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The role of sexual functioning in the sexual desire adjustment and psychosocial adaptation of women with hypoactive sexual desire.

ABSTRACT: The associations among sexual functioning and two categorical constraints, psychosocial adaptation and sexual desire adjustment, were examined in a sample of women (N = 66) with hypoactive sexual desire. The findings suggest that sexual functioning, especially sexual stress, contributes an independent source of variance above and beyond that contributed by demographic characteristics, physical characteristics, and relationship dynamic variables in predicting the women's desire adjustment and psychosocial functioning. High sexual compatibility and high sexual satisfaction contributed unique variance in predicting positive self-motivation in women with hypoactive sexual desire. Acquired type hypoactive sexual desire and sexual stress in the relationships contributed independently to depression in the study sample. Sexual stress also contributed unique variance to the women's self-esteem and the husband's perception of problem impact. Additionally, social class and body weight served as unique predictors of female subjects' self-esteem. The findings suggest that husband-wife relationships and female sexual functioning represent interrelated and independent subsystems within the marital relationship, and both subsystems may influence the sexual desire adjustment and psychosocial functioning of women with hypoactive sexual desire.

Key words: Orgasm Hypoactive sexual desire disorder Waist-hip ratio Psychoevolution Female sexuality Sexual compatibility Sexual dysfunction

INTRODUCTION

Hypoactive sexual desire disorder is the most common sexual dysfunction among couples seeking sex therapy (Davies, Katz, & Jackson, 1999; Donahey & Carroll, 1993; Hurlbert, Apt, & Hurlbert, 1995; MacPhee, Johnson, & Van Der Veer, 1995). Population studies suggest that 22% to 50% of women may experience sexual desire difficulties (Basson, 2001; Laumann, Paik, & Rosen, 1999) and low sexual desire has been the presenting concern in 44% to 49% of female clients in some clinical settings (Hurlbert, 1993; MacPhee et al., 1995).

Despite the growing body of literature linking the development and expression of hypoactive sexual desire (HSD) to a variety of sexual and psychosocial variables, sexual desire problems remain among the most complicated and widespread of the sexual concerns encountered by therapists and other health professionals (Hurlbert et al., 1995; Leiblum & Rosen, 1988).

One focus of the literature on women with low sexual desire has been the role of relationship dynamics and individual psychological adjustment in their experience of HSD. Although a nearly overwhelming number of factors have been associated with HSD in women, relationship function recurs as a prevalent element connected to low sexual desire (Leiblum & Rosen, 1988). This observation seems consistent with the popular notion that female sexuality is, in general, more likely to be holistic, emotional, and interpersonal when compared with the generally more compartmentalized male sexual dynamic (Apt, Hurlbert, Pierce, & White, 1996; Davies et al., 1999; Donahey & Carroll, 1993; Hurlbert & Apt, 1994; Hurlbert, Apt, & Rombough, 1996; Hurlbert & Whittaker, 1991). Although the literature also acknowledges the potential significance of individual sexual functioning variables in HSD in women (Hurlbert et al., 1995; MacPhee et al., 1995), there is little research on these factors in the manifestation of HSD. Research on the individual and dyadic differences in couples with and without HSD in the female partner indicate that a key distinction between the two groups occurs not in general relationship attributes, but in measures of sexuality (MacPhee et al., 1995; Trudel, Fortin, & Matte, 1997). Given these findings, we seek here to more fully explore the possible role of individual sexual variables in women experiencing HSD.

This study examined key sexual and psychosocial variables that past research has associated directly or indirectly with HSD, in an attempt to evaluate the role sexual functioning factors play, relative to relationship dynamics, in the experience of women with HSD. In order to both expand the scope of the study and to attempt to control for as many potential confounds as possible, the analysis also included several demographic variables and selected measures of female physicality. It was hypothesized that sexual functioning variables such as sexual excitability, sexual satisfaction, sexual stress, and sexual-esteem would be associated with key elements of the women's HSD experience, independent of relationship, physical, or demographic factors. Given the wide scope of variables to be measured, it was expected that some notable associations outside of the primary focus of this hypothesis would emerge. Such findings will be included when relevant to the treatment of women experiencing HSD.

LITERATURE REVIEW AND RATIONALE

Despite the conceptual independence of individual sexual functioning and relationship dynamics, research indicates that elements of the two areas are entangled in a web of interdependence (Apt, Hurlbert, Pierce, et al., 1996; Hurlbert & Apt, 1994, Hurlbert, Apt, & Rabehl, 1993; Hurlbert et al., 1996; McCabe, 1999). Such interactions pose a challenge to researchers seeking to go beyond universal measures to assess the impact of variables subsumed within these overlapping paradigms (McCabe, 1999). This type of approach is important in relation to the broad concept of sexual functioning, an area in which researchers need meaningful assessment measures sensitive to their analytical needs (Meston & Derogatis, 2002; Rosen at al., 2000). For example, with respect to the specific dimensions of sexual functioning in the context of women with HSD, a factor such as frequency of sexual activity may not be particularly useful due to potential confounds (Davies et al., 1999; Hurlbert & Apt, 1994; Hurlbert, Apt, Hurlbert, & Pierce, 2000; Hurlbert & Whittaker, 1991; Regan, 2000). In contrast, other elements such as sexual satisfaction seem to be critically relevant in assessing sexual functioning (Rosen at al., 2000). With this cautionary note in mind, the present study chose specific variables of sexual functioning consistent with those used in established instruments (Meston & Derogatis, 2002) with some modifications to meet the specific needs of this research.

Similarly, with respect to relationship dynamics, this study employed common relationship measures that are often associated with disorders of sexual desire from both a research and treatment perspective (Basson, 2001; Davies et al., 1999; Hurlbert et al., 2000; Leiblum & Rosen, 1988; McCabe, 1997).

