachment anxiety             0.02      0.06    0.24
Sexual functioning             0.13      0.02    6.62       **
Sexual functioning X
Attachment anxiety            -0.04      0.02   -1.88   ([dagger])
Conditional effects at attachment anxiety = Mean and [+ or -] 1 SD

Attachment anxiety         Coefficient    SE      z         p

    -1                        -0.24      0.09   -2.59       **
    0                         -0.11      0.05   -2.49       **
    1                         -0.03      0.03   -1.01

* p<.05; ** p<.01; ([dagger]) p = .06
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Article Details
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Author:Stephenson, Kyle R.; Meston, Cindy M.
Publication:The Canadian Journal of Human Sexuality
Article Type:Report
Geographic Code:1USA
Date:Mar 22, 2011
Words:5385
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