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ORIGINAL RESEARCH—PSYCHOLOGY Affective and Cognitive Determinants of Women’s Sexual Response to Erotica Sandra Vilarinho, PhD,* Pedro Laja, BS,† Joana Carvalho, PhD,* Ana Luísa Quinta-Gomes, PhD,* Cátia Oliveira, PhD,* Erick Janssen, PhD,‡ and Pedro J. Nobre, PhD* *Faculty of Psychology and Educational Sciences, University of Porto, Porto, Portugal; †Department of Education, University of Aveiro, Aveiro, Portugal; ‡The Kinsey Institute for Research in Sex, Gender, and Reproduction, Indiana University, Bloomington, IN, USA DOI: 10.1111/jsm.12667
ABSTRACT
Introduction. The specific cognitive–affective mechanisms involved in the activation and regulation of the subjective and genital components of sexual arousal are not fully understood yet. Aim. The aim of the present study was to investigate the contribution of self-reported thoughts and affect to the prediction of women’s subjective and genital responses to erotica. Methods. Twenty-eight sexually functional women (mean age = 32, SD = 6.29) were presented with sexually explicit and nonexplicit romantic films. Genital responses, subjective sexual arousal, state affect, and self-reported thoughts were assessed. Main Outcome Measures. Vaginal pulse amplitude was measured using a vaginal photoplethysmograph. Subjective sexual arousal, thoughts, and affective responses were assessed through self-report scales. Results. Correlations between subjective and physiological sexual arousal were low (r = −0.05, P > 0.05). Selfreported thoughts and affect were significant predictors of subjective sexual arousal. The strongest single predictor of subjective arousal was sexual arousal thoughts (e.g., “I’m getting excited”) (β = 0.63, P < 0.01). None of the cognitive or affective variables predicted women’s genital responses. Conclusions. Overall, results support the role of cognitive (self-reported thoughts) and affective dimensions in women’s subjective sexual arousal to erotica and, consistent with previous findings, suggest that subjective and physiological sexual arousal may be impacted by different processes. Vilarinho S, Laja P, Carvalho J, QuintaGomes AL, Oliveira C, Janssen E, and Nobre PJ. Affective and cognitive determinants of women’s sexual response to erotica. J Sex Med 2014;11:2671–2678. Key Words. Sexual Arousal; Genital Response; Self-Reported Thoughts; Affect; Psychophysiology, Vaginal Photoplethysmography
Introduction
A
lthough a growing body of literature emphasizes the importance of affect and cognitions in sexual response [1–8], the specific cognitive– affective mechanisms involved in the activation and regulation of the subjective (self-report) and genital (physiological) components of sexual arousal are still not fully understood [7,8]. Barlow’s model of sexual functioning [9] is one of the © 2014 International Society for Sexual Medicine
most comprehensive attempts to integrate the impact of cognitive–affective factors on the sexual responses of both sexually functional and dysfunctional individuals. According to this model, sexually healthy individuals tend to respond with positive affect and focus on sexual cues, whereas individuals with sexual problems tend to focus their attention to nonrelevant nonsexual stimuli and are more likely to experience negative affect during sexual activity. Although this model was J Sex Med 2014;11:2671–2678
2672 initially developed for men, various aspects of the model have also been tested in and found relevant to sexual response patterns in women [10–12]. Some researchers have used questionnaire (instead of psychophysiological) methods to study aspects of Barlow’s model [13–16]. For example, Nobre and Pinto-Gouveia [2–4,6,17], using a selfreport measure of automatic thoughts, found that individuals with sexual dysfunction presented more negative thoughts and emotions during sexual activity when compared with sexually healthy individuals. Other studies, using student samples, have examined the content of selfreported thoughts that may interfere with sexual enjoyment and functioning [15,18]. This research has lead to the identification of four categories of distracting thoughts: thoughts related to one’s sexual performance, to one’s body image, to possible emotional consequences of the sexual activity, and to other consequences of the sexual activity (e.g., pregnancy). Furthermore, these studies revealed that regardless of thought category, the frequency of nonerotic thoughts and the anxiety they evoked were positively associated with sexual problems. More recently, in a community sample of men and women in long-term relationships [19], women, as compared with men, were more likely to report body image concerns and thoughts about the physical consequences of the sexual activity. Again, higher frequencies of such nonerotic thoughts were found to be associated with stronger sexual problems. Moreover, greater negative affect in anticipation and during sexual activity was associated with a higher frequency of nonerotic thoughts, and higher levels of anxiety in response to non-erotic thoughts were associated with greater difficulty in dismissing the thoughts. Taken together, this body of research suggests that a range of negative and nonerotic thoughts can interfere with sexual response. In contrast, much less is known about the role of positive thoughts in men and women’s sexual experiences. Furthermore, although the effects of attention [20,21], distraction [22], and body awareness [23] on sexual response have been studied using experimental and psychophysiological methods, experimental research on the impact of thoughts or specific thought content on sexual response is lacking. Regarding emotions and mood states, findings have been mixed. Some studies have found a negative association between depressed affect and sexual arousal [13,24–27]. Other studies, however, J Sex Med 2014;11:2671–2678
Vilarinho et al. have found that negative affect can be positively associated with genital response [8,28]. The literature is equally mixed on the role of positive emotions in sexual response. Some studies [25,29] found that positive affective states are associated with higher levels of subjective sexual arousal. Others [30] have found that the induction of positive affect did not influence women’s subjective or genital sexual responses. Additionally, in a crosssectional study [13] it was found that low positive affect was a strong predictor of sexual response. Wiegel et al. [31], in an expansion of Barlow’s model [9] proposed that positive and negative affect may have independent roles. Consistent with this, Peterson and Janssen [8] found that although positive affect was strongly and positively related to subjective sexual response, ambivalent affect (involving a combination of positive and negative affect) was also associated with higher levels of subjective sexual arousal and desire. The interpretation of the findings of research on the effects of mood and emotions on sexual response is complicated by the fact that many studies have reported different findings for genital responses and subjective sexual arousal. Sex researchers have yet to arrive at a consensus on how to best define sexual arousal and how to weigh its subjective vs. physiological response components [32,33]. Low levels of concordance between subjective and objective measures of sexual arousal are common in women and even more so in women with sexual dysfunction [12]. Despite the lack of significant differences in physiological sexual arousal responses to erotic materials between women with and without sexual dysfunction, Morokoff and Heiman [34] found that those with sexual dysfunction rated their subjective sexual arousal as significantly lower. Moreover, according to the cognitive models of sexual response, the low concordance between subjective sexual arousal and genital responses may be expected to be associated with the experience of negative affect while watching conventional, commercially available erotica (typically used in psychophysiological studies) [35,36]. In sum, the literature reveals that cognitive and emotional determinants play an important role in sexual experiences. Most of the current studies in this area, however, have been conducted using clinical samples or with sexual problems in mind. Moreover, although attention has been devoted to cognitive processes and emotional responses in and out of laboratory settings, few experimental data exist regarding men and women’s thoughts in