Given the complexity of HSD, testing for the possible effects of individual variables related to sexual functioning should include steps to prevent extraneous variables from corrupting the analysis. As noted above, this study evaluated the link between women's experience and relationship dynamics, but it also assessed the effects of demographic and physical factors in order to account for potential confounds and to test for additional noteworthy associations.

Since the research literature presents diverse findings, of varying significance, on the connection between sexual and demographic variables in women (Hurlbert, 1991; Kingsberg, 2002; Laumann et al., 1999; Rosen, Taylor, Leiblum, & Bachmann, 1993), our analysis included several demographic factors that may be associated with women's experience of HSD.

Given the societal emphasis on physical attractiveness, especially in women, it seems likely that individuals would have a conscious, and potentially unconscious, sensitivity to the role that physical characteristics play in their lives, especially when it comes to sex. In light of these potential implications, the present study assessed two relatively objective measures of physical attractiveness (body weight, waist-hip ratio) in an attempt to further test for the relative independence of variables associated with sexual functioning in the experience of HSD. Body shape, to a great extent, depends upon the body's distribution of fat, and waist-hip ratio (WHR) serves as a reliable measurement of this resulting body shape. When asked to judge attractiveness and sexual desirability, both U.S. men and women chose women with lower WHR over the women with identical weight but higher WHR (Singh, 1993). Such preference for lower WHR has been noted across ethnic groups including African-American (Singh, 1994) and non-Western societies, such as Indonesia (Singh & Luis, 1994). The inclusion of such measures in the study made it possible to assess their influence on women with HSD and their partners.

In summary, this study sought to examine the associations between relationship dynamics, sexual function, demographics, and physical characteristics as they relate to women's experience of HSD. Our goal is to better understand and assess how the woman is adjusting to HSD. In many instances, this also involves her partner's adjustment. In the interest of clarity, the eight dependent variables used in this assessment are categorized under two constructs: sexual desire adjustment (assessed on scales for sexual desire; sexual fantasy; relationship impact) and psychosocial adaptation (assessed on scales for self-esteem, sexual assertiveness, self-motivation, depression). The central intent of these descriptive categories is to make the sizable body of data easier for the reader to navigate and understand.

HSD does not merely involve some objective deficiency of desire measured against a universal standard of desire. It also involves the perceived failure to meet levels of desire set by perceived societal norms and expectations (Basson, 2001; Donahey & Carroll, 1993). Given that levels of desire can differ even within a population diagnosed with inhibited desire, the present study sought to measure the sexual desire of the female subjects, if for no other reason than to explore what factors may be affecting sexual desire in this group of women. The same rationale applies to the inclusion of a woman's disposition towards sexual fantasy, which is a consideration found in the diagnostic criteria for HSD and in clinical research (Nutter & Condron, 1983). Thus, this study examined the woman's level of sexual desire and disposition towards sexual fantasy under the category of sexual desire adjustment.

The woman's subjective experience of sexual desire should also be viewed in the context of sexual desire discrepancies within couples (Davies et al., 1999). Similarly, the personal distress characteristic of female sexual dysfunction (Basson et al., 2000; Slowinski, 2001; Sugrue & Whipple, 2001) should also draw attention not only to the subjective experience of the women with HSD, but to the experience of their partners. Studies show that males and females often possess differing perceptions and feelings regarding their sexual relationships (McCabe, 1999; Regan & Berscheid, 1995; Salgado, 2003), and particularly so in the face of sexual problems (Basson, 2001; Dunn, Croft, & Hackett, 2000; McCabe, 1999).

The literature shows correlations between HSD and elevated depression (Donahey & Carroll, 1993; Frolich & Meston, 2002; Hurlbert et al., 2000; MacPhee et al., 1995; McVey, 1997), low sexual assertiveness (Granero, 2002; Hurlbert et al., 1995; Paternostro, 2001; Salgado, 2003), and feelings of inferiority (Basson, 2001). This study examined the effects of depression, sexual assertiveness, and self-esteem as variables under the previously described construct of psychosocial adaptation.

Given the high number of women seeking professional help for HSD, clinicians need to better understand the motivation of clients to overcome such desire difficulties. In one study of women with HSD, Salgado (2003) reported a relationship between treatment outcome and scores on the treatment Rejection Scale (RXR) of the Personality Assessment Inventory (PAI). This scale (Hope, 1999) gauges treatment motivation and likelihood of patient withdrawal from treatment. Treatment attrition has also been associated with depression, in the case of HSD treatment (McVey, 1987), and with marital functioning and certain demographic factors, in the case of couples with sexual dysfunction (Zimmer, 1997). The present study built on this background by including a subjective measure of women's self-motivation to deal with her HSD. This measure is also subsumed under the construct of psychosocial adaptation.

In summary, this research evaluated whether sexual functioning of women with hypoactive sexual desire contributes unique variance to their sexual desire adjustment and psychosocial functioning after controlling for aspects of relationship dynamics and other mediating variables.

METHODS

SUBJECTS

Participants were 66 women with hypoactive sexual desire who presented for treatment as private practice walk-ins. All agreed to participate in a group intervention process designed for couples. They were individually assessed by clinical interview, and met the DSM-IV diagnostic criteria for hypoactive sexual desire disorder (American Psychiatric Association, 1994). The data on this sample were collected between 2000 and 2001. The mean age of the women was 31.2 years (SD = 5.1), and the mean age for their husbands was 33.2 years (SD = 5.7). All participants were married, and the mean length of marriage was 6.27 years (SD = 3.4). Seventy-one percent met the criteria for acquired type hypoactive sexual desire, and the remainder demonstrated lifelong type hypoactive sexual desire. Fifteen percent were African-American and the remainder were White. All the women in the sample were biological mothers, with a mean number of 1.67 children per household (range 1 to 5). The mean age at onset of hypoactive sexual desire was 29.8 years (SD = 3.8), and the average duration of hypoactive sexual desire was 36.21 months (SD = 9.63). The mean socioeconomic status on the Hollingshead (1975) four-factor index was 46 (SD = 13), which falls in the "minor professionals, technical, medium business" category.

