Women's Sexual Function and Dysfunction. Irwin Goldstein MD

Women’s sexuality in context: relationship factors and female sexual function

David R Moore, Julia R Heiman

The great majority of sexual behaviors occur in the context of a relationship between two individuals who feel emotionally connected. Studying sexuality within a relationship is fundamental to the understanding of diagnosis and treatment of female sexual problems.1,2

The primary goal of this chapter is to summarize the research literature on relationship factors and sexual function in women, with a focus on heterosexual relationships, since same-sex relationships are reviewed in Chapter 8.1 of this volume. We have reviewed empirical literature dating back to 1970, using both the PsycInfo and Medline databases, with attention to predictor and outcome relationship measures. This research is primarily correlational rather than experimental, but is valuable for the themes it reveals.

Several studies prior to 1970 deserve brief mention. Terman and colleagues explored correlations between women’s sexual adjustment and marital happiness in a volunteer sample of 792 US couples in intact marriages.3 Marital satisfaction was negatively correlated with number of sexual complaints and discrepancies in sex drive, and positively correlated with satisfaction ratings of intercourse with spouse, wife’s satisfaction with first intercourse, agreeable reactions of spouse to sexual refusals, and wife’s orgasmic frequency. Dickinson and Beam studied a volunteer sample of 1000 British women in intact marriages.4 One of the key findings, shocking at the time, was that nearly 50% of the sample reported being dissatisfied with their sexual relationship. Kinsey and colleagues did not look at relationship factors, except as marker variables (e.g., marital status) to categorize sex behavior.5 Masters and Johnson studied sexual response in couples and individuals,6 but did not consider relationship factors until their treatment study.7 They considered the “relationship” as important, but focused mostly on individual intrapsychic issues. Their main treatment technique, sensate focus, was a couple’s exercise, though they only indirectly measured its efficacy.

Relationship factors and female sexual function

Sex research since 1970 has focused more on the individual with an increasingly physiological perspective. Consequently, few studies have attended to the couple,8 despite the repeated call from researchers and clinicians for the need to consider sexual dysfunction from a relational perspective.1,2,9-11 A variety of relationship factors have been shown to be influential in women’s sexual function and overall satisfaction with their sexual relationships, as summarized in Tables 3.1.1a and 3.1.1b (general empirical literature) and Table 3.1.2 (therapeutic intervention studies).

Relationship quality and sexual function

Frequency of sex

The association between different measures of relationship quality and coital frequency is not a consistent one. Coital frequency has been positively associated with perceptions of overall relationship quality or marital happiness,12-14 while sexual inactivity has been found to be more prevalent among unhappily married individuals.15 Terman et al.’s study3 found no association between marital happiness and intercourse frequency. However, individuals reporting a closer match between actual and desired levels of coitus reported more marital happiness. Other research indicates that sexual frequency does not predict marital happiness, but couples with a higher frequency of sex relative to the number of arguments have been found to report more marital happiness.16 The ratio of sexual frequency to number of arguments has been associated with the woman’s (but not the man’s) feelings of passionate love for partner.17 Women’s perceptions of equity/fairness in the relationship have also been found to moderately predict coital frequency.18

Table 3.1.1a. Summary of empirical research on relationship factors and female sexuality: larger-scale studies (n> 400)













Blumstein ft Schwartz 198323


3656 married couples, 653 heterosex cohab couples; 772 lesbian; 957 gay male couples.

Couple type; rel duration; sex freq; sex satisfxn; several other variables.

Rel satisfxn; sex satisfxn.

Corr design; non-rep sample but inclusive of heterosex and homosex couples.

Self-report: survey; pers interview w/ subsample of 300 couples.

Sex freq: gays > cohab heterosex > married > lesbs. Sex freq neg assoc w/ age and rel duration; sex freq and rel satisfxn (+) assoc w/ sex satisfxn.

Approx 2/3 of all couples satisfied w/ sex life.

Coleman et al., 198395


407 F in same- sex rels (18-62 yrs old); 370 heterosex F (17-59 yrs old).

Sex orientn (lesb vs heterosex).

Sex arousal; sex behav (freq of sex; satisfxn w/ curr sex response).

Comp group. Stat controlled for bet-group diffs in age and ed.

Self-report: SAI;



Lesbs > heteros in: (1) sex freq,

(2) org freq and consistency, and (3) sex satisfxn. Lesbs > heteros in arousal to: (1) sex scenarios depicting init (vs rec) of sex stim and (2) sex w/ direct genital stim.

SAI had est R and V.

Cupach a Comstock, 199025


Married (avg 10.4 yr) univ students (66% women); RS of 1000; M age 33.

Satisfxn w/ sex comm.

Sex satisfxn; marital qual.

Corr design; RS (40% response rate).

Self-report: DAS; ISS; sex comm satisfxn.

Sex comm satisfxn, sex satisfxn, and marital qual all (+) corr. Sex satisfxn mediated satisfxn w/ sex comm and marital qual.

Measures had est R and V.




3,292 F; 2,737 M. NSFH. Natl RS of US pop.

Mar interactn



Sex activity/ inact in past month.

Nationwide RS; no control strategies used.

Self-report: pers interview and q-aire (mostly singleitems).

Sex inact pred by: low lev of mar happiness, fewer shared activities, higher likelihood of sepn, and fewer arguments over sex.

Sex inact may indicate other mar probs.

Ernst et al., 199340


292 M, 299 F; Swiss commun sample (age 20/21 to 29/30) interviewed 4 x over 10 yr.

SD (presence vs absence, severity, chronicity); gender.

Rel stress and conflict); sev other non-rel factors.

Longitud'l; desc study; nat existing comp group (ppts who did not report SD).

Self-report: series of pers interviews.

25% F reported sex difficulties. at each asst, inhib desire 2-3 x more freq among F. SD and distress assoc w/ rel stress and conflict (for both M and F).


Edwards a




RS married persons; longitud'l study (1980-1992); 65% completion rate.

Happiness w/ sex rel; loss of interest in sex; presence of X-marital sex.


happiness, stab, and interaxns; confl freq and severity.

Lg scale RS; longitud'l; corr design.

Self-report: interviews; brief q-aires (sev single-item measures).

Sex satisfxn mod corr w/ mar happiness, (+) interaxns, and wellbeing. Lost interest in sex corr w/ mar unhappiness and neg interaxns. happiness w/ sex rel pred ^ mar happiness and divorce.


[text continues on page 78]

Table 3.1.1a. (Continued)













Rao &




Data from NSFH.Wtd rep US sample. M ages = 28.8 (F), 31.4 (M). 84% married.

Rel status (married vs cohab); rel duration; rel qual; no. child; other vars.

Coital freq (in past mo).

Lg rep sample; corr design.

Self-report: interview (mostly singleitem global ratings).

Rel duration pred lower coital freq. Sex freq of cohab > married couples. F rel qual mod pred > sex freq. Ppts w/ 1 child reported < coital freq than non-parents; parents of 2+ children had = coital freq w/ childless ppts.


Call et al., 199512


6,785 married individuals, 678 cohab; rep nat'l sample from NSFH.

Marital duration,



Sex freq in past mo.

Lg rep sample; corr design.

Self-report: pers



Besides age, mar happiness strongest pred of sex freq over time. Mar duration neg assoc w/ sex freq.

R and V of q-aires not reported.

Haavio- Manila & Kontula, 199724


Rep Finnish sample (1,104 F, 1,146 M). 76% response rate. Ages 18-74 yr. M ages = 43.1 (F), 41.3 (M).

Gender; sex comm w/ partner; rel satisfxn; sex assert, freq, variety; org consist.

Sex satisfxn/ enjoyment.

Corr design.

Self-report: interview (mostly global, single-item Qs) and q-aires.

F < M in sex satisfxn. Sex satisfxn and rel happiness corr (esp for F). Sex satisfxn pred by younger age (F), sex assert, sex freq, sex variety, and org consist. Ease of sex comm w/ partner mod corr w/ sex satisfxn.

Specific q-aires used not specified (unclear psychometric properties).

Dunn et al., 199938


979 F, 789 M (18-75 yr). Anon SRS from UK.

Mar probs.

Sex probs (arousal, org dysfx, inhib enjoyment, dyspareunia).

SRS; commun sample; corr design.

Self-report: q-aire dev for this survey.

For F (but not for M), mar difficulties strongly assoc w/ SD (esp arousal probs, org dysfx, and inhib enjoyment).


Laumann et al., 199980 [See also Laumann et al., 199478]


NHSLS Natl prob sample; 1,410 M, 1,749 F, ages 18-59.

> 79% response rate.

Mar status; health/lifestyle factors; soc status; sev indexes of sex exp and behav.

Sex dysfx (low desire, arousal or org dysfx, perform anx, painful sex, no pleasure).

Rep sample of men and women in US households; corr design.

Self-report: pers survey.

SD fairly prevalent in gen pop, esp for F (43% F vs 31% M).

Pre- and post-mar status assoc w/ greater risk for SD. Being married assoc w/ lower risk for SD.

For F esp, SD also strongly and (-) assoc w/ pers happiness.




967 F, 898 M in L-T rels. From lg rep German student sample.

Rel duration; gender.

Sex freq; sex satisfxn; sex desire; desire for rel closeness.

Rep sampling; corr design.

Self-report: global singleitem Qs in survey q-aire.

Sex freq neg corr w/ rel duration (Mdn 10x/mo in 1st yr; 5x/mo in 5th yr of rel). As rel duration increased: F sex desire decreased

Results interpreted in terms of evolutionary psychology.

Table 3.1.1a. (Continued)
















496 F, 500 M; all cohab or married. 54% resp rate. M ages = 42 (F),

47.6 (M). M rel duration = 18.4 yr (M), 16.8 yr (F).

Sex satisfxn; sex attitudes, and behav; gender; age group (> 60, < 60).

Rel satisfxn/adj; sex satisfxn.

RS strategy; corr design.

Self-report: telephone survey; rel satisfxn assessed by 10 items from DAS; add'l single-item, global Qs.

Rel satisfxn pred by: (1) sex satisfxn (except F > 60), (2) good sex comm (for M and F < 60), (3) satisfxn w/ sex partner (F only), and (4) sex variety (for M < 60). Sig pred of sex satisfxn: (1) qual of sex comm (except for M > 60), (2) satisfxn w/ sex partner (M and F < 60), and (3) satisfxn w/ orgasm (M and F < 60).

Role of sex comm, variety, and pres of org in L-T rels may vary as fx of age and gender.

Bancroft et al, 20 0397


SRS of White and Black F 20-65 yr (M = 40.4). All ppts in rel at least 6 mos.

Emot'l wellbeing; subj sex resp;sex behav; physiologic sex fx (lubr probs, pain).

Distress re:

(1) sex rel w/ partner, and

(2) one's sexuality.

Corr design.

Self-report: mostly singleitem ratings in phone survey;

2 multi-item q-aire scales from SF12 (qual of life measure).

Strong pred of sex distress: neg emot'l well-being, followed by neg feelings re sex contact w/ partner and lack of closeness w/ partner. Physiologic indicators weak pred of sex distress (phys response and subj SA) or nonsig pred (probs w/ lubr, org, pain).


Liu, 200379


Married ppts from NHSLS data set. M age = 38.3. 82% White, 10%

Black. M rel duration = 13.8 yr.

Duration of



Qual of mar sex: phys pleasure and emot'l satisfxn from spousal sex.

