Narcissistic Personality Traits and Sexual Dysfunction in Women: The Role of Body Image Self-Consciousness

BackgroundIndividuals with narcissistic traits, specifically vulnerable ones, are more prone to experiencing concerns related to self-worth and physical appearance and to showing heightened sensitivity to appearance evaluation. Negative body image and body image self-consciousness may, in turn, undermine sexual functioning, especially when apprehension is related to body appearance in sexual contexts.MethodsWe aimed to evaluate the associations between self-reported pathological narcissistic traits, both grandiose and vulnerable, and sexual functioning in a large sample of nonclinical women (N = 656). Furthermore, we tested the mediating role of body image self-consciousness in these associations.OutcomesSexual functioning was measured through the Female Sexual Function Index.ResultsThe results highlight that vulnerable narcissistic traits are associated with lower sexual functioning, this association being mediated by higher levels of body image self-consciousness. Conversely, grandiose narcissistic traits are linked to lower body image self-consciousness and, consequently, higher levels of sexual functioning.Clinical ImplicationsConsidering the link between body image self-consciousness and sexuality is of utmost importance in clinical practice with women, as well as in promoting positive body appreciation. Clinicians working with individuals presenting with pathological personality traits should consider including an assessment of their sexual functioning. S Pavanello Decaro, M Di Sarno, A Anzani, et al. Narcissistic Personality Traits and Sexual Dysfunction in Women: The Role of Body Image Self-Consciousness. J Sex Med 2021;18:1891–1898.     

Anxious and avoidant attachment, vibrator use, anal sex, and impaired vaginal orgasm

IntroductionDisturbances in intimate relationships are among the risk factors for female sexual dysfunction. Insecure styles of anxious attachment (preoccupations about abandonment) and avoidant attachment (avoidance of closeness in relationships) are robustly associated with sexual problems, relationship difficulties, and several indices of poorer physical and mental health. Similar indices of poorer sexual, relationship, and health functioning are associated with impairment of orgasm triggered by penile‐vaginal stimulation (vaginal orgasm), but unrelated or related to greater frequency of other sexual behaviors. However, research examining the differential association of sexual activities with insecure attachment styles has been lacking.AimsThe aim of this study was to test the hypotheses that insecure attachment styles are associated with lesser vaginal orgasm consistency, and are unrelated or directly related to greater frequency of other sexual behaviors.MethodSeventy coitally experienced women recruited at a Scottish university completed the Revised Experience in Close Relationships scale, and reported their frequency of various sexual behaviors (and corresponding orgasms) in a recent representative month.Main Outcome MeasuresThe main outcome measures for this study are multivariate correlations of various sexual activities with insecure attachment styles, age, and social desirability response bias.ResultsAnxious attachment was associated with lesser vaginal orgasm consistency, but with higher frequency of vibrator and anal sex orgasms. Avoidant attachment was associated with higher frequency of vibrator orgasms. Neither anxious nor avoidant attachment was associated with lifetime number of penile‐vaginal intercourse partners.ConclusionsThe results provide evidence that inability to attain a vaginal orgasm is associated with anxious attachment, among other indices of poorer mental health and relatedness. Vaginal orgasm might be the relevant sexual activity for the maintenance of a secure attachment style with a sexual partner and/or more insecurely attached women might have difficulties in attaining vaginal orgasms and be more inclined to sexual activities characterized by more emotional and physical detachment, as part of a characterological discomfort with intimacy. Costa RM and Brody S. Anxious and avoidant attachment, vibrator use, anal sex, and impaired vaginal orgasm. J Sex Med 2011;8:2493–2500.     

Effect of Sexual Esteem and Sexual Communication on the Relationship Between Body Image and Sexual Function in Chinese Heterosexual Women