PROCEDURES

Evaluated couples who agreed to participate in Orgasm Consistency Training (OCT) (McVey, 1997; Hurlbert et al., 1995) were also asked to participate in a study to help professional therapists better understand female sexual desire in a couple context. Eighty-eight percent of the couples approached agreed to participate in OCT; however, only 66% could be scheduled to complete the screening before treatment due to their schedules. Nine percent of the women were not evaluated because their husbands were not available to complete the initial scheduled screening criteria.

After reading and signing consent forms, couples were assured of the confidentiality of the data, and informed of their right to discontinue at any time without jeopardizing treatment services.

Participants completed several questionnaires before treatment. First, the wives completed measures to assess relationship dynamics, while the husbands completed assessments of selected relationship measures and provided information on their perception of the impact that their wives' HSD had on their relationship. Next, two female graduate nursing students obtained body weight and waist and hips circumference on each of the women. Finally, these women completed measures to assess their sexual functioning, desire adjustment and psychosocial adaptation.

MEASURES

A variety of measures were used to tap general and specific dimensions of female HSD. Sexual desire adjustment was assessed by measures of sexual desire, sexual fantasy, and perception of the impact of HSD on the relationship. Physical characteristics included measurements of the women's body weight and waist-hip ratio. Relationship dynamics were examined with measures of marital satisfaction, intimacy, sexual compatibility, and closeness. Psychosocial adaptation was evaluated by measures of self-esteem, sexual assertiveness, perceived motivation, and depression. Sexual functioning was assessed by measures of sexual excitability, sexual satisfaction, sexual stress, and sexual-esteem.

SEXUAL DESIRE ADJUSTMENT

This construct consisted of measures of sexual desire, sexual fantasy, and a scale completed by both the respondents and their husbands to assess the extent to which hypoactive sexual desire had negatively impacted the marital relationship.

Sexual desire. The women in the study completed the Hurlbert Index of Sexual Desire (HISD) as a measure of sexual desire. The validity and other psychometric properties of the HISD are satisfactory (Apt, Hurlbert, Sarmiento, & Hurlbert, 1996; Apt & Hurlbert, 1994; Apt & Hurlbert, 1993; Apt & Hurlbert, 1992; Hurlbert, 1993; Hurlbert et al., 1996).

Sexual fantasy. The women's reports on the Hurlbert Index of Sexual Fantasy (HISF) served as a measure of sexual fantasy. Numerous investigations support the validity of the HISF (Hurlbert & Apt, 1993; Hurlbert et al., 1995; Hurlbert, et al., 2000).

Relationship impact. All participants rated how the sexual desire problems negatively impacted their marital relationship on a five-point scale (1 = not at all; 2 = insignificant; 3 = neither significant nor insignificant; 4 = significant; 5 = extremely significant). This measure is reported as wives' or husbands' perception of problem impact (WPPI; HPPI).

PSYCHOSOCIAL ADAPTATION

This construct consisted of measures of self-esteem, sexual assertiveness, self-motivation, and depression.

Self-esteem. The respondents' reports on the Index of Self-Esteem functioned as a valid and reliable assessment of self-esteem (Hudson, 1981; Hudson, 1982; Hurlbert & Whittaker, 1991).

Sexual assertiveness. The women's reports on the Hurlbert Index of Sexual Assertiveness (HISA) served as a method to examine the emotional, behavioural, and cognitive ease in sexual communicating. The HISA is well validated (Hurlbert, 1991), has high reliability (Pierce & Hurlbert, 1999), and is widely used in the sexual clinical literature (e.g., Apt & Hurlbert, 1993; Apt, Hurlbert, & Powell, 1993).

Self-motivation. The women rated their current level of motivation aimed at correcting their sexual desire difficulties on a five-point scale (1 = extremely unmotivated; 2 = unmotivated; 3 = neither motivated nor unmotivated; 4 = motivated; 5 = extremely motivated).

Depression. The women's reports on the Center for Epidemiological Studies Depression Scale (CES-D) (Radloff, 1977) were used to evaluate depression. This instrument has been found to have satisfactory psychometric properties (Radloff, 1977).

PHYSICAL CHARACTERISTICS

Records of body weight, waist circumference and hip circumference for each woman were included as measures of physical characteristics.

RELATIONSHIP DYNAMICS

This construct contained measures of marital satisfaction, intimacy, sexual compatibility, and relationship closeness.

Because data aggregation procedures provide more reliable and valid constructs (Cohen & Cohen, 1983), and because husbands' and wives' scores were significantly correlated on sexual compatibility and marital satisfaction, composite measures for each of these two indexes were made by averaging total scale scores of the husband and the wife on the particular relationship measure.

Marital satisfaction. The couples completed the Marital Adjustment Scale (Locke & Wallace, 1959), which is a widely used and well-validated measures of marital satisfaction (Jacobson & Margolin, 1979; O'Leary & Turkewitz, 1978).

Intimacy. The wives completed Miller's Social Intimacy Scale as a measure of relationship intimacy (Miller & Lefcourt, 1982). The authors of this scale report satisfactory data on its validity and reliability (Miller & Lefcourt, 1982).