Corr design. Stat controlled for sev demo vars and sex freq.

Self-report: pers interview (vars measured w/ single-item, global indexes from NHSLS interview).

Mar duration and cohab before marriage had small neg effect on qual of sex w/ spouse. Freq of sex (+) assoc w/ sex qual. F < M in satisfxn w/ spousal sex.

Small prop of variance in marital sex qual accounted for (5%).

Abbreviations: adj = adjustment; anon = anonymous; asst = assessment; assert = assertiveness; comm = communication; commun = community; comp = comparison; confl = conflict; corr = correlational, correlated; consist = consistency; desc = descriptive; DAS = Dyadic Adjustment Scale; demo = demographic; diff(s) = difference(s); est = established; F = female; fx = function; ISS = Index of Sexual Satisfaction; inact = inactivity; init = initiating, initiated; interaxn(s) = interaction(s); lg = large; lev = level; L-T = long-term; M = male; M = mean; mar = marital; Mdn = median; mod = moderately; NHSLS = National Health and Social Life Survey; NSFH = National Survey of Families and Households; org = orgasm; ppts = participants; pers = personal; phys = physical; pred = predicted, predictor; pres = present; RS = random sample; R and V = reliability and validity; rec = receiving; rel = relationship; rep = representative; resp = response, responded; satisfxn = satisfaction; sepn = separation; SA = sexual arousal; SAI = Sexual Arousability Inventory; SD = sexual dysfunction(al); stab = stability; stat = statistically; SRS = stratified random sample; vars = variables; wtd = weighted X-marital = extramarital.

Table 3.1.1b. Summary of empirical research on relationship factors and female sexuality













Frank et al., 197 646


29 mar therapy couples; 25 sex therapy couples. Modal age 31.5.

Group status (mar therapy vs sex therapy).

Multiple measures of sex and mar adj/satisfxn.

Comp group; no other control strategies.

Self-report (marital q-aire; KDS-15).

No diffs bet groups in no. and type of sex difficulties. Sex therapy couples > mar therapy couples in mar satisfxn/adjust and confl res.


Howard ft




Married couples; demo characs of sample not reported.

Freq of sex w/ spouse; freq of arguments.



Corr design.

Self-report: global rating of mar happiness; diary reports of sex and arg freq.

Sex freq did not pred marital happiness. Sex freq relative to no. arguments did sig pred marital happiness.


Birchler a Webb, 197713


50 happily married and 50 unhappily married couples.

Marital happiness (happy vs unhappy).

Sex freq; confl res (no. unresolved probs); rec activities.

Comp group. Specific sample characteristics not reported.

Self-report: mar activities inv; areas of change q-aire.

Happily (vs unhappily) married couples: > sex freq < unresolved probs, and > participation in rec activities together vs alone.


Frank et al., 197837


Married couples, vol sample; mostly White, middle-class;

M age = 36.

SD; sex difficulties.

Mar and sex satisfxn.

Corr design.

Self-report: mar q-aire (KDS-15).

> 80% of couples satisfied w/ marriage and sex rel, despite high prev of SD (63% F, 40% M). Sex difficulties (e.g., insuff 4play, uninterest in sex) stronger pred of F sex satisfxn than SD.

Mar satisfxn measure R and V not reported.

Peplau et al., 197898


Self-id lesbians, ages 18-59 (Mdn = 26). 61% in current same-sex rels.

Prim rel values: dyad attachment vs pers autonomy.

Sex satisfxn (sex and org freq); rel satisfxn/ intimacy.

Corr design.

Self-report (anon q-aire incl several singleitem global ratings).

Most ppts reported high sex and rel satisfxn, closeness, and equality. Freq of sex and org (+) assoc w/ sex satisfxn. Dyad attachment (+) assoc with sex satisfxn.

Unreported psychometric properties of measures.

Swieczkowski a Walker, 197819


F students, ages 20-35, married at least 2 yr; mostly White, middle-class, childless.

Sex behav and attitudes (incl spec prefs, positions, and variety).

Mar happiness (adj, satisfxn); infidelity; org exp w/ mar sex.

Desc, corr study.

Self-report: Locke-Wallace MAT, multi-item scales designed by researchers.

Org lower dur times of confl a hostility w/ spouse. Happy (vs. unhappy) married: > satisfxn w/ 4play and oth noncoital sex contacts, > prop org w/ spouse, > sex variety, < sex refusal,

< infidelity.

MAT had est R and V; other measures unreported R and V.




20 fam therapy couples. M age 40 (M), 38 (F). M length of marriage 14 yr.

4 groups: SD, mar confl, SD + mar confl, controls.

Observed couple interaxns.

Incl of comp groups (but small no.). Coders blind to group status.

Self-report (to assign groups); observ'l data.

SD couples: > (+) interaxns.

SD and marital adj possibly indep.

Exact group sizes not spec, but low given no. of groups.

Table 3.1.1b. (Continued)
















F ages 21-58. 51% unmarried (M age = 32); 49% married (M age = 28).

Mar status; SA in resp to erotic audio, film and sex fantasies.

Physiologic SA to erotic materials;

Subj SA at lab a home.

2 exptl sessions (4 mos apart). Exptl stim pres to assess subj and physiologic SA.

Vag resp (VPA); subj SA assessed by global ratings).

Subj SA and vag resp (+) corr, unmarried F, 1 of 2 sessions. At home SA neg corr w/ vag lab resp.

F sex resp is complex, depends on context.

F vag resp and subj SA don't nec coincide.

Berg a Snyder, 198145


45 sex therapy couples; 45 mar therapy couples. M = 36 yr of age, married 11 yr.

Group status (seeking sex therapy vs mar therapy); gender.

Rel and sex distress.

Comp group; mar therapy couples matched on key demo characs.

Self-report: q-aire w/ est R and V (Marital Satisfaction Inventory).

Both groups had poor mar adj. Sex therapy > mar therapy couples in sex dissatisfxn. Sex therapy < mar therapy couples in global rel distress.

Multidimensional measure w/ est R and V.

Chesney et al., 198143


36 sex therapy couples; 37 univ student couples.

Group status (sex therapy vs student comp group).

Rel adj (comm, perceptn of rel).

Comp group (univ sample); no other control strategies.

Self-report: MCI SII; Sex Attitude and Behav Q-aire.

Sex therapy couples vs normals:

> comm probs (gen and spec to sex contacts), > disagreements,

> neg percepts of rel, and < rel satisfxn.

2 measures used had est R and V (MCI, SII).

Persky et al., 198214


Couples from yg cohort (n = 11,

M age = 24 yr); and older cohort (n = 19, M age = 54 yr).

Mar adj.

Sex adj.

Small but carefully screened sample (for phys and mental health).

Multimethod asst. Self-report (MAT and SII) and obs ratings of dyad interaxn from interv data.

Mar adj (based on self and obs ratings) corr w/ sex adjustmt.

Mut supportive/warm couples had greater: sex desire, F sex resp, sex freq, and F sex gratification.

MAT, SII had est R and V; high R for obs ratings.




50 F, 30 M married for < 5 yrs. RS using random digit dialing.

Sex freq in 1st yr of marriage; dur of marriage; pres of children; demo vars.

Sex freq after 1st yr of marriage; subj imp of sex; subj reasons for ^ sex freq.

RS; exploratory study; no formal hyp testing.

Self-report: pers interview.

^ in sex freq after 1st yr of marriage (due to work, parent'g and partner familiarity. Sex freq in 1st yr strongest pred of later sex freq. Most ppts rep that sex was imp, despite sex freq declines.

Unreported R and V of measures. Findings sugg that sex freq doesn't nec reflect stated importance.

Snyder a Berg, 198383


45 sex therapy couples (wives and husbands analyzed separately).

Gender (husbands and wives).

SD; sex satisfxn.

No comp group; corr design.

Self-report: 15-item CL for SD; Sex Dissatisfxn Scale (from MSI).

For F, SA and org dysfx most prev complaints. Partner's lack of resp to sex requests and lack of partner affectn pred sex distress stronger than SD.

Sex dissatisfxn Scale validated.

Table 3.1.1b. (Continued)















Study 1:


20 happy couples,

19 mar distressed,

20 SD couples.

M age = 33.4 (M), 30.2 (F).

Group status (happy vs mar distress vs SD).

Self-reported comm skills.

Comp groups; no other control strategies.

Self-report: KIP q-aire.

Mar and sex distressed couples vs normals: > comm probs (e.g., more hostile expressions). Few diffs bet mar and sex distressed couples in reported comm.

Reported adeq R; unclear validity of q-aire.




Study 2:


10 happy, 6 mar distressed, 10 dep+sex distressed, 11 sex distressed.

Group status (happy vs mar distress vs. sex dist+dep).

Observed interaxns (rated on sev dimensions of comm).

Comp groups.

Observ'l data (videotaped and coded couple interaxns).

Sex distressed couples (esp if dep) vs marital distressed: > neg comm happy couples showed more (+) interaxns.

Adequate interrater R of coding procedure.

Hawton &




Couples rec CB tx for mult SDs (99 F w/ chief c/o impaired desire and vagin.

Pred of tx outcome: rel qual, sex rel qual; and tx motivation.

Tx outcome.

No comp/cont group.

Self-report: q-aires assessing rel qual and feelings tow sex.

(+) tx outcome assoc w/ rel qual, sex rel qual, and partner's motivation for tx.

96 couples completed tx.

Heiman et al., 198635


94 clin couples (WL for sex therapy); 110 nonclin couples.

Couple type: clin vs nonclin couples.

Sex and mar satisfxn; sev other sex, soc, and mar vars.

Cont group; screened for med and psych probs; no demo diffs bet groups.

Self-report: MAS; SAS; pers history q-aire.

Sex and mar satisfxn indep; clin couples sex distressed in context of (+) mar satisfxn; sex vs mar factors disting clin from nonclin couples.

Standardized measures used to assess sex and mar satisfxn (and soc desirability).

Whitehead &




Couples w/ chief c/o lack of F sex interest or enjoyment who rec 3-mo tx based on M and J.

All F were premenopausal.

Resp to tx: improved (n = 26) and nonimproved (n = 22).

Rel qual; sex rel qual; enjoyment of sex; percept of self and part attractn and love; rel dur; dur of SD.

Comp group (+ vs neg resp to tx); init tx study based on random assign; clearly def groups w/ incl and excl crit.

Self-report: q-aires w/ unrep psychometric prop; blind rater asst of qual of sex and gen rel qual.

Rel qual (+) assoc w/ successful tx outcomes. Improved (vs nonimproved) couples: > self and part ratings of attractn and love,

< arguments, < compat interests,

< affection and acceptance. Non- sig pred of tx: rel dur, severity of SD, F sex resp.

Sugg import of qual of couples' rel when making tx decisions, also per attractn and love w/in dyads.

Stuart et al., 198747


Married F (59 w/ ISD; 31 non-ISD) seeking tx for mar sex prob; M age = 33.5 yr; married

Group status (ISD vs non-ISD).

Mar adj; global rel satisfxn and dyad interaxns; sev aspects of sex rel.

Comp/cont group; screened for med illness; excl ambig diag. No demo diffs bet groups.

Self-report: DAS; global measure of rel satisfxn.

ISD (vs non-ISD) group: poorer mar adj, > dissatisfxn w/ confl res, < attractn to spouse, < emot'l closeness, and < romantic feelings. No diffs bet groups in sex freq.