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Women’s Response to Erotica: Affect and Thoughts Table 1
Sample characteristics (N = 28)
Age
Marital status
Educational level (%)
Relationship duration
Mean SD Range Single Married Divorced Living in common law 5–9 years 10–12 years 13–15 years >15 years Mean SD Range
32.3 6.29 22–45 22.2% 40.7% 3.7% 33.3% 0% 25.9% 48.1% 23.9% 7,8 years 6 years 9 months–22 years
response to erotic stimuli. Furthermore, despite the accumulated data, little is known about the relationships of cognitions, emotions, and sexual response (both subjective and genital) to erotica. The aim of the present study was to investigate, in a laboratory setting, the affective and cognitive predictors of sexually healthy women’s response to erotica. Specifically, we aimed to examine the impact of state affect and self-reported thoughts on genital and subjective sexual response. We hypothesized that positive and negative affect would both have a significant impact on sexual response, particularly on subjective arousal. We also expected to find a significant impact of selfreported thoughts (negative thoughts and erotic thoughts) on sexual response to erotica. Specifically, considering Barlow’s model (the positive loop) and the nonclinical sample’s nature, we hypothesized that erotic thoughts would be positively associated with subjective sexual response. Method
Participants Twenty-eight women (mean age = 32, SD = 6.29) participated in the study. Most participants reported more than 12 years of education, and the majority were married. The characteristics of the sample are presented in Tables 1 and 2. Participants were recruited by means of flyers, advertisements in media (television, newspapers, and radio), and notice boards. Volunteers went through a phone screening interview to establish eligibility. Inclusion criteria were the following: being 18–50 years old; being in a heterosexual relationship and cohabitating for at least 6 months; and absence of psychopathology, medical problems, sexual dysfunction, or use of medications (e.g., antidepressants, antihypertensives, antipsychotics)
or drugs that interfere with sexual function. Participants received a 50-euro shopping coupon. The study protocol was approved by the ethics committee of a major local hospital.
Measures Genital Response Women’s genital responses were measured using a vaginal photoplethysmograph [37]. The AC signal was taken as a measure of vaginal pulse amplitude (VPA). The Biopac MP100 system with Acqknowledge software (BIOPAC Systems, Inc., Goleta, CA, USA) was used for data acquisition and processing. VPA was sampled at 1,000 Hz and high-pass-filtered (3 Hz). VPA signals were visually inspected and movement artifacts were removed, after which peak-to-peak amplitudes were calculated. All the physiological sexual responses were standardized within-participants to z-scores. Genital responses were defined in terms of differences between sexual and baseline stimuli. Subjective Sexual Arousal Subjective sexual arousal was measured by asking subjects to rate how sexually aroused they felt after each stimulus presentation, using a nine-point Likert scale (1, not at all, to 9, extremely). Affective Responses Affective responses to the stimuli were assessed using a Portuguese version of the Positive and Negative Affect Schedule (PANAS) [38]. The PANAS is a 20-item scale developed to assess the dimensions of positive and negative affect using a set of adjectives (10 positive affect items, e.g., “interested,” “excited,” “enthusiastic”; 10 negative affect items, e.g., “distressed,” “irritable,” “upset”). In the present study, the state-affect version of the PANAS was administered. Participants responded to the PANAS after each stimulus presentation,
Table 2 Genital and subjective sexual arousal, positive and negative affect, and self-reported thoughts during exposure to erotica (N = 28) Response to erotica
Mean
SD
Subjective response after film Genital response after film* Sexual arousal thoughts Distracting/disengaging thoughts Positive affect Negative affect
4.87 0.98 73.06 6.48 22.05 3.21
1.75 1.08 38.90 8.01 7.87 6.65
*Changes in z-scores from baseline.
J Sex Med 2014;11:2671–2678
2674 using a five-point Likert scale, ranging from 1, “not at all,” to 5, “extremely.” Reliability of the original scale was demonstrated with Cronbach’s alpha coefficients ranging from 0.86 to 0.90 for the positive affect scale and 0.84 to 0.87 for the negative affect scale [38]. The Portuguese version of the scale also revealed good internal consistency, with Cronbach’s alpha of .86 for the positive affect subscale and .87 for the negative affect subscale [39].
Self-Reported Thoughts For the purpose of this study and to investigate the role of self-reported thoughts during sexual scenarios, a previously generated list [40] of possible negative thoughts and erotic thoughts occurring (30 items) was used. Participants were asked to rate after each stimulus presentation how frequent those thoughts were, using a six-point Likert scale, ranging from 1, “never,” to 6, “frequently.” A previous exploratory factor analysis was conducted with the original list, and five domains were identified: sexual arousal thoughts (e.g., “I’m getting excited”), distractive/disengaging thoughts (e.g., “This is a waste of time”), body image thoughts (e.g., “My body is not as sexy as that one”), actress’s physical attractiveness (e.g., “That woman is really exciting”), and sinful thoughts (e.g., “This is immoral”). The questionnaire presented a good internal consistency (Cronbach’s alpha for the total scale = 0.91), with Cronbach’s alpha values ranging from 0.75 to 0.94 for the subscales [40]. For this study, only the sexual arousal thoughts and sexually distractive/disengaging thoughts were considered (total of 13 items). The scores were computed as means or sums. Sexual Films Two erotic films were used: a 3-minute sexually explicit erotic film (sexual interaction with a focus on genitalia during oral and vaginal intercourse) and a 3-minute romantic erotic film (displaying an affectionate interaction and intercourse but without a focus on the genitalia). The sexually explicit film was a segment selected from an adult erotic film and has been used in previous research [41]. Both films elicited high levels of subjective sexual arousal in a previous study conducted in a sample of Portuguese undergraduate students [42]. For baseline assessment, a neutral film was used consisting of an excerpt of a scientific documentary. All films were presented with SuperLab 4.5 software (Cedrus Corporation, San Pedro, CA, USA). J Sex Med 2014;11:2671–2678
Vilarinho et al.