Sexual compatibility. The couples' reports on the Hurlbert Index of Sexual Compatibility (HISC) were used to assess the emotional, behavioural, and cognitive components of sexual compatibility. The validity and reliability of the HISC are supported by numerous investigations (Apt, Hurlbert, Sarmiento, et al., 1996; Hurlbert, White, Powell, & Apt, 1993; Hurlbert et al., 1996; Singh, Meyer, Zambarano, & Hurlbert, 1998).

Closeness. The wives completed the Relationship Closeness Inventory to assess closeness (Berscheid, Snyder, & Omoto, 1989). Data on the validity and reliability of this instrument have been published (Berscheid et al., 1989; Hurlbert, Apt, & Rabehl, 1993).

SEXUAL FUNCTIONING

This construct consisted of measures of sexual excitability, sexual satisfaction, sexual stress, and sexual-esteem.

Sexual excitability. The women's reports on the Hurlbert Index of Sexual Excitability (HISE) were used as a measure of sexual arousal. Investigations support the validity and reliability of the HISE (Hurlbert, Apt, & Rabehl, 1993).

Sexual satisfaction. The women completed the Index of Sexual Satisfaction as a measure of sexual satisfaction (Hudson, 1982). The psychometric properties of this measure are supported (Hudson, 1981; Apt & Hurlbert, 1992).

Sexual stress. The respondent's reports on the Apt Index of Sexual Stress were used to measure sexual stress (Apt, Hurlbert, Pierce, et al., 1996). This index has displayed satisfactory psychometric properties (Apt, Hurlbert, Pierce, et al., 1996; Hurlbert, et al., 2000).

Sexual-esteem. The women's reports on the Sexuality Scale were used as a measure of sexual-esteem (Snell & Papini, 1989). Although this inventory consists of three subscales, only the measure of sexual-esteem was used in this study. Studies have demonstrated the satisfactory psychometric properties of this scale (Snell & Papini, 1989; Snell, Fisher, & Schuh, 1992).

RESULTS

The central purposes of the analyses were: (1) to assess the associations among sexual functioning and the sexual desire adjustment and psychosocial functioning of women with hypoactive sexual desire; and (2) to determine whether the links among sexual functioning, sexual desire adjustment and psychosocial functioning are independent of physical characteristics, relationship dynamics, and demographic factors that correlate with sexual desire adjustment and psychosocial functioning. To address these issues, zero-order correlations were calculated, followed by hierarchical multiple regression analyses.

ZERO-ORDER CORRELATES

As a preliminary step in identifying pertinent factors to include in the hierarchical multiple regression analyses, zero-order correlations were calculated between the independent variables (demographics, physical characteristics, relationship dynamics, and sexual functioning) and the dependent variables (sexual desire adjustment and psychosocial adaptation). In light of the relatively small sample size and concomitant statistical power, Type II error was minimized by including independent variables in the hierarchical multiple regression analyses that were associated marginally (p [less than or equal to] .05) with the dependent variables. Subsequent interpretations and conclusions are based exclusively on the results from the hierarchical multiple regression analyses.

DEMOGRAPHICS

As shown in Table 1, several correlations were consistent with previous research. Older age of the women with HSD was related significantly with a more positive disposition toward sexual fantasy, and marginally, with the less they perceived their sexual desire problem as negatively impacting their marital relationship. Longer duration of HSD was linked to less sexual desire and a more negative disposition toward sexual fantasy. Lower socioeconomic status was marginally associated with lower self-esteem and significantly correlated with less sexual assertiveness. A larger family size was linked marginally to a more negative disposition to sexual fantasy. Women with acquired type HSD reported marginally more pronounced feelings of depression than women with lifelong type HSD. The husbands of those women with acquired type hypoactive sexual desire viewed their wives' sexual desire problems as having a greater negative impacted on their marital relationship than did those husbands married to women with lifelong type hypoactive sexual desire.

PHYSICAL CHARACTERISTICS

One significant and one marginal correlation were observed in the physical characteristics of women with HSD as shown in Table 1. Significantly, husbands married to women with low WHR perceived their wives' HSD problem as having a greater impact on the marital relationship than did those husbands married to women with high WHR. Marginally, greater body weight was associated with lower self-esteem.

RELATIONSHIP DYNAMICS

The three significant and correlations of measures of relationship dynamics with sexual desire adjustment and psychosocial adaptation were as follows: (1) a woman's positive disposition toward sexual fantasy was significantly linked with high marital satisfaction, and (2) high intimacy; (3) high sexual compatibility in the relationship was associated with a woman's perceived level of self-motivation to address her sexual desire difficulties. The eight marginal correlations were: (1) high sexual assertiveness and high marital satisfaction, sexual compatibility, and closeness; (2) high intimacy and high sexual desire; (3) husband perceiving less relationship impact of HSD and high closeness; and (4) less depression and greater marital satisfaction, sexual compatibility, and closeness (Table 1).

SEXUAL FUNCTIONING

High sexual stress was significantly related to low self-esteem, to the husband's perception of the impact of HSD, and high levels of depression. Additionally, high sexual stress was marginally associated with a woman's low self-motivation. High levels of sexual satisfaction were significantly associated to high self-motivation, and marginally associated with high self-esteem, high sexual assertiveness, and lower levels of depression. High sexual excitability was related marginally to high self-esteem in women with HSD (Table 1).

In summary, many associations emerged between sexual desire adjustment and psychosocial adaptation and the measures of physical characteristics, relationship dynamics, and sexual functioning. With the exception of socioeconomic status, body weight, and desire type (lifelong and acquired), demographic variables and physical characteristics were generally not related to the women's psychosocial adaptation.

