Women's Sexual Function and Dysfunction. Irwin Goldstein MD

Cognitive and affective processes in female sexual dysfunctions

Markus Wiegel, Lisa A Scepkowski, David H Barlow

There is an increasing recognition that important differences exist between male and female sexual response and function. The relational and cultural factors prominent in the development and maintenance of sexual complaints and dysfunction in women have been discussed in previous sections. In addition to these external factors, cognitive and affective processes at the level of the individual influence sexual responding, and include attention and distraction, expectancies, and negative mood states such as anxiety and depression. Differences between men and women in cognitive and affective processes, as they relate to sexual response and function, occur primarily in the context of sexual performance concerns, while the related mechanisms of action are similar in men and women.

Barlow’s cognitive-affective model of sexual (dys)function

Over the last two decades, Barlow and colleagues have developed and empirically supported a model of sexual function and dysfunction that focuses on cognitive and affective processes (Fig. 3.2.1).1,2 This model has recently been updated (Fig. 3.2.2) to incorporate new empirical findings from the fields of sexual and anxiety research.3-5 In this model, dysfunctional sexual response results from a negative feedback loop (Fig. 3.2.3). Individuals with sexual dysfunction exhibit a “sexually dysfunctional mentality” that includes perceived lack of control over sexual arousal, sexual failure expectancies, maladaptive causal attributions, and cognitive bias (hypervigilance).

For women with sexual dysfunctions, sexual situations and their associated implied and expressed demands for sexual per- formance/response result in a state of anxious apprehension that is characterized by heightened autonomic arousal, negative affect, failure expectancies, and shifts in attentional focus to interoceptive cues and negative self-evaluative cognitions. Sexual failure expectancies, concerns regarding negative evaluation by her partner, and sexual (non)response worries can evoke anxious apprehensive states in women. A narrowing of attentional focus, which accompanies heightened levels of sympathetic arousal, increases the salience of nonerotic thoughts and decreases the woman’s ability to focus on the erotic and romantic aspects of the sexual situation. Furthermore, her attention shifts to an internal, self-evaluative focus. This shift to an internal attentional focus forms an additional feedback loop within the overall negative feedback cycle and results in a heightened subjective experience of negative affect (Fig. 3.2.3). Increased negative affect and distraction from erotic cues lead to problems in sexual responding. Repeated experiences with sexual response difficulties result in further failure expectancies and can lead to avoidance of potentially sexual situations. In contrast, sexually functional women associate positive affect and sexual success expectancies with sexual stimuli. They are focused on the erotic and romantic cues necessary for sexual response. With increased autonomic arousal (due to sexual stimulation), their attention narrows, focusing more efficiently on the sexual and romantic aspects, resulting in further increases in their sexual arousal.

Figure 3.2.1. Original model of sexual function and dysfunction. Reproduced with permission from Barlow2. Copyright 1986 by the American Psychological Association.

Sexual performance concerns

Early empirical support for Barlow’s model of sexual dysfunction focused primarily on the concepts of performance anxiety and spectatoring and was largely derived from laboratory studies of men with and without erectile dysfunction.1 A man’s ability to attain and maintain adequately a rigid erection is intimately tied to his self-esteem and self-evaluation.6,7 For women, sexual performance concerns have a different focus because the signs of sexual arousal are less publicly evident. Women experience a wide array of sexual concerns, including worries about pleasing her partner, fears of pregnancy and sexually transmitted infections, fear of partner rejection, and unease related to the ability to reach orgasm.8,9 One common source of nonerotic cognitive distraction for women that has been empirically studied is the concept of body image self-consciousness.