BackgroundSexual self-esteem and communication on sexual issues with a partner contribute greatly to an individual's quality of sex life; however, their effects on the relationship between body image and sexual function are underexplored.AimTo test a serial mediating pathway of sexual self-esteem and sexual communication underlying the relationship between body image and sexual function.MethodsA total of 510 women aged 18–53 years (mean = 28, SD = 5.5) who were involved in an intimate relationship completed an online survey.OutcomesWomen's (i) body appreciation, (ii) body image self-consciousness during sexual intimacy, (iii) sexual self-esteem, (iv) dyadic sexual communication, (v) negative disclosure apprehension, and (vi) sexual function were assessed.ResultsFindings revealed that sexual self-esteem and dyadic sexual communication played a serial mediating role in the relationship between body image (body appreciation and body image self-consciousness during sexual intimacy) and sexual function, and the relationship between body image and arousal, lubrication, orgasm, satisfaction, and pain. Sexual self-esteem and negative disclosure apprehension also played a serial mediating role in the relationship between body image and sexual pain. In addition, dyadic sexual communication played a unique mediating role in the relationship between body image and sexual function, which is isolated from the effect of sexual self-esteem.Clinical ImplicationsWomen's sexual self-esteem and sexual communication with their partner can make beneficial contributions to the relationship between body image and sexual function. Therefore, promoting women's positive body image, sexual self-esteem, and sexual communication skills deserves attention from women themselves and clinicians.Strengths & LimitationsThis study used a robust method of data analysis to test the mediating effect of sexual self-esteem and sexual communication to clarify the mechanism underlying the relationship between body image and sexual function among Chinese women; however, causal conclusions cannot be drawn. Furthermore, various demographics including participants' age, education level, sexual orientation—factors such as relationship status and length, relationship functioning, and partner-related variables—and other aspects of sexual self-concept and sexual communication should be examined in future research.ConclusionThe current study indicates that women's thoughts and feelings regarding sexuality and communicating sexual issues with their partner are associated closely with their body image and sexual function.Wu T, Zheng Y. Effect of Sexual Esteem and Sexual Communication on the Relationship Between Body Image and Sexual Function in Chinese Heterosexual Women. J Sex Med 2021;18:474–486.     

Adult Attachment and Sexual Functioning: A Review of Past Research

IntroductionThe association between adult attachment and sexual functioning is an important area of research. However, there has been no previous attempt to systematically review the available literature between these dimensions, and how their interrelationships may vary within different populations.AimTo provide an in‐depth critical investigation of the literature on the association between adult attachment and sexual functioning (satisfaction, dysfunction, and behaviors).MethodsA systematic literature review of research reported in PsychINFO, Scopus, PubMed, and Psychology and Behavioral Sciences Collection from January 1, 1990 to November 8, 2011.ResultsThe results demonstrated that higher levels of anxious and avoidant attachment were related to less satisfying sexual relationships, higher levels of sexual dysfunction, and different sexual intercourse frequencies and motivations for sex.ConclusionsThere is a need for further research to target the sexual functioning of males and to incorporate representative samples (ethnicity, sexual orientation, and relationship status) into the analyses. Moreover, measurement of sexual behavior needs to encompass a range of sexual functioning variables. Stefanou C and McCabe MP. Adult attachment and sexual functioning: A review of past research. J Sex Med **;**:**–**.     

The Association Between Sexual Satisfaction and Body Image in Women

IntroductionAlthough sexual functioning has been linked to sexual satisfaction, it only partially explains the degree to which women report being sexually satisfied. Other factors include quality of life, relational variables, and individual factors such as body image. Of the few studies that have investigated the link between body image and sexual satisfaction, most have considered body image to be a single construct and have shown mixed results.AimThe present study assessed multiple body image variables in order to better understand which aspects of body image influence multiple domains of sexual satisfaction, including sexual communication, compatibility, contentment, personal concern, and relational concern in a community sample of women.MethodsWomen between the ages of 18 and 49 years in sexual relationships (N = 154) participated in an Internet survey that assessed sexual functioning, five domains of sexual satisfaction, and several body image variables.Main Outcome MeasuresBody image variables included the sexual attractiveness, weight concern, and physical condition subscales of the Body Esteem Scale, the appearance-based subscale of the Cognitive Distractions During Sexual Activity Scale, and body mass index. Total score of the Sexual Satisfaction Scale for Women was the main outcome measure. Sexual functioning was measured by a modified Female Sexual Function Index.ResultsConsistent with expectations, correlations indicated significant positive relationships between sexual functioning, sexual satisfaction, and all body image variables. A multiple regression analysis revealed that sexual satisfaction was predicted by high body esteem and low frequency of appearance-based distracting thoughts during sexual activity, even after controlling for sexual functioning status.ConclusionSeveral aspects of body image, including weight concern, physical condition, sexual attractiveness, and thoughts about the body during sexual activity predict sexual satisfaction in women. The findings suggest that women who experience low sexual satisfaction may benefit from treatments that target these specific aspects of body image. Pujols Y, Meston CM, and Seal BN. The association between sexual satisfaction and body image in women.     

Avoidant Attachment Style Moderates the Recovery of Healthy Sexuality in Women With Anorexia Nervosa Treated With Enhanced Cognitive Behavior Therapy (CBT-E): A 2-Year Follow-Up Study