Procedure All participants underwent a phone screening interview during which the goal and procedures used in the study were explained. The presence of psychological disorders, sexual and medical problems, and use of drugs were also assessed. The interview was adapted from the Anxiety Disorders Interview Schedule for DSM-IV [43] and the Sexual Dysfunction Interview [44]. Eligible participants were then scheduled for the experimental session. Participants were tested individually. Upon arrival to the laboratory, information about specific procedures and potential risks and benefits and a description of the experimental equipment were provided to the participants. The option to withdraw from the study at any time was also emphasized. After the participant read and signed an informed consent statement, a series of questionnaires was completed. Afterward, participants entered a room furnished with a recliner, desk with a keyboard, and television monitor. Additional instructions were provided regarding the procedures and materials. Following that, the experimenter left the room and the participant put the genital response measurement device in place as instructed and placed a disposable sheet and towel over her lap. Following this, participants began a 10-minute adaptation period. During this adaptation period, the participants viewed a neutral film excerpt. After the adaptation period, participants viewed the films, in a counterbalanced order, each followed by completion of the subjective measures. All the instructions were displayed on the screen. At the end of the testing session, payment arrangements were made, and participants were questioned about their experiences and debriefed regarding the purpose of the study. Testing sessions took about 90 minutes. Results
Predictors of Subjective Sexual Response Regression analysis were performed (using the enter method) to estimate the accuracy of affect and self-reported thoughts as predictors of subjective sexual response. SPSS 17 software (IBM, Armonk, NY, USA) was used for data analysis. The first regression included self-reported thoughts (sexual arousal thoughts and distracting/ disengaging thoughts) as predictors and average subjective sexual arousal (mean response to the films) as dependent variable. The regression model was statistically significant and accounted
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Women’s Response to Erotica: Affect and Thoughts Table 3 Multiple regression analysis, enter method: Self-reported thoughts as predictors of subjective sexual response Predictors
B
β
SE
t
P
Sexual arousal thoughts 0.15 0.02 0.86 8.40*** 0.000 Distracting/disengaging thoughts −0.06 0.09 −0.06 −0.623 0.539 *P < 0.05; **P < 0.01; ***P < 0.001.
Table 4 Multiple regression analysis, enter method: Affect as predictor of subjective sexual response Predictor
B
SE
β
t
P
Positive affect Negative affect
0.71 0.11
0.12 0.18
0.80 0.07
6.63*** 0.61
0.000 0.546
*P < 0.05; **P < 0.01; ***P < 0.001.
films, we conducted two multiple regression analyses (using the enter method). The first regression used the positive and negative scales of the PANAS, and the second regression used sexual arousal thoughts and distracting/disengaging thoughts as predictors. The average genital response to the two sexual films was used as dependent variable in both regressions. Neither regression analysis revealed any significant findings. Thus, neither thoughts (distracting/disengaging and sexual arousal; adjusted R2 = −0.03; P > 0.05) nor affect (positive and negative; adjusted R2 = −0.03; P > 0.05) accounted for a significant amount of the variance in women’s genital response (see Tables 6 and 7). Discussion
Table 5 Multiple regression analysis, enter method: Self-reported thoughts and affect as predictors of subjective sexual response Predictor
B
SE
β
t
P
Sexual arousal thoughts Positive affect
0.11 0.26
0.03 0.14
0.63 0.30
4.01** 1.91
0.001 0.068
*P < 0.05; **P < 0.01; ***P < 0.001.
for 74% (adjusted R2 = 0.74; P < 0.001) of the variance in subjective sexual response (F(2,24) = 37.63, P < 0.001). Sexual arousal thoughts were the best predictor of subjective sexual response (β = 0.86, P < 0.001; see Table 3). In the second analysis, we included both dimensions of affect (positive and negative affect) as predictors and subjective sexual arousal as criterion. A significant model also emerged, which accounted for 61% (adjusted R2 = 0.61; P < 0.001) of the variance in subjective sexual response; F(2,25) = 22.12, P < 0.001. Positive affect was the only significant predictor of subjective sexual response (β = 0.80, P < 0.001; see Table 4). In the last regression, positive affect and sexual arousal thoughts were both entered as predictors of subjective sexual arousal (criterion variable). The results showed a significant model (F(2,23) = 44.28, P < 0.001) accounting for 77% of subjective sexual arousal’s variance (adjusted R2 = 0.77; P < 0.001). Only sexual arousal thoughts reached significance as predictor of subjective sexual response (β = 0.63, P < 0.01; see Table 5).
Predictors of Genital Response To evaluate the ability of affect and self-reported thoughts to predict genital response to the sexual
The aim of this study was to investigate the impact of state affect and self-reported thoughts on women’s genital and subjective sexual arousal to erotic film. None of the variables predicted genital response in women. Positive affect was associated with subjective sexual arousal. However, sexual arousal thoughts emerged as the strongest single predictor of subjective sexual arousal in the regression analyses. Negative affect and distracting/ disengaging thoughts during exposure to sexual material did not contribute to the prediction of subjective sexual arousal. Our findings appear to support part of Barlow’s model [9], especially when it comes to the part of the model that involves a positive feedback loop. Considering that the present sample included only women without sexual problems, it may be that the participants experienced mostly positive thoughts and positive affect in response to erotica, height-
Table 6 Multiple regression analysis, enter method: Automatic thoughts as predictors of genital response Predictor
B
SE
β
t
P
Sexual arousal thoughts 0.02 0.02 0.20 0.92 0.368 Distracting/disengaging thoughts 0.09 0.09 0.20 0.94 0.359 *P < 0.05; **P < 0.01; ***P < 0.001.