In Western cultures particularly, women’s bodies are evaluated and sexualized with greater frequency than men’s bodies.10,11 Some women may view their sexual attractiveness to their partners as an aspect of sexual performance. To the extent that a woman internalizes the view equating her sexual desirability with her bodily attractiveness (such as thinness), she is prone to heightened awareness of how her body appears to her sexual partners. Such a view is not entirely unrealistic, as demonstrated by the finding that weight gain by women was associated with decreased sexual interest and sexual satisfaction among their husbands, while men’s weight gain did not detrimentally affect their wives’ sexual interest.12 Nevertheless, body image self-consciousness has negative effects on female sexual function, above and beyond actual body size or general body image dissatisfaction. Wiederman13 found that body image selfconsciousness was related to lower sexual esteem, less sexual assertiveness, greater sexual avoidance, less sexual experience, and a lower probability of being in a relationship, while statistically controlling for body size, general body dissatisfaction, sexual anxiety, and social avoidance due to negative body image. Importantly, while only 9.6% of the college women studied met criteria for obesity, 35.1% of the sample reported experiencing body image self-consciousness during physical intimacy with a partner at least some of the time.

Figure 3.2.2. Updated model of sexual function and dysfunction. Reproduced with permission from Wiegel et al.4

Anxious apprehension, anxiety, and cognitive distraction

In women, as in men, sexual performance concerns result in a state of anxious apprehension. The state of anxious apprehension incorporates a sense of uncontrollability focused largely on future negative events, a strong physiologic component [sympathetic nervous system (SNS)], a vigilance (or hypervigilance) for threat-related cues, and a shift in attention to a self-focus (self-preoccupation) in which the evaluation of one’s (inadequate) capabilities to cope with the threat is prominent.5 Sexual arousal is likewise composed of physiologic, cognitive, affective, and behavioral components. Different components of “anxious apprehension” influence the various components of sexual response differentially, and not always in the same direction (i.e., facilitate or decrease). For example, Meston and colleagues14-18 have attempted to separate the effects of increased SNS arousal from the effects of cognitive and affective components of anxiety on sexual response. In general, these studies found that in women without sexual dysfunction and women with hypoactive sexual desire disorder, heightened SNS activation prior to watching an erotic film increases genital sexual response, as measured by vaginal photoplethysmography. Subjective reports of sexual arousal, on the other hand, do not seem to be influenced by SNS activation. The implication of this line of research is that the somatic component of anxious apprehension may facilitate genital response, while the negative affective component may concurrently decrease subjective sexual arousal. The cognitive component (selective attentional focus) may either facilitate or interfere with physiologic sexual arousal, depending on whether or not the individual has a sexual dysfunction.

The above-described complex interaction should inform interpretation of empirical research examining the effects of anxiety on sexual response. Studies on the effects of anxiety have yielded numerous conflicting results in both men and women, with some showing detracting effects8, and others showing enhancement of sexual responding.19,20 A few key studies with women will be discussed to illustrate the effects of anxiety and distraction on sexual arousal in the framework of a cognitive-affective model.

Palace and Gorzalka19 found that for both sexually functional and dysfunctional women, exposure to an anxiety- provoking stimulus prior to visual sexual stimulation enhanced physical sexual arousal, compared to a neutral preexposure stimulus. In contrast, anxiety during a sexual encounter was shown by Beggs et al.8 to reduce significantly physiologic arousal compared with a pleasurable encounter without anxiety. Methodological differences in the timing and type of the anxiety stimulus (sexually relevant or nonrelevant) account for the opposite valenced effects of anxiety (facilitation vs reduction) on sexual arousal in these two studies.

Palace and Gorzalka19 presented a nonsexually relevant anxiety stimulus just prior to the erotic stimulus. The anxiety stimulus consisted of a film depicting threatened amputation, which resulted in increased anxiety along with the associated SNS activation. In addition to the facilitative impact of SNS activation on female genital arousal, sympathetic activation also increases the efficiency of attentional focus. Since the anxiety stimulus was not personally relevant to the participants (it was a sexual arousal study, not an amputation study), as the erotic film began, the increasingly efficient attentional focus probably resulted in greater salience of the positive sexual cues. Thus, vaginal vasocongestion was enhanced in both the women with and without sexual dysfunction.

In contrast, Beggs et al. compared the effect of selfgenerated descriptions of sexual anxiety and sexual pleasure experiences that were then played back to participants as narratives while they underwent physiologic assessment. The anxiety-provoking stimuli were personally relevant to participants and were presented concurrent with the sexual stimuli. Sympathetic activation in the presence of both erotic cues and sexual anxiety-provoking cues presumably enhanced attention to the latter since they were a source of threat. Negative sexual cues may have deterred sexual response by eliciting negative affect as well as distracting nonerotic cognitions.

