Vaginismus

Recently, a growing body of research on the role of cognitions and emotions in sexual response has emerged. In fact, since Barlow's formulation on cognitive-affective factors of sexual dysfunction (Barlow, 1986; Cranston-Cuebas & Barlow, 1990; Sbrocco & Barlow, 1996), several laboratory and clinical studies were conducted to analyze the role of some cognitive and emotional dimensions in the sexual health field. Cognitive distraction (J. G. Beck, Barlow, Sakheim, & Abrahamson, 1987; Dove & Wiederman, 2000; Elliot & O'Donohue, 1997; Farkas, Sine, & Evans, 1979; Geer & Fuhr, 1976; Przybyla & Byrne, 1984), efficacy expectancies (Bach, Brown, & Barlow, 1999; Creti & Libman, 1989; Palace, 1995), causal attributions (Fichten, Spector, & Libman, 1988; Weisberg, Brown, Wincze, & Barlow, 2001), and perfectionism (DiBartolo & Barlow, 1996) are among the most studied cognitive dimensions in sexual functioning. In general, results from these studies support the main role performed by cognitive factors in sexual dysfunction processes.

For the present discussion cognitive distraction studies assume a central role. Research with both male and female samples suggests that distraction from sexual cues during sexual activity decreases subjective and physiological arousal in both males and females (J. G. Beck et al., 1987; Dove & Wiederman, 2000; Elliot & O'Donohue, 1997; Farkas et al., 1979; Geer & Fuhr, 1976; Przybyla & Byrne, 1984). These psychophysiological studies support several clinical suggestions that dysfunctional subjects, when in sexual situations, focus their attention on negative thoughts rather than on sexually erotic thoughts. In males, these thoughts are mostly related to performance concerns (erection concerns), anticipating failure and its consequences (Hawton, 1985; Wincze & Barlow, 1997; Zilbergeld, 1999), whereas females orient their attention to self-body-image concerns, sexual performance concerns, and failure thoughts (Dove & Wiederman, 2000; Hawton, 1985). Despite these laboratory findings and clinical suggestions, there is still a lack of naturalistic empirical studies investigating the cognitive content of sexually dysfunctional males and females during sexual activity. With the exception of the Dove and Weiderman study (2000), which indicates a negative impact of distraction thoughts (sexual performance and bodily appearance) on female sexual functioning, there is no published data about cognitive content during sexual activity and its influence on sexual performance.

Moreover, studies about the role of emotions on sexual functioning, although receiving some recent attention, are still lacking. Research on depressed affect has shown some consistent results suggesting a negative impact on sexual arousal. Heiman and Rowland (1983) and J. G. Beck and Barlow (1986) found that dysfunctionals reported significantly more negative affect during erotic exposure. Experimental studies have further supported these findings, showing that manipulated negative affect in sexually functional subjects produced a delay in subjective sexual arousal (Meisler & Carey, 1991) and a decrease in penile tumescence (Mitchell, DiBartolo, Brown, & Barlow, 1998).

Research on the role of anxiety in sexual functioning has also shown some consistent results in both men and women. Contradicting classic theoretical perspectives based on clinical observations (Kaplan, 1974; Masters & Johnson, 1970), results systematically suggest a neutral or even a facilitative effect of anxiety on both male and female sexual arousal (Barlow, Sakheim, & J. G. Beck, 1983; Elliot & O'Donohue, 1997; Laan, Everaerd, Aanhold, & Rebel, 1993; Palace & Gorzalka, 1990).

Studies on the impact of anger and worry on sexual functioning are lacking and present some inconsistent results. Yates, Barbaree, and Marshall (1984), studying the relationship between anger and deviant sexual arousal, showed that this emotion might facilitate sexual arousal, while Bozman and J. G. Beck (1991) reported that anger decreases both desire and arousal. Katz and Jardine (1999) analyzed the relationship between a tendency to worry and sexual desire and aversion in a non-clinical population, and found some moderate but not conclusive correlations.