Table 7 Multiple regression analysis, Enter method: Affect as predictor of genital response Predictor
B
SE
β
t
P
Positive affect Negative affect
0.03 0.20
0.11 0.18
0.05 0.22
0.25 1.11
0.807 0.280
*P < 0.05; **P < 0.01; ***P < 0.001.
J Sex Med 2014;11:2671–2678
2676 ening women’s subjective sexual arousal, while negative affect played less of a role. The present results emphasize the importance of sexual-arousal-related thoughts such as “I want to touch myself,” “I feel like doing this,” and “This is really great” to subjective sexual response during the erotic clip presentations. We could speculate that those thoughts might work as sexual selfverbalizations that serve as additional internal stimuli [32] and therefore, in theory, could be expected to increase sexual arousal and motivation. The powerful effects of sexual thoughts have already been previously recognized [45]. It may also be the case that focusing on and recognizing certain pleasant sensations or pleasing content as depicted in the sexual scenarios heightens erotic awareness, helps to sustain attention to erotic cues, and minimizes distraction, thus increasing subjective sexual arousal. In contrast, negative and nonerotic thoughts have been recognized as important determinants of sexual problems, most likely by preventing individuals from focusing their attention on the sexual content of erotic stimuli [3,4,6,15,17–19]. This interpretation is consistent with other research that suggests that the recognition of a situation “as sexual” may contribute to increased levels of subjective sexual arousal [16,46], probably by facilitating processing of sexual stimuli. Moreover, related to the topic of body awareness, results previously reported by Seal and Meston [23] indicate that as long as cognitive distraction does not occur, awareness of one’s body is associated with increased subjective sexual response. Taken together, the findings of our study may have clinical implications, supporting the relevance of strategies that help women to focus their attention on what’s happening, on sexual cues, and on the positive and sensual aspects of the sexual experience (e.g., sensate focus, cognitive restructuring, mindfulness meditation). As for the effect of positive affect on subjective sexual response, when analyzed together with sexual arousal thoughts, its contribution was weaker than when it was analyzed together with negative affect. One possible explanation for this involves the high correlation between positive affect and sexual arousal thoughts (r = 0.80, P < 0.001) . Apparently, including both as predictors resulted in a loss of explanatory power of positive affect, leaving sexual arousal thoughts as the stronger predictor. We found no significant effects for the prediction of genital responses. Thus, in this study using J Sex Med 2014;11:2671–2678
Vilarinho et al. self-report measures, genital response, in contrast to subjective arousal, did not reveal any association with positive or negative affect or with sexualarousal-related thoughts. For negative affect in particular, the lack of any effects is intriguing, considering that previous studies have found some evidence of an effect on genital response [8,28]. We may speculate that the findings are partly attributable to the fact that our participants reported relatively low levels of negative affect to begin with. Not only did the regression analyses show different results for genital responses and subjective sexual arousal, the two were strongly dissociated from each other (r = −0.05, P > 0.05). The relative independence of the two dimensions of sexual arousal is consistent with previous findings in both women with sexual dysfunction and those without [47]. According to Chivers and Bailey [48], it is possible for some women to show genital responses without reporting any experience of sexual arousal. Laan and Everaerd [28] suggest that women in general do not rely much on physiological cues to estimate their sexual arousal, which may contribute to discordant response patterns. Some limitations of this study need to be acknowledged. First of all, the use of a convenience sample, although common practice in sexual psychophysiological studies, creates constraints to generalization. Future psychophysiological studies could explore the role of self-reported thoughts and state affect in samples more diverse in, for example, age, ethnicity, and sexual orientation. Another limitation involves the lack of a comparison group of women who experience sexual problems. This would have allowed for a more in-depth assessment of the role of cognitive–affective determinants in subjective sexual arousal, and in particular of sexual-arousal-related thoughts, and their relevance to sexual dysfunction. Another important limitation is related to the specificity of the current analysis, not including other contextual variables that may possibly exert an important impact on sexual arousal in women. Despite these limitations, this study is one of the first to examine the connection between sexual-arousal-related thoughts and subjective sexual arousal in women in a laboratory setting and therefore contributes to the literature on the role of cognitive and affective processes in sexual arousal. Our findings are congruent with previous questionnaire-based studies [13] supporting the importance of sexual arousal-related thoughts and attention to erotic cues. We believe the findings of
Women’s Response to Erotica: Affect and Thoughts this study are clinically relevant and could have implications for both the assessment and the treatment of sexual problems. For example, attentional processes—in particular the role of distracting or negative thoughts—could be addressed by incorporating cognitive restructuring techniques and mindfulness training together with sensate focus. Learning to direct attention to pleasurable body sensations could enhance sexual pleasure and reduce distractions from erotic cues. Additionally, thought content could be targeted by training the mind to focus on the positive and arousing aspects of sexual activity. Future research could explore the possibility that this approach might facilitate a body–mind “reconnection” and strengthen the association between women’s physiological and subjective sexual responses. Acknowledgments
This research was supported by the Foundation for Science and Technology in Portugal. Corresponding Author: Sandra Vilarinho, PhD, Faculty of Psychology and Educational Sciences, University of Porto, Praceta Manuel Regado Júnior, n° 80, 1° Esquerdo, Águas Santas—MAIA 4425-124, Portugal. Tel: +351 96 3083411; Fax: +351 22 2423360; E-mail: [email protected] Conflict of Interest: The authors report no conflicts of interest. Statement of Authorship
Category 1 (a) Conception and Design Sandra Vilarinho; Pedro J. Nobre; Erick Janssen (b) Acquisition of Data Sandra Vilarinho; Pedro Laja; Joana Carvalho; Ana Luísa Quinta-Gomes; Cátia Oliveira (c) Analysis and Interpretation of Data Sandra Vilarinho; Pedro J. Nobre; Erick Janssen
Category 2 (a) Drafting the Article Sandra Vilarinho (b) Revising It for Intellectual Content Pedro J. Nobre; Erick Janssen
Category 3 (a) Final Approval of the Completed Article Sandra Vilarinho; Pedro Laja; Joana Carvalho; Ana Luísa Quinta-Gomes; Cátia Oliveira; Pedro J. Nobre References 1 Bancroft J. Human sexuality and its problems. Edinburgh: Churchill Livingstone; 1989.