BackgroundInsecure Attachment style has been associated with interpersonal problems in persons with Anorexia Nervosa (AN), and it might moderate the recovery of healthy sexuality in these subjects.AimThe aim of the present 2-year follow-up study was to evaluate the role of insecure attachment style as a moderator of the recovery of healthy sexuality in women with AN.Methods63 Italian women with AN treated with a multidisciplinary approach including Enhanced Cognitive Behavior Therapy were evaluated by means of a clinical interview and self-administered questionnaires. Individual psychotherapy sessions were administered by experienced psychotherapists over the course of at least 40 weeks (median number of sessions = 43, range: 38–50); trained dieticians provided personalized nutritional counselling to facilitate weight recovery. The assessment was performed at baseline (T0) and after 1 (T1) and 2 (T2) years.OutcomesThe administered questionnaires investigated general psychopathology (SCL-90-R), eating disorder-specific psychopathology (EDE-Q), female sexuality (FSFI) and adult attachment style (ECR).ResultsAt baseline, avoidant attachment style was associated with all domains of sexual dysfunction. Longitudinal analysis showed a significant decrease in both eating disorder-specific psychopathology and sexual dysfunctions at follow-up evaluations. However, only 45% of remitted subjects also recovered healthy sexuality: these women reported significantly lower avoidance scores than those who only recovered from AN. Moderation analysis indicated that sexual desire did not increase in participants with higher levels of avoidant attachment.Clinical ImplicationsThese novel findings highlighted the importance of the assessment of adult attachment in the clinical setting, for better characterization and treatment of persons suffering from AN.Strengths & LimitationsThe long follow-up duration, the multidisciplinary nature of the treatment, and the novelty of the topic were major strengths of the study, whereas the limited sample size and the absence of biological data were the main limitations.ConclusionThis study highlighted the crucial role of avoidant attachment in the relationship between AN and sexual dysfunctions, underlining the importance of integrating treatments with attachment-focused interventions.Cassioli E, Rossi E, Vizzotto C, et al. Avoidant Attachment Style Moderates the Recovery of Healthy Sexuality in Women With Anorexia Nervosa Treated With Enhanced Cognitive Behavior Therapy (CBT-E): A 2-Year Follow-Up Study. J Sex Med 2022;19:347–355.     

Pelvic Floor Dysfunction: Women’s Sexual Concerns Unraveled

IntroductionSexual function of women suffering from pelvic organ prolapse (POP) and/or urinary incontinence (UI) is adversely affected. However, our current understanding of the exact relationship between female sexual dysfunction and POP and/or UI is incomplete. A qualitative study can improve our understanding by describing what women themselves perceive as the real problem.AimTo gain a more in‐depth understanding of the impact of POP and/or UI on the different categories of female sexual dysfunction by way of a qualitative study.MethodsQualitative semistructured interviews were conducted in 37 women scheduled for pelvic floor surgery, and one was excluded from analysis due to incomplete recordings.Main Outcome MeasuresThe impact of POP and/or UI on female sexual function.ResultsOnly 17% of women were completely positive about their sex life. Both POP and UI had a negative effect on body image. Women with POP had a negative image of their vagina, which caused them to be insecure about their partner's sexual experience, while women with UI were embarrassed about their incontinence and pad use, and feared smelling of urine. Worries about the presence of POP during sexual activity, discomfort from POP, and reduced genital sensations were the most important reasons for decreased desire, arousal, and difficulty reaching an orgasm in women with POP. Fear of incontinence during intercourse affected desire, arousal, and orgasm and could be a cause for dyspareunia in women with UI. Desire was divided into two main elements: “drive” and “motivation.” Although “drive,” i.e., spontaneous sexual interest, was not commonly affected by POP and/or UI, a decrease in “motivation” or the willingness to engage in sexual activity was the most common sexual dysfunction mentioned.ConclusionsBody image plays a key role in the sexual functioning of women with POP and/or UI with the biggest impact on women's “motivation.” Roos A‐M, Thakar R, Sultan AH, Burger CW, and Paulus ATG. Pelvic floor dysfunction: Women's sexual concerns unraveled. J Sex Med 2014;11:743–752.     

The Vagina Dialogues: Genital Self-Image and Communication with Physicians About Sexual Dysfunction and Dissatisfaction Among Jewish Patients in a Women's Health Clinic in Southern Israel

IntroductionThe health-care system offers a variety of solutions for problems related to sexual dysfunction. To gain access to treatment options, women must be willing to discuss these issues with their physicians.AimTo examine the extent to which women discuss issues of sexual dysfunction with their physicians and to examine the contribution of aspects of sexual dysfunction, level of satisfaction, body image, and genital self-image to their comfort with communicating with physicians about these issues.MethodsOne hundred ten secular-appearing, Hebrew-speaking Jewish women waiting for a routine gynecological appointment at a clinic in southern Israel responded to a self-report questionnaire.Main Outcome MeasuresThe Female Sexuality Function Index was used to assess sexual dysfunction, Gray's Modified Questionnaire to assess body image, and the Genital Self-Image Scale to assess genital self-image. We compiled a new measure to assess level of comfort in discussing sexual functioning and satisfaction with a physician.ResultsForty-four percent of the women had discussed sexual functioning issues with a gynecologist. Of those, 91.7% reported that the gynecologist initiated the discussion. The proportion of participants who would consult a gynecologist about sexual dysfunction was 74.5%, but only 41% would consult a family physician. Half of the women would expect a gynecologist to initiate such consultations, but only 20% would expect a family physician to do so. In a multivariate regression analysis, genital self-image was the only significant predictor of women's comfort level with discussing sexual dysfunction with a gynecologist.ConclusionsThe respondents perceived the gynecologist, rather than the family physician, as an appropriate professional to consult regarding sexual dysfunction. However, they expected the gynecologist to initiate the discussion. Women with a positive genital self-image are more comfortable in consulting about sexual dysfunction. Gynecologists should be made aware of their significant role in eliciting women's cooperation in such consultations and in contributing to improving women's genital perception. Yulevitch A, Czamanski-Cohen J, Segal D, Ben-Zion I, and Kushnir T. The vagina dialogues: Genital self-image and communication with physicians about sexual dysfunction and dissatisfaction among Jewish patients in a women's health clinic in Southern Israel. J Sex Med 2013;10:3059–3068.     