MULTIPLE REGRESSION ANALYSES

Hierarchical multiple regression analyses were used to evaluate whether sexual functioning added a significant amount of the variance to the women's sexual desire adjustment and their psychosocial adaptation when pertinent demographics, physical characteristics, and relationship dynamics were controlled for. Dependent variables included measures of sexual desire adjustment and psychosocial adaptation that were associated significantly or marginally with sexual functioning in the preceding correlation analyses. Independent variables included those measures that were significantly or marginally linked with the respective dependent variables. In the multiple regression analyses, demographics were entered in the first step, physical characteristics in the second step, relationship dynamics in the third step, and sexual functioning variables were entered last. The results of the multiple regression analyses predicting the women's sexual desire adjustment are reported in Table 2, and those involving the psychosocial adaptation are presented in Table 3.

SEXUAL DESIRE ADJUSTMENT

Husband's Perception of Problem Impact. As indicated in Table 1, one demographic variable (desire type), one measure of physical characteristics (waist-hip ratio), one measure of relationship dynamics (closeness), and one measure of sexual functioning (sexual stress) were correlated with the husband's perception of the relationship impact of HSD. In the multiple regression analyses, each of these variables was entered in a separate step as illustrated in Table 2. Although a significant amount of variance was added in the second and fourth steps, sexual stress was the only variable that contributed significantly in the final equation, F(1,61) = 6.45, p < .013. High sexual stress was a relatively strong predictor of this element of desire adjustment, contributing 8% of additional variance.

PSYCHOSOCIAL ADAPTATION

Self-esteem. One demographic variable (socioeconomic status), one physical characteristic (body weight) and three measures of sexual functioning (sexual excitability, sexual satisfaction, and sexual stress) were correlated with the women's self-esteem. As presented in Table 3, a significant amount of variance was added at each step; together the predictor variables accounted for 29% of the variance. In the final equation, high self-esteem was predicted by high socioeconomic status, F(1,53) = 6.29, p < .015; less body weight, F(1,53) = 3.82,p <.055); and low sexual stress, F(1,53) = 4.16, p < .046. Sexual stress contributed 12% of additional variance.

Sexual assertiveness. One demographic variable (socioeconomic status), three relationship dynamics (marital satisfaction, sexual compatibility, closeness) and one measure of sexual functioning (sexual satisfaction) were correlated with sexual assertiveness. High socioeconomic status was the only variable associated significantly with sexual assertiveness in the final equation, F(1,53) = 7.52, p < .008.

Self-motivation. Sexual compatibility was entered first in the multiple regression analyses because it was the only one among three demographic, physical characteristics, and relationship dynamic variables that correlated with self-motivation. Two measures of sexual functioning (sexual satisfaction, sexual stress) were entered as the next block. As shown in Table 3, significant variance was contributed at each step. High sexual compatibility, F(1,55) = 8.12,p < .006, and high sexual satisfaction in the marital relationship, F(1,55) = 5.71, p < .020, were associated significantly with a woman's positive self-motivation in the final equation. The quality of sexual functioning added 11% of the variance.

Depression. One demographic variable (desire type), three relationship dynamics (marital satisfaction, sexual compatibility, closeness); and two measures of sexual functioning (sexual satisfaction, sexual stress) were correlated with depression. Sexual functioning contributed 14% of the variance beyond that contributed by desire type and relationship dynamics. In the final equation, depressive symptoms were predicted by acquired type hypoactive sexual desire, F(1,52) = 5.20, p < .027, and high sexual stress, F(1,52) = 6.86, p < .012.

CORRELATES OF SEXUAL STRESS AND SEXUAL SATISFACTION

Given the complex interactive nature of all of the variables studied, further analysis was conducted on the two sexual functioning variables found to contribute unique variance to elements under the categories of sexual desire adjustment and psychosocial adaptation. In this analysis, zero-order correlations were calculated between sexual stress and sexual satisfaction and each of the demographic variables, physical characteristics, and relationship dynamics. High sexual stress for the women correlated significantly with longer durations of hypoactive sexual desire, r(66) = -.22, p < .037, and low marital satisfaction, r(66) = -.30, p < .007. In addition, sexual stress was marginally and inversely associated with age, r(66) = -. 16, p < .097, and having lower waist-hip ratios, r(66) = -.18, p < .071. A simultaneous multiple regression analysis was conducted with the four significant and marginal correlates of sexual stress. The overall equation was significant, F(4,61) = 3.24, p < .017, accounting for 17% of the variance. Marital satisfaction was the only significant predictor, F(1,61 ) = 5.24, p < .025; the woman's relative waist-hip ratio was a marginal predictor, F(1,61) = 2.97, p < .089. Thus, sexual stress in the marital relationship was high when the couple reported low marital satisfaction and the woman tended to have low waist-hip ratios.

High sexual satisfaction was associated with an older age of the women, r(66) = .21, p < .044, and with a shorter duration of hypoactive sexual desire, r(66) = -.58, p < .001. A simultaneous multiple regression analyses showed that the duration of hypoactive sexual desire was a very strong predictor of sexual satisfaction, F(1,63) = 29.20, p < .001, accounting for 31% of the variance. Thus, the sexual satisfaction of women in this study was determined primarily by duration of hypoactive sexual desire. Namely, older women with a shorter duration of hypoactive sexual desire experienced greater sexual satisfaction.

DISCUSSION

The results of this study highlight the potential significance of sexual functioning variables in the sexual and psychosocial well being of women with HSD. Specifically, findings suggest that women's levels of sexual stress and sexual satisfaction contribute independently to elements of their sexual desire adjustment and psychosocial adaptation after controlling for the effects of relationship, physical, and demographic factors. Further examination of sexual stress and sexual satisfaction shows these two elements of sexual functioning to be influenced significantly by relationship, demographic, and physical characteristics, thus indicating the complexity of these issues in examining the experience of female HSD. Nonetheless, when broken down to specific dimensions, the findings support this study's hypothesis that variables of sexual functioning play a uniquely significant role in facets of the sexual desire adjustment and psychosocial well being of women experiencing low sexual desire. Also as predicted, several notable associations surfaced from the data analysis in addition to those results supporting the main hypothesis. The following discussion shares insights on both primary and secondary findings, organized respectively by independent variable.