Despite this growing body of scientific literature, we think there is a lack of integrated studies on the link between cognitions and emotions and their impact on sexual functioning. Our purpose is to move in that direction using cognitive theory as a preferential framework to better understand the processes involved in sexual dysfunction. In fact, cognitive theory has led to a better understanding of the cognitive processes involved in a large spectrum of psychopathological situations and has been successfully used in the comprehension and treatment of several disorders: depression (A. T. Beck, Rush, Shaw, & Emery 1979), anxiety (A. T. Beck & Emery, 1985), relationship disorders (A. T. Beck, 1988), personality disorders (A. T. Beck & Freeman, 1990), substance abuse disorders (A. T. Beck, Wright, Newman, & Liese, 1993), and hostility (A. T. Beck, 2000).

Of particular interest is the later development of A. T. Beck's theoretical thinking (1996). In this recent revision, Beck proposed a new conception for the structure and processes involved in psychopathology. He developed the modes theory, substituting the linear schematic processing for a more integrated and interactional model. In this new concept, the central role of cognitive processing (mediating emotional and behavioral reactions) is substituted by a network of interdependent cognitive, emotional, and behavioral dimensions. Modes are conceptualized as specific suborganizations within the personality organization composed of cognitive, affective, and behavioral systems. A. T. Beck (1996) suggests that the various psychopathological disorders can be conceptualized in terms of modes. For example, specific phobia would be characterized by specific dangerous thoughts, anxiety responses, and a behavioral impulse to escape, whereas depression would be characterized by loss thoughts accompanied by sadness and regression behaviors.

Our goal is to study sexual dysfunctions using this theoretical perspective, which, besides its conceptual soundness, is largely based in empirical findings and proven to be clinically effective in a wide range of psychopathological situations (A. T. Beck, 1996). For this purpose, we developed the Sexual Modes Questionnaire (SMQ), specifically oriented to assess the interaction between the automatic thoughts and the related emotions and sexual responses. We hypothesized that dysfunctional subjects when in sexual situations activate negative cognitive schemas, which elicit a synchronic and interactional response by the cognitive, emotional, and behavioral systems. This interactional response would be characterized by negative automatic thoughts and emotions and low sexual response. Thus, dysfunctional subjects would present thoughts not relevant to the sexual task (i.e., lack of sexual or erotic thoughts) but oriented to performance demands (focus on erection) or anticipating failure and its consequences in males, and sexual abuse thoughts, failure and disengagement thoughts, or low self-body-image thoughts in females. These negative automatic thoughts would be associated with negative emotions (mostly related to depressed mood--lack of pleasure and satisfaction accompanied by sadness, disillusion, or guilt) and with poor sexual response (i.e., low sexual arousal levels). These three systems, once activated, will feed each other and maintain the dysfunctional cycle.

This study is also part of a more global research project developed to assess the role of cognitive-emotional variables in sexual functioning (Nobre, 2003). For this purpose, two other measures were also created to study different levels of cognitive interference: a measure of sexually dysfunctional beliefs (Nobre, Pinto-Gouveia, & Gomes, 2003; meant to assess sexual beliefs hypothesized as vulnerability factors to sexual dysfunction) and a measure of cognitive schemas activated in sexual context (Nobre & Pinto-Gouveia, 2003; assessing the cognitive schemas activated by nonsucceeded sexual situations). We hypothesized that sexual beliefs would stipulate the conditions for the activation of the cognitive schemas in specific sexually unsuccessful experiences. Once activated, these cognitive schemas would elicit a systemic structure composed of thoughts, emotions, and sexual response. Past research with erectile disorders seems to support this model (Nobre, 1997; Nobre & Pinto-Gouveia, 2000).

METHOD

Participants and Procedures

A total of 456 subjects (201 females and 255 males) participated in the study. A community sample of 360 people (154 females and 206 males) and a clinical sample of 96 people (47 females and 49 males) constituted the group. Participants from the community sample were recruited with the help of volunteers in different country regions. Volunteers directly contacted participants, explained the purpose of the study (to assess psychological variables associated with sexual functioning), and gave them the questionnaire with the respective instructions. These participants were instructed to answer the questionnaires when alone and in the privacy of their homes and then to return them by mail using prestamped envelopes. We did not pay participants for their participation. The response rate was 30.6% (demographic characteristics presented in Table 1).