Profiles of Sexual Disorders and Eating Disorder Symptoms: Associations With Body Image

BackgroundAlthough the empirical evidence supporting the co-occurrence of sexual disorders and eating disorders is growing, it is not yet known how often these 2 conditions co-occur, and whether the comorbidities of sexual disorders and eating disorders differ in any specific ways.AimTo examine the co-occurrence of sexual disorders and eating disorders.MethodsIn the current study, we used latent profile analysis to identify distinct profiles of sexual disorders and eating disorder symptoms among a large non-clinical sample of women (n = 985). We also examined how these profiles differed in terms of body image self-consciousness. The study was conducted as an online survey among a convenience sample of Israeli women.Main Outcome MeasuresFor sexual disorders we used the Arizona Sexual Experience Scale, and for eating disorders we used the Eating Disorders Inventory 2.ResultsLatent profile analysis revealed 4 profiles: no disorder (low levels of sexual disorders and eating disorder symptoms), eating disorder symptoms (low levels of sexual disorders and high levels of eating disorder symptoms), sexual disorders (high levels of sexual disorders and low levels of eating disorder symptoms), and comorbidity (high levels of both sexual disorders and eating disorder symptoms). Women in the comorbidity group had significantly more body image self-consciousness during sexual activity than did women in the other groups.ConclusionThe 4 profiles identified in the study support the co-occurrence of sexual disorders and eating disorder symptoms, yet also raise many clinical considerations. Limitations of the study, directions for future research, and clinical implications are discussed.Gewirtz-Meydan A, Spivak-Lavi Z. Profiles of Sexual Disorders and Eating Disorder Symptoms: Associations With Body Image. J Sex Med 2021;18:1364–1373.     

Sexual Functioning Among Childhood Sexual Abuse Survivors From an Attachment Perspective

BackgroundDespite the fact that childhood sexual abuse can affect a survivor's sexual functioning in adulthood, few studies have examined survivors' adult sexual functioning from the perspective of attachment theory.AimThe present study sought to examine how sexual abuse in childhood might shape the associations between attachment insecurities and sexual functioning among adults.MethodsThe study sample consisted of 265 participants (166 women and 99 men), 45 (16.9%) of whom were classified as survivors of childhood sexual abuse. Participants completed an online questionnaire about their history of childhood sexual abuse, attachment insecurities, and sexual functioning over the past 6 months.OutcomesThe findings of the present study suggest that attachment insecurities may have unique implications for sexual functioning among survivors of childhood sexual abuse.ResultsFindings indicated that a history of childhood sexual abuse significantly moderated the associations between attachment insecurities and sexual functioning. Whereas the effect of attachment avoidance in predicting sexual desire was not significant among nonabused participants, it was significant among survivors; specifically, higher levels of attachment avoidance predicted lower levels of sexual desire. A different pattern was found for attachment anxiety. Although attachment anxiety did not predict vaginal lubrication/penile erection among nonabused participants, it had significant effects among survivors; specifically, higher levels of attachment anxiety predicted higher levels of vaginal lubrication/penile erection.Clinical TranslationFindings from the present study may help facilitate sex therapy interventions for childhood sexual abuse survivors, from an attachment theory perspective.Strengths & LimitationsThe study included a nonclinical, convenience sample and used self-report measures, which are highly subjective and increase the possibility of social-desirability biases. However, on the plus side, it relied on simple, short, self-report questionnaires that are accessible and can be easily used by professionals to examine a survivor's current condition relative to any of the variables, establish intervention goals, and evaluate treatment.ConclusionA history of childhood sexual abuse is related to 2 opposite patterns of association between attachment insecurity (depending on type) and sexual functioning.Gewirtz-Meydan A, Lahav Y. Sexual Functioning Among Childhood Sexual Abuse Survivors From an Attachment Perspective. J Sex Med 2020;17:1370–1382.     