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ORIGINAL RESEARCH—PSYCHOLOGY Affective and Cognitive Determinants of Women’s Sexual Response to Erotica Sandra Vilarinho, PhD,* Pedro Laja, BS,† Joana Carvalho, PhD,* Ana Luísa Quinta-Gomes, PhD,* Cátia Oliveira, PhD,* Erick Janssen, PhD,‡ and Pedro J. Nobre, PhD* *Faculty of Psychology and Educational Sciences, University of Porto, Porto, Portugal; †Department of Education, University of Aveiro, Aveiro, Portugal; ‡The Kinsey Institute for Research in Sex, Gender, and Reproduction, Indiana University, Bloomington, IN, USA DOI: 10.1111/jsm.12667
ABSTRACT
Introduction. The specific cognitive–affective mechanisms involved in the activation and regulation of the subjective and genital components of sexual arousal are not fully understood yet. Aim. The aim of the present study was to investigate the contribution of self-reported thoughts and affect to the prediction of women’s subjective and genital responses to erotica. Methods. Twenty-eight sexually functional women (mean age = 32, SD = 6.29) were presented with sexually explicit and nonexplicit romantic films. Genital responses, subjective sexual arousal, state affect, and self-reported thoughts were assessed. Main Outcome Measures. Vaginal pulse amplitude was measured using a vaginal photoplethysmograph. Subjective sexual arousal, thoughts, and affective responses were assessed through self-report scales. Results. Correlations between subjective and physiological sexual arousal were low (r = −0.05, P > 0.05). Selfreported thoughts and affect were significant predictors of subjective sexual arousal. The strongest single predictor of subjective arousal was sexual arousal thoughts (e.g., “I’m getting excited”) (β = 0.63, P < 0.01). None of the cognitive or affective variables predicted women’s genital responses. Conclusions. Overall, results support the role of cognitive (self-reported thoughts) and affective dimensions in women’s subjective sexual arousal to erotica and, consistent with previous findings, suggest that subjective and physiological sexual arousal may be impacted by different processes. Vilarinho S, Laja P, Carvalho J, QuintaGomes AL, Oliveira C, Janssen E, and Nobre PJ. Affective and cognitive determinants of women’s sexual response to erotica. J Sex Med 2014;11:2671–2678. Key Words. Sexual Arousal; Genital Response; Self-Reported Thoughts; Affect; Psychophysiology, Vaginal Photoplethysmography
Introduction
A
lthough a growing body of literature emphasizes the importance of affect and cognitions in sexual response [1–8], the specific cognitive– affective mechanisms involved in the activation and regulation of the subjective (self-report) and genital (physiological) components of sexual arousal are still not fully understood [7,8]. Barlow’s model of sexual functioning [9] is one of the © 2014 International Society for Sexual Medicine
most comprehensive attempts to integrate the impact of cognitive–affective factors on the sexual responses of both sexually functional and dysfunctional individuals. According to this model, sexually healthy individuals tend to respond with positive affect and focus on sexual cues, whereas individuals with sexual problems tend to focus their attention to nonrelevant nonsexual stimuli and are more likely to experience negative affect during sexual activity. Although this model was J Sex Med 2014;11:2671–2678
2672 initially developed for men, various aspects of the model have also been tested in and found relevant to sexual response patterns in women [10–12]. Some researchers have used questionnaire (instead of psychophysiological) methods to study aspects of Barlow’s model [13–16]. For example, Nobre and Pinto-Gouveia [2–4,6,17], using a selfreport measure of automatic thoughts, found that individuals with sexual dysfunction presented more negative thoughts and emotions during sexual activity when compared with sexually healthy individuals. Other studies, using student samples, have examined the content of selfreported thoughts that may interfere with sexual enjoyment and functioning [15,18]. This research has lead to the identification of four categories of distracting thoughts: thoughts related to one’s sexual performance, to one’s body image, to possible emotional consequences of the sexual activity, and to other consequences of the sexual activity (e.g., pregnancy). Furthermore, these studies revealed that regardless of thought category, the frequency of nonerotic thoughts and the anxiety they evoked were positively associated with sexual problems. More recently, in a community sample of men and women in long-term relationships [19], women, as compared with men, were more likely to report body image concerns and thoughts about the physical consequences of the sexual activity. Again, higher frequencies of such nonerotic thoughts were found to be associated with stronger sexual problems. Moreover, greater negative affect in anticipation and during sexual activity was associated with a higher frequency of nonerotic thoughts, and higher levels of anxiety in response to non-erotic thoughts were associated with greater difficulty in dismissing the thoughts. Taken together, this body of research suggests that a range of negative and nonerotic thoughts can interfere with sexual response. In contrast, much less is known about the role of positive thoughts in men and women’s sexual experiences. Furthermore, although the effects of attention [20,21], distraction [22], and body awareness [23] on sexual response have been studied using experimental and psychophysiological methods, experimental research on the impact of thoughts or specific thought content on sexual response is lacking. Regarding emotions and mood states, findings have been mixed. Some studies have found a negative association between depressed affect and sexual arousal [13,24–27]. Other studies, however, J Sex Med 2014;11:2671–2678
Vilarinho et al. have found that negative affect can be positively associated with genital response [8,28]. The literature is equally mixed on the role of positive emotions in sexual response. Some studies [25,29] found that positive affective states are associated with higher levels of subjective sexual arousal. Others [30] have found that the induction of positive affect did not influence women’s subjective or genital sexual responses. Additionally, in a crosssectional study [13] it was found that low positive affect was a strong predictor of sexual response. Wiegel et al. [31], in an expansion of Barlow’s model [9] proposed that positive and negative affect may have independent roles. Consistent with this, Peterson and Janssen [8] found that although positive affect was strongly and positively related to subjective sexual response, ambivalent affect (involving a combination of positive and negative affect) was also associated with higher levels of subjective sexual arousal and desire. The interpretation of the findings of research on the effects of mood and emotions on sexual response is complicated by the fact that many studies have reported different findings for genital responses and subjective sexual arousal. Sex researchers have yet to arrive at a consensus on how to best define sexual arousal and how to weigh its subjective vs. physiological response components [32,33]. Low levels of concordance between subjective and objective measures of sexual arousal are common in women and even more so in women with sexual dysfunction [12]. Despite the lack of significant differences in physiological sexual arousal responses to erotic materials between women with and without sexual dysfunction, Morokoff and Heiman [34] found that those with sexual dysfunction rated their subjective sexual arousal as significantly lower. Moreover, according to the cognitive models of sexual response, the low concordance between subjective sexual arousal and genital responses may be expected to be associated with the experience of negative affect while watching conventional, commercially available erotica (typically used in psychophysiological studies) [35,36]. In sum, the literature reveals that cognitive and emotional determinants play an important role in sexual experiences. Most of the current studies in this area, however, have been conducted using clinical samples or with sexual problems in mind. Moreover, although attention has been devoted to cognitive processes and emotional responses in and out of laboratory settings, few experimental data exist regarding men and women’s thoughts in