We recruited the clinical sample from the sexology clinic of Coimbra's University Hospital. Subjects diagnosed with sexual dysfunction using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) criteria constituted this clinical group. Participants answered the questionnaire after completing a clinical assessment for sexual dysfunction conducted by a group of trained sex therapists from the clinic. One of the researchers involved in the project explained the study purpose, and participants signed a consent form. Participants then answered the questionnaires by themselves in a private space and returned them directly to the member of the research team present. Erectile disorder (70%) and premature ejaculation (25%) were the most common diagnoses in the male sample, while hypoactive sexual desire (38%), vaginismus (24%), and orgasmic disorders (20%) were the main female complaints.

To perform a discriminant analysis, we also selected a control group. Participants (46 females and 49 males) were selected from the community sample above to match the clinical group regarding age, marital status, and education level. Subjects from this control group were also screened using the International Index of Erectile Function (IIEF; Rosen et al., 1997) and the Female Sexual Function Index (FSFI; Rosen et al., 2000) to eliminate sexual dysfunction. Detailed demographic data from both male and female clinical and control groups are presented in Table 2.

Materials

Sexual Modes Questionnaire (SMQ)

This questionnaire was developed to evaluate the modes model proposed by A. T. Beck (1996). Because of the interactional character of the modes concept, we created a questionnaire that assesses three different areas (automatic thoughts, emotional response, and sexual response).

Automatic thought subscale (AT). A 30-item male and a 33-item female scale were developed to evaluate automatic thoughts and images presented by the participants during sexual activity. We asked participants to rate the frequency (from 1 = never to 5 = always) with which they usually experience those automatic thoughts during their sexual activity. Thoughts included in the scale were selected based on their theoretical and clinical relevance. Using some of the empirical and clinical findings presented above, we selected items to assess whether the thought content was oriented to sexual and erotic stimuli or to nonrelevant cues. Among the nonsexual thoughts, we assessed several dimensions. For the male version we generated items to cover sexual performance thoughts (mostly oriented to the erectile response), failure anticipation thoughts, negative thoughts toward sexuality (conservative thoughts), and thoughts about the negative impact of age on sexual functioning. We generated items for the female version to assess failure and disengagement thoughts, low body-image thoughts, sexual abuse thoughts, thoughts about a partner's lack of affection, and sexual passivity and control thoughts. An index of negative automatic thoughts was calculated by summing all automatic thought items (thoughts related to erotic cues were scored in reverse order). The negative automatic thought score ranges for both male and female versions are presented in the factor analysis and domain score section.

Emotional response subscale (ER). We developed a 30-item male and a 33-item female scale to evaluate emotions experienced by the subjects during sexual activity. The items were directly connected to the items of the automatic thought scale. So, for each automatic thought, subjects indicate their emotional response. A list of ten emotions was presented (worry, sadness, disillusion, fear, guilt, shame, anger, hurt, pleasure, satisfaction), and participants were asked to check which they usually experienced whenever they endorsed each automatic thought. An index for each emotional response was calculated based on the following formula: total number of each emotion endorsed / total number of emotions endorsed. The indices based on this formula represent the ratio at which participants usually experience each emotion during sexual activity. The emotional response index ranges from 0.0 to 1.0.

Sexual response subscale (SR). We developed a 30-item male and a 33-item female scale to evaluate the subjective sexual response during sexual activity (subjective sexual arousal). The items were directly connected to the items of the automatic thought scale. So, for each automatic thought presented, the subjects were asked to rate the intensity of their subjective sexual arousal (from 1 = very low to 5 = vet-y high). An index of sexual response was calculated based on the following formula: sum of the sexual response for each item / total number of sexual response items endorsed. The index based on this formula gives an indication of the average sexual response (subjective sexual arousal) presented by the participants during sexual activity. The sexual response index ranges from 1 to 5.