DAS is standardized measure; other measures unreported psychometric properties.

Table 3.1.1b. (Continued)













Rust et al., 1988™


28 sex and mar therapy couples from UK; M =

33.6 yr of age,

10.6 yr rel dur.

Overall mar satisfxn (assessed by GRIMS).

Sex satisfxn and sex fx (assessed by GRISS).

Corr design.

Standardized Self-report q-aires (est R and V).

Sex satisfxn (+) assoc w/ mar qual. Sex dissatisfxn assoc w/ lower perc mar qual for M and F. Stronger assoc found for M vs F.

Prop of couples seeking tx for M vs F SD not stated.

Byers a




55 F, 22 M;

65% married,

35% cohab w/ opp-sex partner. Mdn age = 29.6 yr (18-63). M rel dur = 8.7 yr. 52% w/ child.

Mar status; dyad adj; sex pleasure; rel dur; erotophilia; satisfxn w/ sex confl res; gender.

Sex initiatn; accept vs refusal of sex initiatns; freq of

considering init sex desp sex interest.

Corr design.

Self-report: global indexes, sev q-aires, including DAS, SOS, and sex activity q-aire (based on diary of sex behav).

Cohab > married in freq sex initiatns. T sex and rel satisfxn assoc w/ T freq initiatns. ^ sex satisfxn assoc w/ T F sex refusals. ^ F pleasure assoc w/ dec to not init sex despite interest. M > F in initiatns.

All multi-item q-aires had est R and V.

Kelly et al., 199075


24 org F, 10 anorg F; 21-40 yr old, all in rels w/ sex fx'l M; screened for med probs and med use.

Org vs anorg; resp to sex explic vid segments depicting dir and indirect clit stim.

Sex arousal; deg comfort in comm w/ partner re: sex acts; sex attitudes, guilt, knowl.

Controlled, selective incl criteria; comp group. Assessed resp to exptl stim; counterbal order of videos.

Self-report: moment by moment subj SA; q-aire data (unrep R and V).

Anorg > orgasmic F in: discomfort talking w/ partners re sex acts involving direct clit stim (cunnil and partner man'l stim). Anorg > org F in sex myths, guilt. Anorg < org F in sex knowl.

Strongest pred of anorg was comm probs re sex acts likely to result in orgasm.

Hawton et al., 199188


Couples rec modif M and J tx for low F sex desire. M ages = 30 (F), 32.9 (M). M rel dur = 9.4 yr. M dur of SD =

6.1 yr.

Pred of tx outcome: ther and pt ratings; sex and gen rel qual; tx motivatn; SD probs and dur.

Completion of tx and tx outcome (change in presenting probs and couples' sex fx post-tx).

No comp/ cont group; tx not std (varied in dur from 2 to 25 sess).

Self-report: rel q-aire (unrep psychometric prop) and ther global ratings of tx outcome.

M partner's motivatn pred tx completion (vs dropout). h/o mar sepn assoc w/ poor tx outcome.

Yg age of male partner and shorter dur of presenting prob also pred poorer tx outcomes.

Lack of pred power of rel factors may be due to fact that couples w/ ser mar probs were excl in study.

Kurdek, 199129


Couples (49 married, 36 hetero cohab,

58 lesb, 77 gay). M age 31.

Couple type (married, hetero cohab, lesb, gay); sex satisfxn.

Sex satisfxn; rel satisfxn; Sex perfectionism.

Comp groups. Groups equiv on age and ed; diffs in income and rel dur stat contr.

Self-report: anon q-aire. Global ratings and mult items from rel/sex q-aires.

No bet-group diffs in sex and rel satisfxn. Sex satisfxn sig assoc w/ rel satisfxn. Sex perfectionism neg assoc w/ rel satisfxn among hetero cohab and gays.

One of few studies specifically examining homosex and hetero rels.

Table 3.1.1b. (Continued)













Hurlbert et al.,



Nondistressed married F, M age 26.7. 68.4% White, 18.4% Black, 9.1% Hisp, 4.1% Asn.

rel closeness; sex assert; response to sex cues; sex freq, desire; org freq.

Sex satisfxn.

Corr design; Select screening proc (excluded mar distress, ETOH abuse, and anorgasmia).

Self-report: Sex diary; RCI; Hurlbert Indices of Assert and Excitability; SOS; ISS.

Rel closeness, erotophilia, and sex assert pred sex satisfxn more strongly than no. orgasms, sex freq, or sex excitability.

All measures had est R and V.

Oggins et al., 1993102


199 Black, 174 White couples; rep sample of couples obt 1st marriage lic. All F < 31 yr.

Race; gender.

Mar rel qual; sex rel qual.

Rep, ethnically diverse sample. Comp group by race; corr design.

Self-report: Individual pers interviews.

Caring and affirmation strongly assoc w/ sex enjoy, esp for F. Neg mar rel (esp irritation w/ spouse) assoc w/ sex upset (but gender and racial diffs seen).

Adeq R and V of measures; findings sugg imp of race and gender diffs.

Trudel et al., 199348


20 couples w/ HSD; 20 non- HSD couples; 20-50 yr old; in 1+ yr stable rel.

Group: HSD vs no HSD.

Dyad adj; rel satisfxn, con sensus, aff expression, cohesion.

Comp group; no other control strategies.



HSD < non-HSD couples in global dyad adj. HSD F < non-HSD F in cohesion, rel satisfxn, consensus, and aff expression.

DAS has est R and V.

Henderson- King a Veroff, 199432


199 B, 174 W couples; 4-yr longitud'l study RS from marr lic bureau; 65% response rate.

Race, gender; feelings of affirmation vs tension in rel w/ partner.

Sex satisfxn/


mar equity,




Nat-existing groups (by race and gender). RS, racially diverse; longitud'l, yrs 1 and 3 of marriage.

Self-report; Q- aire data based prim on 2-6 item Likert scales.

Feeling affirmed by partner pred sex satisfxn; tension w/ partner pred sex dissatisfxn (for B and W couples). Sex satisfxn pred mar well-being (but varied by gender and race).

R and V of measures not reported.

Hulbert a Apt, 1994103


Married couples @ military fam support ctr. M ages = 31 (M), 28 (F). Married avg of 5 yr.

Mar and sex satisfxn (created 4 groups based on cut scores).

Sex desire, freq, interest; arousal and satisfxn w/ sex acts; org freq.

Single sample; groups created using cut scores; no cont strat.

Self-report. Pers Interviews and Q-aires: Index of Marital Satisfxn; ISS; HISD.

For F, mar dissatisfxn assoc w/ < desire, indep of sex satisfxn. Mar and sex satisfxn not assoc w/ sex freq. Mar satisfied F had > interest, SA, and sex satisfxn. Org freq highest for Sex+mar satisfxn.

All measures had est R and V.

Aron a




60 F, 38 M (2 did not indicate gender); all

Passionate love.

Rel satisfxn; freq of sex (minus arg).

Corr design; stat controlled for soc desirability.

Self-report:DAS; PLS; Add'l q-aires.

For F (but not M), rel satisfxn mod corr w/ passionate love. For M (but not F), passionate

DAS and PLS have est R and V.

Table 3.1.1b. (Continued)













Beck a




24 M and 24 F univ students.

M age = 23.8, all sex active in heterosex rels.

Gender; 3 exptl conditn (erotic audio: anger, anx, neut sex sitn).

Subj SA; dec to



Exptl; control condition, counterbal w/in- subj design; manip checks.

Self-report: Subj SA; reported dec to terminate interaction.

Sex encounters marked by anx and anger lowered sex desire, esp for F. Sig more F vs M reported they would end encounter in anger condition.

F arousal may be esp influenced by neg interaxns and emotions.

Lawrance a Byers, 199533


90 F, 53 M in heterosex rels (avg 12 yr). 85% married, 12% cohab. M age = 37.4; gen sex satisfied.

Sex rewards/ costs; equity of sex costs and rewards w/in dyad; rel satisfxn; gender.

Sex satisfxn.

Repeated assts (over 3 mos); Avoided item overlap in measures bet IVs and DV. No comp group.

Self-report: Exchange Q-aire; GMREL; GMSEX.

High rewards/costs ratio and equity of rewards/costs pred sex satisfxn. Rel satisfxn added to pred of sex satisfxn (and vice versa) beyond vars above. Rewarding sex contacts for F vs M more depend on rel factors.

Measures had est R and V.

Regan a




56 F, 52 M (all univ students). M age = 20.2 yrs. 87% white, 98% heterosex.


Reported det of sex desire for M vs F.

Corr design; nat occurring groups (M and F).

Self-report: 5 essay Qs, coded for attributions about causes of M and F sex desire.

F sex desire seen as more depend on rel factors and romance. M sex desire viewed more internally driven and depend on erotic factors.

Adeq interrater R of coding proc.

Apt et al., 199636


F nurses. M age 36.4 yr. M rel dur = 10.8 yr.

« 73% W, 19% Hisp, 9% Black.

5 groups, based on clust analysis of mar and sex satisfxn.

Sex adj, desire, stress,

compatibility and sex assert.

Corr design; groups est using clust analysis.

Self-report: Mar satisfxn scale; ISS; HISD; HISC; HISA; Apt Index of Sexual Stress.

Sex and mar satisfxn partly indep. Subgroups of F exp mod satisfxn w/ marriage desp low sex satisfxn (or vice versa). F w/ highest mar and sex satisfxn had > desire/assert and < sex stress.

All measures had est R and V.

Long et al., 199670


Univ students (51% F). M age = 22.2 yr. 19% engaged/cohab, 81% dating

Premar sex conflict; Gender.

Sex satisfxn; rel satisfxn; generic conflict; rel qual.

Brief longitud'l (4 mo duration). Corr study.

Self-report: global indexes and q-aires (incl PMSCS).

Higher sex conflict (e.g., conflicts over sex freq or behav) assoc w/ lower sex and rel satisfxn, after controlling for generic conflict.

All but 1 depend measure had est R and V. Init evid of R and V for PMSCS.

Van Lankveld et al., 199652


F w/ VVS (avg dur 3.2 yr) and 38 partners. From Dutch OB-GYN clinic. M age 27.5 yr.

Group (F compared to Dutch std group scores for each measure used).

Mar satisfxn; Sex fx; psychologic distress and probs.

Single sample design, w/ sep std samples used as comp groups. Excluded pts w/ vulvovaginitis.

Self-report: sub scale from Maudsley Mar q-aire; q-aire for SD screen; SCL; MMPI.

VVS F (and partners) = “normal" std pops in mar satisfxn, psych distress, and psych probs. VVS pts > distress spec in context of sex contacts w/ partners (same pattern not seen for masturbation).

Standardized q-aires used.

Table 3.1.1b (Continued)













Hirst a




56 F and 133 M seeking sex tx, either w/o curr partner (58), w/ non-particip partner in tx (92), or w/ particip partner in tx (39).


involvement of partner in tx; motivatn for tx.

Tx outcome (global ther ratings of successful, sufficient, or poor).

Corr design (w/ nat existing groups and no cont strategies); retrospective study.

Self-report: Q-aires (IIP, BDI, SCL-90); ther assts of ther outcome (based on case notes; inter-rater R assessed w/ blind raters).

Strongest pred of (+) outcome was partner involvement in tx. Among pts w/ curr partner, 84% whose part attended ther had (+) outcome, vs 51% of pts w/ nonparticip partners. Poor outcomes or prem terminatn assoc w/ > interpers probs.