When Are Sexual Difficulties Distressing for Women? The Selective Protective Value of Intimate Relationships

IntroductionRecent studies have shown that sexual functioning and sexually related personal distress are weakly related in women, with only a minority of sexual difficulties resulting in significant levels of distress. However, there has been little systematic research to date on which factors moderate the relationship between sexual functioning and sexual distress.AimTo assess the degree to which relational intimacy and attachment anxiety moderate the association between sexual functioning and sexual distress in college-age women.MethodsTwo hundred women (mean age = 20.25) completed surveys assessing sexual functioning, relational intimacy, attachment anxiety, and sexual distress.Main Outcome MeasuresParticipants completed the Sexual Satisfaction Scale for Women, the Female Sexual Function Index, the Dimensions of Relationship Quality Scale, and the Revised Experiences in Close Relationships Measure of Adult Romantic Attachment.ResultsRelational intimacy and attachment anxiety moderated the association between multiple aspects of sexual functioning and sexual distress. For lubrication and sexual pain, functioning was more strongly associated with distress in low-intimacy vs. high-intimacy relationships, but only for women with high levels of attachment anxiety. Results regarding desire were mixed and neither intimacy nor attachment anxiety interacted with subjective arousal or orgasm in predicting distress.ConclusionBoth relational intimacy and attachment anxiety are important moderators of the association between sexual functioning and subjective sexual distress in women. Theoretical and practical implications are discussed. Stephenson KR, and Meston CM. When are sexual difficulties distressing for women? The selective protective value of intimate relationships.     

Sexual Functioning among Women with and without Diabetes in the Boston Area Community Health Study

AimTo examine sexual dysfunction among women with and without diabetes in a community-based sample of women aged 30–79 years.MethodsWe conducted a cross-sectional analysis of survey responses of female participants in the Boston Area Community Health Study, a community-based random sample, who answered questions regarding sexual functioning and diabetes status and also reported sexual activity (n = 1,291). Associations between diabetes and overall sexual function as well as domain of sexual function were examined in multivariable linear regression models.ResultsWomen with type 2 diabetes (n = 75) were older, less often white, and more likely to have decreased physical activity levels, elevated body mass index, and cardiovascular disease than women without diabetes (n = 1,190). Women with type 1 diabetes (n = 26) were similar to women without diabetes except for higher depression scores and lower levels of activity. Age, marital status, and depressive symptoms were correlated with overall sexual function. After adjustment for age and race, women with and without diabetes had similar arousal, lubrication, orgasm, dyspareunia, satisfaction, and desire. After further adjustment for other factors, including age, depression, and marital status, women with type 1 diabetes had increased dyspareunia compared with women without diabetes, and women with type 2 diabetes had similar functioning to women without diabetes.ConclusionWomen with type 2 diabetes may have similar sexual functioning to women without diabetes, although women with type 1 diabetes may more often have dyspareunia. Factors such as depression, which are common in women with diabetes, are more strongly related to sexual dysfunction than diabetes status. Wallner LP, Sarma AV, and Kim C. Sexual functioning among women with and without diabetes in the Boston Area Community Health Study.     

Psychosexual Functioning and Body Image Following a Diagnosis of Ductal Carcinoma In Situ

IntroductionThere has been exponential growth in diagnoses of ductal carcinoma in situ (DCIS) in the past decade, yet little is known about sexual functioning and body image in women after diagnosis of DCIS. This is of particular importance because many of the parallel treatment modalities also used to treat invasive breast cancer, e.g., surgery and hormonal therapy, have been shown to have a detrimental effect on psychosexual function.AimThe aim was to explore changes in sexual function and body image after diagnosis and treatment of in situ cancer.Main Outcome MeasuresEvidence‐based self‐report measures assessing psychosexual functioning and body image.MethodsWomen diagnosed with DCIS within the past 3 months and who reported being sexually active completed measures assessing various aspects of psychosocial and sexual functioning and body image. Outcomes were evaluated at baseline, 9‐, and 18‐month time points. All statistical tests were two sided.ResultsThree hundred four women completed this prospective survey. Overall, sexual function in women with DCIS appears to be very similar to women in the general population and does not seem to be significantly disrupted by a diagnosis of DCIS. Sexual function and body image were notably stable across the 18‐month length of follow‐up. Of those patients who underwent mastectomy, there were no differences in sexual satisfaction for patients who had reconstruction compared with patients who did not.ConclusionAlthough it has been shown that women with DCIS have a number of psychosocial challenges, results from this large‐scale prospective study of women suggest that sexual function and body image may not be significantly negatively affected by this diagnosis. Of note, these results were also the case for women who underwent mastectomy and hormonal therapy. These findings are reassuring for both patients and physicians in the context of decision making about treatment options. Bober SL, A Giobbie‐Hurder, Emmons KM, Winer E, and Partridge A. Psychosexual functioning and body image following a diagnosis of ductal carcinoma in situ. J Sex Med **;**:**–**.     