Convergent Validity

To assess convergent validity, we used measures of male and female sexual functioning: the International Index of Erectile Function (IIEF; Rosen et al., 1997) and the Female Sexual Function Index (FSFI; Rosen et al., 2000).

The International Index of Erectile Function (IIEF). The IIEF (Rosen et al., 1997) is a brief 15-item self-administered measure of erectile function, evaluating five domains: erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction. Psychometric studies supported the validity (significant mean difference scores between a clinical and a control group) and reliability (Cronbach's [alpha] values of .73 and higher and test-retest from r = .64 - .84) of the measure. Studies with clinical samples also demonstrated its sensitivity and specificity for detecting treatment-related changes (Rosen et al., 1997).

The Female Sexual Function Index (FSF1). The FSFI (Rosen et al., 2000) is a 19-item instrument, easily administered and scored, providing detailed information on the major dimensions of sexual function: sexual interest and desire, sexual arousal, lubrication, orgasm, sexual satisfaction, and sexual pain. The measure presents acceptable test-retest reliability (r = .79 - .86), internal consistency (Cronbach's [alpha] = .82 and higher), and validity (demonstrated by significant mean difference scores between a clinical and a control group).

RESULTS

This section presents data regarding the psychometric characteristics of the questionnaire. The process used for item generation and selection is explained, and data about reliability (internal consistency and test-retest) are presented. We also present factorial analysis of both male and female versions, as well as convergent validity (relationship between our measure and sexual function instruments) and divergent validity analysis (comparing the mean scores from a clinical and a control group).

Item Analysis

To develop the automatic thought subscale, we completed an item analysis of an initial pool of 68 items (female version) and 54 items (male version). This initial pool was generated by the authors with the help of a panel of experts on sex therapy (group of sex therapists from the sexology clinic of Coimbra's University Hospital). As presented above, item generation was based on theoretical and clinical data with the purpose of testing some hypotheses derived from cognitive distraction studies. This initial pool of items was submitted to an item analysis, where item-total correlation was calculated, as well as its relationship with sexual function instruments (IIEF and FSFI). Items presenting low correlations with the total (r < .35) as well as nonsignificant correlations with the IIEF (male version) or the FSFI (female version) were excluded. We then conducted an exploratory factor analysis and excluded items not loading significantly on any of the factors extracted or presenting factor loadings higher than .4 on more than one factor. The remaining 33 items (female version) and 30 items (male version) constitute the final version of the automatic thoughts subscale.

Reliability Studies

Test-Retest Reliability

Test-retest reliability of both male and female automatic thought subscales was assessed by computing a Pearson product-moment correlation between two consecutive administrations with a 4-week interval (Table 3). Results from the female version clearly show the stability of our measure across time with a very high correlation for the total scale (r = .95, p < .01) and moderate to high correlations when considering the specific dimensions assessed (correlations range from r = .52, p < .05 to r = .90, p < .01).

Regarding the male version, results show a more moderate Pearson product-moment correlation between the two consecutive administrations (r = .65, p = .08). However, despite this moderate result, correlations for the several specific dimensions of our measure show statistically significant results for every domain except one (correlations range from r = .71, p < .05 to r = .95, p < .01). One of the dimensions assessed (negative thoughts toward sex) presented very low stability across time (r = .20, p = .61) and was responsible for the moderate reliability of the total scale. However, since this analysis was based on a small sample (n = 9), no consistent conclusion should be made regarding test-retest reliability for both total and dimensional scales.

Internal Consistency

Internal consistency of both male and female automatic thoughts subscales was assessed using Cronbach's [alpha] for the total scale and for each dimension separately (Table 3). Results were high for male and female total scales ([alpha] = .87 and .88 for female and male versions, respectively), showing the general consistency of the measures. Looking at the internal consistency of the specific dimensions assessed by our instrument, we may also observe high interitem correlations within each factor. Cronbach's [alpha] statistics range from .71 to .80 for the female version and from .69 to .83 for the male one.

Factor Analysis and Scores

To study the internal structure of the automatic thought subscale (AT), we performed a factor analysis of both male and female measures.