Figure 3.2.3. Detail of updated model of sexual function and dysfunction: sexually dysfunctional individuals. CRF = Corticotropin Releasing Factor. Reproduced with permission from Wiegel et al.4.

Several studies have documented the detrimental effects of distraction on female sexual response.21-24 For example, using questionnaires to assess the amount of cognitive distraction recalled during sexual activity with a partner, Dove and Wiederman23 found that women who reported greater levels of cognitive distraction also reported lower sexual self-esteem, less sexual satisfaction, and experiencing orgasms less consistently than women who reported lower levels of cognitive distractions. These differences remained significant when general life satisfaction, general body dissatisfaction, sexual attitudes, level of sexual desire, and trait self-focus propensity were controlled.

Elliot and O’Donohue24 attempted to tease apart the differential effects of anxiety and distraction on sexual arousal. The distraction conditions involved dichotic listening tasks in which women either had to listen to (no distraction), repeat forward (low distraction), or repeat backward (high distraction) distracting target sentences while listening to an erotic narrative. Women in the anxiety condition listened to target dis- tracters designed to induce sexually relevant anxiety (e.g., fears of sexually transmitted disease, self-consciousness) and were also told they were being videotaped and evaluated during this task. The comparison group listened to neutral distracters and were not told that they were being taped. Results indicated no significant differences in subjective sexual arousal or physical sexual arousal between the anxiety and comparison groups under the no-distraction condition. However, a manipulation check indicated that the video-related manipulation failed to induce significant anxiety. With the distraction task, levels of anxiety increased as the difficulty of the distraction task increased, as expected. In addition, the group listening to sexually relevant anxiety-producing distracters experienced higher levels of anxiety than the other group at both low and high levels of distraction. Though the data revealed a trend in the predicted direction, there were no significant differences in subjective or physiologic sexual arousal between the two groups at each distraction level. The findings provide preliminary evidence that at low levels of autonomic arousal, a woman is able to attend to sex-related worries as well as the sexual and romantic cues; however, as autonomic arousal increases, whether from sexual or anxious arousal, the focus of attention narrows, increasing the salience of the threatening stimuli and blocking the erotic cues. Unfortunately, with only 48 subjects in this study, it did not have enough power (0.38) to detect significant group differences. The interaction between distraction and anxiety is an important topic for future research.

Mood and affect

Barlow’s model2,4 theorizes that individuals with sexual dysfunctions react to erotic stimuli with greater negative affect, including anxiety and depression. The link between depression and reductions in sexual function has been well established and studied in women.25 Frohlich and Meston25 found that women reporting greater depressive symptoms also reported greater difficulties with becoming aroused and reaching orgasm, more experience of pain, as well as reduced sexual satisfaction and pleasure. Surprisingly, the women with greater depressive symptoms reported higher levels of sexual desire.

Beck and Bozman26 demonstrated that induced anger and anxiety in women reduced sexual desire compared to the control condition, with anger having a more pronounced effect. In this study (which also included men), women listened to three erotic scripts describing sexual interactions ranging from casual contact to foreplay and intercourse between the female participant and a sexual partner. Participants continuously rated their levels of sexual desire (not arousal) with a subjective lever. The anger script included statements by partners regarding reluctance to engage in the sexual activity and self-statements (referring to the participant) indicating feelings of frustration and anger. The anxiety script included statements by the partner regarding the perception of the participant’s nervousness and self-statements acknowledging feelings of tension and anxiety. The control script included statements designed to be arousing. The results indicated that both men and women reported the highest levels of sexual desire during the control condition, significantly lower levels during the anxiety condition, and the lowest levels of desire during the anger condition. Another finding of this study was that while female subjects’ sexual desire decreased steadily throughout the narrative in the anger and anxiety conditions, male subjects’ desire decreased only until the foreplay portion. For men, the detrimental effects of anxiety and anger decreased as the described degree of sexual activity increased, despite many male subjects reporting intent to terminate the narrative because of extreme unpleasantness. Thus, for men, but not for women, increasingly erotic cues and sexual stimulation reduced the impact of negative affect on sexual desire.