Bet-group diffs in tx, presnt probs and demo vars not contr. Some meas used had est R and V (IIP, BDI, SCL-90).

MacNeil a




53 F, 34 M in hetero L-T rels; M age = 39 yrs; M rel dur=13 yr 85.5% married, 9.2% cohab.

Sex and non sex comm; sex probs and concerns; gender.

Sex satisfxn.

Corr design.

Self-report: PCI; Sex Self-Discl Q-aire; CLs for sex probs and concerns; GMSEX.

Gen comm and discl to partner of sex likes/dislikes sig pred sex satisfxn. Sex comm contrib sig variance in satisfxn beyond nonsex comm alone.

GMSEX has evidence of R and V; PCI has reported evidence of V.




145 fx'l (102 F); 198 SD (84 F). Mostly White, middle-class.

Sex fx (sex clinic vs community group).

Reported intimacy; qual of life.

Comp group (vol



Self-report PAIR; qual of life assessed by ComQual.

SD < fx'l F in intimacy w/ partner and qual of qual of life. F w/ lack of sex desire had less emot'l closeness w/ partner.

PAIR has est R and V.

Purnine a




63 married, 13 cohab couples; 91% W; avg of 2 children and 9.6 yr rel duration.

Understnd of part sex prefs; agreement re sex prefs; dyad adj.

Sex satisfxn; sex adj (no. sex probs).

Corr study; controlled for soc desirability.

Self-report: ISS; Inventory of Dyad Heterosex Prefs; DAS.

M part understnd of F sex prefs and couple compat in sex prefs contrib to F sex satisfxn and sex adj. Dyad adj sig pred F sex satisfxn.

DAS and ISS have est R and V.

Byers et al., 199827


52 F, 47 M (all univ students). M age = 19.3 yr. 85% exclusive dating rel.

Sex rewards/ costs; equity re rew/costs; rel satisfxn; self-discl.

Sex satisfxn.

Corr design.

Self-report: Exchange Q-aire; GMSEX; GMREL.

Sex satisfxn sig pred by: rel satisfxn, perceived rewards/costs in sex contacts (after contr for gender and sex self-discl).


McCabe a




145 fx'l (43 M, 102 F); 198 SD (114 M, 84 F); ages 25-68 yr.

Group: sex fx'l vs SD.

Rel qual; comm; conflict; sex satisfxn.

Comp group; no diffs bet groups on age or SES; ppts screened for med probs.

Self-report: Sex Fx Scale (SFS); Sex Dysfx Scale (SDS).

SD F (esp w/ arousal and desire probs) < fx'l F on rel qual. Rel probs strongly assoc w/ F (but not M) SD.

Adeq psychometric properties for all measures.

Table 3.1.1b. (Continued)













Byers a




52 F a 47 M univ students;

M age = 19.3 yrs.; M rel duration = 13 mo.

Sex comm; Nonsex discl; Perc costs/ rewards of sex rel.

Sex satisfxn; Rel satisfxn.

Corr design.

Self-report; comm Q-aire; GMSEX; GMREL.

(+) comm to partner about sex prefs contrib to T sex satisfx thru T overall rel satisfxn & more (+) sex exchanges.

All measures had reported R and V except for comm Q-aire.

Davies et al., 199930


Heterosex undergrad couples w/ sex rels of 6+ mos. M age = 20 yr; 88% W.M rel dur = 26.9 mos.

Sex desire discrepancies.

Sex satisfxn; rel satisfxn.

Corr design.

Self-report: SDI; ISS; Hendrick's

When F sex desire < M partner's, assoc w/ lower F rel and sex satisfxn. Discrep in desire contrib to F sex satisfxn, after contr for partner's sex satisfxn. Sex satisfxn med'd assoc bet sex desire discrep and rel satisfxn.

All measures had est R and V.

Hurlbert et al.,

20 0020


F w/ diag of HSDD; M age = 31 yr; 76% W; 80% mothers; avg marriage 6.3 yr.

Sex compat; Sex satisfxn; Mar satisfxn; Sex stress.

Sex desire; Sex motivatn.

Corr design; Screened for sex abuse, ETOH/ drug abuse, med use, dyspar, and phys illness.

Self-report: sex diaries; HISC; ISS; Index of Mar Satisfxn; Apt Index of Sex Stress.

Higher sex compat assoc w/ > sex motivatn and desire (and < sex stress). F mar satisfxn and (+) attitudes tow sex fantasy assoc w/ > sex desire. Sex compat assoc w/ mar satisfxn and sex satisfxn.

Measures had sound



Birnbaum et al., 200149


36 clin anorg F seeking tx for org probs; 26 subclin anorg F; 36 sex fx'l controls. Israeli sample. M ages 28.6 to 32.4.

Group (clin anorg, subclin anorg, org controls).

Sev characs of self-rep intercourse exp.

Comp/cont groups; Clearly spec incl crit. Subclin and clin anorg group matched on org probs. No demo diffs bet groups.



Anorg > org in aversive feelings and thoughts dur intercourse, isolatn, anx, distracting thoughts, sense of sex inadeq. Anorg < org pleasure, closeness w/ partner in during sex, love, connectn w/ partner). Clin > subclin anorg in disappt w/ partner, sex burnout.

WEHI had prelim evid of R and V. Anorg F had < emot'l connectn w/ partner dur intercourse vs > overall dyad probs.

Hallam- Jones et al., 200150


F presenting at dermatol clin in UK; 85 w/ vulvodyn, 87 controls w/ nonvulv

dermatol probs. Ages 18-70 yr.

Group (vulvodyn vs control).

Rel satisfxn; sex satisfxn; sex freq; pain freq and severity w/ sex activity; also assessed dep and anx.

Cont group of pts presenting at same clinic.

Self-report: Pers interviews and q-aires (GRIMS, GRISS); HAD (measure of dep and anx).

Vulvodyn F < control F on sex freq, rel and sex satisfxn. Vulvodyn > controls in reporting rel and sex probs caused by their condition, sex pain, dep, anx.

Standardized measures used for all q-aires.

Table 3.1.1b. (Continued)















Couples dating

Sex satisfxn

Rel satisfxn;

Longitud'l study


Sex satisfxn corr w/ rel satisfxn,

Adeq int consist for all



for avg of 18.6

(and change


(5 annual assts,


commitment, and love. Increase

q-aires; evid of R and V


mos (at 1st of

in satisfxn over

mitment; rel

1988 to 1992).

RAS; Lund's

in sex satisfxn assoc w/ increase

for RAS.


5 assts). M

time) [In one

stab (also

Corr design.


in rel satisfxn, commitment, and


age = 20.

set of analyses,

change in vars

Avoided item-

Scale; Braiker

love. Sex satisfxn pred rel stab


IVs and DVs

over time).

overlap bet

and Kelley

for M; poor rel. satisfxn pred




measure of

Love Scale;

dissolutn for F.


love and sex

Add'l global







F (29 w/ vagin,

Group (vagin

Rel adj; sex

Cont groups,


No diffs bet groups in rel adj

Measures used were all

et al.,


29 w/ VVS, and

vs VVS vs

fx; sex

matched on age,

MAT; Sex

(based on small subset of sample




29 no-pain



rel status, and


in committed rels) or psych


controls). M age



parental status;

Brief Symptom

distress. Vagin group: less (+) sex


28 yr (18-43).



clearly def incl


self schemas. Both pain groups >


Can sample.


other vars.

and excl crit.


controls in SD.


Abbreviations adeq = adequate; aff = affective; ambig = ambiguous; anorg = anorgasmic; arg = arguments; Asn = Asian; assert = assertiveness; assign = assignment; BDI = Beck Depression Inventory; B = Black; Can = Canadian; characs = characteristics; CL = checklist; clin = clinical; CB = cognitive behavioral; ComQual = Comprehensive Quality of Life scale; confl res = conflict resolution; contr = controlling; counterbal = counterbalanced; crit = criteria; cunnil = cunnilingus; curr = current; DAS = Dyadic Adjustment Scale (for assessment of marital satisfaction); dec = decision, decided; def = defined; deg = degree; depend = dependent; dep = depressed, depression; det = determinants diag = diagnoses; discl = disclosure; dist = distressed; disappt = disappointment; dissatisfxn = dissatisfaction; dir = direct; dur = duration; dyad = dyadic; dyspar = dyspareunia; ed = education; emot'l = emotional; enjoy = enjoyment; ETOH = alcohol; evid = evidence; excl = exclusion, excluded; exp = experience(d); exptl = experimental; explic = explicit; F = female; fam = family; GMREL/GMSEX = Global Measure of Relationship/Sexual Satisfaction; GRIMS/SS = Golomok-Rust Inventory of Marital/Sexual Satisfaction; HAMA = Hamilton Anxiety Scale; HAMD = Hamilton Depression Scale; Hisp = Hispanic; HISC/A = Hurlbert Index of Sexual Compatibility/Assertiveness; HISD = Hurlbert Index of Sexual Desire; hyp = hypothesis; imp = importance; inadeq = inadequacy; incl = inclusion, included; id = identified; indep = independent; ISS = Index of Sexual Satisfaction; init = initiating; int consist = internal consistency; interv = interview; IIP = Inventory of Interpersonal Problems; inv = inventory; knowl = knowledge; M = male; M = mean; M and J = Masters and Johnson; manip = manipulation; MAT = Marital Adjustment Test; MAS = Marital Attitudes Scale; MCI = Marital Communication Inventory; MSI = Marital Satisfaction Inventory; man'l = manual; mar = marital; Mdn = median; med'd = mediated; modif = modified; nat = naturally; observ'l = observational; obs = observer; observ'l = observational; obt = obtaining; partic = participating; part = partner; PLS = Passionate Love Scale; perc = perceived; PAIR = Personal Assessment of Intimacy in Relationships; prelim evid = preliminary evidence; PMSCS = Premarital Sexual Conflict Scale; premar = premarital; prem = premature; pres = presence; presnt = presenting; prev = prevalent; PCI = Primary Communication Inventory; prim = primarily; proc = procedure; prop = properties; rec = receive(d); RAS = Relationship Assessment Scale; RCI = Relationship Closeness Inventory; R and V = reliability and validity; rew = rewards; ser = serious; sess = sessions; sitn = situation; std = standardized; SA = sexual arousal; SAS = Sexual Attitudes Scale; disting = distinguished; SDI = Sexual Desire Inventory; SII = Sexual Interaction Inventory; SOS = Sexual Opinion Survey; spec = specific; stim = stimuli, stimulation; subj = subjective; sugg = suggest(s); SCL = symptom checklist; SCL-90 = Symptom Checklist 90; ther = therapist, therapy; tow = toward; tx = treatment; understnd = understanding; vag = vaginal; VPA = vaginal pulse amplitude; vagin = vaginismus; vid = video; vol = volunteer; vulvodyn = vulvodynia; VVS = vulvar vestibulitis syndrome; WEHI = Women's Experience of Heterosexual Intercourse Scale; WL = wait list; W = white; yg = young; Ti = higher/increased, lower/decreased

Table 3.1.2. Treatment outcome studies relevant to relationship factors and female sexuality













Crowe et al.,


24 couples w/

Mixed SD in

(1) Modif M and J tx w/

Random asst to 1 of

All 3 tx groups

1-yr follow-up

Change in



chief c/o FSD

F and M. In

co-ther (sens focus; genital

the 3 txs. Each ther

showed sig imprv

(n=36). Gains

target behav


(anorg or desire

couples w/

focus later in tx); (2) Modif

conducted tx w/ all

from pre-tx in sex

(from pre-tx

assessed by


dysfx); 24 w/

M presenters,

M and J tx w/ single ther;

groups. Txs bal for

and rel satisfxn and

levels) maintained

self-rep and


M SD. M ages =

13 F partners

(3) Mar therapy + Relax

gender of pt and ther.

sex interest. No

for all 3 groups.

blind raters.