SEXUAL FUNCTIONING

Sexual Stress. The results show that sexual stress contributes a unique variance to sexual desire adjustment through the husband's perceived problem impact (HPPI) of his wife's HSD on the marriage. The current findings suggest that the amount of stress the woman is experiencing regarding sex, especially in the context of the relationship, may have something to do with this perception.

Men appear to be very sensitive to the sexual component of a relationship, especially regarding behaviour and affect. In males there seems to be a link between negative affect during sex and marital dissatisfaction (Morokoff & Gillilland, 1993). Morokoff and Gillilland (1993) also discovered that men tend to gauge the quality of the marital relationship by subjective feelings about sex with the partner. The same study noted marital satisfaction for both sexes is at least partially dependent on the perception of the partner meeting one's sexual expectations. As sexual expectations can differ from individual to individual, males seem to place a greater emphasis on sexual activities than females (McCabe, 1999). Even without accounting for HSD in the female, men generally report higher levels of sexual interest than women (Beck & Bozman, 1995). In addition, there appears to be a marginally significant correlation between a women's level of sexual stress and her motivation to engage in sexual acts (Hurlbert et al., 2000). It is possible that the woman's level of sexual stress may be an indicator or a cause of sexual tension in the relationship. The implications of this pressure could include conflict or a shortcoming to the husband's sexual expectations, possibly in the area of sexual activity, thus making a significant impact on the marriage from his point of view.

Notwithstanding the male disposition towards negative sexual attributions concerning his partner (McCabe, 1999), there exists the tendency for the husband to feel poorly about himself in light of his wife's HSD experience (MacPhee et al., 1995). These potential feelings, which may include rejection and inadequacy, could create or maintain conflict regarding sex in the relationship (MacPhee et al., 1995). The possible association between sexual stress and the partner's insecurity or inhibited self-esteem highlight a potential source of influence over HPPI as it relates to women's reports of sexual stress. It seems that men facing sexual problems may perceive, more than their partners themselves, the sexual stress their partner's experience. This in turn might affect their self-perception as a suitable sex partner. It is possible that investigating the relationship among masculine assertiveness and HSD in women could deepen the understanding of relationship factors and the connection between sexual stress and HPPI.

In the analysis and treatment of HSD, clinicians and researchers give a great deal of attention to the struggles experienced by the symptomatic member of the relationship. Although this attention is rational and necessary, when HSD occurs in a dyadic context, as it most often does, it seems critical to gain an understanding of the partner's position with regard to the situation. Future research may want to expand the focus on the partner's point of view by gauging different variables in their experience.

Our findings indicated that sexual stress is a unique predictor of both depression and self-esteem in women with HSD. Research links various general forms of stress to low self-esteem (Zuckerman, 1989) and the development of depressive disorders (Rojo-Moreno, Livianos-Aldana, Cervera-Martinez, Dominquez-Carabantes, & Reig-Cerbrian, 2002), thus adding support to the current findings regarding sexual stress.

Women with HSD seem prone to greater psychological distress, including levels of depression that rival the psychiatric outpatient population (Donahey & Carroll, 1993). Still, research supports the notion that HSD by itself does not constitute a sufficient state for the occurrence of depression in women (MacPhee et al., 1995; McVey, 1997). Therefore, the current findings associating sexual stress and depression may apply either independently or in conjunction with HSD in women.

It is important to note in what appears to be the only other analysis of these two variables, Hurlbert et al. (2000) found no significant correlation between sexual stress and depression in an HSD sample, thus begging further examination of this relationship in future research.

The current findings on sexual stress and depression indirectly complement the inference (Frolich & Meston, 2002) that greater rumination about sex may have associations with depressive symptoms. Given the possibility that cognitive preoccupation with sex, and even more so the sexual relationship, may overlap sexual stress, the above assumption provides one conceivable explanation for the present results.

Basson (2001) discusses the potential feelings of abnormality and inferiority that are often present in women with HSD. It is possible that these feelings contribute in some way to the level of sexual stress a woman is experiencing. In addition, it would seem that feelings of inferiority and abnormality would be negatively related to self-esteem. Salgado's (2003) findings support this idea, suggesting that women's experiences of inferiority, as related to their inability to respond to the sexual expectations of their male partners, and the social milieu, included lowered self-esteem and increased sexual anxiety. This idea that sexual stress is contributing variance to self-esteem through feelings of defectiveness is another possible explanation for the current findings.

Sexual Satisfaction. Our findings show that the woman's sexual satisfaction had an independent connection with her perceived motivation to deal with her desire difficulty.

The concept of cognitive dissonance provides a relatively simple interpretation of the association between sexual satisfaction and self-motivation. Although sexual satisfaction does not necessitate a desire for sex (Hurlbert & Apt, 1994), if a woman is satisfied sexually, but does not desire sex, there stands to be some level of dissonance in that she does not desire an expression of something that she claims is satisfying. This may inspire her to either engage in the act even absent of desire, or possibly motivate her to obtain the desire commensurate with her feelings of satisfaction.

With regard to the findings involving a woman's self-motivation to correct her desire difficulty, it is important to acknowledge this sample as a group of women in the process of seeking treatment, thus indicating the exhibition of a behaviour directed at improving their condition. Although, there is certainly a difference between behaviour and cognition, the use of a clinical sample, while conducive to the development of treatment practices, must be taken into account when interpreting these specific results.