Several studies have experimentally manipulated affect during laboratory studies of sexual arousal. Laan et al.27 used musical selections to induce a positive affect in 51 women and examined its effects on subjective and genital measures of sexual arousal during both fantasy and in response to erotic films. Results indicated no significant effect of the mood induction on post-film/fantasy measures of subjective or genital sexual arousal. There was a marginally significant reduction in negative emotions in response to the erotic film in the mood- induction group compared with the no-induction group.

Other studies have found associations between positive affect and subjective sexual arousal in women.28,29 In addition, past studies have found that individuals with sexual dysfunction report significantly less positive affect during erotic exposure.29,30 However, it is difficult to ascertain from available studies what the impact of affect itself is on sexual responding. One possibility is that, as with anxious apprehension, changes in autonomic arousal and attentional focus, rather than negative affect itself, affect sexual response. Although it is possible that depression influences sexual responding via biochemical mechanisms,31 Bancroft32 suggested that mood is likely to influence sexual responding by its effect on cognition. Depressed mood is characterized by negative, self-deprecating, rigid thoughts about self and the world, and biased perception of cues. One cognitive component that interacts with affect is self-focused attention.

Self-focused attention

Concerns over her sexual function and response may lead a woman with sexual dysfunction to be hypervigilant for signs of lack of arousal, thereby shifting her attention away from erotic and romantic cues to her unpleasant cognitions. In response to implied or expressed demands for sexual response, her attention shifts from an external focus (on erotic cues) to an internal, predominantly self-evaluative focus, which is analogous to what occurs in performance-related anxiety conditions such as social phobia and test anxiety.5 She becomes focused on the discrepancy between her perceived current state of sexual performance (e.g., sexual attractiveness) and her internal, a priori standards of sexual performance. This results in a negative evaluation of herself, increased negative affect, and predictions of not being able to cope with the consequences of failing to meet her a priori standards, which further increase anxious arousal. Additionally, an internal focus has been found to increase the intensity with which affective states are experienced. Individuals with a greater tendency to self-focus were found to experience experimental provocation of various emotions as more intense than individuals with a greater disposition to focus externally.33,34 Thus, focusing on internal proprioceptive sensations not only distracts attention from erotic cues, but also intensifies the experience of negative affect after the emotion has been elicited. Evidence suggests that this shift to an internal, self- evaluative-focused attentional state further increases both arousal and negative affect, thus forming its own negative feedback loop (Fig. 3.2.3).

A further important consequence of self-focused attention is a failure to habituate to external stimuli. This selective internal attentional focus functions as avoidance of the anxiety- producing stimuli; in female sexual dysfunction, this may be the lack of sexual response or the appearance of her body. Paradoxically, women with sexual dysfunction may be more interoceptively aware of the somatic consequences of negative affect, while at the same time less aware of their degree of sexual arousal. Several studies have found that women with orgasm difficulties (i.e., experience orgasm less consistently than comparison women) also showed less awareness of physiologic changes accompanying sexual arousal and orgasm.35,36

Expectancies and attributions

Women with and without sexual dysfunction differ in the expectancies with which they enter sexual situations. For example, women with female orgasmic disorder more strongly endorse fears and anxieties related to intercourse.9 Such negative associations can result from repeated experiences of not being able to achieve orgasm, and these associations may motivate avoidance of future partner sexual activity. A study by Loos et al.37 explored causal attributions for orgasm among women who consistently experienced orgasms and women who reported experiencing them infrequently. The study showed that women who tended frequently to experience orgasm attributed their orgasms to internal, stable causes, while lack of orgasm was attributed to external, unstable factors. In contrast, women who infrequently experienced orgasm attributed lack of orgasm to internal causes, blaming themselves rather than the situation or their partners, and tended not to take credit for instances of orgasm, suggesting selfhandicapping attributions.