30 (F), 35.5(M).

diag w/ SD.

trng. Txs not std.

No WL or plac cont.

diffs bet the 3 txs.


Hartman ft


Couples diag w/

Mixed SD.

(1) Sex ther: CB tx w/

Bal, crossover design.

Sex ther > mar ther

6-mo follow-up

Measures had

Daly, 19 8 359


mult SDs (F,

Screened to

focus on educ, disinhib, sens

Random asst to mar

in sex satisfxn (trend

conducted, but

est R and V. Sex


mostly prim org

R/O organic

focus. (2) Mar ther: comm

ther 1st, then sex

tow sig). Couples w/

data not reported.

ther alone may


dysfx and HSD).


skills and confl res. 5 wkly

therapy (or reverse).

> pre-tx dyad adj resp


be eff w/ SD, in


M ages = 33.2


sess (90 min) in group


best to sex ther 1st;


abs of ser rel


(F), 36.7 (M).


format w/ husb/ wife ther


couples w/ < dyad adj




M dur = 6.2 yr.

relev phys

team. Txs not blind or


resp better to mar





ther 1st.




Married couples

F sec org

CB tx in: (1) std couple ther

Random asst to

Improvements seen


Measures had

et al.,


(ages 25-44;


or (2) group ther format.

couple ther, group

for all 3 txs; couple


est R and V.



1-20 yr rel dur)


Plac/pseudo-tx (minimum

ther, or placebo/

ther slightly > group


w/ F c/o sec


contact and biblio-ther/




org dysfx. M




dur of SD=10 yr.




Couples c/o sec

F sec org

Comm skills trng: sex comm

Random asst to 1 of

Tx couples > Plac or

6-mo follow-up

2 of 3 q-aires

et al.,


coital org dysfx

dysfx w/

and generic confl res. Sex

6 conditns: (1) comm

WL on sex satisfxn

(WL cont group

had est R ft V.



(51 married, 1

partner. Excl:

skills trng: dir masturb and

skills, (2) sex skills;

and sex harmony. No

not incl). Tx gains

Clearly spec incl


engaged, 3

organic etiol,

sens focus. Comb comm+

(3) comm+sex skills;

single tx superior. F

not maint overall.

and excl crit.


cohab). M ages


sex skills. Attn plac: lect,

(4) sex skills + comm.;

w/ no prev coital org

Poorer pre-tx rel

Lack of sig


= 32.6 (F), 34.5

severe psych

educ, and bibliother. All txs

(5) attn plac; (6) WL

> F w/ prev coital org

adj pred > gains in



(M). M yr

probs, ED in

manual and conducted by


in dyad adj pre- to

org freq at

compar may be


cohab = 9.5; M


individ ther in groups of 4-6




due to low stat


dur of dysfx = 9.6 yr.


couples each (8 wk sess).





Couples; F

Mixed sec

(1) 9 sess of mar ther

Random asst to: (1)

Mar ther + sex ther >

3-mo follow-up: tx

q-aires w/ est

19 8 754


partner diag w/

FSDs (no. pts

(comm/confl res), followed

mar ther+sex ther;

plac + sex ther. Both

gains maint for

R and V; obs


sec SD. High

w/ spec diag

by 12 sess of CB sex tx

(2) plac+ sex ther; or

txs > WL cont on sex

both tx groups.

couple interaxns


preval of mar

not reported).

based on M and J; (2) 9 sess

3) WL cont. No pre-tx

and mar adj. Mar +


(w/ good inter-


and psych

Pts excl w/

of Plac tx (relaxation, educ),

(diffs in demo or

sex ther vs placebo


rater R. High


distress (50%

organic etiol,

followed by 12 sess of sex


group: < sex probs,


attrition rate for


of pts w/

SD assoc w/

ther. Tx manual used.


> sex desire, > mar


tx groups.


severe dep).

psych probs.


adj post-tx.


Table 3.1.2. (Continued)
















Hurlbert, 199 371


F (ages 28-38) with HSD.


Std group ther; Std group ther + org consistency trng.

Random asst to std group tx, or group tx + org consist trng.

Combined tx > std tx in SA and sex assertiveness.

3 and 6 mo fu: Combined tx > std tx in SA and assert (and satisfxn 6 mos).

Increase in assert and SA assoc w/ incr in sex satisfxn.

Hurlbert et al.,

199 386


F c/o HSD, ages 25-37 (M 29.6 yr). 68.4% W, 24.6% B, 7% Hisp. Married avg 7.7 yr. M yr of educ = 12.8.

HSD; excl F w/ mental illness, etoh/ drug abuse, dysp, relev phys illness, h/o trauma.

10 wkly sess of Org Consistency Trng (dir masturb, sens focus, tech to improve M climax, coital alignmt). Std tx protocol followed by M/F ther team.

Random asst to F-only group format, couple group format, or WL cont.

Partner involvemt in tx assoc w/ superior outcome. Couple tx > F-only group in sex satisfxn and sex compat. Couple tx > WL.

6-mo follow-up: Couple tx superior on 5 of 6 outcome measures; tx gains maint for both tx groups.

All measures used had est R and V.

MacPhee et al., 199555


49 couples cohab for 2+ yr; F diag w/ ISD (M dur 6.7 yr); 15 non-ISD cont couples in ther for other probs.

ISD; excl desire-related illnesses or med use, etoh/drug abuse, dom violence, preg, severe mar probs.

Emotion-focused couple ther (integ of experiential and sys approaches); 10 wkly sess. Not manual. Admin by individ ther w/ wkly supervision.

Pts w/ ISD Randomly assigned to tx (n = 25) or WL cont (n = 24). Pre-tx diffs bet groups ruled out or controlled.

Tx > WL on sex desire, dyad adj. Lower pre-tx mar distress pred higher post-tx sex satisfxn, sex freq, and sex desire. ISD < non-ISD in mar distress and sex satisfxn.

3-mo follow-up: dyad adjust further improved for tx couples; sex desire increase maint, desire tow partner decl slightly from post-tx (still higher than pre-tx levels).

4 of 6 measures used had est R and V; several std instrum used.

Trudel et al., 2001107


Couples diag w/ F HSD (M= 6 yr). Cohab for avg of 13 yr; 20-55 yr old (M age = 37.4 (F), 39.4 (M).

F HSD. Excl ser psych disord or mar probs.

Multimodal CB tx in group format (4-6 couples). 12 wkly (2 hr) sess. Focus on educ, comm skills, sens focus, sex intimacy exerc, and cog restruct. M/F co-ther.

Random asst to tx (n = 38) or WL control (n = 36). No sig diffs bet groups on key demo or study vars.

Tx > WL on HSD sympt improvemt, sex fx / satifxn, rel adjust, and decrease in (-) sex thoughts. 74% tx F improved.

3-mo and 1-yr follow-up: 64% of tx F still classified as improved. 38% sympt-free at 1-yr follow-up.

Sev std instrum used. Sec finding of study: HSD F said rel factors maj contrib to SD.

39.4 (M). co-ther.

Abbreviations: abs = absence; adj = adjustment; asst = assignment bal = balanced; B = Black; CB = cognitive behavioral; comb = combined; compar = comparison; compat = compatibility; comm = communication; confl res = conflict resolution; crit = criteria; decl = declined; demo = demographic; dur = duration; dyad = dyadic; dysfx = dysfunction; dysp = dyspareunia; educ = education; eff = effective; excl = excluded, exclusion; exerc = exercises; F = female; Hisp = Hispanic; imprv = improvement; instrum = instruments; integ = integration; interaxns = interactions; maint = maintained; maj = major; M = male; manual = manualized; mar = marital; M and J = Masters and Johnson; modif = modified; obs = observed; org = orgasm(ic); plac cont = placebo control; preg = pregnancy; preval = prevalence; prim = primary; psych = psychological/psychiatric; psychpath = psychopathology; R and V = reliability and validity; relev = relevant; resp = responded; sec = secondary; self-rep = self-report(ed); ser = serious; SA = sexual arousal; sev = several; SD = sexual dysfunction; sig = significant, significance; std = standardized; stat = statistical. sys = systems; ther = therapist, therapy; tow = toward; trng = training; tx = treatment; vagin = vaginismus; WL = waitlist; W = white.

Sexual response

Better relationship adjustment/satisfaction with one’s partner tends to be accompanied by greater sexual response.14,19,20 For example, Hurlbert et al.20 found that women (but not male partners) who were dissatisfied with their marriage reported lower sexual desire, regardless of their overall sexual satisfaction. Maritally satisfied women reported greater sexual interest, higher levels of sexual arousal, and higher orgasmic frequency. Marital happiness has been found to predict higher frequency of orgasm during spousal intercourse, greater sexual variety, and fewer refusals of sexual initiations.19,21 Female orgasmic response has been found to be lower in the context of spousal conflict and hostility,19 and couples marked by mutual warmth, caring, and affection have been reported to exhibit greater female sexual arousal, desire, and enjoyment of sex.14 In a rare experimental study, responses to erotic audiotapes depicting sexual interactions containing different emotional contexts (anger, anxiety, and neutral/control) were examined.22 It was found that sexual encounters containing anxiety and anger lowered sexual desire, and that women were significantly more likely than men to terminate sexual encounters when they felt angry.