The relationship between sexual functioning and depressive symptomatology in postpartum women: a pilot study

IntroductionPrevious research on postpartum sexuality has primarily focused on the impact of physical factors on the resumption and frequency of sexual intercourse; fewer studies have focused on the impact of psychological factors on women's sexual functioning.AimThe aim of this study is to assess current sexual functioning and sexual behavior in women with and without symptoms of postpartum depression using validated measures of postpartum depression and sexual functioning.MethodsWomen attending postpartum appointments were consecutively recruited over a 12‐month period and completed questionnaires assessing sexual functioning, current sexual behavior, and mental health.Main Outcome MeasuresThe Female Sexual Function Index (FSFI), the Edinburgh Postnatal Depression Scale (EPDS), and items assessing current sexual behaviors.ResultsA total of 77 women returned completed questionnaire packages (mean postpartum weeks: 13, range 3–24). Of these, 57 women (74%) had engaged in sexual activity with a partner in the 4 weeks prior to completing the questionnaire. The mean FSFI score was 23.0 (range 6–34), with 37 women (65%) scoring in the range associated with clinical sexual dysfunction. Women with elevated EPDS scores had significantly lower total FSFI, arousal, orgasm, and satisfaction FSFI subscale scores (all P values <0.005) than nondepressed women, suggesting more problematic sexual functioning. Desire, lubrication, and pain FSFI subscale scores were not significantly associated with depression status.ConclusionsA substantial proportion of women experience sexual problems in the postpartum period; these problems are particularly pronounced among women with symptoms of postpartum depression. Longitudinal research is needed to better understand the relationship between sexual dysfunction and depression among postpartum women, and to identify implications for prevention and treatment of both conditions. Chivers ML, Pittini R, Grigoriadis S, Villegas L, and Ross LE. The relationship between sexual functioning and depressive symptomatology in postpartum women: A pilot study. J Sex Med 2011;8:792–799.     

Sexual Function and Pessary Management among Women Using a Pessary for Pelvic Floor Disorders

IntroductionPessaries are commonly used to treat pelvic floor disorders, but little is known about the sexual function of pessary users.AimWe aimed to describe sexual function among pessary users and pessary management with regard to sexual activity.MethodsThis is a secondary analysis of a randomized trial of new pessary users, where study patients completed validated questionnaires on sexual function and body image at pessary fitting and 3 months later.Main Outcome MeasuresWomen completed the Pelvic Organ Prolapse—Urinary Incontinence Sexual Function Questionnaire, International Urogynecological Association Revised (PISQ-IR), a validated measure that evaluates the impact of pelvic floor disorders on sexual function, a modified female body image scale (mBIS), and questions regarding pessary management surrounding sexual activity.ResultsOf 127 women, 54% (68/127) were sexually active at baseline and 42% (64/114) were sexually active at 3 months. Sexual function scores were not different between baseline and 3 months on all domains except for a drop of 0.15 points (P = 0.04) for sexually active women, and a drop of 0.34 points for non-sexually active women (P = 0.02) in the score related to the sexual partner. Total mBIS score did not change (P = 0.07), but scores improved by 0.2 points (P = 0.03) in the question related to self-consciousness. Pessary satisfaction was associated with improved sexual function scores in multiple domains and improved mBIS scores. The majority (45/64, 70%) of sexually active women removed their pessary for sex, with over half stating their partner preferred removal for sex (24/45, 53%).ConclusionMany women remove their pessary during sex for partner considerations, and increased partner concerns are the only change seen in sexual function in the first 3 months of pessary use. Pessary use may improve self-consciousness and pessary satisfaction is associated with improvements in sexual function and body image.     

Correlates of Female Sexual Functioning: Adult Attachment and Differentiation of Self

IntroductionFemale sexual functioning is affected by a range of factors including motivation, psychological well‐being, and relationship issues. In understanding female sexual dysfunction (FSD), there has been a tendency to privilege diagnostic and medical over relationship issues.AimTo investigate the association between women's experience of intimacy in close relationships—operationalized in terms of attachment and degree of differentiation of self—and FSD.MethodsTwo hundred thirty sexually active Australian women responded to an invitation to complete a set of validated scales to assess potential correlates of sexual functioning.Main Outcome MeasuresThe Female Sexuality Function Index, the Experiences in Close Relationships Scale, the Differentiation of Self Inventory, as well as a set of study‐specific questions were subject to hierarchical multiple regression analyses.ResultsRelational variables of attachment avoidance and to a lesser degree, attachment anxiety were associated with FSD. Participants with lower levels of differentiation of self were more likely to report sexual difficulties. The inability to maintain a sense of self in the presence of intimate others was the strongest predictors of sexual problems. A history of sexual abuse in adulthood and higher levels of psychological distress were also associated with sexual difficulties.ConclusionsThe findings provide support for a relational understanding of female sexual functioning. Attachment avoidance, attachment anxiety, and degree of differentiation of self are shown to be associated with sexual difficulties. The findings support the need to focus on relational and psychological factors in women's experience of sex. Burri A, Schweitzer R, and O'Brien J. Correlates of female sexual functioning: Adult attachment and differentiation of self. J Sex Med 2014;11:2188‐2195.     