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Women’s Response to Erotica: Affect and Thoughts Table 1
Sample characteristics (N = 28)
Age
Marital status
Educational level (%)
Relationship duration
Mean SD Range Single Married Divorced Living in common law 5–9 years 10–12 years 13–15 years >15 years Mean SD Range
32.3 6.29 22–45 22.2% 40.7% 3.7% 33.3% 0% 25.9% 48.1% 23.9% 7,8 years 6 years 9 months–22 years
response to erotic stimuli. Furthermore, despite the accumulated data, little is known about the relationships of cognitions, emotions, and sexual response (both subjective and genital) to erotica. The aim of the present study was to investigate, in a laboratory setting, the affective and cognitive predictors of sexually healthy women’s response to erotica. Specifically, we aimed to examine the impact of state affect and self-reported thoughts on genital and subjective sexual response. We hypothesized that positive and negative affect would both have a significant impact on sexual response, particularly on subjective arousal. We also expected to find a significant impact of selfreported thoughts (negative thoughts and erotic thoughts) on sexual response to erotica. Specifically, considering Barlow’s model (the positive loop) and the nonclinical sample’s nature, we hypothesized that erotic thoughts would be positively associated with subjective sexual response. Method
Participants Twenty-eight women (mean age = 32, SD = 6.29) participated in the study. Most participants reported more than 12 years of education, and the majority were married. The characteristics of the sample are presented in Tables 1 and 2. Participants were recruited by means of flyers, advertisements in media (television, newspapers, and radio), and notice boards. Volunteers went through a phone screening interview to establish eligibility. Inclusion criteria were the following: being 18–50 years old; being in a heterosexual relationship and cohabitating for at least 6 months; and absence of psychopathology, medical problems, sexual dysfunction, or use of medications (e.g., antidepressants, antihypertensives, antipsychotics)
or drugs that interfere with sexual function. Participants received a 50-euro shopping coupon. The study protocol was approved by the ethics committee of a major local hospital.
Measures Genital Response Women’s genital responses were measured using a vaginal photoplethysmograph [37]. The AC signal was taken as a measure of vaginal pulse amplitude (VPA). The Biopac MP100 system with Acqknowledge software (BIOPAC Systems, Inc., Goleta, CA, USA) was used for data acquisition and processing. VPA was sampled at 1,000 Hz and high-pass-filtered (3 Hz). VPA signals were visually inspected and movement artifacts were removed, after which peak-to-peak amplitudes were calculated. All the physiological sexual responses were standardized within-participants to z-scores. Genital responses were defined in terms of differences between sexual and baseline stimuli. Subjective Sexual Arousal Subjective sexual arousal was measured by asking subjects to rate how sexually aroused they felt after each stimulus presentation, using a nine-point Likert scale (1, not at all, to 9, extremely). Affective Responses Affective responses to the stimuli were assessed using a Portuguese version of the Positive and Negative Affect Schedule (PANAS) [38]. The PANAS is a 20-item scale developed to assess the dimensions of positive and negative affect using a set of adjectives (10 positive affect items, e.g., “interested,” “excited,” “enthusiastic”; 10 negative affect items, e.g., “distressed,” “irritable,” “upset”). In the present study, the state-affect version of the PANAS was administered. Participants responded to the PANAS after each stimulus presentation,
Table 2 Genital and subjective sexual arousal, positive and negative affect, and self-reported thoughts during exposure to erotica (N = 28) Response to erotica
Mean
SD
Subjective response after film Genital response after film* Sexual arousal thoughts Distracting/disengaging thoughts Positive affect Negative affect
4.87 0.98 73.06 6.48 22.05 3.21
1.75 1.08 38.90 8.01 7.87 6.65
*Changes in z-scores from baseline.
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2674 using a five-point Likert scale, ranging from 1, “not at all,” to 5, “extremely.” Reliability of the original scale was demonstrated with Cronbach’s alpha coefficients ranging from 0.86 to 0.90 for the positive affect scale and 0.84 to 0.87 for the negative affect scale [38]. The Portuguese version of the scale also revealed good internal consistency, with Cronbach’s alpha of .86 for the positive affect subscale and .87 for the negative affect subscale [39].
Self-Reported Thoughts For the purpose of this study and to investigate the role of self-reported thoughts during sexual scenarios, a previously generated list [40] of possible negative thoughts and erotic thoughts occurring (30 items) was used. Participants were asked to rate after each stimulus presentation how frequent those thoughts were, using a six-point Likert scale, ranging from 1, “never,” to 6, “frequently.” A previous exploratory factor analysis was conducted with the original list, and five domains were identified: sexual arousal thoughts (e.g., “I’m getting excited”), distractive/disengaging thoughts (e.g., “This is a waste of time”), body image thoughts (e.g., “My body is not as sexy as that one”), actress’s physical attractiveness (e.g., “That woman is really exciting”), and sinful thoughts (e.g., “This is immoral”). The questionnaire presented a good internal consistency (Cronbach’s alpha for the total scale = 0.91), with Cronbach’s alpha values ranging from 0.75 to 0.94 for the subscales [40]. For this study, only the sexual arousal thoughts and sexually distractive/disengaging thoughts were considered (total of 13 items). The scores were computed as means or sums. Sexual Films Two erotic films were used: a 3-minute sexually explicit erotic film (sexual interaction with a focus on genitalia during oral and vaginal intercourse) and a 3-minute romantic erotic film (displaying an affectionate interaction and intercourse but without a focus on the genitalia). The sexually explicit film was a segment selected from an adult erotic film and has been used in previous research [41]. Both films elicited high levels of subjective sexual arousal in a previous study conducted in a sample of Portuguese undergraduate students [42]. For baseline assessment, a neutral film was used consisting of an excerpt of a scientific documentary. All films were presented with SuperLab 4.5 software (Cedrus Corporation, San Pedro, CA, USA). J Sex Med 2014;11:2671–2678
Vilarinho et al.