Female Version

We performed a principal component analysis (using varimax rotation) on the 33 items of the female version (Table 4). Six factors were identified using the Catell's scree test criteria, explaining 53.1% of the total variance (F1 = 23.2%, F2 = 10.0%, F3 = 6.0%, F4 = 5.3%, F5 = 4.4%, F6 = 4.2%). A Kaiser-Meyer-Olkin measure of .84 supported the adequacy of the sample, and Bartlett's test of sphericity was significant ([chi square] = 528, p < .001).

The item selection for each factor was based on statistical and interpretability criteria. We based our inclusion decisions on loadings higher than .4 on the respective factor. Items that didn't load high on any of the factors or that presented high correlations with more than one factor were excluded (two items were excluded using this criteria: Item 13, "I'm not satisfying my partner"; and Item 18, "He only does what I want when he needs me for sex"). The six factors identified were as follows:

1. Sexual Abuse Thoughts: the dimension that expresses thoughts of being abused, disrespected, and even violated by the sexual partner.

2. Failure and Disengagement Thoughts: the domain that is constituted by thoughts of incapacity for sexual performance and lack of motivation to engage in sexual activity.

3. Partner's Lack of Affection: the factor characterized by thoughts of not being treated with care and affection by the partner during sexual activity. This dimension reflects the dichotomy between sex as an affective activity and sex as a physical activity.

4. Sexual Passivity and Control: the dimension represented by thoughts of female sexual passivity and control, reflecting the idea that women must wait for the male's first step in order to match cultural values (not being seen as frivolous) and also to prevent eventual emotional harm.

5. Lack of Erotic Thoughts: the domain formed by thoughts of sexual erotic content. Since these items were scored in reverse order, higher results on this factor represent lack of erotic thought content during sexual activity.

6. Low Self-Body-Image Thoughts: the factor characterized by thoughts of not being comfortable with one's body image.

The factor intercorrelations (Table 5) show the strong relationships between the factors identified, suggesting they assess concepts that are somehow related to each other. We may observe that, with the exception of Factor 5 (Lack of Erotic Thoughts), all other dimensions present statistically significant intercorrelations.

The range, means, and standard deviations of possible factor and total scores for the automatic thought subscale (female version) are presented in Table 6. Higher scores on the total scale represent negative automatic thoughts during sexual activity.

Male Version

Regarding the male version, we identified five factors after performing a principal component analysis (Table 7) using varimax rotation on its 30 items (using the Catell's scree test criteria). The factors explained 54.7% of the total variance (F1 = 31.8%, F2 = 7.8%, F3 = 6.0%, F4 = 5.1%, F5 = 4.1%). A Kaiser-Meyer-Olkin measure of .88 supported the adequacy of the sample, and Bartlett's test of sphericity was significant ([chi square] = 435, p < .001).

The item selection for each factor was based on statistical and interpretability criteria. We based our inclusion decision on loadings higher than .4 on the respective factor. Items that didn't load high on any of the factors or that presented high correlations with more than one factor were excluded. Three items were excluded using this criteria: Item 13, "What is she thinking about me?"; Item 15, "If others know that I can't perform..."; and Item 27, "I must show my virility." The five factors identified were the following:

1. Failure Anticipation and Catastrophyzing Thoughts: the factor characterized by thoughts of incapacity to perform, failure anticipation, and magnifying the negative consequence of failure.

2. Erection Concern Thoughts: the dimension constituted by thoughts specifically related to penis reaction and concerns about capacity for intercourse.

3. Age and Body Function Related Thoughts: the factor represented by thoughts of being old and its implications regarding sexual activity and partner's attraction.

4. Negative Thoughts Toward Sex: the factor characterized by conservative and negative thoughts toward sexuality.

5. Lack of Erotic Thoughts: the dimension represented by sexual and erotic thoughts. Since these items were scored in reverse order, higher values on this domain represent lack of erotic thought content during sexual activity.

The factor intercorrelations presented in Table 8 show once again the strong relationships among all factors, with the exception of Lack of Erotic Thoughts.