Sexual satisfaction

Most research has found general relationship satisfaction and sexual satisfaction to be positively correlated in married, cohabitating, and dating couples.23-29 The limited longitudinal data available indicates that decreased happiness with one’s sexual relationship predicts a subsequent decline in relationship satis-faction.26 However, the more likely conclusion is that sexual and relationship satisfaction are reciprocal. 26,28,30

Other relationship factors have been shown to relate to sexual satisfaction. In a community sample of married women, self-reported closeness with one’s partner was more predictive of sexual satisfaction than the number of orgasms, frequency of sex, or sexual arousal.31 In one of the few studies including a large number of African-American couples, tension with partner predicted sexual dissatisfaction, whereas affirmation with one’s partner predicted sexual satisfaction.32 Investigations testing the sexual exchange theory27,33 found that relationship satisfaction contributed unique variance to sexual satisfaction beyond indices of sexual rewards and costs. Likewise, sexual satisfaction significantly added to the prediction of relationship satisfaction beyond indexes of sexual exchange.27

Decreased sexual satisfaction has been found to predict subsequent divorce in married couples26 and relationship dissolution in dating couples.28 It has also been found that relationship instability may be more related to sexual dissatisfaction in men, and relationship dissatisfaction in women.28 This is consistent with evidence that relationship satisfaction in women, but not men, is significantly associated with feelings of passionate love toward one’s partner.17

Sexual and relationship satisfaction can operate at least partially independently of each other.34-36 In their comparison of sexually distressed, clinical and nondistressed/nonclinical couples, Heiman and colleagues35 observed that indicators of sexual adjustment, rather than marital satisfaction, distinguished couples seeking sex therapy from nonclinical couples. Clinical couples reported relatively high marital satisfaction despite their sexual distress, suggesting that sexual distress does not inevitably entail serious relationship problems.35 Some couples experience sexual dysfunction in the absence of marital problems. Likewise, positive sexual function can occur despite relationship difficulties.34,35,37

Mixed sexual dysfunctions and difficulties

A large survey of British men and women found that marital difficulties were strongly associated with reported sexual dysfunction (arousal problems, orgasmic dysfunction, and lack of sexual enjoyment) for women only.38 Other investigations have found that sexually dysfunctional women have significantly more relationship problems (including lower overall relationship quality, poorer communication, and more conflict)39,40 and impaired emotional closeness and sexual intimacy than sexually functional controls.41

Studies comparing couples seeking sex therapy with either nonclinical couples or those seeking marital therapy have typically found significant differences between these groups in overall relationship adjustment.42 Compared with nonclinical couples, dyads seeking therapy for sexual dysfunction have been found to report more disagreements and lower relationship satisfaction.43 Metz and Lutz found that both marital and sex therapy couples were less playful and spontaneous in their interactions than couples not seeking intervention for sexual or marital problems.44 Sex therapy couples, however, reported higher overall relationship satisfaction than their marital therapy counterparts. Less global relationship distress and fewer nonsexual relationship complaints tend to characterize sex therapy versus marital therapy couples.45,46

Sexual dysfunction is assumed to be greater among sex therapy than marital therapy couples. However, Frank and colleagues found no significant differences between sex therapy and marital therapy couples in type or number of sexual difficulties, although sex therapy couples did report experiencing better marital adjustment.46 Couples may self-select to marital or sex therapy despite experiencing similar problems, perhaps reflecting differences in the interpretations of their problems (i.e., as primarily indicative of “relational” or “sexual” difficulties) rather than differences in level of sexual dysfunction.

Specific sexual dysfunctions

Compared with women without hypoactive sexual desire, women with hypoactive sexual desire have been shown to report poorer dyadic adjustment, greater dissatisfaction with conflict resolution in their relationship, and less attraction to and emotional closeness with their spouses.47,48 Furthermore, women receiving treatment for hypoactive sexual desire have been found to report that relationship factors were major contributors to their sexual problems.48

Findings also suggest that women with orgasmic dysfunction, compared with those orgasmic, report less satisfaction in their overall relationships and have sexual interactions that are characterized by less closeness and intimacy, fewer feelings of connection, less mutual love, and more aversive feelings and thoughts during intercourse.49

Results of research on sexual pain disorders are less consistent, perhaps because of the several different types of sexual pain dysfunctions. Women with vulval pain, mostly diagnosed with vulvar vestibulitis, have been shown to have lower relationship and sexual satisfaction than control patients with nonvulval pain.50 Others have found no difference in women with vaginismus or vulvar vestibulitis syndrome, in regards to relationship satisfaction.51,52

Relationship quality and the treatment of sexual dysfunction

Interventions that specifically address relationship issues are usually more successful than treatments focused only on the presenting sexual symptoms.53 Marital therapy plus sex therapy has been found to be superior to education plus sex therapy on both sexual and relational outcomes for mixed female sexual dys- functions,54 and relationship-focused treatments have demonstrated positive effects on sexual adjustment and overall relationship quality.55,56

Higher pretreatment relationship quality has been associated with successful treatment outcome.52,57,58 Whitehead and Matthews found that successful treatment response on both sexual and nonsexual measures was predicted by overall relationship quality, but not by severity of sexual dysfunction and an index of female sexual response.57

Severity of relationship problems suggests an initial focus on marital therapy. In one study, sexually dysfunctional couples were randomly assigned to receive sex therapy followed by marital therapy or the reverse (marital therapy followed by sex therapy). Couples with poor dyadic adjustment before treatment responded best to marital therapy first, and couples with good pretreatment relationship adjustment responded best to sex therapy first, with few gains resulting from additional marital therapy.59


General (nonsexual) communication

Both self-reported and observed interactions marked by mutual warmth, affection, and support are associated with higher frequency of coital sex, higher female sexual responsiveness, greater sexual desire, and a higher level of women’s reported gratification with partnered sex.14 Compared with a nonhypo- active sexual desire disorder sample, women with hypoactive sexual desire disorder have been found to report greater dissatisfaction with partners’ conflict resolution and ability to listen.47,48 Frequent and severe disagreements have been found to predict loss of interest in sex with one’s partner and involvement in extramarital affairs,26 and the quality of couples’ nonsexual communication has been found to predict sexual satisfaction, both concurrently60 and longitudinally.61 Zimmer found that sexually distressed couples exhibited more negative interactions than happily married couples or couples seeking therapy for marital problems.54 Sexually distressed couples’ interactions demonstrated fewer expressions of acceptance, less congruence, and more negative nonverbal behaviors. It has also been found that, compared with sexually functional couples, sexually dysfunctional dyads reported more communication and conflict resolution problems.40,43,62

In their review of the literature on the role of communication in sexual dysfunction, Metz and Epstein noted that significant sexual difficulties can be experienced in the absence of communication problems.34,63,64 Hartman concluded that sexual dysfunction (or at least the process of attributing dyadic problems to sexual dysfunction) may actually enhance relationship satisfaction and buffer against relational distress.34 Couples who attribute their relationship difficulties to sexual dysfunction may be less likely to experience relationship distress than couples who view their problems as reflective of wide-ranging deficits in their relationships.

Research on specific patterns of interaction implicated in sexual dysfunction is scant. This stands in stark contrast to marital interaction research, which has identified several interactional patterns predictive of overall relationship satisfaction, marital stability, and divorce.65-68 The association between these patterns and sexual satisfaction or sexual function is unknown, as marital researchers have largely ignored sexual relationships of couples.

Taken together, there are several possible ways in which general communication problems may be associated with sexual dysfunction.63 First, communication problems may directly lead to sexual dysfunction (or conversely, sexual dysfunction may lead to problems in communication). Second, sexual dysfunction may be compartmentalized and hence not affect general communication or relationship distress, possibly buffering the couple from global relational dissatisfaction/distress. Third, sexual dysfunction may emerge independently of relationship conflict, contributing to communication problems via an indirect impact on the affective tone of the relationship.

Sexual communication

Generic communication skills and positive interactions do not necessarily translate to positive communication about sex. It has been found that sexual communication (particularly disclosure of one’s sexual likes and dislikes to one’s partner) contributes unique variance to sexual satisfaction beyond general communication alone.60 Individuals are significantly more likely to make nonsexual than sexual disclosures to their partners. It seems that sexual disclosure is more likely if one’s partner takes the initiative to discuss sexual issues; nevertheless, partners are much more willing to disclose their sexual likes rather than their dislikes.69

Based on a sample of 6029 women and men from the National Survey of Families and Households, Donnelly found that sexually inactive respondents (defined as no partner sex during the month prior to interview) reported having fewer arguments about sex with their partners than sexually active individuals.15 This finding was interpreted as reflecting resignation to a lower level of sexual interaction among sexually inactive respondents. Studies investigating more global measures of sexual conflict have generally found that higher levels of sexual conflict are associated with lower sexual and relationship satis-faction.70

Couples seeking therapy for sexual dysfunction have been found to report more sexual communication problems than nonclinic control couples.43 Similar findings have been reported for maritally distressed couples, with quality of sexual communication also predicting overall relationship adjustment and quality of global communication.62

Sexual communication contributes significantly to sexual satisfaction.31'48,60,69,71 It has been found that women’s sexual assertiveness (in addition to emotional closeness and erotophilia) predicts sexual satisfaction beyond orgasm frequency, rating of sexual excitability, or frequency of coital sex. For women with hypoactive sexual desire disorder, increases in sexual assertiveness after treatment have been associated with subsequent gains in sexual satisfaction.71

The effect of sexual communication on sexual and relationship satisfaction may vary by age and gender. The results of one study of 996 women and men obtained from a community sample (selected randomly from a list of telephone subscribers) found that sexual communication was a significant predictor of sexual satisfaction for women and men under 60 years old as well as for women over 60.96 Good sexual communication was significantly associated with relationship satisfaction only for younger cohorts of women and men, but not for respondents over 60.

Although sexual communication is often nonverbal, subtle, and complex,72,73 most empirical research has examined verbal expressions of sexual interest.74 In one study, men were more likely to initiate sex than women. However, after controlling for initiation frequency, women were just as likely as men to respond positively to sexual advances.21 Women reporting greater sexual and relationship satisfaction initiated more frequently, and those with less sexual satisfaction refused sex more often.3,21

Sexual communication satisfaction has been found to contribute significantly to marital quality indirectly through its positive impact on sexual satisfaction.25 Anorgasmic (versus orgasmic) women have reported more discomfort with sexual communication, especially in discussing sexual activities, such as direct clitoral stimulation, that are most likely to lead to orgasm.

Relationship status: duration, marital status, and sexual orientation

Relationship duration

Research on relationship duration and sexuality has focused almost exclusively on the frequency of coital sex, with the nearly ubiquitous finding that frequency of sex declines with increasing duration of the relationship.12,18,23,7.78 Coital frequency is highest in committed relationships during the first 2 years, with a steady and gradual decline thereafter.12,77 Typical reasons given for this decline include familiarity with one’s partner (and accompanying lack of novelty or “routine” nature of sex) as well as child-rearing and job demands.77

In the National Survey of Families and Households sample, age and marital happiness were stronger predictors of coital frequency than relationship duration.12 In contrast, Blumstein and Schwartz found that relationship duration uniquely predicted frequency of sex, after controlling for age.23

There is evidence that sexual desire changes in committed relationships may vary by gender. In a representative sample of 1865 German students in committed heterosexual relationships, the duration of the relationship was positively associated with tenderness/closeness and negatively associated with desire in women, but not in men.76

Changes in the quantity of sex are not necessarily mirrored by changes in sexual satisfaction. Greenblat found that individuals continued to report that sex was both satisfying and personally important despite declines in frequency of partner sex.77

Using data from the US nationally representative National Health and Social Life Survey, Liu found that marital duration was moderately and negatively associated with reported quality of sex with spouse, with women reporting less satisfaction than men with the quality of marital sex.79 Marital duration nevertheless accounted for a very small proportion of variance in marital quality.