Procedure All participants underwent a phone screening interview during which the goal and procedures used in the study were explained. The presence of psychological disorders, sexual and medical problems, and use of drugs were also assessed. The interview was adapted from the Anxiety Disorders Interview Schedule for DSM-IV [43] and the Sexual Dysfunction Interview [44]. Eligible participants were then scheduled for the experimental session. Participants were tested individually. Upon arrival to the laboratory, information about specific procedures and potential risks and benefits and a description of the experimental equipment were provided to the participants. The option to withdraw from the study at any time was also emphasized. After the participant read and signed an informed consent statement, a series of questionnaires was completed. Afterward, participants entered a room furnished with a recliner, desk with a keyboard, and television monitor. Additional instructions were provided regarding the procedures and materials. Following that, the experimenter left the room and the participant put the genital response measurement device in place as instructed and placed a disposable sheet and towel over her lap. Following this, participants began a 10-minute adaptation period. During this adaptation period, the participants viewed a neutral film excerpt. After the adaptation period, participants viewed the films, in a counterbalanced order, each followed by completion of the subjective measures. All the instructions were displayed on the screen. At the end of the testing session, payment arrangements were made, and participants were questioned about their experiences and debriefed regarding the purpose of the study. Testing sessions took about 90 minutes. Results
Predictors of Subjective Sexual Response Regression analysis were performed (using the enter method) to estimate the accuracy of affect and self-reported thoughts as predictors of subjective sexual response. SPSS 17 software (IBM, Armonk, NY, USA) was used for data analysis. The first regression included self-reported thoughts (sexual arousal thoughts and distracting/ disengaging thoughts) as predictors and average subjective sexual arousal (mean response to the films) as dependent variable. The regression model was statistically significant and accounted
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Women’s Response to Erotica: Affect and Thoughts Table 3 Multiple regression analysis, enter method: Self-reported thoughts as predictors of subjective sexual response Predictors
B
β
SE
t
P
Sexual arousal thoughts 0.15 0.02 0.86 8.40*** 0.000 Distracting/disengaging thoughts −0.06 0.09 −0.06 −0.623 0.539 *P < 0.05; **P < 0.01; ***P < 0.001.
Table 4 Multiple regression analysis, enter method: Affect as predictor of subjective sexual response Predictor
B
SE
β
t
P
Positive affect Negative affect
0.71 0.11
0.12 0.18
0.80 0.07
6.63*** 0.61
0.000 0.546
*P < 0.05; **P < 0.01; ***P < 0.001.
films, we conducted two multiple regression analyses (using the enter method). The first regression used the positive and negative scales of the PANAS, and the second regression used sexual arousal thoughts and distracting/disengaging thoughts as predictors. The average genital response to the two sexual films was used as dependent variable in both regressions. Neither regression analysis revealed any significant findings. Thus, neither thoughts (distracting/disengaging and sexual arousal; adjusted R2 = −0.03; P > 0.05) nor affect (positive and negative; adjusted R2 = −0.03; P > 0.05) accounted for a significant amount of the variance in women’s genital response (see Tables 6 and 7). Discussion
Table 5 Multiple regression analysis, enter method: Self-reported thoughts and affect as predictors of subjective sexual response Predictor
B
SE
β
t
P
Sexual arousal thoughts Positive affect
0.11 0.26
0.03 0.14
0.63 0.30
4.01** 1.91
0.001 0.068
*P < 0.05; **P < 0.01; ***P < 0.001.
for 74% (adjusted R2 = 0.74; P < 0.001) of the variance in subjective sexual response (F(2,24) = 37.63, P < 0.001). Sexual arousal thoughts were the best predictor of subjective sexual response (β = 0.86, P < 0.001; see Table 3). In the second analysis, we included both dimensions of affect (positive and negative affect) as predictors and subjective sexual arousal as criterion. A significant model also emerged, which accounted for 61% (adjusted R2 = 0.61; P < 0.001) of the variance in subjective sexual response; F(2,25) = 22.12, P < 0.001. Positive affect was the only significant predictor of subjective sexual response (β = 0.80, P < 0.001; see Table 4). In the last regression, positive affect and sexual arousal thoughts were both entered as predictors of subjective sexual arousal (criterion variable). The results showed a significant model (F(2,23) = 44.28, P < 0.001) accounting for 77% of subjective sexual arousal’s variance (adjusted R2 = 0.77; P < 0.001). Only sexual arousal thoughts reached significance as predictor of subjective sexual response (β = 0.63, P < 0.01; see Table 5).
Predictors of Genital Response To evaluate the ability of affect and self-reported thoughts to predict genital response to the sexual
The aim of this study was to investigate the impact of state affect and self-reported thoughts on women’s genital and subjective sexual arousal to erotic film. None of the variables predicted genital response in women. Positive affect was associated with subjective sexual arousal. However, sexual arousal thoughts emerged as the strongest single predictor of subjective sexual arousal in the regression analyses. Negative affect and distracting/ disengaging thoughts during exposure to sexual material did not contribute to the prediction of subjective sexual arousal. Our findings appear to support part of Barlow’s model [9], especially when it comes to the part of the model that involves a positive feedback loop. Considering that the present sample included only women without sexual problems, it may be that the participants experienced mostly positive thoughts and positive affect in response to erotica, height-
Table 6 Multiple regression analysis, enter method: Automatic thoughts as predictors of genital response Predictor
B
SE
β
t
P
Sexual arousal thoughts 0.02 0.02 0.20 0.92 0.368 Distracting/disengaging thoughts 0.09 0.09 0.20 0.94 0.359 *P < 0.05; **P < 0.01; ***P < 0.001.