The range, means, and standard deviations of possible factor and total scores for the automatic thought scale (male version) are presented in Table 9. Higher scores on the total scale represent negative automatic thoughts during sexual activity.

Correlations Between the Questionnaire Subscales

To test the integrative nature of the cognitive, emotional, and behavioral systems, we conducted a series of correlational studies between the automatic thought, emotional response, and sexual response subscales.

Automatic Thoughts and Emotions

Correlations between the automatic thought subscale (AT) and the emotional response subscale (ER) show the strong link between these two dimensions (Table 10). For the total score of the female automatic thought subscale (negative automatic thought index) we observed a statistically significant relationship with almost all emotions presented: sadness, disillusionment, fear, guilt, shame, pleasure, and satisfaction. So, the greater the negative thoughts presented during sexual activity, the greater the tendency to experience negative emotions and the lesser the tendency to feel pleasure and satisfaction.

For the male sample, correlations between the different dimensions of the automatic thought subscale and the emotional response subscale proved to be statistically significant in several factors. In summary, the greater the dysfunctional thoughts presented during sexual activity, the greater the probability of experiencing disillusionment, sadness, and shame and the lesser the tendency to feel pleasure and satisfaction.

Automatic Thoughts and Sexual Response

Correlations between the automatic thought subscale and the sexual response subscale highlight the strong relation ship between what people think during sexual activity and their sexual response (measured as the amount of subjective arousal experienced). Results show statistically significant negative correlations among all dimensions of the automatic thought subscale and the sexual response index. The greater the number of negative thoughts, the less the subjective arousal experienced (Table 11).

Emotions and Sexual Response

Correlations between the emotions experienced during sexual activity and the intensity of sexual response show that there is a link between some emotional responses and behavioral dimensions in sexual expression. Emotions of sadness, disillusionment, guilt, shame, anger, and hurt were inversely related to sexual response intensity, whereas pleasure and satisfaction feelings correlated positively and significantly with sexual response indices (Table 12).

Correlational studies supported the strong links among the three subscales assessed in our questionnaire. In fact, thoughts, emotions, and sexual response showed high correlational levels, supporting the usefulness of an interactional assessment strategy.

Convergent Validity

To assess the convergent validity of our measure, we used the Female Sexual Function Index (FSFI; Rosen et al., 2000) and the International Index of Erectile Function (IIEF; Rosen et al., 1997). We expected that the automatic thoughts and emotions presented during sexual activity would be strongly correlated with measures of sexual functioning.

Regarding the correlations between the automatic thought subscale and both male and female sexual function, we found several statistically significant correlations. This shows that when participants were in sexual situations, their thoughts and mental images were closely related to their sexual functioning (Table 13). Looking at the female sample, the FSFI presented high negative correlations with Sexual Abuse Thoughts (FI), Failure and Disengagement Thoughts (F2), and Lack of Erotic Thoughts (F5). Interestingly, Partner's Lack of Affection (F3) and Low Self-Body-Image Thoughts (F6) presented low correlations with sexual functioning. Sexual Passivity and Control Thoughts (F4), although not strongly correlated with the sexual function index, presented statistically significant negative correlations with the FSFI dimensions of arousal, lubrication, and orgasm.

Regarding the male sample, there were strong negative correlations between the IIEF total scores and Failure Anticipation Thoughts (F1), Erection Concern Thoughts (F2), and Lack of Erotic Thoughts (F5). Negative Thoughts Toward Sex (F4), although not correlated highly with the sexual function index, showed a statistically significant negative correlation with the orgasm dimension.

Correlations between the emotional response subscale (ER) and the male and female sexual function indices are presented in Table 14. Regarding the female sample, we observed strong negative correlations between the female sexual function index and sadness, guilt, and anger, and significantly positive correlations with pleasure. In the male sample, higher correlations were observed between the IIEF and sadness, disillusionment, pleasure, and satisfaction.