ADDITIONAL FINDINGS

Relationship Dynamics

Sexual Compatibility. Additional findings show sexual compatibility in the relationship as having an independent connection with a woman's perceived motivation to deal with her desire difficulty.

One theoretical explanation for the association between sexual compatibility and self-motivation derives from the expectancy theory of motivation (Vroom, 1964). The sexual compatibility in the relationship may be affecting the motivation of women to deal with their low desire, both positively and negatively, via their treatment expectancy or their perceived instrumentality of increased sexual desire. If a woman feels that the challenges and difficulties of having differing sexual values and preferences from her partner will be a hindrance to treatment, or will remain even after the potential elevation of desire, she may be less motivated to deal with her sexual desire problem. In other words, why should one spend all this time and energy finding the key to start the car when that key doesn't fit in the ignition or may not even exist at all? It also seems that the opposite would hold true, where the potential benefits of sexual compatibility may increase self-motivation.

The current link between sexual compatibility and self-motivation, coupled with the absence of a significant finding between relationship variables such as satisfaction, intimacy and closeness with self-motivation, is notable. Given that the present measure of sexual compatibility is more likely a focus on the sexual relationship as opposed to the overall marital relationship (Hurlbert et al. 1996), the findings could support the notion that sexual elements of the relationship, independent from more comprehensive relationship dynamics, are highly significant factors in the female HSD experience (MacPhee et al., 1995; Trudel et al., 1997).

Sexual compatibility seems to hold ties with female sexual stress, sexual motivation (Hurlbert et al., 2000), sexual desire in women regardless of desire difficulties (Hurlbert et al., 1996, 2000), and potentially treatment motivation. Therefore, clinicians might well focus on the issue of sexual compatibility as both a possible motivator and as a potential link to increased sexual functioning and adjustment.

Demographic Variables

While the data reveal autonomous effects for sexual functioning, the numbers also show demographic factors to play an independently significant part in women's psychosocial adaptation. Such findings include a link between socioeconomic status and both sexual assertiveness and self-esteem. In addition, the data reveal a unique relationship between HSD type and depression in this sample of women.

Socioeconomic status. Our finding of a relationship between socioeconomic status and self-esteem is consistent with previous analyses, especially within the age and generational range of the current study population (Twenge & Campbell, 2002). Literature offers several theoretical models for this relationship (Twenge & Campbell, 2002), and the potential for countless lay explanations.

Research supports a link between women's societal status as a gender and general assertiveness (Twenge, 2001), adding indirect support to the current findings associating high socioeconomic status and greater sexual assertiveness. It is possible that elevated social class is associated with a greater sense of independence, expectation, and entitlement. Possible socioeconomic status implications of having needs and wants met in a socioeconomic environment that inspires less domestication and more opportunity could contribute to a woman asserting herself in many ways, including sexually. Kahn's (2001) findings of a link between entitlement and sexual assertiveness lend support to this interpretation.

Desire Type. The multiple-regression analysis found acquired type HSD to be a unique predictor of depression compared to lifelong type HSD. Although McVey (1997) found no relationship between disorder type and depression, there are several rational explanations as to why the present study found such a relationship. Notably, almost 30% of the current sample displayed lifelong type HSD, accounting for a representation 27% greater than the previous study (McVey, 1997). One can easily rationalize this finding with the idea that the decline from function to dysfunction may be more conducive to depression, relative to the ever-present inhibition of desire; however, given the inconclusive findings on this matter (McVey, 1997), further research is necessary to make any assertions regarding this relationship.

Physical Characteristics

The examination of physical characteristics produced findings consistent with reasonable expectations and past literature.

Body weight. The results show a unique negative relationship between a woman's body weight and her level of self-esteem. This finding is in general agreement with past research (Martin et al., 1988; Miller & Downey, 1999) and societal perceptions regarding appearance and worth.

Waist-hip ratio. Although not a unique predictor, results also show a significant correlation between a woman's WHR and the degree of relationship impact her husband feels in light of her HSD. This implies that the more attractive the woman is (based on WHR), the greater the impact her HSD has on the husband.

There is strong support for the notion that low female sexual desire does not necessarily imply lowered sexual frequency, as other factors are often more powerful in determining the actual occurrence of a sexual act (Hurlbert & Apt, 1994; Hurlbert et al., 2000; Hurlbert & Whittaker, 1991; Regan, 2000). However, the lack of desire for sex, which presents as HSD, is bound to affect the sexual activity aspect of the relationship in some way. It is possible that the physical attractiveness of the wife may dictate whether the man internally or externally attributes his partner's anticipation and experience of sex with him as desirable, potentially resulting in differing feelings, reactions, and perceptions about the relationship. Of course, this interpretation ignores the man's level of physical attractiveness, which may also play a key role in this dynamic.

On the whole, the data show bodily measures to have an impact on the HSD experience of women. Although the effects of attractiveness, as measured by WHR, failed to contribute unique variance to HPPI, the strong correlation is notable. Thus, it may be of interest to investigate the husband's level of sexual stress as it relates to his perception of his wife's attractiveness, as inferred by WHR.

It is important to describe the study limitations. First, the external validity of the findings is limited. The sample was restricted to women with HSD in heterosexual relationships and it remains to be determined whether these findings will generalize to other female, community, or clinical samples. Second, the problem impact of female sexual desire was based on the perceptions of the husband and wife. Future research should consider gathering more objective data from established research instruments. Third, the small sample size is a limitation and the current findings should be interpreted with caution. Fourth, the complexity of the concepts examined, as noted by the high level of associations, encourages further need for expansion and replications of the hypotheses studied. Finally, the findings are correlational. Therefore, it is certainly plausible, that relationship dynamics and sexual functioning contribute to women's desire adjustment and psychosocial adaptation. Most likely, associations between relationship dynamics and psychosocial adaptation are reciprocal and recursive.