Table 7 Multiple regression analysis, Enter method: Affect as predictor of genital response Predictor
B
SE
β
t
P
Positive affect Negative affect
0.03 0.20
0.11 0.18
0.05 0.22
0.25 1.11
0.807 0.280
*P < 0.05; **P < 0.01; ***P < 0.001.
J Sex Med 2014;11:2671–2678
2676 ening women’s subjective sexual arousal, while negative affect played less of a role. The present results emphasize the importance of sexual-arousal-related thoughts such as “I want to touch myself,” “I feel like doing this,” and “This is really great” to subjective sexual response during the erotic clip presentations. We could speculate that those thoughts might work as sexual selfverbalizations that serve as additional internal stimuli [32] and therefore, in theory, could be expected to increase sexual arousal and motivation. The powerful effects of sexual thoughts have already been previously recognized [45]. It may also be the case that focusing on and recognizing certain pleasant sensations or pleasing content as depicted in the sexual scenarios heightens erotic awareness, helps to sustain attention to erotic cues, and minimizes distraction, thus increasing subjective sexual arousal. In contrast, negative and nonerotic thoughts have been recognized as important determinants of sexual problems, most likely by preventing individuals from focusing their attention on the sexual content of erotic stimuli [3,4,6,15,17–19]. This interpretation is consistent with other research that suggests that the recognition of a situation “as sexual” may contribute to increased levels of subjective sexual arousal [16,46], probably by facilitating processing of sexual stimuli. Moreover, related to the topic of body awareness, results previously reported by Seal and Meston [23] indicate that as long as cognitive distraction does not occur, awareness of one’s body is associated with increased subjective sexual response. Taken together, the findings of our study may have clinical implications, supporting the relevance of strategies that help women to focus their attention on what’s happening, on sexual cues, and on the positive and sensual aspects of the sexual experience (e.g., sensate focus, cognitive restructuring, mindfulness meditation). As for the effect of positive affect on subjective sexual response, when analyzed together with sexual arousal thoughts, its contribution was weaker than when it was analyzed together with negative affect. One possible explanation for this involves the high correlation between positive affect and sexual arousal thoughts (r = 0.80, P < 0.001) . Apparently, including both as predictors resulted in a loss of explanatory power of positive affect, leaving sexual arousal thoughts as the stronger predictor. We found no significant effects for the prediction of genital responses. Thus, in this study using J Sex Med 2014;11:2671–2678
Vilarinho et al. self-report measures, genital response, in contrast to subjective arousal, did not reveal any association with positive or negative affect or with sexualarousal-related thoughts. For negative affect in particular, the lack of any effects is intriguing, considering that previous studies have found some evidence of an effect on genital response [8,28]. We may speculate that the findings are partly attributable to the fact that our participants reported relatively low levels of negative affect to begin with. Not only did the regression analyses show different results for genital responses and subjective sexual arousal, the two were strongly dissociated from each other (r = −0.05, P > 0.05). The relative independence of the two dimensions of sexual arousal is consistent with previous findings in both women with sexual dysfunction and those without [47]. According to Chivers and Bailey [48], it is possible for some women to show genital responses without reporting any experience of sexual arousal. Laan and Everaerd [28] suggest that women in general do not rely much on physiological cues to estimate their sexual arousal, which may contribute to discordant response patterns. Some limitations of this study need to be acknowledged. First of all, the use of a convenience sample, although common practice in sexual psychophysiological studies, creates constraints to generalization. Future psychophysiological studies could explore the role of self-reported thoughts and state affect in samples more diverse in, for example, age, ethnicity, and sexual orientation. Another limitation involves the lack of a comparison group of women who experience sexual problems. This would have allowed for a more in-depth assessment of the role of cognitive–affective determinants in subjective sexual arousal, and in particular of sexual-arousal-related thoughts, and their relevance to sexual dysfunction. Another important limitation is related to the specificity of the current analysis, not including other contextual variables that may possibly exert an important impact on sexual arousal in women. Despite these limitations, this study is one of the first to examine the connection between sexual-arousal-related thoughts and subjective sexual arousal in women in a laboratory setting and therefore contributes to the literature on the role of cognitive and affective processes in sexual arousal. Our findings are congruent with previous questionnaire-based studies [13] supporting the importance of sexual arousal-related thoughts and attention to erotic cues. We believe the findings of
Women’s Response to Erotica: Affect and Thoughts this study are clinically relevant and could have implications for both the assessment and the treatment of sexual problems. For example, attentional processes—in particular the role of distracting or negative thoughts—could be addressed by incorporating cognitive restructuring techniques and mindfulness training together with sensate focus. Learning to direct attention to pleasurable body sensations could enhance sexual pleasure and reduce distractions from erotic cues. Additionally, thought content could be targeted by training the mind to focus on the positive and arousing aspects of sexual activity. Future research could explore the possibility that this approach might facilitate a body–mind “reconnection” and strengthen the association between women’s physiological and subjective sexual responses. Acknowledgments
This research was supported by the Foundation for Science and Technology in Portugal. Corresponding Author: Sandra Vilarinho, PhD, Faculty of Psychology and Educational Sciences, University of Porto, Praceta Manuel Regado Júnior, n° 80, 1° Esquerdo, Águas Santas—MAIA 4425-124, Portugal. Tel: +351 96 3083411; Fax: +351 22 2423360; E-mail: [email protected] Conflict of Interest: The authors report no conflicts of interest. Statement of Authorship
Category 1 (a) Conception and Design Sandra Vilarinho; Pedro J. Nobre; Erick Janssen (b) Acquisition of Data Sandra Vilarinho; Pedro Laja; Joana Carvalho; Ana Luísa Quinta-Gomes; Cátia Oliveira (c) Analysis and Interpretation of Data Sandra Vilarinho; Pedro J. Nobre; Erick Janssen
Category 2 (a) Drafting the Article Sandra Vilarinho (b) Revising It for Intellectual Content Pedro J. Nobre; Erick Janssen
Category 3 (a) Final Approval of the Completed Article Sandra Vilarinho; Pedro Laja; Joana Carvalho; Ana Luísa Quinta-Gomes; Cátia Oliveira; Pedro J. Nobre References 1 Bancroft J. Human sexuality and its problems. Edinburgh: Churchill Livingstone; 1989.
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