Discriminant Validity

To perform a discriminant validity analysis, we used a t test of mean differences between the clinical group (subjects who presented themselves in a sexology clinic complaining of a sexual difficulty) and the control group (demographic data for both groups presented in Table 2). We hypothesized that dysfunctional subjects would present higher scores on both male and female negative automatic thoughts, as well as more negative emotions and lower sexual response indices, supporting our hypothesis that the SMQ assesses automatic thoughts and emotions that play an important role in the development and maintenance of sexual problems.

Results demonstrated that there were several statistically significant differences in the automatic thoughts, emotions, and sexual responses between clinical and control groups in both male and female samples (Table 15). In the female sample, the clinical group presented significantly higher scores on Failure and Disengagement Thoughts (F2), Lack of Erotic Thoughts (F5), and the total scale.

In the male sample, the clinical group presented significantly higher scores (compared to the control group) on Failure Anticipation (F1), Erection Concern (F2), and Lack of Erotic Thoughts (F5). Interestingly, subjects from the control group presented significantly higher results in Negative Thoughts Toward Sexuality (F4), possibly indicating that dysfunctional males do not necessarily have negative thoughts or ideas about the sexual act itself.

These results show that our questionnaire measures thoughts and images in sexual situations that are closely related to sexual problems, and that its assessment and analysis may be important in understanding human sexual difficulties.

As observed for the automatic thought scale, emotional response during sexual activity also discriminated clinical from nonclinical populations. Observing the results in Table 16, we may conclude that sexually dysfunctional subjects present significant differences from functional subjects in several emotional responses facing sexual situations. This is true for both male and female samples.

The female clinical group showed significantly higher scores on hurt and lower scores on pleasure and satisfaction. Male dysfunctional subjects presented significantly higher results on sadness and lower results on pleasure and satisfaction. These results highlight the importance and significance of assessing emotional responses in a sexual context.

Regarding the sexual response subscale, the results suggest that this measure presents a capacity to discriminate between clinical and nonclinical groups (Table 17). As expected, scores on both the male and female sexual response index were significantly higher in sexually functional subjects than in dysfunctionals (t = -4.26, p < .001 for male sample and t = -3.94, p < .001 for female subjects).

DISCUSSION

The aim of this study was to develop a new measure to assess the interdependent character of the mode concept and apply it to the sexual field. Since this is a recent development from A. T. Beck's cognitive theory, and since there is a lack of integrated cognitive-emotional studies in the area of sexual problems, we felt the need to develop this assessment tool to meet new theoretical advances.

In the present article, the Sexual Modes Questionnaire (with its three subscales: automatic thoughts, emotional response, and sexual response) was described, and several psychometric studies were presented. Both male and female automatic thought subscales were submitted to a principal component analysis, with six factors identified in the female version (Sexual Abuse Thoughts, Failure and Disengagement Thoughts, Partner's Lack of Affection, Sexual Passivity and Control, Lack of Erotic Thoughts, and Low Self-Body-Image Thoughts) and five in the male version (Failure Anticipation Thoughts, Erection Concern Thoughts, Age Related Thoughts, Negative Thoughts Toward Sex, and Lack of Erotic Thoughts).

Correlational studies between the three subscales indicated strong relationships between several dimensions of the automatic thoughts, emotions, and sexual responses. It is interesting to note that the emotional responses which correlated more strongly with the negative automatic thought index (sadness, disillusionment, pleasure, and satisfaction in the male version and disillusionment, guilt, pleasure, and satisfaction in the female version) also correlated strongly with the sexual response index in both male and female versions. Moreover, the automatic thought factors strongly correlated with the mentioned emotions (Sexual Abuse Thoughts and Failure and Disengagement Thoughts in the female version, and Failure Anticipation and Erection Concern Thoughts in the male version) were also strongly correlated with the sexual response index. These results indicate that some cognitive and emotional variables have a common component which seems to be related to the subjective sexual arousal experienced during sexual activity. The strong correlations among these variables also support our strategy of assessing these three variables as interdependent dimensions.