In addition to orgasm, cognitive expectancies also affect women’s level of sexual arousal. As in Barlow’s2,4 model, Palace and Gorzalka19,38-40 have proposed that negative cognitive expectancies in conjunction with a physiologic tendency toward low autonomic lability produce a negative feedback loop resulting in dysfunctional sexual response. Palace39 presented women with sexual dysfunction false-positive feedback regarding their level of genital arousal to an erotic film in order to manipulate their expectancies. Results indicated that women who received the false-positive feedback not only expected to become more aroused during subsequent erotic films, but actually showed higher levels of genital and subjective sexual arousal to subsequent films than the women who received no feedback. A follow-up analysis demonstrated that among the women who received false-positive feedback, those that reported significantly increased expectancies demonstrated significantly greater increases in physiologic sexual arousal than the women who did not report increased expectancies regarding their sexual arousal.


In summary, it may be that an affect-laden attentional process focusing on sexual performance (e.g., body image for women) and other self-evaluative concerns, combined with a tendency to exhibit biased observation of one’s sexual function, may characterize the cognitive-affective processes in female sexual dysfunctions. The basic cognitive and affective mechanisms of action in men and women appear to be similar, while the content of sexual performance concerns differs substantially between men and women.

Much of the empirical inquiry into sexual performance concerns has focused on men and erectile dysfunction; however, cognitive and affective processes may play an even more important and integral role in female sexual response and (dysfunction. The cognitive-affective processes described in this chapter may represent the mechanism of action through which negative interpersonal and cultural factors exact their detrimental effects on female sexual response, including impact on a woman’s sense of sexual well-being and overall sexual satisfaction. In addition, preliminary findings from psychophysiologic studies indicate that women’s genital sexual arousal is less stimulus specific than men’s. Chivers et al. found that female genital arousal (vaginal vasocongestion), but not subjective sexual arousal, occurred regardless of the type of stimulus, as long as it was sexual in nature.41 Furthermore, because it is more difficult for a woman to notice vaginal lubrication and clitoral engorgement than for a man to notice his erection, women are more dependent on interoceptive and contextual cues for feedback regarding their sexual response. As a result, the contextual features of a sexual interaction, both internal and external, largely determine a woman’s overall experience during sexual activity, thereby increasing the potential for negative affect, sexual failure expectancies, maladaptive causal attributions, and cognitive bias (hypervigilance) to impair female sexual response.

While the importance of cognitive and affective factors in female sexual (dys)function may be self-evident, the actual cognitive and affective processes are tremendously complex, with different components of affect (e.g., autonomic vs cognitive) influencing the various components and aspects of sexual response differently, and at times in oppositely valenced directions (facilitate and decrease). A bio-psycho-social perspective on the etiology of sexual dysfunction is crucial for developing a comprehensive understanding of the cognitive processes involved in these disorders. Predisposing factors that can lead one to develop the cognitive schemata seen in individuals with recurrent sexual difficulties can be conceptualized similarly to the triple vulnerability theory of the etiology of anxiety dis- orders.5,42 In this model, individuals vary in generalized biologic vulnerability factors (e.g., temperament, androgen levels), generalized psychologic vulnerability factors (e.g., perceived uncontrollability of life-events as a result of experience, depression, and anxiety), and specific psychologic vulnerabilities (e.g. sexual attitudes, sexual inhibition as described in the dual control model,43 sexual self-concept). Factors in each category of vulnerabilities can influence approaches to sexual situations, cognitive processing of sexual stimuli in terms of bias and affective valence, expectancies for successful or unsuccessful sexual outcomes, and coping styles for dealing with occasions of sexual difficulty.

The importance and complexities of female sexual function will provide fertile ground for cognitive and affective research in the future. For example, women experience worry-related anxiety disorders twice as frequently as men. Worry, with its close relationship to depression, autonomic inflexibility, and prominent intrusive negative thoughts, is likely to have a significant impact on women’s sexual function, yet little empirical work has examined the impact of worry on female sexual response. Research aimed at increasing the understanding of bio-psycho-social factors involved in female sexual response and dysfunction fuels the hope that more efficacious treatments for the sexual dysfunctions experienced by women are not far behind. Pharmacologic interventions may provide increased physiologic sexual arousal for women, but better understanding of the cultural, interpersonal, cognitive, and emotional factors in female sexual response is required to help women with sexual dysfunctions and complaints to increase their sexual enjoyment, sexual well-being, and overall sexual satisfaction.


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