Factors Associated With Specific Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition Sexual Dysfunctions in Breast Cancer Survivors: A Study of Patients and Their Partners

BackgroundMany women develop sexual problems after breast cancer (BC) treatment. Little is known about BC survivors with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) sexual dysfunction and their partners, and the factors associated with their sexual functioning.AimTo evaluate (i) patient-related and clinical factors associated with (a) specific DSM-IV sexual dysfunctions and (b) level of sexual functioning and sexual distress as reported by BC survivors and (ii) the association between the sexual functioning of BC survivors and that of their partners.MethodsWe analyzed baseline data from a study of the efficacy of online cognitive-behavioral therapy for sexual dysfunction in BC survivors.OutcomesWomen completed self-report questionnaires assessing sexual functioning, sexual distress, relationship intimacy, marital functioning, menopausal symptoms, body image, and psychological distress. Their partners completed questionnaires assessing sexual functioning.ResultsThe study included 169 BC survivors and 67 partners. The most prevalent female sexual dysfunctions were hypoactive sexual desire disorder (HSDD; 83%), sexual arousal disorder (40%), and dyspareunia (33%). Endocrine therapy was associated with HSDD (P = .003), and immunotherapy was associated with dyspareunia (P = .009). Older age was associated with lower sexual distress (P < .001). Depressive symptoms were highest in women with sexual arousal disorder (P = .004). An indication for erectile disorder was present in two thirds of partners. Lower overall partner sexual satisfaction was associated with lower overall BC survivor sexual functioning (P = .001), lower female arousal (P = .002), and lower female sexual satisfaction (P = .001). Poorer male erectile function was related to higher female sexual pain (P = .006). Partners of women who underwent breast reconstruction reported marginally significantly better orgasmic functioning (P = .012) and overall sexual functioning (P = .015) than partners of women who had undergone breast-conserving treatment.Clinical ImplicationsBC survivors and their partners experience sexual problems after BC treatment. This suggests that not only the BC survivor but also her partner could benefit from sexual counseling.Strengths and LimitationsThis is the first study focusing on BC survivors with a DSM-IV sexual dysfunction and their partners. The results cannot necessarily be generalized to women experiencing milder sexual problems or who have no interest in receiving sexual counseling.ConclusionEndocrine therapy and immunotherapy are relevant risk factors for HSDD and dyspareunia in BC survivors. The sexual functioning of women and their partners is affected, underscoring the importance of involving both partners in sexual counseling after BC treatment.Hummel SB, Hahn DEE, van Lankveld JJDM, et al. Factors Associated With Specific Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Sexual Dysfunctions in Breast Cancer Survivors: A Study of Patients and Their Partners. J Sex Med 2017;14:1248–1259.     

Attachment Insecurity and Sexual and Relational Experiences in Saudi Arabian Women: The Role of Perceived Partner Responsiveness and Sexual Assertiveness

BackgroundAttachment and intimacy play an important role in shaping sexual and relational experiences. Yet, their interrelation has rarely been investigated in the context of sexual problems and never been tested in Saudi Arabian women.AimThe present study examined the interrelations of attachment orientation and sexual function, distress, satisfaction, and relational satisfaction in a sample of Saudi Arabian women and explored whether this link can be explained by 2 important aspects of (sexual) intimacy, namely perceived partner responsiveness (PPR) and sexual assertiveness.MethodThis is a cross-sectional, observational study in a sample of 50 heterosexual women with sexual problems and 50 control women without problems, who completed an Arabic version of questionnaires on attachment orientation, sexual assertiveness, PPR, relationship satisfaction, sexual satisfaction, sexual distress, and sexual function.ResultsWe found that both attachment anxiety and sexual refusal showed a significant association with the level of sexual function, sexual distress, and sexual satisfaction (P < .01) in the clinical group. No mediating effects of sexual refusal were found. In the control group, sexual function, sexual distress, and sexual satisfaction were predicted by attachment avoidance (P < .01). Level of sexual function was also predicted by sexual initiation (P < .05). PPR fully mediated the association between attachment anxiety and relational satisfaction in the clinical group (P < .01), while in the control group the link between attachment avoidance and relational satisfaction was only partially mediated by PPR (P < .01).Strengths & LimitationsThis study offers unique information on relational and sexual functioning in a culture in which sexual expression and intimate behavior are restricted, particularly in women.Clinical ImplicationsPerceiving the partner as being more responsive is an important target of intervention to increase satisfaction with the relationship.ConclusionsOur results suggest that attachment anxiety and low sexual assertiveness, as indicated by lower tendencies to refuse sex when not desired, play a significant role in predicting negative sexual experiences in women who cope with sexual difficulties.Attaky A, Kok G, Dewitte M. Attachment Insecurity and Sexual and Relational Experiences in Saudi Arabian Women: The Role of Perceived Partner Responsiveness and Sexual Assertiveness. J Sex Med 2020;17:1383–1394.     