Overall, the findings are consistent with our hypothesis that sexual functioning variables make a contribution independent of relationship factors, demographics, and physical characteristics, in predicting facets of sexual desire adjustment and psychosocial adaptation in women with HSD. The findings imply that relationship dynamics and female sexual functioning operate both as independent and integrated concepts that warrant further consideration in the research and treatment of HSD in women and couples.

ACKNOWLEDGEMENT: Our thanks to Melissa Towery for her invaluable technical support throughout this research project and its publication.

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Correspondence concerning this paper should be addressed to David Farley Hurlbert, 1028 Hemingway Lane, Roswell, GA, USA 30075-7011. Email: dhurlbert@acf.hhs.gov

David Farley Hurlbert

U.S. Department of Health and Human Services

Atlanta, Georgia

Devendra Singh

Department of Psychology

University of Texas, Austin

D.A. Menendez

Izon Communications

Tampa, Florida

Evan R. Fertel

Private Consultant

Arlington, Virginia

Ferdinand Fernandez

V.A. Medical Center

Brownwood, Texas

Camila Salgado

Department of Psychology

Andes University, Bogota, Columbia
Table 1 Correlates of Sexual Desire Adjustment and Psychosocial
Adaptation

Variable Sexual Desire Adjustment

 HISD HISF WPPI HPPI

Demographic Variables
Age .16 .36 *** -.25 * .01
Desire type -.06 .18 .13 .21 *
Race -.01 -.02 .00 -.12
Socioeconomic status .00 .02 .10 .11
Duration of HSD -.25 * -.31 ** .20 .08
Family size -.12 -.22 * .08 -.01
Length of marriage -.11 -.13 .09 .02

Physical Characteristics
Waist-hip ratio .09 .16 .08 -.27 **
Body weight .02 -.10 -.11 -.04

Relationship Dynamics
Marital satisfaction .04 .37 *** .10 -.10
Intimacy .25 * .29 ** .01 -.05
Sexual compatibility .06 .12 .01 -.15
Closeness .16 .11 .16 -.22 *

Sexual Functioning
Sexual excitability .00 .08 -.12 .13
Sexual satisfaction .10 .07 .17 .15
Sexual stress -.02 -.19 -.06 .38 ***
Sexual-esteem .12 .02 .17 .05

Variable Psychosocial Adaptation

 SE SA SM DP

Demographic Variables
Age -.10 -.02 .19 .04
Desire type -.O1 -.01 .03 .22 *
Race -.02 -.21 .05 .01
Socioeconomic status .27 * .33 ** -.13 -.05
Duration of HSD .02 -.14 .18 -.02
Family size .04 .04 -.15 -.16
Length of marriage .07 .02 .08 .11

Physical Characteristics
Waist-hip ratio .01 .11 -.13 -.12
Body weight -.24 * .00 .01 -.15

Relationship Dynamics
Marital satisfaction .17 .24 * .15 -.22 *
Intimacy .08 .13 .06 -.11
Sexual compatibility .01 .21 * .37 ** -.22 *
Closeness .16 .20 * .16 -.20 *

Sexual Functioning
Sexual excitability .25 * .11 .13 -.01
Sexual satisfaction .28 * .21 * .35 ** -.23 *
Sexual stress -.34 *** -.08 -.23 * .42 ***
Sexual-esteem .12 .02 .15 -.14

Note: HISD = sexual desire; HISF = sexual fantasy; WPPI = wives'
perception of problem impact on the relationship; HPPI = husbands'
perception of problem impact on the relationship; SE = self-esteem;
SA = sexual assertiveness; SM = self-motivation. DP = depression.
Desire type: 1 = primary; 2 = secondary.

* p < .05. ** p < .01. *** p < .001.

Table 2 Regression Analyses Predicting Sexual Desire
Adjustment Using Husband's Perception of
Problem Impact on the Relationship

Variable B F Change R2

Demographics 3.00 .045
 Desire type .21
Physical Characteristics 4.60 * .109
 Waist-hip ratio .19
Relationship Dynamics 3.43 .156
 Closeness .13
Sexual Functioning 6.45 ** .237
 Sexual stress .30 **
Overall R2 .237

* p < .05. ** p < .01.

Table 3 Regression Analyses Predicting Psychosocial
Adaptation

Variable B F Change R2

Self-esteem
Demographics 4.31 * .108
 Social class .30 *
Physical Characteristics 6.83 ** .171
 Body weight -.24
Sexual Functioning 2.99 * .291
 Sexual excitability .14
 Sexual satisfaction .10
 Sexual stress -.25 *
Overall R2 .291

Sexual assertiveness
Demographics 6.90 ** .070
 Social class .34 **
Relationship Dynamics 1.93 .194
 Marital satisfaction .22
 Sexual compatibility .06
 Closeness .07
Sexual Functioning 2.77 .234
 Sexual satisfaction .20
Overall R2 .234

Self-motivation
Relationship Dynamics 8.91 ** .135
 Sexual compatibility .34 **
Sexual Functioning 4.14 * .248
 Sexual satisfaction .29 *
 Sexual Stress .10
Overall R2 .248

Depression
Demographics 2.84 .048
 Desire type .28 *
Relationship Dynamics 2.43 .160
 Marital satisfaction .15
 Sexual compatibility .12
 Closeness .07
Sexual Functioning 5.06 ** .297
 Sexual satisfaction .10
 Sexual stress .34 **
Overall R2 .237

* p < .05. ** p < .01.
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Publication:The Canadian Journal of Human Sexuality
Geographic Code:1USA
Date:Mar 22, 2005
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