Marital status

Comparisons of cohabiting and married couples have consistently suggested that cohabiting couples engage in higher sexual activity.18,21,23 Yet, the National Health and Social Life Survey found that being married (relative to single, divorced, widowed, or separated) decreased the risk of sexual dysfunction80 and that cohabitation had a weak negative effect on reported quality of sex.79

Same-sex relationships

Research on homosexual relationships is rare (see Peplau et al.81 for a review and elsewhere in this volume). The extant research on women in same-sex relationships is somewhat inconsistent in terms of whether lesbians (and bisexuals) are similar to heterosexuals in sexual function and satisfaction. Kinsey et al.found orgasm frequency to be higher for lesbians than heterosexual women, with 68% of lesbians reporting that they experienced orgasm 90-100% of the time when having sex, compared with 40% of married women. Similarly, only 7% of lesbians reported never reaching orgasm, compared with 17% of married women. Masters and Johnson found that perceived sexual quality was greater for same-sex couples than heterosexual couples.82 Others have found lesbian couples to have less frequent sexual activity than heterosexual couples.23

Partner variables

Individual partner characteristics

Besides the obvious but critical characteristics of being sexually arousing and providing adequate sexual stimulation, several additional characteristics of the male partner have been shown to influence female sexual function and satisfaction. A woman’s age, as well as the age and health of her male partner, have been found to be especially salient for women’s reported coital fre- quency.18 Important contributors to female sexual satisfaction (versus sexual distress) are the partner’s understanding of the woman’s sexual preferences, his responsiveness to sexual requests, and his empathy.32,61,83,84 In 45 couples seeking therapy for sexual dysfunction (predominantly arousal and orgasmic problems), the partner’s lack of responsiveness to sexual requests more strongly predicted sexual distress than sexual dysfunction itself.83 The male partner’s empathy prior to marriage predicted the woman’s (and man’s) sexual satisfaction 1 year after the wedding.61 Feeling affirmed and generally emotionally supported by one’s partner has also been found to predict significantly women’s sexual satisfaction.32

Partner discrepancies and sexual compatibility

Compatibility in sexual preferences has been found to contribute positively to women’s sexual satisfaction, whereas sexual conflict (including discrepancies in the frequency of sex, types of desired sexual behaviors, partners’ expectations of sex, and other aspects of sexual interactions) has been associated with sexual dissatisfaction and overall unhappiness with the relationship - even after controlling for the level of generic, nonsexual disagreements.70,84 In a study of undergraduate cohabiting couples, women with lower sexual desire than their male partners reported lower relationship and sexual satisfaction. Sexual desire discrepancies contributed unique variance to women’s sexual satisfaction, even after controlling for partners’ level of sexual satisfaction.30

Partner’s involvement in the treatment of women’s sexual dysfunction

Partner involvement in treatment is associated with superior treatment outcomes for women with orgasmic dysfunction85 or hypoactive sexual desire disorder.86 Women with hypoactive sexual desire disorder who were randomly assigned to a couple’s group treatment, as opposed to a women-only group, fared significantly better (at post-treatment and 6-month follow-up) on measures of sexual satisfaction and sexual compatibility.86 In a study of mixed sexual dysfunctions, 84% of patients whose partners attended therapy experienced positive outcomes compared with 51% of individuals with nonparticipating partners.87 The treatment motivation of women’s partners has also been found to be important, predicting treatment completion (vs dropout), as well as superior outcomes.88,89

Postpregnancy and children

While pregnancy is addressed elsewhere in this volume, we would like to highlight a few points, since pregnancy and children affect many women’s lives. The transition to parenthood is important and challenging, and associated with dramatic biologic, psychologic, and interpersonal changes that can have a significant impact on women’s (and their partner’s) sexual function and satisfaction.

Once intercourse resumes after childbirth, the frequency of sexual activity tends to be lower than prepregnancy levels for several months.90 Sexual problems during the postpartum period are the norm, rather than the exception,90 with only 14% reporting an absence of sexual difficulties during this time (Hames, 1980; cited in Bitzer and Alder, 2000).91

Fortunately, most women and their partners weather this transition without severe marital distress or clinically diagnos- able sexual dysfunction.91 Research by Gottman and his colleagues92 has identified several factors that appear to buffer couples against relationship distress during the transition to parenthood. Of particular importance are the male partner’s attentiveness and expression of fondness and affection toward his spouse, awareness on the part of both partners of each other and of the relationship, and a positive attitude toward conflict resolution.92 In contrast, husbands’ negativity and disappointment with the marriage predict greater relationship distress and declines in marital satisfaction during this transition.92

Research on the impact of children on women’s sexual function and satisfaction is limited and tends to focus on coital frequency. Fatigue and responsibilities related to child rearing are frequently given as reasons for declines in sexual activity among couples.77 It has been found that couples with one child in the home report lower coital frequency than nonparenting couples. However, parents with two or more children report equivalent coital frequency to childless couples.18 These findings suggest that the impact of having children on sexuality may be greatest after the initial transition to parenthood.

Summary and conclusions

It remains surprising that so little empirical research has included sexuality and relationship variables, particularly since sexual frequency and satisfaction relate to relationship quality, strength, durability, and family stability. While more research is clearly needed, it is important to remember that the above work strongly suggests that relationship factors play an important role in women’s sexual function and sexual satisfaction.

Caveats are in order with regard to generalizing too broadly from the studies in this area. Many designs are (1) correlational; (2) based on small, nonrepresentative, or specialized samples and (3) incompletely characterized with regard to social variables (e.g., education, social status, and ethnicity), health, or specification of diagnostic category and severity. They are nevertheless a helpful perspective to direct future research.

There is a danger in the common tendency to view sexual dysfunction as a purely physiologic or psychologic phenomenon. As has been recognized by researchers and clinicians, sexuality is a multidimensional phenomenon that is influenced by a complex web of biologic, psychologic, sociocultural, and interpersonal determinants.1'2'10'93'94 There is consistent evidence that the interpersonal context of one’s relationship is particularly fundamental to women’s sexual function and satisfaction.

Research on physiologic factors implicated in women’s sexual dysfunction, as well as potential physiologically based treatments for these dysfunctions, is important. However, a purely individualistic and physiologic approach is bound to fall short of a thorough understanding of female sexual dysfunction and its treatment.


1. Byers ES. Evidence for the importance of relationship satisfaction for women’s sexual functioning. In E Kaschak, L Tiefer, eds. A New View of Women’s Sexual Problems. New York: Haworth Press, 2001: 23-6.

2. Basson R, Leiblum S, Brotto L et al. Definitions of women’s sexual dysfunction reconsidered: advocating expansion and revision. J Psychosom Obstet Gynaecol 2003; 24: 221-9.

3. Terman LM, Buttenweiser P, Ferguson LW et al. Psychological Factors in Marital Happiness. New York: McGraw-Hill, 1938.

4. Dickinson RL, Beam L. A Thousand Marriages. Oxford: Williams & Wilkins, 1931.

5. Kinsey AC, Pomeroy WB, Martin CE et al. Sexual Behavior in the Human Female. Oxford: Saunders, 1953.

6. Masters WH, Johnson VE. Human Sexual Response. Oxford: Little, Brown, 1966.

7. Masters WH, Johnson VE. Human Sexual Inadequacy. Boston: Little, Brown, 1970.

8. Aubin S, Heiman, JR. Sexual dysfunction from a relationship perspective. In JH Harvey, A Wenzel, S Sprecher, eds. The Handbook of Sexuality in Close Relationships. Mahwah: Erlbaum, 2004: 477-517.

9. Tiefer L. Historical, scientific, clinical and feminist criticisms of “the human sexual response cycle”. Annu Rev Sex Res 1991; 2: 1-23.

10. Beck JG. Hypoactive sexual desire disorder: an overview. J Consult Clin Psychol 1995; 63: 919-27.

11. Heiman JR, LoPiccolo J. Clinical outcome of sex therapy: effects of daily v. weekly treatment. Arch Gen Psychiatry 1983; 30: 443-9.

12. Call V, Sprecher S, Schwartz P. The incidence and frequency of marital sex in a national sample. JMaHOeFüm 1995; 57: 639-52.

13. Birchler GR, Webb LJ. Discriminating interaction behaviors in happy and unhappy marriages. J Consult Clin Psychol 1977; 45: 494-5.

14. Persky H, Charney N, Strauss D et al. The relationship of sexual adjustment and related sexual behaviors and attitudes to marital adjustment. Am J Fam Ther 1982; 10: 38-49.

15. Donnelly DA. Sexually inactive marriages. J Sex Res 1993; 30: 171-9.

16. Howard JW, Dawes RM. Linear prediction of marital happiness. Pers Soc Psychol Bull 1976; 2: 478-80.

17. Aron A, Henkemeyer L. Marital satisfaction and passionate love. J Soc Pers Relat 1995; 12: 139-46.

18. Rao KV, DeMaris A. Coital frequency among married and cohab- itating couples in the United States. J Biosoc Sci 1995; 27: 135-50.

19. Swieczkowski JB, Walker CE. Sexual behavior correlates of female orgasm and marital happiness. J Nerv Ment Dis 1978; 166: 335-42.

20. Hurlbert DF, Apt C, Hurlbert MK et al. Sexual compatibility and the sexual desire-motivation relation in females with hypoactive sexual desire disorder. Behav Modif 2000; 24: 325-47.

21. Byers ES, Heinlein L. Predicting initiations and refusals of sexual activities in married and cohabitating heterosexual couples. J Sex Res 1989; 26: 210-31.

22. Beck JG, Bozman AW. Gender differences in sexual desire: the effects of anger and anxiety. Arch Sex Behav 1995; 24: 596-612.

23. Blumstein P, Schwartz P. American Couples. New York: William Morrow, 1983.

24. Haavio-Manilla E, Kontula O. Correlates of increased sexual satisfaction. Arch Sex Behav 1997; 26: 399-418.

25. Cupach WR, Comstock J. Satisfaction with sexual communication in marriage: links to sexual satisfaction and dyadic adjustment. J^oçPrsRlat 1990; 7: 179-86.

26. Edwards JN, Booth A. Sexuality, marriage, and well-being: the middle years. In AS Rossi, ed. Sexuality Across the Life Course. Chicago: University of Chicago Press, 1994: 233-59.

27. Byers ES, Demmons S, Lawrance K. Sexual satisfaction within dating relationships: a test of the interpersonal exchange model of sexual satisfaction. J^oçPrs^elat 1998; 15: 257-67.

28. Sprecher S. Sexual satisfaction in premarital relationships: associations with satisfaction, love, commitment, and stability. J Sex Res 2002; 39: 190-6.

29. Kurdek LA. Sexuality in homosexual and heterosexual couples. In K McKinney, S Sprecher, eds. Sexuality in Close Relationships. Hillsdale, NJ: Erlbaum, 1991: 177-91.

30. Davies S, Katz J, Jackson JL. Sexual desire discrepancies: effects on sexual and relationship satisfaction in heterosexual dating couples. Arch Sex Behav 1999; 28: 553-67.

31. Hurlbert DF, Apt C, Rabehl SM. Key variables to understanding female sexual satisfaction: an examination of women in nondistressed marriages. J Sex Marital Ther 1993; 19: 154-65.

32. Henderson-King DH, Veroff J. Sexual satisfaction and marital well-being in the first years of marriage. J Soc Pers Relat 1994; 11: 509-34.

33. Lawrance K, Byers ES. Sexual satisfaction in long-term heterosexual relationships: the interpersonal exchange model of sexual satisfaction. Pers Relatsh 1995; 2: 267-85.

34. Hartman LM. The interface between sexual dysfunction and marital conflict. AmJPycfaary 1980; 137: 576-9.

35. Heiman JR, Gladue BA, Roberts CW et al. Historical and current factors discriminating sexually functional from sexually dysfunctional married couples. JMaxitalVamTher 1986; 12: 163-74.

36. Apt C, Hurlbert DF, Pierce AP et al. Relationship satisfaction, sexual characteristics, and the psychosocial well-being of women. Can J Hum Sex 1996; 5: 195-210.

37. Frank E, Anderson C, Rubenstein D. Frequency of sexual dysfunction in “normal” couples. NEgLLMed 1978; 299: 111-15.

38. Dunn KM, Croft PR, Hackett GI. Association of sexual problems with social, psychological, and physical problems in men and women: a cross sectional population survey. J Epidemiol Community Health 1999; 53: 144-8.

39. McCabe M, Cobain MJ. The impact of individual and relationship factors on sexual dysfunction among males and females. Sex Marital Ther 1998; 13: 131-43.