Test-retest reliability analysis supported the stability of the female version (r = .52 - .90 for the factors and r = .95 for the total scale). Results for the male version were not so strong (r = .20 - .95 for the factors and r = .65 for the total scale) and should be interpreted with caution since they were based on a small sample (n = 9). Also, the test-retest correlation for the Negative Thoughts Toward Sex factor (r = .20) raises the question of its reliability. Future analyses should be carried out to achieve a more stable estimate. Cronbach's [alpha] of .87 for the female and .88 for the male version supported the general consistency of the measures.

Correlational studies with measures of sexual functioning (IIEF, FSFI) and discriminant analysis using clinical and control groups suggest that cognitions and emotions in sexual situations play an important role in sexual function. Specifically, some patterns of automatic thoughts not oriented to erotic cues (failure anticipation, erection concerns, and lack of erotic thoughts in males and thoughts of being abused, failure and disengagement thoughts, and lack of erotic thoughts in females) and emotions of sadness, guilt, anger, and lack of pleasure or satisfaction seem to be strongly related to sexual dysfunction. These findings seem to support some previous studies on cognitive distraction (J. G. Beck et al., 1987; Dove & Wiederman, 2000; Elliot & O'Donohue, 1997; Farkas et al., 1979; Geer & Fuhr, 1976; Przybyla & Byrne, 1984), depressed mood (Meisler & Carey, 1991; Mitchell et al., 1998), and anger (Bozman & J. G. Beck, 1991), providing an integrated conceptualization of the role of these cognitive and emotional variables in the sexual dysfunction process. However, some dimensions from both the automatic thoughts and emotional response subscales failed to discriminate between the clinical and the control groups. Thoughts related to partner's lack of affection, sexual passivity and control, or low self-body-image in the female sample and age related thoughts or negative thoughts toward sex in the male sample appear less related to sexual dysfunction processes. Also, emotions of worry and fear seem to be unrelated to sexual functioning.

These findings, although interesting, need to be interpreted with caution. The main purpose of the present study was not to test hypotheses regarding the role of the presented cognitive and emotional variables but rather to develop a measure to assess those variables in an integrated perspective. Thus, results should be understood as preliminary and further research using larger clinical and control samples should be conducted (now in progress).

In conclusion, we would like to highlight the innovative character of the Sexual Modes Questionnaire, developed to assess the interdependent roles played by cognitive, emotional, and behavioral variables in sexual functioning. Systematic use of this reliable and valid measure could help shed some light on the processes involved in sexual dysfunction. We hope this will be an important aid in the implementation of cognitive behavioral therapy approaches for treating sexual dysfunction in men and women.

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Manuscript accepted July 9, 2003

This research was partially supported by a grant from PRODEE The authors would like to thank to Allen Gomes, M.D., Hospitais da Universidade de Coimbra, Portugal, for making possible the collection of the clinical sample and also for his comments and suggestions. Thanks also to D. Rijo, M.A., C. Salvador, M.A., M. Lima, Ph.D., Faculdade de Psicologia, Universidade de Coimbra. Portugal; A. Gomes, M.A., L. Fonseca, M.A., A. Carvalheira, M.A.. J. Teixeira, M.D., G. Santos, M.D., J. Quartilho, M.D., Ph.D., P. Abrantes, M.D., and A. Canhao, M.D., Hospitais da Universidade de Coimbra, for their suggestions and help in sample collection. H. Ramsawh, M.A., L. Scepkowski. M.A., and M. Santos, B.A., Center for Anxiety and Related Disorders, Boston University, for reviewing the English version of the measures. John Wincze, Ph.D., Brown University and Center for Anxiety and Related Disorders, Boston University, for his review and suggestions on a previous version of the paper. Thanks also to participants who volunteered to participate in the study.

Pedro J. Nobre

Universidade de Tras-os-Montes e Alto Douro, Miranda do Douro, Portugal

Jose Pinto-Gouveia

Universidade de Coimbra, Portugal

Address correspondence to Pedro Nobre, Rua Amorim de Carvalho, 97, 4460 SENHORA DA HORA, PORTUGAL; e-mail: pedro.j.nobre@clix.pt.

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