Pelvic Floor Muscle Problems Mediate Sexual Problems in Young Adult Rape Victims

IntroductionPrior studies have addressed sexual abuse and sexual function in adult women. No studies have focused on the effect of adolescence rape on sexual functioning.AimTo investigate the effect of rape on sexual problems and on pelvic floor problems, as well as the mediating role of pelvic floor problems on sexual problems, in a homogenous group of victims of adolescence rape without a history of childhood sexual, physical, and/or emotional abuse.Main Outcome MeasuresSexual functioning and pelvic floor functioning were assessed using self‐report questionnaires.MethodsIn this cross‐sectional study, a group of 89 young women aged 18–25 years who were victimized by rape in adolescence was compared with a group of 114 nonvictimized controls. The rape victims were treated for posttraumatic stress disorder (PTSD) 3 years prior to participation in the study.ResultsThree years posttreatment, rape victims were 2.4 times more likely to have a sexual dysfunction (lubrication problems and pain) and 2.7 times more likely to have pelvic floor dysfunction (symptoms of provoked vulvodynia, general stress, lower urinary tract, and irritable bowel syndrome) than nonvictimized controls. The relationship between rape and sexual problems was partially mediated by the presence of pelvic floor problems. Rape victims and controls did not differ with regard to sexual activities.ConclusionsRape victims suffer significantly more from sexual dysfunction and pelvic floor dysfunction when compared with nontraumatized controls, despite the provision of treatment for PTSD. Possibly, physical manifestations of PTSD have been left unaddressed in treatment. Future treatment protocols should consider incorporating (physical or psychological) treatment strategies for sexual dysfunction and/or pelvic floor dysfunction into trauma exposure treatments. Postma R, Bicanic I, van der Vaart H, and Laan E. Pelvic floor muscle problems mediate sexual problems in young adult rape victims. J Sex Med 2013;10:1978–1987.     

Body Esteem as a Common Factor of a Tendency Toward Binge Eating and Sexual Dissatisfaction Among Women: The Role of Dissociation and Stress Response During Sex

BackgroundSeveral studies have suggested a relevant overlap between eating disorders and sexual dysfunction involving the emotional component of body image esteem and dissociative experiences.AimTo evaluate the common maintaining factors of sexual dysfunction and vulnerability to pathologic eating behaviors and their relation to a physiologic stress response.MethodsIn the present cross-sectional study, we evaluated a non-clinical sample of 60 heterosexual women (25–35 years old) for dissociation during sex with a partner, body image disturbance, and tendency toward pathologic eating behaviors. We also evaluated the stress-induced hypothalamic-pituitary-adrenal axis activation in response to a sexual stimulus and its association with binge eating and dissociation.OutcomesParticipants completed the Clinician-Administered Dissociative States Scale, the Sexual Satisfaction Scale–Women, the Body Esteem Scale for Adolescents and Adults, and the Eating Attitudes Test Short Version. Furthermore, we assessed cortisol levels before, during, and after exposure to explicit sexual stimuli shown within a laboratory setting.ResultsDysfunctional body image esteem and a tendency toward binge-eating behaviors were associated with greater sexual distress in women. In particular, body esteem was significantly associated with greater dissociation during sex with a partner. Moreover, women who reported greater dissociation during sex with a partner and a tendency toward binge-eating behaviors showed higher levels of cortisol in response to sexual stimuli.Clinical ImplicationsThese results support further research based on trans-diagnostic treatments targeted to dissociation and body image esteem, which could lessen sexual dysfunction and vulnerability to pathologic eating behaviors.Strengths and LimitationsDespite the small sample and self-reported questionnaires, this is the first study to consider the association of the stress response during sexual stimuli with sexual distress and with pathologic eating behaviors adopting a dimensional approach.ConclusionBody uneasiness and dissociation represented factors underlying pathologic eating behaviors and sexual dysfunction. Women reporting a tendency toward binge-eating episodes and dissociation during sexual experiences represented a subpopulation with a higher stress response during sexual stimuli.Castellini G, Lo Sauro C, Ricca V, Rellini AH. Body Esteem as a Common Factor of a Tendency Toward Binge Eating and Sexual Dissatisfaction Among Women: The Role of Dissociation and Stress Response During Sex. J Sex Med 2017;14:1036–1045.