40. Ernst C, Fôldeny^ M, Angst J. The Zurich study. XXI. Sexual dysfunctions and disturbances in young adults: data of a longitudinal epidemiological study. J Eur Arch Psychiatry Neurosci 1993; 243(3-4): 179-88.

41. Moore KA, McCabe MP, Stockdale JE. Factor analysis of the Personal Assessment of Intimacy in Relationships (PAIR): engagement, communication, and shared friendships. Sex Marital Ther 1998; 13: 361-8.

42. Metz ME, Dwyer SM. Relationship conflict management patterns among sex dysfunction, sex offender, and satisfied couples. J Sex Marital Ther 1993; 19: 104-22.

43. Chesney AP, Blakeney PE, Cole CM et al. A comparison of couples who have sought sex therapy with couples who have not. J Sex Marital Ther 1981; 7: 131-40.

44. Metz ME, Lutz G. Dyadic playfulness differences between sexual and marital therapy couples. J Psychol Hum Sex 1990; 3: 169-82.

45. Berg P, Snyder, DK. Differential diagnosis of marital and sexual distress: a multidimensional approach. JSxMaital.TLerr 1981; 7: 290-5.

46. Frank E, Anderson C, Kupfer, DJ. Profiles of couples seeking sex therapy and marital therapy. Am J Psychiatry 1976; 133: 559-62.

47. Stuart FM, Hammond DC, Pett MA. Inhibited sexual desire in women. ArchSexBhav 1987; 16: 91-106.

48. Trudel G, Boulos L, Benoit M. Dyadic adjustment in couples with hypoactive sexual desire. J Sex Educ Ther 1993; 19: 31-6.

49. Birnbaum G, Glaubman H, Mikulincer, M. Women’s experience of heterosexual intercourse - scale construction, factor structure, and relations to orgasmic disorder. J Sex Res 2001; 38: 191-204.

50. Hallam-Jones R, Wylie KR, Osborne-Cribb J et al. Sexual difficulties within a group of patients with vulvodynia. Sex Relat Ther 2001; 16: 113-26.

51. Reissing ED, Binik YM, Khalifé S et al. Etiological correlates of vaginismus: sexual and physical abuse, sexual knowledge, sexual self-schema, and relationship adjustment. J Sex Marital Ther 2003; 29: 47-59.

52. Van Lankveld JJDM, Weijenborg PTM, TerKuile MM. Psychologic profiles of and sexual function in women with vulvar vestibulitis and their partners. ObsJçtGyneçol 1996; 88: 65-70.

53. Althof SE, Leiblum SR. Psychological and interpersonal dimensions of male and female sexual function. In T Lue, R Basson, R Rosen et al., eds. Sexual Medicine: Sexual Dysfunctions in Men and Women. Paris: Health Publications, 2004.

54. Zimmer D. Does marital therapy enhance the effectiveness of treatment for sexual dysfunction? JS^MartalTer 1987; 13: 193-209.

55. MacPhee DC, Johnson SM, Van Der Veer MMC. Low sexual desire in women: the effects of marital therapy. J Sex Marital Ther 1995; 21: 159-82.

56. Crowe MJ, Gillan P, Golombok, S. Form and content in the conjoint treatment of sexual dysfunction: a controlled study. Behav Res Ther 1981; 19: 47-54.

57. Whitehead A, Matthews A. Factors related to successful outcome in the treatment of sexually unresponsive women. Psychol Med 1986; 16: 373-8.

58. Hawton K, Catalan J. Prognostic factors in sex therapy. Behav Res Ther 1986; 24: 377-85.

59. Hartman LM, Daly EM. Relationship factors in the treatment of sexual dysfunction. Behav£es.Th£r 1983; 21: 153-60.

60. MacNeil S, Byers E. The relationships between sexual problems, communication, and sexual satisfaction. Can J Hum Sex 1997; 6: 277-83.

61. Larson JH, Anderson SM, Holman TB et al. A longitudinal study of the effects of premarital communication, relationship stability, and self-esteem on sexual satisfaction in the first year of marriage. J Sex Marital Ther 1998; 24: 193-206.

62. Banmen J, Vogel NA. The relationship between marital quality and interpersonal sexual communication. Fam Ther 1985; 12: 45-58.

63. Metz ME, Epstein N. Assessing the role of relationship conflict in sexual dysfunction. J Sex Marital Ther 2002; 28: 139-64.

64. Roffe MW, Britt BC. A typology of marital interaction for sexually dysfunctional couples. J Sex Marital Ther 1981; 7: 207-22.

65. Gottman JM. What Predicts Divorce? The Relationship Between Marital Processes and Marital Outcomes. Hillsdale: Erlbaum, 1994.

66. Baucom DH, Epstein N. Cognitive-Behavioral Marital Therapy. New York: Brunner/Mazel, 1990.

67. Christensen A, Heavey, CL. Gender differences in marital conflict: the demand/withdraw interaction pattern. In S Oskamp, M Constanzo, eds. Gender Issues in Contemporary Society. Newbury Park: Sage, 1993: 113-41.

68. Karney BR, Bradbury TN. The longitudinal course of marital quality and stability: a review of theory, methods, and research. Psychol Bull 1995; 118: 3-34.

69. Byers ES, Demmons S. Sexual satisfaction and sexual self-disclosure within dating relationships. JSxRs 1999; 36: 180-9.

70. Long ECJ, Cate RM, Fehensfeld DA et al. A longitudinal assessment of a measure of premarital sexual conflict. Fam Relat 1996; 45: 302-8.

71. Hurlbert DF. A comparative study using orgasm consistency training in the treatment of women reporting hypoactive sexual desire. J Sex Marital Ther 1993; 19: 41-55.

72. Hickman SE, Muehlenhard CL. “By the semi-mystical appearance of a condom”: how young women and men communicate sexual consent in heterosexual situations. J Sex Res 1999; 36: 258-72.

73. Cupach WR, Metts S. Sexuality and communication in close relationships. In K McKinnery, S Sprecher, eds. Sexuality in Close Relationships. Hillsdale: Erlbaum, 1991: 93-110.

74. Sprecher S, Cate RM. Sexual satisfaction and sexual expression as predictors of relationship satisfaction and stability. In JH Harvey, A Wenzel, S Sprecher, eds. The Handbook of Sexuality in Close Relationships. Mahwah, NJ: Erlbaum, 2004: 235-56.

75. Kelly MP, Strassberg DS, Kircher JR. Attitudinal and experiential correlates of anorgasmia. ArchSexBehav 1990; 19: 165-77.

76. Klussmann D. Sexual motivation and the duration of partnership. Arch Sex Behav 2002; 32: 193-208.

77. Greenblat CS. The salience of sexuality in the early years of marriage. J Marriage Fam 1983; 45: 289-99.

78. Laumann EO, Gagnon JH, Michael RT et al. The Social Organization of Sexuality: Sexual Practices in the United States. Chicago: University of Chicago Press, 1994.

79. Liu C. Does quality of marital sex decline with duration? Arch Sex Behav 2003; 32: 55-60.

80. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999; 281: 537-44.

81. Peplau LA, Fingerhut A, Beals KP. Sexuality in the relationships of lesbians and gay men. In JH Harvey, A Wenzel, S Sprecher, eds. The Handbook of Sexuality in Close Relationships. Mahwah: Erlbaum, 2004: 49-69.

82. Masters WH, Johnson VE. Homosexuality in Perspective. Boston: Little, Brown, 1979.

83. Snyder DK, Berg P. Determinants of sexual dissatisfaction in sexually distressed couples. ArchSexBhav 1983; 12: 237-45.

84. Purnine DM, Carey MP. Interpersonal communication and sexual adjustment: the roles of understanding and agreement. J Consult Clin Psychol 1997; 65: 1017-25.

85. Libman E, Fichten CS, Brender W et al. A comparison of three therapeutic formats in the treatment of secondary orgasmic dysfunction. J Sex Marital Ther 1984; 10: 147-59.

86. Hurlbert DF, White LC, Powell RD. Orgasm consistency training in the treatment of women reporting hypoactive sexual desire: an outcome comparison of women-only groups and couples-only groups. J Behav Ther Exp Psychiatry 1993; 24: 3-13.

87. Hirst JF, Watson JP. Therapy for sexual and relationship problems: the effects on outcome of attending as an individual or as a couple. J Sex Marital Ther 1997; 12 : 321-37.

88. Hawton K, Catalan J, Fagg J. Low sexual desire: sex therapy results and prognostic factors. BehavRes-Tberr 1991; 29: 217-24.

89. Hawton K, Catalan J. Prognostic factors in sex therapy. Behav Res Ther 1986; 24: 377-85.

90. von Sydow K. Sexuality during pregnancy and after childbirth: a metacontent analysis of 59 studies. J Psychosom Res 1999; 47: 27-49.

91. Bitzer J, Alder J. Sexuality during pregnancy and the postpartum period. J Sex Educ Ther 2000; 25: 49-58.

92. Shapiro AF, Gottman JM, Carrere S. The baby and the marriage: identifying factors that buffer against decline in marital satisfaction after the first baby arrives. J Fam Psychol 2000; 14: 59-70.

93. Heiman JR. Psychologic treatments for female sexual dysfunction: are they effective and do we need them? Arch Sex Behav 2002; 31: 445-50.

94. Leiblum SR, Wiegel M. Psychotherapeutic interventions for treating female sexual dysfunction. 2002; 20: 127-3.

95 Coleman EM, Hoon PW, Hoon EF. Arousability and sexual satisfaction in lesbian and heterosexual women. J Sex Res 1983; 19: 58-73.

96. Trudel G. Sexuality and marital life: results of a survey. J Sex Marital Ther 2002; 28: 229-49.

97. Bancroft J, Loftus J, Long SJ. Distress about sex: a national survey of women in heterosexual relationships. Arch Sex Behav 2003; 32: 193-208.

98. Peplau LA, Cochran S, Rook K et al. Loving women: attachment and autonomy in lesbian relationships. J_SocmJssus 1978; 34: 7-27.

99. Heiman J. Female sexual response patterns: interactions of physiological, affective, and contextual cues. Arch Gen Psychiatry 1980; 37: 1311-16.

100. Zimmer D. Interaction patterns and communication skills in sexually distressed, maritally distressed, and normal couples: two experimental studies. J Sex Marital Ther 1983; 9: 251-65.

101. Rust J, Golombok S, Collier J. Marital problems and sexual dysfunction: how are they related? BrJPyçhzatry 1988; 152: 629-31.

102. Oggins J, Leber D, Veroff J. Race and gender differences in Black and White newlyweds’ perceptions of sexual and marital relations. JJexRcs 1993; 30: 152-60.

103. Hulbert DF, Apt C. Female sexual desire, response, and behavior. Behav Modif 1994; 18: 488-504.

104. Regan PC, Berscheid E. Gender differences in beliefs about the causes of male and female desire. Pers Relat 1995; 2: 345-58.

105. McCabe MP. Intimacy and quality of life among sexually dysfunctional men and women. JS^MahaLTher 1997; 23: 276-90.

106. Kilmann PR, Mills KH, Caid C et al. Treatment of secondary orgasmic dysfunction: an outcome study. Arch Sex Behav 1986;15: 211-29.

107. Trudel G, Marchand A, Ravart M et al. The effect of a cognitive- behavioral group treatment program on hypoactive sexual desire in women. SexRdatTha 2001; 16: 145-64.